Every finding on record at University Nursing & Rehab Center

Based on observations, staff interview, and review of the facility's policy titled DATING AND LABELING POLICY, the facility failed to ensure that food items were properly labeled, dated, and discarded in accordance with facility policy to prevent potential foodborne illness. This deficient practice had the potenitial to affect all 98 residents receiving an oral diet.Findings include:During tour of the kitchen on 05/11/2026 from 9:40 AM to 10:00 AM, and interview with the Dietary Manager (DM) revealed the following concerns:Observation of the walk-in freezer revealed a bag with french toast with use by date of 05/7/2026, a bag with hash brown patties, dated 04/19 with no use-by date indicated, a plastic-wrapped hash brown patties labeled with an open date of 04/19 with no use-by date indicated, and a bag uncooked french fries, dated 05/2/2026 and use by date 05/6/2026.Review of the facility's policy titled, DATING AND LABELING POLICY, revised date 01/1/2026, revealed under Policy: Kitchen will assure food safety by maintaining proper dates and labels to all ready to eat food products. Under Procedure: 9. Follow Label and date Protocol chart for all for all perishable foods. 10. Discard all foods that expire immediately.During the tour and interview, the Dietary Manager acknowledged the expired and improperly labeled food items and stated the items would be discarded immediately.

Based on observations, staff and resident interviews, record review, and review of the facility's policies titled Self-Administration of Medications, the facility failed to offer and assess a resident for administering her own calcium and medicated mouthwash for one of 49 sampled residents (R) (R48). This deficient practice had the potential to cause the resident to leave medication at her bedside until she was ready to take it and could endanger other residents who wander and are confused. Findings include: Review of the facility's policy titled Self-Administration of Medications, revised 01/2026, section 1, revealed that if the resident expressed his/her desire to self-administer medications, as part of their overall evaluation, the staff and or practitioner shall assess the resident's mental and physical abilities to determine whether self-administering medications is clinically appropriate for the resident.Review of the electronic medical record (EMR) revealed resident R48 was admitted to the facility on [DATE] with pertinent diagnoses, including but not limited to bipolar disorder, severe with psychotic features, generalized anxiety disorder, Alzheimer's disease, Parkinson's disease with dyskinesia, and schizoaffective disorder.Review of R48 quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 15, which indicated R48 had little to no cognitive impairment.Section GG, functional status, revealed R48 was independent of activities of daily living (ADLs).Review of R48 care plan dated 03/2026 indicated a problem of gastroesophageal reflux disease (GERD) and at risk for adverse reactions.Goals-R48 will remain free from discomfort, complications, or signs/symptoms (s/sx) related to the diagnosis or GERD through the review date.Interventions: Give medications as ordered. Monitor/document side effects and effectiveness. Monitor/document/report PRN (as needed) s/sx of GERD: Belching, coughing/choking when lying down, heartburn, dyspepsia, N/V, indigestion, regurgitation, increased salivation, swallowing problems, bitter taste in mouth, dysphagia, substernal chest pain, increased gag response.Review of assessments- There is no assessment present for medication self-administration in R48 EHR.Review of the Physician's Orders for R48 included, but was not limited to:Tums Oral Tablet Chewable 500mg (Calcium Carbonate). Give 2 tablets by mouth every 6 hours as needed for GERDPrilosec OTC oral tablet Delayed Release 20mg. Give 1 tablet by mouth twice daily to treat reflux disease.Calcium Carbonate Oral Tablet: Give 1500mg by mouth one time a day for Calcium deficiency.Pepcid tablet 20mg: Give 20mg by mouth at bedtime for GERD.An observation and interview on 05/11/2026 at 11:44 am with R48 revealed 2 large chewable tablets inside a medication cup on the resident's bedside table. The resident states that they are TUMS for her low calcium. The nurse gives them to her, but she likes to take them later.An observation made on 05/13/2026 at 10:15 AM of R48 revealed that the resident had 2 medication cups on her bedside table: one contained 2 large, orange-colored tablets that were smooth and intact, and the other cup contained 5ml of a clear substance. When asked, the resident said that the liquid is her mouthwash, which the nurse gives her every morning, and the other is for calcium. Both cups were set there by the medication nurse. She stated that she does not take them right away.An interview with Certified Medication Technician (CMT) BB on 05/13/2026 at 10:20 AM revealed and confirmed the presence of the medication at the bedside, and she stated, She must have spit them back in the cup after I gave them to her. CMT BB then picked up the cup with the Tums in it and handed it to R48 for her to take. The resident took the tablets. CMT BB then turned and walked out of the room, leaving the mouthwash in the cup at the resident's bedside.An interview with a Licensed Practical Nurse (LPN) AA Unit manager on 05/13/202 at 10:30 AM revealed she was surprised that the CMT left the medication at the bedside. LPN AA stated that the CMT in question was always very thorough when administering medications and that they are trained the same way nurses are. An interview with the Director of Nursing (DON) and the Administrator on 05/14/2026 at 1:30 PM revealed that the practice of leaving medications at the bedside is unacceptable, and that education would be provided to the CMTs and the nursing staff.

Based on observations, staff and resident interviews, record review, and review of the facility's poliies titled Care Plans-Baseline, the facility failed to provide an updated baseline care plan for one of 49 residents sampled (R) (R8). This deficient practice had the potential to cause a lapse in care for Foley catheter care, JP (Jackson Pratt) drain, and surgical incision care. Findings include:Review of the facility's policy titled Care Plan-Baseline, revised 09/20/2023, section 1 revealed that to ensure the resident's immediate care needs are met and maintained, a baseline care plan will be developed within 48 hours of the resident's admission. Section 2a and b state that the baseline care plan will include initial goals based on admission orders and Physician orders.Review of the electronic medical record (EMR) revealed R8 was admitted to the facility originally in 2023, but was hospitalized for a hernia repair surgery and was admitted on [DATE], with pertinent diagnoses, including but not limited to encounter for surgical aftercare following surgery on the digestive system, incisional hernia without obstruction, resolution of an ileus, and failed catheter protocol twice with urinary retention. Review of R8's most recent, before his hospitalization, Minimum Data Set (MDS) assessment revealed a Brief Interview for Mental Status (BIMS) score of 08, which indicated R8 had moderate cognitive impairment.The review of R8s care plan dated 03/26/2026 was the last review date, and there is no mention of care for a Foley catheter, a JP drain, or a surgical incision.Review of the Physician's Orders for R8 included, but was not limited to: Order dated for 05/9/2026 Enhanced Barrier Precautions: Wear gowns and gloves Order dated for 05/09/2026: Full Liquids diet, other texture, regular consistency Order dated for 05/11/2026 Record JP drain output Order dated 05/14/2026: Foley catheter care every shift.Observation and interview on 05/11/2026 at 11:23 AM with R8 revealed the resident was in discomfort; he was agitated and had expressive aphasia, so he was unable to fully communicate his needs. Observation revealed he had a Foley catheter connected to a bedside drainage bag that had over 800 ml of clear amber urine in it. R8 pulled up his covers to show his midline abdominal incision with multiple staples and a JP drain located on the lower quadrant of his abdomen. There was no cover on the drainage bag, but the tubing was secured to the resident's right leg by a Foley securement device.Observation made on 05/13/2026 at 9:00 AM of R8 revealed that the R8 had been shaved, and the catheter bag had a privacy cover. There is no mention of the Foley catheter, JP drain, or midline incision in the care plan.An interview with the Registered Nurse (RN) MDS coordinator on 05/13/2026 at 12:30 PM revealed that the R8 care plan had not been updated with his new admission information and should have been updated within 48 hours of his admission. Neither his Foley catheter, the JP drain, nor the surgical incision care is addressed. She stated that this deficient practice can prevent timely care for the resident's needs.An interview with the Director of Nursing (DON) and Administrator on 05/14/2026 at 1:30 PM revealed that they expect every resident's care plan to include a baseline within 48 hours of admission. The negative consequences of not having a baseline care plan include delays in care.

Based on observations, staff interviews, record review, and review of the facility policy titled Oxygen Administration, the facility failed to ensure a physician's order was obtained for oxygen therapy administration for one resident of 13 residents (R) (R19) reviewed who were receiving oxygen therapy. This deficient practice had the potential to affect resident safety by administering oxygen without a current physician order.Findings include:Review of the electronic medical record (EMR) for R19 revealed diagnoses including, but not limited to, chronic obstructive pulmonary disease (COPD).Review of the most recent Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition.Review of the care plan initiated 07/17/2025 revealed a focus stating, Staff explained to me that I need to keep O2 cannula on with humidifier bottle in place to prevent another nosebleed. Interventions included, Encourage me to wear O2 nasal cannula.Further review of the EMR revealed no active physician order for oxygen administration.Observation on 05/11/2026 at 10:20 AM revealed R19 receiving oxygen via nasal cannula from an oxygen concentrator set at 3 liters per minute (LPM).Review of the facility policy titled Oxygen Administration undated revealed under Preparation: Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration.Observation on 05/13/2026 at 10:30 AM revealed R19 sitting in a geri-chair in the hallway while receiving oxygen via nasal cannula. Observation of the oxygen concentrator revealed the oxygen flow rate was set at 3 LPM.Interview with LPN AA on 05/13/2026 at 11:33 AM confirmed R19 did not have an active physician order for oxygen therapy. Review of the electronic medication administration record (eMAR) also revealed no active order for oxygen administration.Interview with the Director of Nursing (DON) on 05/13/2026 at 11:40 AM revealed her expectation that all residents receiving oxygen therapy should have an active physician order. The DON stated nurses were responsible for verifying physician orders.

Based on record review, resident representative interview, staff interviews, and review of the facility policy titled Infection Prevention and Control Program, the facility failed to ensure one of five residents (R) (R10) reviewed for immunizations were provided education regarding influenza and pneumococcal immunizations and failed to ensure documentation related to vaccine administration, refusal, contraindication, consent, and/or declination for sampled residents reviewed for influenza and pneumococcal immunizations. The deficient practice had the potential to place the 98 residents at increased risk of vaccine-preventable illnesses, including influenza and pneumococcal disease.Findings included:Review of the facility policy titled Infection Prevention and Control Program, revised 09/2023, revealed, in part, The infection prevention and control program is a facility-wide effort involving all disciplines and individuals. The policy further revealed, Policies and procedures are utilized as the standards of the infection prevention and control program. The policy additionally revealed infection prevention practices included implementation of measures intended to prevent and reduce the transmission of communicable diseases within the facility.Record review revealed R10 was admitted on [DATE] with a Brief Interview for Mental Status (BIMS) score of 00, indicating the resident was not cognitively intact.Record review revealed R10 had no documented evidence the influenza vaccine had been offered since the last documented consent dated 10/1/2025. Further record review revealed no current documentation related to influenza vaccine administration, refusal, contraindication, consent, education, and/or declination at the time of review.During an interview 05/12/2026 at 3:04 PM, R10's responsible representative/daughter stated she declined the pneumococcal immunizations vaccine only for R10.Further record review revealed no documented evidence R10 and/or the responsible representative was provided education regarding influenza and/or pneumococcal immunizations, and no documented evidence the influenza and/or pneumococcal vaccines were administered, refused, contraindicated, consented to, and/or declined at the time of review.During an interview conducted on 05/13/2026 at 1:00 PM, the Infection Control Preventionist Nurse (ICPN) stated she reviewed the Georgia Registry of Immunization Transactions and Services (GRITS) and was unable to locate documentation related to Influenza and pneumoccal vaccine offering, administration, refusal, contraindication, and/or consent for R10 prior to 05/14/2026.Further record review revealed no documented evidence R10 had previously been offered the vaccine or educated regarding the risks and benefits of the vaccine prior to 05/14/2026.Further record review revealed no documented evidence R10 had previously been offered the influenza and/or pneumococcal immunizations vaccine or educated regarding the risks and benefits of the vaccine prior to 5/14/2026.During a joint interview conducted on 05/14/2026 at 1:00 PM, the Director of Nursing (DON) and Administrator stated residents are educated regarding immunizations upon admission. The DON and Administrator acknowledged documentation related to pneumococcal immunizations vaccine offering, education, administration, refusal, contraindication, and/or consent for R10 could not be located at the time of review. The DON and Administrator further acknowledged the facility was unable to provide documentation demonstrating R10 was timely offered the pneumococcal immunizations vaccine or educated regarding the risks and benefits of vaccination prior to 05/14/2026. The DON and Administrator stated the importance of timely offering, educating, and documenting pneumococcal immunizations is to reduce the risk for transmission of communicable disease and protect vulnerable residents from complications associated with pneumococcal immunizations infection. The DON further stated the potential negative outcome of failing to timely offer and document pneumococcal immunizations could place residents at risk for contracting, transmitting, and experiencing complications related to pneumococcal immunizations within the facility.

Based on observations, staff interviews, record review, and review of the facility policy titled Infection Prevention and Control Program, the facility failed to ensure residents were timely offered the COVID-19 vaccine, educated regarding the risks and benefits of the COVID-19 vaccine, and failed to ensure documentation related to COVID-19 vaccine administration, refusal, contraindication, and/or consent for one of five sampled residents (R) (R9) reviewed for COVID-19 immunizations. This deficient practice had the potential to place R9 at increased risk of medical complications related to COVID-19. Findings include:Review of the facility policy titled Infection Prevention and Control Program, revised 09/2023, revealed, in part, The infection prevention and control program is a facility-wide effort involving all disciplines and individuals. The policy further revealed, Policies and procedures are utilized as the standards of the infection prevention and control program. The policy additionally revealed infection prevention practices included implementation of measures intended to prevent and reduce the transmission of communicable diseases within the facility.Record review revealed R9 was admitted on [DATE] and readmitted on [DATE] with a Brief Interview for Mental Status (BIMS) score of 11, indicating R9 was cognitively intact. Further record review revealed no documented evidence R9 had previously been offered the COVID-19 vaccine or educated regarding the risks and benefits of the vaccine prior to 05/14/2026.During an interview conducted on 05/13/2026 1:00 PM, the Infection Control Preventionist Nurse (ICPN)/ Regional Consultant reviewed the Georgia Registry of Immunization Transactions and Services (GRITS) and was unable to locate documentation related to COVID-19 vaccine administration, refusal, contraindication, and/or consent for R9 prior to 05/14/2026.During an interview conducted on 05/14/2026 1:33PM, R9 stated he had not been offered the COVID-19 vaccine until 05/14/2026. R9 stated he authorized the facility to administer the COVID-19 vaccine at that time.During a joint interview conducted on 05/14/2026 at 11:06 AM, the Director of Nursing (DON) and Administrator stated residents are educated regarding immunizations upon admission. The DON and Administrator acknowledged documentation related to COVID-19 vaccine offering, education, administration, refusal, contraindication, and/or consent for R9 could not be located at the time of review. The DON and Administrator further acknowledged the facility was unable to provide documentation demonstrating R9 was offered the COVID-19 vaccine or educated regarding the risks and benefits of vaccination prior to 05/14/2026. The DON and Administrator stated the importance of offering education, and documentation of COVID-19 immunizations. The DON further stated the potential negative outcome of failing to timely offer and document COVID-19 immunizations would place residents at risk for contracting, transmitting, and experiencing complications related to COVID-19 within the facility.

Based on observations, interviews, and cleaning schedule review, the facility failed to maintain the cleanliness of the kitchen creating the potential for contaminated food to be served to 97 of 102 residents that received an oral diet. Findings include: 1. During the initial tour of the kitchen and interview on 3/31/2025 from 8:30 am to 9:15 am, the following was observed: a. The floor in the dish room was missing a section of tiles which measured approximately 11 inches by six inches making it an uncleanable surface. Several more tiles were missing underneath the counter in the dish room. The wall underneath the counter had a dark black substance on the entire wall. The Dietary Manager (DM) stated, We try to clean the wall with a power washer each week. It [wall] needs to be replaced. b. A plastic cover over the cart with the large baking pans had a buildup of grime and was sticky to touch. The cover was over the clean baking pans. c. The air conditioning unit, next to the cart with clean baking pans, was observed with a heavy buildup of dust, dirt, and an unidentifiable sticky substance. Two large vents had areas of torn tape and a heavy buildup of dirt, dust, and grime. d. A floor fan was observed to have food particles on the outside of the fan. e. A fan next to the microwave had a heavy buildup of dust, dirt, and grime. The fan was pointed toward the steamtable; however, it was not turned on during meal service observations. f. A wall plug, located above the clean dishes, near the dish room, was not secured into the wall and had no cover plate. g. A fan located near the hand sink was observed to have a heavy buildup of dust, dirt, and grime. At the time of the observation, the fan was not turned on; however, it was pointed toward the food preparation table. h. The vent above the three-compartment sink was observed to have a black substance on it. The DM stated that the Maintenance Director (MD) was supposed to clean the fans and vents. The DM stated a bid for the floor was to be requested, however the facility had been without an MD for months. 2. During the second tour of the kitchen on 4/2/2025 at 11:10 am, the following was observed: a. The conditions identified above remained. b. There was a metal fence-like apparatus hanging on the end of the stove next to the deep fryer. The apparatus had a heavy build-up of grease, dirt, and grime. The DM said he thought the MD was supposed to clean that. c. The walls were observed to have peeling and chipped paint, dust, dirt, and black substance throughout. Review of the undated Cleaning Schedule, provided by the DM, noted the kitchen staff were to clean the equipment, floors, appliances, etc. The items identified during the kitchen tours were not on the schedule to be cleaned by the kitchen staff. During an interview on 4/2/2025 at 4:30 pm, the Corporate Maintenance Director (CMD) said he thought the kitchen staff was to clean the kitchen, and the MD would clean the fans, and fix the air conditioning ducts, and the dish room floor. During an interview on 4/3/2025 at 10:02 am, the Administrator stated, We have had three Maintenance Directors in four months. They just don't stay. The Administrator provided the contract for the kitchen staff to show the responsibilities for cleaning, dated 4/19/2022 and updated 4/5/2024. The contract failed to include the identified concerns for cleaning.

Based on observations and interviews, the facility failed to provide necessary maintenance to five of 49 rooms creating an unsafe, uncomfortable, and unhomelike environment for eight of eight residents (Resident (R) 11, R48, R71, R43, R49, R64, R19, and R25) reviewed for the environment of 29 sample residents. This failure had the potential to affect the residents' homelike environment. Findings include: During observations and interviews on 3/31/2025 from 10:11 am to 11:30 am; at 4:58 pm; and on 4/1/2025 at 10:27 am, the following was observed: a. The end of the handrail was missing outside room [ROOM NUMBER] which exposed a sharp end creating the potential for injuries when residents utilized the rail. b. The call light bulb outside room [ROOM NUMBER] was burnt out. Staff would not know if R11, R48, or R71 turned on their call light for assistance if they were not at the nurses' station, at the opposite end of the hall, to hear the light ringing on the call board. c. There was no call light available for R43. R43's roommate, R49, stated on 3/31/2025 at 10:32 am, I push the call light for [R43] when needed. I watch out for her. Neither R43 nor R49 knew how long the call light had been missing. d. The light above R64's bed did not work. R64 stated, on 3/31/2025 at 11:10 am, It's been out for two months. I'd really like to have a light above my bed. My bedside lamp is too hard to get to sometimes. Additionally, the window had a film like substance on it which prevented one from looking outside. e. There was no screen on the window in R19's room. The window was open approximately three inches. Leaves and dead bugs were observed on the windowsill inside the room. f. There was no screen on the window in R25's room. R25 stated, on 3/31/2025 at 11:22 am, I would really like to have some fresh air, but I'm told I can't open the window. During observations and interview on 4/2/2025 at 4:00 pm, of the identified concerns, the Corporate Maintenance Director stated, This will be fixed. We haven't had a Maintenance Director stay. During an interview on 4/3/2025 at 10:02 am, the Administrator stated, We have had three Maintenance Directors in four months. They just don't stay.

Based on observations, record review, interviews, and review of the facility policy titled, Nail Care, the facility failed to ensure nail care was provided for two of three residents (Residents (R) 85 and R8) reviewed for activities of daily living (ADL). This failure had the potential to cause R85 and R8 to have unmet care needs. Findings include: Review of the facility's policy titled, Nail Care, revised 02/18, documented The purposes of this procedure are to clean the nail bed, to keep nails trimmed, and prevent infections . General guidelines, nail care includes daily cleaning and regular trimming . Proper nail care can aid in the prevention of skin problems around the nail bed .Unless otherwise permitted, do not trim the nails of diabetic residents or residents with circulatory impairments . 1. Review of R85's Face Sheet located under the Profile tab of the electronic medical record (EMR), revealed R85 was admitted to the facility on [DATE] with diagnoses which included hypertension, acute kidney failure, and cerebellar stroke syndrome. Review of R85's annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/23/2024, located under the Resident Assessment Instrument (RAI) tab, revealed a Brief Interview for Mental Status (BIMS) of eight out of 15 which indicated R85 had moderately impaired cognition. Review of R85's Care Plan located in the EMR under the Care Plan tab and last revised 2/27/2025, revealed R85 Resident is resistive to care .Refusing medication and ADLs at times .Provide me with opportunities for choice during care provision. During an observation and interview on 3/31/2025 at 10:35 am, R85 was observed lying in his bed watching television. R85's fingernails were noted to be greater than half an inch over his fingertips. His toenail on his left foot was greater than two inches past the tip of his toe. When asked if he preferred his fingernails and toenails to be this long, R85 stated no I really want them trimmed. During an observation on 4/1/2025 at 9:30 am, R85's nails remained greater than half an inch over his fingertips, and toenails greater than two inches over tip of toe. During an interview on 4/1/2025 at 11:25 am, Licensed Practical Nurse (LPN) 6 was asked to verify what R85's toenails look like. She stated yes, they are very long and need trimming. 2. Review of R8's Face Sheet located under the Profile tab of the EMR revealed R8 was admitted to the facility on [DATE] with diagnoses which included cerebral infarction, hypertension, type two diabetes, and heart failure. Review of R8's significant change MDS with an ARD of 2/28/0225, located under the RAI tab, revealed R8 had a BIMS of six out of 15 which indicated R8 had severely impaired cognition. Review of R8's Care Plan located in the EMR under the Care Plan tab and last revised 3/27/2025, revealed R8 Resident is experiencing difficulty in performing task of daily living such as feeding self, dressing, bathing, toileting . During an observation on 3/31/2025 at 10:40 am, R8 had whiskers (facial hair around chin), and fingernails were greater than one inch over fingertips, chipped red nail polish, and thick whitish/brown debris underneath every fingernail. R8's toenails were greater than 1/2 inch over tips of toes. During an observation 4/2/2025 at 12:24 pm, R8 continued to have whiskers (facial hair around chin), fingernails were greater than one inch over fingertips, chipped red nail polish, and thick whitish/brown debris underneath every fingernail. R8's toenails were greater than 1/2 inch over tips of toes. During an interview on 4/2/2025 at 3:30 pm, Certified Nursing Assistant (CNA) 12 was asked who was responsible for trimming resident's fingernails, and toenails, she stated CNA's during their shower, and anytime it's needed. CNA12 stated facial hair should be removed during the resident's shower. During an interview on 4/2/2025 at 4:45 pm, LPN6 was asked who was responsible for trimming resident's fingernails, and toenails, and taking care of resident's facial hair. She stated primarily the CNAs, but everyone here should assist the residents with their needs. During an interview on 04/03/25 at 10:45 AM, the Director of Nursing (DON) was asked who was responsible for trimming resident's fingernails, toenails, and taking care of resident's facial hair. She stated primarily the CNAs during showers, but everyone there should assist the residents with their needs.

Based on observations, record review, staff and resident interviews, and review of the facility policies titled, Infection Prevention and Control Program and Cleaning and Disinfection of Resident-Care Items and Equipment, the facility failed to maintain proper infection control and prevention in 11 of 46 resident rooms (17, 18, 19, 20, 21, 22, 23, 24, 25, 26, and 27) related to storage of resident personal care items. In addition, the facility failed to adhere to and to serve food to residents in isolation using transmission-based precautions (TBP). The deficient practice had the potential to affect all facility residents by exposing them to infection. The facility census was 90. Findings include: Review of the facility policy titled, Infection Prevention and Control Program revised September 2023 revealed: 6. Prevention of Infection a. Important facets of infection prevention include: 3) educating residents, visitors, and staff and ensuring that they adhere to proper techniques and infection control practices (i.e. Hand Hygiene, Proper Use of PPEs, Transmission-based precautions . 6) implementing appropriate isolation precautions when necessary; and 7) following established general and disease-specific guidelines such as those of the Centers for Disease Control (CDC). Review of the facility policy titled, Cleaning and Disinfection of Resident-Care Items and Equipment revealed: Policy Statement: Resident-care equipment, including reusable items and durable medical equipment will be cleaned and disinfected according to current recommendations for disinfection and the OSHA [Occupational Safety and Health Administration] Bloodborne Pathogen Standard .3. Durable medical equipment (DME) must be cleaned and disinfected before reuse by another resident. 4. Reusable resident care equipment will be decontaminated and/or sterilized between residents according to manufacturers' instructions .6. Single use items will be discarded after a single use. 1. Observation on 12/5/2023 at 10:17 am revealed that there was oxygen (O2) tubing in room [ROOM NUMBER]-A attached to an O2 tank and hanging off the over bed table. There was a bedpan on the shelf in the shared bathroom of room [ROOM NUMBER] and room [ROOM NUMBER] that was dirty and was not labeled with a resident name or stored in a bag. Also noted in the shared bathroom was a bath basin that was labeled with the name of a resident that was no longer staying in room [ROOM NUMBER]. Observation on 12/5/2023 at 10:27 am in room [ROOM NUMBER] revealed a nebulizer (a device for producing a fine spray of liquid, used for inhaling a medicinal drug) mask laying on a nightstand that had a date of 11/27/2023 written on the nebulizer and was not stored in a bag. It was also observed that O2 tubing was hanging over the handle of a wheelchair and was attached to an O2 tank. Observation on 12/5/2023 at 10:43 am revealed in room [ROOM NUMBER] a bath basin that was on the shelf in the bathroom that was not labeled or stored in a bag. Observation on 12/5/2023 at 11:02 am revealed in room [ROOM NUMBER]'s private bathroom had a bedpan that was lying on the floor, not stored in a bag, and filled with liquid. Observation on 12/5 2023 at 11:14 am revealed in the shared bathroom of room [ROOM NUMBER] and room [ROOM NUMBER], two bath basins that were stored in a bag and were not labeled. Observation on 12/5/2023 at 11:28 am revealed in room [ROOM NUMBER] a urinal in the shared bathroom of room [ROOM NUMBER] and room [ROOM NUMBER] that was not labeled or stored in a bag. There was also a bath basin stored on the floor and was not in a bag. Observation on 12/5/2023 at 11:42 am revealed in room [ROOM NUMBER] the shared bathroom of room [ROOM NUMBER] and room [ROOM NUMBER] had two bath basins that were labeled with a resident's name that was no longer residing in room [ROOM NUMBER]. There were also 2 urinals, one emesis basin, and three more bath basins, all not labeled or stored in a bag. Observation on 12/5/2023 at 12:25 pm revealed the bathroom for room [ROOM NUMBER] had a urinal that was not labeled or properly stored in a bag. Observation on 12/6/2023 at 8:33 am revealed in room [ROOM NUMBER] the shared bathroom for room [ROOM NUMBER] and room [ROOM NUMBER] had two bath basins that were not labeled or stored in a bag. Observation on 12/6/2023 at 8:35 am revealed that room [ROOM NUMBER] did not have a trash can liner in the trash can. The resident residing in room [ROOM NUMBER] was on enhanced barrier precautions due to having a Foley catheter. It was also observed that the shared bathroom for room [ROOM NUMBER] and room [ROOM NUMBER] had a bath basin lying on the floor that was not stored in a bag. Observation on 12/6/2023 at 8:36 am revealed in the shared bathroom of room [ROOM NUMBER] and room [ROOM NUMBER] that there were four bed pans, seven bath basins, two urinals, and one emesis basin stored on the shelf that were not labeled or in a bag. Observation on 12/6/2023 at 8:40 am revealed there was a mesh barrier stop sign attached to the doorway of room [ROOM NUMBER] with one side of the barrier laying on the floor and was noted to be dirty. It was also observed that a bedpan was stored, not labeled or bagged, lying on the floor full of liquid. Observation on 12/6/2023 at 8:48 am revealed in room [ROOM NUMBER] O2 tubing that was laying on the floor. Observation on 12/6/2023 at 9:00 am revealed a dirty bedpan stored on the shelf that was not labeled or bagged in the shared bathroom of room [ROOM NUMBER] and room [ROOM NUMBER]. It was also noted a bath basin with a resident name that no longer resided in the room. Interview on 12/6/2023 at 1:44 pm with the Director of Nurses (DON) revealed that resident's personal care items should be labeled with the resident's name and be stored in a bag. She also revealed that multi use equipment, like blood pressure cuffs and mechanical lifts, should be cleaned with red top wipes in between each resident. 2. Observation on 12/6/2023 at 2:16 pm, Unit Clerk SS was observed with surgical mask on with nose exposed. Observation on 12/6/2023 at 2:18 pm, the Staffing Coordinator was observed with a surgical mask down on her face that allowed her nose to be exposed. Observation on 12/6/2023 at 6:10 pm of Certified Nursing Assistant (CNA) II and Licensed Practical Nurse (LPN) HH sitting at the nurse's station with their masks down under their noses. Interview on 12/9/2023 at 3:20 pm with the DON revealed that staff are required to wear masks until the end of the year. She stated that everyone had been educated on the proper use of personal protective equipment. 3. Observation on 12/6/2023 at 1:21 pm of CNA OO removing a lunch tray from room [ROOM NUMBER], an isolation room on Unit 1 East. Interview on 12/6/2023 at 1:40 pm with CNA OO, she confirmed and verified she removed a tray from an isolation room and walked the tray to the kitchen. She stated she placed the tray on a metal rack in the kitchen so the kitchen staff would know the tray was an isolation tray. She revealed the normal process in the facility was to pass trays from the insulated cart which she called the hot cart to all patients, then when picking up trays, return all trays to the hot cart, except isolation trays. She stated the isolation trays were placed on a metal cart in the hallway and returned to the kitchen. She confirmed the metal cart was uncovered. She stated that this was the first facility that she had worked for that did not provide disposable trays for residents in isolation. Interview on 12/6/2023 at 2:00 pm with the Infection Preventionist (IP) revealed that the kitchen staff should prepare meals on disposable trays for residents who are on enteric contact and droplet precautions. She stated she was not aware the kitchen was sending out regular trays for residents who were in isolation. Interview on 12/9/2023 at 3:26 pm with the DON revealed that her expectation was that residents who are on contact precautions/isolation would receive their meals in a disposable container and when the resident was done eating, the disposable tray would be thrown away in the room and removed from the room when the trash was taken out in a closed trash bag. She stated the kitchen ran out of Styrofoam and was utilizing regular trays. She stated the CNAs were to keep the trays separate so the dishwasher could sanitize them properly. She stated that her expectation was for the carts the non-disposable trays were transported on were to be covered. 47146 47946

Based on observations, record review, staff and resident interviews, and review of the facility policies titled, Infection Prevention and Control Program and Antibiotic Stewardship, the facility failed to establish an infection prevention and control program that included an Antibiotic Stewardship Program with included antibiotic use protocols and a system to monitor antibiotic use for four of 27 sampled residents (R) (R77, R38, R58, and R83). This deficient practice had the potential to affect all residents that receive antibiotics. The facility census was 90. Findings include: Review of the facility policy titled, Infection Prevention and Control Program with a revision date of September 2023 revealed: 3. Surveillance a. Standard criteria are used to distinguish between community-acquired from facility -acquired infections .4. Antibiotic Stewardship a. An antibiotic stewardship program shall be implemented as part of the overall infection prevention and control program. b. Culture reports, sensitivity data, and antibiotic usage reviews are included in surveillance activities. d. Antibiotic usage is evaluated, and practitioners are provided feedback on reviews. Review of the facility policy titled, Antibiotic Stewardship with a revision date of September 2023 revealed: Policy Interpretation and Implementation .1. The purpose of our Antibiotic Stewardship Program is to monitor the use of appropriate antibiotics in our residents to improve clinical outcomes and decrease the risks of adverse effects .3. The facility shall have the pharmacy review antibiotic usage for appropriateness. 5. The facility shall monitor for adverse reactions/outcomes related to antibiotic therapy. Interview on 12/6/2023 at 12:35 pm with the Infection Preventionist (IP) revealed Clostridium difficile infections (CDI-an infection from a bacterium that causes colitis, an inflammation of the colon, causing diarrhea) that were present in the facility. The interview further revealed that there were four cases of CDI in the facility. She stated that there were two that were admitted with CDI, the third case developed in the facility, and she stated that she was unsure if it was from antibiotic use or related to the fact that she was next door to a resident that was admitted with CDI. The fourth case had two negative results and two positive results, and she stated that the physician asked her to treat the resident as if, he was positive. 1. Review of the electronic medical record (EMR) for R77 revealed he was admitted with CDI and other Multidrug-Resistant Organisms (MDRO's). R77 was admitted from the hospital CDI positive, Extended Spectrum Beta Lactamase (ESBL) in abdominal abscess, and carbapenem-resistant klebsiella (CRK) in urine. He has a supra (above) pubic catheter. Review of lab results from 10/25/2023 revealed R77 was positive for C. difficile PCR and toxin positive. 2. Review of the EMR for R38 revealed that she was readmitted from the hospital after complaints of abdominal pain, diarrhea, and GI Bleeding. The resident started complaining of abdominal pain that was uncontrolled. She was sent to the emergency room (ER) and returned with orders for an antibiotic for a urinary tract infection (UTI). She received the antibiotic for seven days. Continued review revealed that R38 had no bowel movements, and a sample was not collected on 11/17/2023 and 11/18/2023. Review of lab reports for R38 revealed that a stool was collected and sent to the lab. It was resulted on 12/1/2023 and it was positive for CDI toxins. Per the McGeer Criteria, it did not meet criteria for gastrointestinal tract infection, and the form completed by the IP revealed that criteria was met. Observation on 12/5/2023 at 10:15 am of R38 sitting in her doorway in her wheelchair, with the door open. 3. Review of the EMR for R58 revealed that there was a change of condition that was documented for the resident that alerted the physician that on 11/20/2023 R58 had a new skin tear/ulcer. There was no documentation as to why the resident needed a stool sample collected. R58 was receiving an antibiotic for a chronic urinary tract infection that was colonized. He received that antibiotic until 11/9/2023, and then started back again on 11/21/2023 until it was discontinued on 11/24/2023. A stool sample was collected for R58 with the preliminary report resulting on 11/9/2023 and had returned with a positive result for CDI toxins. Per medical record, the was a nurses note that stated that the lab called and stated the lab test for CDI toxins was positive in error. The final report was reported on 11/10/2023, had a negative result for CDI antigen and toxins. R58 was started on metronidazole on 11/27/2023 and discontinued on 12/1/2023 for CDI. A second sample was collected on 11/20/2023 and had a preliminary result that was positive for CDI toxins. The result was reported on 12/4/2023 and was negative for CDI antigens and toxins. Per a note written on the lab result with release date of 12/4/2023, the IP wrote, MD [medical doctor] advised to treat resident as positive for c-diff. The resident started on vancomycin 125mg (milligram) tablet four times a day on 12/4/2023 and was ordered to end on 12/10/2023. Per the McGeer Criteria form completed by the IP on 11/10/2023, it did not state whether it was met or not met. Per the McGeer Criteria form completed by the IP on 12/4/2023, it stated that criteria were met for gastrointestinal tract infection for CDI. Interview on 12/5/2023 at 9:45 am with R58 revealed that he was in isolation for some kind of infection, but he didn't have it now. Interview on 12/9/2023 at 3:15 pm with the Director of Nurses (DON) revealed that R58 was prescribed vancomycin because he had two positive results and two negative results. During this time, she verified that the CDI test results were interpreted incorrectly by the IP, and that the resident did not have a positive result at all. She then continued the interview by stating that the physician wanted him to have the antibiotic, related to the complaints of chronic diarrhea. When asked if she could provide documentation that the physician was aware that there were no positive CDI results, she stated that progress notes are not immediately available to them, and at times, takes several weeks for them to be sent to the facility. 4. Review of the EMR revealed that R83 was admitted on [DATE] on antibiotics and completed the round on 10/19/2023. Per a nurses note, the resident started having complaints of feeling bad and diarrhea on 11/8/2023. A second note and a change of condition note to the physician revealed that R83 was unable to take medications, food, or drink much. A stool sample was collected prior to the resident's admission to the hospital on 11/8/2023, and per a nurses note on 11/7/2023, CDI results were pending. It resulted on 11/9/2023 as positive for CDI antigens and toxins. R83 returned and was readmitted [DATE]. At time of the readmission, R83 was receiving three different antibiotics, fidaxomicin, vancomycin, and cefepime. Per the McGeer criteria form that was completed by the IP, the infection did not meet criteria due to it was on admission. Interview on 12/5/2023 at 11:20 am with R83, he stated that he went to the hospital with CDI and was in the hospital for what seemed to be three weeks.

Based on staff interviews, record review, and review of policy and procedures titled Transfer or Discharge, preparing a Resident for, and Bed-Holds and Returns, the facility failed to provide one resident (R) (R290) a discharge summary, three residents (R38, R4, and R291) and/or their representative a notice of transfer or discharge and the reason for the move in writing. Additionally, the facility failed to send a copy of the notice to the representative of the office of the State Long Term Care Ombudsman for four of 52 residents sampled (R290, R38, R4, and R291). Findings include: A review of the undated policy Transfer or Discharge, Preparing a Resident for revealed the policy statement was that residents will be prepared in advance for discharge. The Policy and Interpretation and Implementation section revealed lines numbered 2. A post discharge plan is developed for each resident prior to his or her transfer or discharge. 3. Nursing services are responsible for: (a) obtaining orders for discharge or transfer; (b) preparing the discharge summary and post discharge plan; (c) providing the resident or representative with required documents; (h) completing a discharge note in the medical record. 4.(b) The business office is responsible for informing residents or their representatives of the facility's re-admission appeal rights, bed holding policies, etc. A review of the undated policy Bed-Holds and Returns revealed a policy statement of prior to transfer and therapeutic leaves, residents or resident representatives will be informed in writing of the bed-hold and return policy. The section titled Policy Interpretation and Implementation lines numbered 3(d) revealed prior to transfer, written information will be given to the resident and the residents representative that explains in detail the details of the transfer per the notice of transfer. 6. If the resident is transferred with the expectation that he or she will return, but it is determined that the resident cannot return, that resident will be formally discharged . 1. Record review of the Electronic Medical Record (EMR) revealed Resident (R) 290 was readmitted to the facility on [DATE] and discharged to home on 6/1/2023. Record review of R290's Admission Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 15, which indicated that R290 was cognitively intact. Record review of R290's Discharge MDS assessment dated [DATE] revealed discharge was unplanned to the community and return was not anticipated. A review of the Physicians ' Orders revealed there was not an order for discharge from the facility. A review of the EMR by the Social Service Director (SSD) dated 6/6/2023 noted late documentation for 6/1/2023. The note revealed the SSD offered to set up home health services for R290, but she declined. He documented that he requested R290 to confirm her discharge date and time and she declined to do so. He documented a discharge packet was prepared for R290 with the facility's contact information, her medication list, and her physician's contact information. A review of the EMR revealed the discharge summary/discharge packet was not located. Paper documentation of discharge was requested but not provided. Interview on 12/7/2023 at 11:33 am with the SSD revealed that he was not sure of R290's exact circumstances but normally if a resident wants to leave, he tries to provide a discharge summary and arrange home health. He revealed that it appears R290 refused home health. He stated that R290 left the faciity on [DATE]. He verified and confirmed that there was not a discharge summary packet for 6/1/2023 in the EMR. Interview on 12/7/2023 at 11:58 am with the Director of Nursing (DON) revealed that on 6/1/2023 R290 was sitting on the front porch of the facility and a Certified Nursing Assistant (CNA) reported that R290 was seen leaving in a car with her significant other without notifying the facility. She revealed that an agency nurse was caring for R290 at the time this occurred and that the nurse did not document this event. The DON revealed that social services were working on discharge planning with the resident, but she did not reveal to them when she was leaving the facility. She stated under normal circumstances she should have been given a discharge packet, medications reviewed, and the resident and nurse sign documentation of the discharge. She stated social services should have called and followed up with R290 and the physician should have been notified. She verified and confirmed there was no documentation to support the physician was notified. She verified and confirmed there was no documentation in the EMR related to the discharge of R290. Interview on 12/7/2023 at 2:02 pm with the Administrator revealed that if a resident leaves the facility without notification, the facility staff calls the physician to determine if it was a safe discharge. 2. A review of the EMR revealed that R38 was admitted to the facility on [DATE] and was readmitted to the facility on [DATE] after an acute care hospital stay. Record review of the Annual MDS, dated [DATE] revealed a BIMS of 5, indicating severe cognitive impairment. A review of Nursing Notes dated 10/16/2023 revealed nurse documented R38 was experiencing a change in condition and listed abdominal pain, abnormal vital signs, and diarrhea/GI bleeding. The nurse documented that she notified the physician at 1:15 pm and noted there was no responsible party in R38's EMR profile. Interview with the SSD on 12/7/2023 at 9:40 am revealed that R38 is her own representative, and that the unit manager would notify her in writing of the reason for the hospital stay. He stated the Administrator notifies the ombudsman of transfers and discharges to the hospital. Interview with Licensed Practical Nurse (LPN) GG on 12/7/2023 at 9:43 am revealed staff completed a change of condition assessment and notified the responsible party by phone. She revealed R38 is her own responsible party therefore there was not anyone to notify. She stated they do not provide written notification to anyone when a resident is transferred to the hospital. She stated the nurse notifies the physician and the responsible party by phone. Interview on 12/7/2023 at 9:51 am with the Administrator revealed she normally speaks to the ombudsman on the phone and does not remember if she notified her of this specific discharge to the hospital. She stated it is a team effort between nursing and social services to notify residents and/or resident representatives with written information related to why the resident was transferred to the hospital. Interview with LPN GG on 12/7/2023 at 10:22 am revealed a packet goes with each resident who is transferred to the hospital which includes a copy of the face sheet, medication list, and the resident's diagnoses. She stated she was not sure what else was in the packet but printed one and confirmed it also contained contact information, an order summary, and the change in condition evaluation documentation. Interview on 12/7/2023 at 10:38 am with the DON verified and confirmed that there was no evidence found in the EMR that supported R38 was notified in writing of the reason she was transferred to the hospital. 3. Record review of the EMR for R4 revealed the resident was admitted on [DATE]. A review of the Nurse's Notes dated 4/7/2023 at 2:57 pm revealed nurse documented R4 experienced acute pain to right retroperitoneal area. The nurse documented an attempt to notify the family by phone and new orders were obtained to send R4 to the hospital for evaluation and treatment per R4's request. A review of the Hospital Discharge document dated 4/11/2023 revealed that R4 was admitted to the hospital on 4/7/2023 and discharged to a skilled nursing facility on 4/11/2023. Interview on 12/7/2023 at 9:43 am with LPN GG revealed the staff nurse completes a change of condition assessment and notifies the responsible part and physician by phone. She stated they only notify the physician and the responsible party by phone of reason why resident was transferred to the hospital. Interview on 12/7/2023 at 10:22 am with LPN GG revealed a packet goes with each resident who is transferred to the hospital which includes a copy of the face sheet, medication list, and the resident's diagnoses. She stated she was not sure what else was in the packet but printed one and confirmed it also contained contact information, an order summary, and the change in condition evaluation documentation. Interview on 12/9/2023 at 11:11 am with the DON revealed that staff give verbal notification to residents and their family when they are transferred out to the hospital, and it is explained verbally but no written documentation is given to the resident. She stated the ombudsman is notified verbally by the Administrator. She stated that they have a document called e-interact transfer located in the EMR which should be completed and given to the resident or family. She verified and confirmed that R4 did not have this document completed or given to her at the time of discharge to the ER. Interview on 12/9/2023 at 11:15 am with the Administrator revealed that she notified the ombudsman via telephone. She stated she would check and verify written notification was sent to the ombudsman and provide for the surveyor, however, there was no notification provided to the surveyor. 48338 4. Review of the clinical record for R291 revealed an admitted [DATE], the most recent readmitted [DATE], and a discharge date of [DATE]. Review of the Anticipated Return Discharge Minimum Data Set (MDS) dated [DATE] Section A revealed the type of assessment was discharge with return not anticipated, unplanned, and the discharge status was left blank. An interview on 12/6/2023 at 3:25 pm with the SSD and Social Services Assistant (SSA) revealed the resident became difficult to manage in this environment and was transferred to the emergency room (ER) for evaluation on 9/12/2023. SSD stated R291 was transferred from the local hospital to a local behavioral hospital in September. He stated the resident's family was notified by phone and he did not give the family a written notice of transfer/discharge. An interview with the Administrator on 12/6/2023 at 4:10 pm revealed they transferred the resident out with the expectation of returning to the facility. She stated it was communicated by the marketer to the hospital to find placement for the resident because they could no longer manage her behavior at the facility. She stated that the psychiatric hospital sent the resident to another facility, and they were not aware of the resident's discharge. A request was made for proper transfer/discharge documentation and notification to family as to why the resident was discharged /transferred, and documentation that the Ombudsman was notified. On 12/6/2023 at 5:00 pm the Administrator provided progress notes from the SSD of speaking to R291's brother but failed to provide a written notice of transfer/discharge to the family, resident, or Ombudsman. Interview on 12/8/2023 at 10:15 am with the DON revealed when residents are transferred from the facility to the hospital the nurse completes the form Change of Condition in the electronic medical record (EMR) that shows notification of the physician and the family.

Based on observation, staff interviews, record reviews, review of the manufacturer's package insert, and review of the facility policy titled, Administering Medications, the facility failed to ensure that one of three residents (R) (R61) received the correct dosage of medication as prescribed by the physician. The deficient practice had the potential to result in medication not being given in accordance with the physician's orders and had the potential to affect the residents' clinical conditions. Findings include: Review of the undated facility policy titled, Administering Medications revealed the policy line numbered: 2. The Director of Nursing Services will supervise and direct all nursing personnel who administer medications and/or have related functions. 3. Medications must be administered in accordance with the orders, including any required time frame. 7. The individual administering the medications must check the label three times to verify the right resident, right medication, right dosage, right time, and right route of administration before giving the medication. Review of the manufacturer's package insert section titled Dosage and Administration revealed: Total dose should not exceed 32 grams (gm) per day, overall affected joints. Voltaren Gel (a medication used to treat pain) should be measured onto the enclosed dosing card to the appropriate 2 gm or 4 gm designation. Observation of Medication Administration on 12/6/2023 at 9:00 am, revealed Licensed Practical Nurse, (LPN) HH was observed giving R61 her morning medication. The medications included Voltaren gel 4 gm. The nurse stated she just squeezed about two-three milliliters (ml) in the cup without using the designated plastic ruler for measuring ointments/gel as instructed by the manufacturer. Interview on 12/6/2023 at 9:00 am with LPN HH revealed she did not know how much of the Voltaren gel to give but put the ointment in a cup titrated in ml. Interview on 12/8/2023 at 9:40 am with LPN GG revealed when she gives pain gel or ointment, she uses a paper/plastic ruler to measure the dosage ordered then she rubs it off into the measuring cup. An interview on 12/8/2023 at 10:15 am with the Director of Nursing (DON) revealed her expectations for nurses when passing medication were for them to follow the five rights of medication pass. She said with the electronic medication record system, it is easy for them to follow with three checks and balances. The first is to click the name, second to check the medication from the medication cards and third was when they put the medication cards back to read and make sure it matches. She confirmed the pain gel is to be squeezed on a paper ruler or plastic ruler to determine the exact dose, then it can be smoothed off into the cup, as it measures the gel in grams which delivers the correct dose. She clarified if an order does not match, they must clarify it through her or call the doctor for verification of the order. She stated she does a lot of education on basic things, and they are forgotten as time passes and they fall back into the old habits of doing them the wrong way.

Based on observations, staff and resident interviews, record review, and review of the facility policy titled, Resident Rights and Protected Health Information (PHI), Management and Protection of the facility failed to ensure privacy of clinical information for one resident (R) (R9), specifically by posting signage containing clinical information in R9 room and failed to ensure confidentiality of electronic medical records was maintained for seven residents, specifically by allowing the electronic medical record screen to be visible in a hallway. The sample size was 51 residents. Findings include: Review of the undated facility policy titled Resident Rights indicated the following: 1. Federal and State laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: (t) privacy and confidentiality. 8. The unauthorized release, access, or disclosure of resident information is prohibited. Review of the undated facility policy titled Protected Health Information (PHI), Management and Protection of revealed the Policy Interpretation and Implementation section line numbered 1. It is the responsibility of all personnel who have access to resident and facility information to ensure that such information is managed and protected to prevent unauthorized release and disclosure. 1. Review of R9's most recent Quarterly Minimum Data Set (MDS) dated [DATE] documented R9 had a Brief Interview for Mental Status (BIMS) score of 10, indicating the resident had moderate impaired cognition. Observation on 12/5/2023 at 11:20 am, 12/6/2023 at 8:45 am, and 12/7/2023 at 9:00 am revealed a yellow sign posted on R9's wall with bold black letters stating Please give me my eyedrops at bedtime. 1 drop, both eyes. Thank you! The signage was viewable from the hall doorway. Interview on 12/5/2023 at 11:20 am with R9 revealed she requested the nurse to post a reminder to the nursing staff caring for her to prompt them that she must take eye drops. 2. Observation on 12/5/2023 at 11:40 am revealed an Electronic Medical Record (EMR) computer monitor screen mounted on a wall, located between rooms [ROOM NUMBERS], opened with resident names visible to residents and visitors. Interview on 12/5/2023 at 11:45 am with Certified Medication Aide (CMA) BB revealed the information on the computer was confidential and not supposed to be open and visible. CMA BB confirmed and verified the monitor was left accessible for navigating and viewing information of seven residents. Interview on 12/9/2023 at 3:45 pm with Director of Nursing (DON) confirmed that the residents' personal health information should not be written on posted signs and visible from the resident's hall doorway to other residents and visitors. DON confirmed that the staff have a responsibility to protect EMR information on hallway wall monitors by effectively logging out to lock the screen before walking away. She further stated the facility conducted an in-service education training immediately to train on Health Insurance Portability and Accountability Act (HIPAA) with all nursing staff.

Based on staff interviews, record reviews, and review of the facility's policy titled, Transfer or Discharge, Preparing a Resident for, the facility failed to document preparation and orientation to ensure a safe and orderly discharge from the facility for one of 52 Residents (R) (R290) reviewed for discharges. Findings include: Review of the facility's policy titled Transfer or Discharge, Preparing a Resident for undated, Policy Statement revealed Residents will be prepared in advance for discharge. Review of the Electronic Medical Record (EMR) revealed R290 was readmitted to the facility on [DATE] with diagnoses listed but not limited to infection and inflammatory reaction due to peritoneal dialysis catheter and cutaneous abscess of abdominal wall. She was discharged on [DATE]. Review of R290's Admission Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 15, which indicated R290 was cognitively intact. Review of R290's Discharge MDS assessment dated [DATE] revealed in Section A: Identification Information-indicated discharge was unplanned to the community and return was not anticipated. Section O: Special Treatments and Programs- indicated occupational therapy started on 5/19/2023 and ended on 6/1/2023 and physical therapy started on 5/19/2023 and ended on 5/31/2023. Review of the Physician Order's with last review date of 5/31/2023 revealed physical therapy services five times a week for six weeks and occupational therapy five times a week for 12 weeks. There was not an order for discharge from the facility. Review of Progress Notes dated 6/6/2023 revealed late documentation for 6/1/2023 by the Social Service Director (SSD) that stated home health was offered for R290, but she declined. SSD documented that he requested R290 to confirm her discharge date and time, but she declined. SSD documented a discharge packet was prepared for R290 with the facilities contact information, her medication list, and her physician contact information. Review of the EMR revealed there was no discharge summary/discharge packet completed. Interview with the Rehab Manager on 12/7/2023 at 11:09 am revealed that R290 was seen by physical therapy and occupational therapy. She stated that R290 was independent and was able to ambulate100 feet with a walker. She stated the rehab discharge note revealed R290 completed self-care tasks independently per nursing, goals for function, endurance, and strength were met, and she was discharged home on 6/1/2023. She revealed that she was discharged from therapy because of payor source change which she stated usually means the insurance has stopped payment for therapy related to all therapy goals were met. She further revealed that a home health referral was sent per the therapy notes. Interview with the Social Service Director on 12/7/2023 at 11:33 am revealed that he was not sure of R290's exact circumstances surrounding the discharge of R290. He revealed that it appeared R290 refused home health. He confirmed the Notice of Medicare Non-Coverage (NOMNC) was issued, and the last date of service was listed as 5/29/2023, he stated she appealed the NOMNC which resulted in upholding the NOMNC. He stated R290 left the faciity on [DATE]. He verified and confirmed that there was not a discharge summary/packet for 6/1/2023 in the EMR. Interview with the Director of Nursing (DON) on 12/7/2023 at 11:58 am revealed that a Certified Nursing Assistant (CNA) reported that R290 was seen leaving the facility without notifying staff on 6/1/2023. She revealed that the agency nurse assigned to R290 at the time this occurred did not document this event. She revealed that social services were working on discharge planning with the resident, but R290 did not want to reveal to them when she was leaving the facility. She verified and confirmed there was not any documentation to support the physician was notified. She verified and confirmed there was no documentation in the EMR related to the discharge of R290. Interview with the Social Service Director and the Social Service Assistant revealed R290 was generally pleasant when speaking with her except for communication related to family and discharge planning. They stated they did not have any concerns about her returning home. The Social Service Assistant stated she did attempt to follow up with R290, but she did not document her attempt nor did they document the discussions with R290 related to discharge planning. Interview with the Administrator on 12/7/2023 at 2:02 pm revealed that if a patient discharge from the facility without notification, the facility staff should call the physician to determine if it was a safe discharge. She stated R290 had a safe discharge. A paper documentation of discharge was requested from the facility but was not provided prior to exit.

Based on staff interviews, record reviews, and review of the facility's policy titled, Bed-Holds and Returns, the facility failed to notify residents of the bed-hold policy during which the resident was permitted to return and resume residence in the nursing facility for two residents (R) out of 52 Residents (R4 and R38) reviewed for discharges. Findings include: Review of the facility's policy titled Bed-Holds undated, under the Policy Statement revealed Prior to transfer and therapeutic leaves, residents or resident representatives will be informed in writing of the bed-hold and return policy. Under the Policy Interpretation and Implementation .revealed 3. Prior to transfer, written information will be given to the resident and the resident's representative that explains in detail: a. The rights and limitations of bed-holds; b. The reserve bed payment policy as indicated by the state plan (Medicaid residents); c. The facility per diem rate required to hold a bed (non-Medicaid residents), or to hold a bed beyond state bed-hold period (Medicaid residents); and d. The details of the transfer. 1. Review of R4's Electronic Medical Record (EMR) revealed that she was admitted with diagnoses that included but not limited to hydronephrosis, hypertension, and anxiety. Review of R4's Annual Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) of 12 which indicated R4 had moderate cognitive impairment. Review of R4's nurse's notes dated 4/7/2023 at 2:57 pm revealed R4 experienced acute pain to right retroperitoneal area. The nurse documented an attempt to notify the family by phone and new orders were obtained to send R4 to the ER for evaluation and treatment per R4's request. Review of the hospital discharge records dated 4/11/2023 revealed R4 was admitted to the hospital on 4/7/2023 and discharged to skilled nursing facility on 4/11/2023 with a diagnosis of pyelonephritis. Review of the EMR revealed there was no evidence to support R4 and/or representative was informed in writing of the bed-hold and return policy prior to transfer. Interview conducted on 12/9/2023 at 11:00 am with the Business Office Manager verified and confirmed that there was no written bed hold policy sent to R4 or her representative at the time of transfer to the hospital on 4/7/2023. She stated that there should be a copy of the letter regarding the bed-hold policy at the nurse's station and the nurse should provide one to the resident at the time of transfer. 2. Review of the EMR revealed R38 was admitted to the facility on [DATE] and was readmitted to the facility on [DATE] after an acute care hospital stay. Review of EMR revealed diagnoses included but not limited to gastrointestinal (GI) bleed, anxiety, and anemia. Review of R38's Annual MDS assessment dated [DATE] revealed a BIMS score of five (5) which indicated severe cognitive impairment. Review of R38's care plans dated 4/15/2020 revealed a focus for diagnosis of anemia and takes ferrous sulfate daily. Goals included but not limited to free of signs and symptoms of anemia. Interventions included but not limited to give medications as ordered, monitor/document/report as needed signs/symptoms of anemia and obtain and monitor lab/diagnostic work as ordered, report results to physician and follow up as needed. Review of nursing note dated 10/16/2023 revealed nurse documented R38 was experiencing a change in condition and listed abdominal pain, abnormal vital signs, and diarrhea/GI bleeding. The nurse documented that she notified the physician at 1:15 pm and noted there was no responsible party in R38's EMR profile. Review of the EMR revealed there was no evidence to support R38 and/or representative was informed in writing of the bed-hold and return policy prior to transfer. Interview conducted on 12/7/2023 at 9:43 am with Licensed Practical Nurse (LPN) GG revealed that nursing does not provide written documentation of the bed-hold policy to anyone when a resident is transferred out to the hospital. Interview conducted on 12/7/2023 at 10:03 am with the Admissions Director revealed that the business office notifies the resident and/or their representative of the bed-hold policy. She stated that she was not sure if the Business Office Manager notified the residents of the bed hold policy. Interview conducted on 12/7/2023 at 10:15 am with the Business Office Manager revealed that she did not notify R38 of the bed-hold policy because R38 was self-responsible, and she did not have a phone number to contact her. She stated nursing was responsible for sending the bed-hold policy with all residents who were transferred to the hospital. Interview on 12/7/2023 at 10:22 am with LPN GG revealed that the packet sent with the resident at the time of transfer to the hospital did not include a copy of the bed-hold policy Interview conducted on 12/7/2023 at 10:38 am with the Director of Nursing (DON) verified and confirmed that there was no evidence in the EMR that a copy of the bed-hold policy was sent with R38 at the time of discharge/transfer to the hospital on 10/16/2023. She stated typically it was the business office and social services responsibility to notify the resident and/or their representative of the bed-hold policy.

Based on observation, interviews, record review, and review of the facility's policy titled, Care Plans, Comprehensive Person-Centered, the facility failed to implement the comprehensive-person centered care-plan for one of 52 Residents (R) (R59), related to dental services. Findings include: Review of the facility's policy titled Care Plans, Comprehensive Person-Centered revision date September of 2023 under the Policy Statement revealed, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Under the section titled, Policy Interpretation and Implementation revealed 2. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. 4. Each resident's comprehensive person-centered care plan will be consistent with the residents' rights to participate in the development and implementation of his or her plan of care, including the right to: (g) receive the services and /or items included in the care plan. 8. The comprehensive, person-centered care plan shall: (b) Describe services that are to be furnished to attain or maintain the residents highest practicable physician, mental and psychosocial well-being; (g) Incorporate identifies problem area; (h) Incorporate risk factors associated with identified problems; (j) Reflect the residents expressed wishes regarding care and treatment goals; (m) Aid in preventing or reducing decline in the residents functional status and/or functional levels; and (o) Reflect currently recognized standards of practice for problem area and conditions. Observation and interview on 12/5/2023 at 1:56 pm with R59 revealed his teeth were in poor condition. R59 stated he did not have a toothache at that time. He revealed he saw a dentist, and believes he needs an oral surgeon; however, he does not remember what the dentist told him. During further interview, he stated no one had spoken to him regarding his dental visit, and stated he didn't have any tooth pain at this time. Review of the Electronic Medical Record (EMR) revealed R59 admitted to the facility with diagnoses including nutritional anemia, hemiparesis following cerebral infarction. Review of the most recent Quarterly Minimum Data Set (MDS) assessment for R59 dated 9/29/2023 revealed a Brief Interview for Mental Status (BIMS) of eight, indicating moderate cognitive impairment. Section L: Oral/Dental status revealed no mouth or facial pain, discomfort, or difficulty chewing. Review of R59's care plan dated 6/12/2023indicated a focus of care on oral/dental health problems, complaints of tooth pain at times, and risk for complications. Goals included but not limited to free of infection, pain, and/or bleeding in the oral cavity. Interventions included but not limited to administer medications as ordered, monitor effectiveness and side effects of medications, coordinate arrangements for dental care and transportation as needed/ordered, monitor/document/report as needed signs symptoms of oral/dental problems needing attention, provide mouth care as per the activities of daily living (ADL) personal hygiene. Review of R59's EMR revealed physician's orders for R59 include podiatry/dental/ophthalmic/psychiatry care as needed date of 6/9/2023, lyrica 75 milligrams (mg) two capsules every day revised on 11/21/2023, and hydrocodone/acetaminophen 5/325 mg one tablet every six hours as needed for pain revised on 10/5/2023. A post exit telephone interview with the Director of Nursing (DON) on 12/14/2023 at 3:06 pm confirmed the care plan interventions for R59 include coordinating arrangements for dental care and transportation as needed. The DON further revealed that the MDS develops comprehensive care plans. She expects that the discipline (nursing, therapy, activities, etc.) assigned to the intervention are expected to follow the care plan. Cross refer F745 and F790

Based on staff interviews, record reviews, and review of the facility's policy titled, Transfer or Discharge, Preparing a Resident for, the facility failed to complete a discharge summary that includes a recapitulation of the residents stay, reconciliation of medications, and a post discharge plan of care developed for one out of 52 Residents (R) (R87) reviewed for discharges. Findings include: Review of the policy titled Transfer or Discharge, Preparing a Resident for undated, revealed under section titled Policy Interpretation and Implementation 2. A post-discharge plan is developed for each resident prior to transfer or discharge. This plan will be reviewed with the resident, and/or his or her family at least twenty-four (24) hours before the resident's discharge or transfer from the facility. Review of the Electronic Medical Record (EMR) revealed R87 was admitted to the facility on [DATE] with diagnoses listed but not limited to traumatic subarachnoid hemorrhage without loss of consciousness. She was discharged on [DATE]. Review of R87's Discharge Minimum Data Set (MDS) assessment dated [DATE] revealed Section C: Cognitive Patterns- indicated memory was as ok, cognitive skills were modified independence with no acute onset mental change; a Brief Interview for Mental Status (BIMS) was not documented. Section GG: Functional Abilities and Goals-revealed functional status upon discharge was independent with eating and toileting; required set up/clean up assistance with upper/lower body dressing, putting on/off footwear, personal hygiene/oral hygiene, and supervision/touch assistance with shower. Section Q: Participation in assessment and goal setting- revealed an active discharge plan and referral to local contact agency. Review of R87's care plan dated 10/22/2023 revealed no focus, goal, or interventions were developed for discharge. Review of R87's discharge summary dated 10/23/2023 revealed documentation had been started but was incomplete and not signed by staff, resident and/or resident representative. Review of the discharge instructions dated 10/23/2023 revealed documentation had been started but was incomplete and not signed by staff, resident and/or resident representative. The document had a place for the resident/family to sign to attest they received a copy of instructions but was not located in the EMR. Review of the EMR revealed physician's orders dated 10/23/2023 for R87 included but was not limited to discharge with skilled nursing, physical therapy, and occupational therapy. Interview with the Director of Nursing on 12/9/2023 at 11:34 am stated the discharge summary in the EMR appeared complete except the nurse did not sign the document. She revealed the document could be printed without the nurse's signature, allowing staff to obtain the resident/family signature, and then scanned into the EMR. She stated the staff member who scans documents had not been uploading documents in a timely fashion. She stated she would look to see if she could locate the signed paper document and provide it for the survey team. She stated the discharge summary should be signed by the nurse and the discharging resident or their family, this document should be in the chart. The signed paper discharge summary or discharge instructions was not provided for the survey team before exit.

Based on observations, staff interviews, record reviews, and review of the facility's policy titled, Referrals, Social Services, the facility failed to ensure one out of 52 Residents (R) (R24) received proper treatment and assistive devices to maintain vision and hearing abilities. Specifically, the facility failed to arrange appointments for vision or hearing services to meet the residents' needs. Findings include: Review of the facility's policy titled, Referrals, Social Services undated Policy Statement revealed, Social services shall coordinate most resident referrals with outside agencies. Under the section titled Policy Interpretation and Implementation revealed 1. Social services shall coordinate most resident referrals. Exceptions might include emergency or specialized services that are arranged directly by a physician or the nursing staff. 2. Referrals for medical services must be based on physician evaluation to resident need and related physician order. 3. Social services will collaborate with nursing staff or other pertinent disciplines to arrange for services that have been ordered by the physician. 4. Social services will document the referral in the resident's medical record. 5. Social services and administration will maintain a listing of referral agencies that may provide assistance or therapy to residents with special problems and/or needs. 6. Social services will help arrange transportation to outside agencies, clinic appointments as appropriate. Observation and Interview on 12/05/2023 at 2:13 pm with R24 revealed he was very hard of hearing, and he was wearing glasses. He reported he requested an appointment with an eye doctor because he needed new glasses. R24 stated he also requested an appointment with an auditory specialist because he needed hearing aids. R24 revealed he was unable to recall the staff member he had spoken to about the appointments. Review of the Electronic Medical Record (EMR) revealed R24 was admitted to the facility with diagnoses listed but not limited to paroxysmal atrial fibrillation and acute on chronic combined systolic and diastolic heart failure. Review of R24's Admission Minimum Data Set (MDS) assessment dated [DATE] revealed Section C: Cognitive Patterns- a Brief Interview for Mental Status (BIMS) of 13 which indicated little to no cognitive impairment. Section B: Hearing, speech, Vision revealed moderate difficulty with hearing without hearing aid used and vision as adequate without corrective lenses. Section D: Mood revealed a total severity score of zero indicating no depression. Section F: Preferences for customary Routine and Activities revealed his activity preferences as somewhat important were for reading and listening to music. Review of R24's care plan dated 11/2/2023 indicated a Focus related to impaired hearing. Goals included but are not limited to being able to understand basic communications from staff and make needs known. Interventions included but not limited to face resident when speaking, speak clearly, slow and loud enough to make self-heard, repeat information as needed and use signs and gestures as needed. Review of R24's EMR revealed the nursing admission assessment was not located. Review of the R24's EMR revealed physician's orders included but was not limited to skilled nursing care (10/21/2023), podiatry/dental/ophthalmic/psychiatry care as needed. Interview on 12/6/2023 at 4:08 pm with the Social Service Director (SSD) stated he spoke to R24 during his circle of care meeting to discuss his discharge plans. He stated he remembered speaking with R24 regarding podiatry, eye care, etc. and explained the services the facility utilized to provide care services to the residents which were payor source specific. He stated he discussed the facility could expedite an application for the payor source if needed and he understood the business office was following up with the Family of R24 with the payor source application process. He revealed the last documentation related to his payor source application was documented on 11/17/2023 at 11:00 am. He revealed that it was his understanding, R24 was interested in setting up services later when his payor source was approved. He revealed he did not realize R24 was interested in an eye appointment. He stated R24 was hard of hearing and stated that social services could have initiated the conversation with the resident for services needed such as an auditory evaluation for hearing aids but did not do this because he did not think the need was immediate and it would be better to wait until his payor source was approved. He stated that he had followed up with R24 but the last follow up was related to the Notice of Medicare Non-Coverage (NOMNC). He stated R24's payor source was pending and awaiting approval. He revealed he did not document the circle of care meeting nor any follow up meetings with the resident. Interview on 12/6/2023 at 4:39 pm with the Business Office Manager revealed she had spoken to R24 during his circle of care and found that his living conditions were not appropriate for discharge. She stated R24 received a NOMNC on 11/17/2023 and a status change was submitted to his payor source on 11/27/2023. She revealed that R24 had insurance coverage the entire time he was in the facility, but it was not designated for the long-term care (LTC) facility. Interview on 12/6/2023 at 4:43 pm with the Social Service Director, stated R24 did not indicate to him that he had a payor source. He stated that he should have checked with the business office to verify his coverage. He stated the normal process would be to communicate with the business office related to resident's insurance and determine if an application for the payor source was needed. He stated he was not aware that R24 had active insurance at the time of his admission nor was he aware if the provider service would accept the community payor source or not. He stated he understood the provider services would only accept the Long-Term Care (LTC) payor source. He stated he was aware that R24 was hard of hearing and remembered discussing his need for hearing aids but did not remember discussing his need for glasses. He stated he did not realize R24 wanted an appointment right away otherwise he would have set up an appointment in the community. He stated he did not follow up with R24 regarding these needs nor did he update R24 on the status of his payor source or why he had not made the appointments for him. SSD stated he did not document any follow up meetings with R24. Interview on 12/7/2023 at 12:18 pm with the Director of Nursing (DON) revealed that if a short term or rehab patient request an appointment for care such as eyeglasses or hearing evaluation the information should be communicated with Unit Clerk QQ and she would set up an appointment in the community. She stated the circle of care meeting should have been documented by social services. DON verified this meeting was not documented in R24's EMR. She stated she expected staff to communicate the resident's request for care services to the appropriate person/department and follow up on their requests.

Based on observations, staff interviews, record reviews, and review of facility's policy titled, Oxygen Administration, the facility failed to ensure that two of 11 Residents (R) (R17 and R70) were administered oxygen therapy in accordance with the physician orders. In addition, the facility failed to ensure that all necessary administration equipment and supplies were in use for one of 11 residents (R70) reviewed with oxygen orders. Findings include: Review of the facility's policy titled, Oxygen Administration, undated, under subtitle Purpose revealed, The purpose of the policy is to provide guidelines for safe oxygen administration. Under subtitle Preparation revealed, Verify that there is a physician's order for this procedure. Review the physician orders or facility protocol for oxygen administration. Under subtitle, Steps in the Procedure revealed, Place an Oxygen in Use sign on the outside of the room entrance. Close the door. 3. Check the tubing connected to the oxygen cylinder to assure that it is free of kinks. 4. Turn on the oxygen. Unless otherwise ordered, start the flow of oxygen at the rate of 2 to 3 liters per minute. 5. Place appropriate oxygen device on the resident (i.e., mask, nasal cannula and/or nasal catheter). 6. Adjust the oxygen delivery device so that it is comfortable for the resident and the proper flow of oxygen is being administered. 1. Review of the R17's Electronic Medical Record (EMR), revealed that he was admitted to the facility with diagnoses that included but are not limited to acute and chronic respiratory failure, and chronic obstructive pulmonary disease (COPD). Review of R17's physician orders revealed an order for oxygen to be administered at two (2) liters per minute via nasal canula (NC) to maintain oxygen saturation greater than 93 percent. Review of R17's Annual Minimum Data Set (MDS) dated [DATE], revealed Section C: Cognitive Patterns- a Brief Interview of Mental Status (BIMS) score of five (5), which indicated the resident had severe cognitive impairment; Section O: Special Treatments, Procedures, and Programs- indicated the resident received oxygen prior to being admitted to the facility and during his stay in the facility. Observation on 12/5/2023 at 2:18 pm revealed R17 sitting in his wheelchair and watching television. R17 was observed with oxygen administered at three (3) liters per minute via nasal cannula (NC). Observation on 12/6/2023 at 8:35 am revealed R17 sitting in his wheelchair with his breakfast tray in front of him. R17 was observed with oxygen administered at 3 liters via NC. Observation on 12/8/2023 at 2:15pm revealed R17 lying on his left side in the bed. R17 was observed not wearing his nasal cannula, that was infusing oxygen with concentrator set at two (2) liters per minute. Interview on 12/8/2023 at 2:25pm with Licensed Practical Nurse/Unit Manager (LPN/UM) GG, confirmed that R 17 had his nasal cannula off and the tubing was laying across the concentrator. She stated that R17 was ordered oxygen continuously and should be administered at 2 liters per minute. She revealed that the resident would sometime remove his oxygen, but he would never change the flow amount. Interview on 12/8/2023 at 3:00 pm with the Director of Nurses (DON) revealed that nurses are expected to check the oxygen flow being administered to residents every shift and it should be documented in the electronic medication administration record (eMAR). 2. Review of R70's EMR revealed he was admitted to the facility with diagnoses to include but not limited to chronic obstructive pulmonary disease (COPD), chronic respiratory failure, and personal history of pulmonary embolism. Review of R70's physician's orders revealed an order for oxygen to be administered via NC at two to four (2-4) liters per minute. Review of R70's care plan revealed the resident had COPD and chronic respiratory failure with risk for complications. The resident was unable to sleep lying flat, had multiple hospital stays and had frequent shortness of breath. Interventions for this risk included but not limited to administering oxygen at two (2) liters via NC as ordered. Review of the R70's Significant Change MDS assessment dated [DATE] revealed Section C: Cognitive Patterns- a BIMS score of 10, which indicated the resident had moderated cognitive impairment; Section O: Special Treatments, Procedures, and Programs- indicated the resident received oxygen prior to being admitted to the facility and during his stay in the facility. Observation on 12/5/2023 at 4:28 pm revealed R70 lying in his bed with eyes closed and not receiving oxygen administration. The oxygen concentrator was turned off without the oxygen tubing connected to it and laying across the handles of the resident's wheelchair. There was no oxygen in use signage on the door frame. Observation on 12/8/2023 at 2:20 pm revealed R70 sitting on the side of the bed with oxygen administered at 1.5 liters via NC. There was no oxygen in use signage on the door frame. Interview on 12/8/2023 at 2:30 pm with LPN/UM GG, confirmed the oxygen concentrator was turned off without oxygen tubing connected to it and laying across the handles of the resident's wheelchair. She stated that R70 was to receive oxygen continuously and that it should be administered at 2 liters per minute. She revealed that the resident would sometime remove his oxygen, and there should be signage on the door to alert staff that oxygen was in use. Interview on 12/8/2023 at 3:00 pm with the Director of Nurses (DON) revealed that nurses were expected to check the oxygen flow being administered to residents every shift and that it should be documented on the electronic medication administration record (eMAR).

Based on record review, interviews, and policy review, the facility failed to accurately assess the Advance Directive status and provide Cardiopulmonary Resuscitation (CPR) to prevent death when a resident was found without a pulse or respirations for 4 of 4 residents (R) (R#243, R#141, R#191, and R#291) reviewed with a full code status who expired in the last six months. R#243, R#141, and R#291 had a full code status, as directed by the residents' POLST (Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . All residents were unresponsive, CPR was not initiated, and the residents expired. On [DATE], a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment, or death to residents. The facility's Administrator and Director of Nursing were notified of the immediate jeopardy (IJ) on [DATE] at 1:16 p.m. The noncompliance related to the immediate jeopardy was identified to have existed on [DATE]. The immediate Jeopardy continued through [DATE] and was removed on [DATE]. The facility implemented a Credible Allegation of Compliance related to the Immediate Jeopardy on [DATE]. The IJ is outlined as follows: The IJ began on [DATE] when the facility failed to honor residents' advance directives to be a full code by failing to perform cardiopulmonary resuscitation (CPR) when the resident experienced cardiopulmonary arrest for four residents (R) (R#243, R#141, R#191, and R#291) of four residents who expired in the last six months. The facility identified 68 residents with a full code status. 1. Review of the R#243's medical record indicated the resident was a full code. The resident was receiving hospice services. On [DATE] at 11:05 p.m., the resident expired. There was no indication that CPR had been initiated. 2. Review of R#141's medical record indicated the resident was a full code. A Progress Notes dated [DATE] at 4:30 a.m. revealed during morning rounds, the resident was found to be without vital signs. Hospice Notes dated [DATE], revealed that the resident had passed in her sleep. The patient had no heartbeat or respirations. The resident was pronounced deceased at 5:23 a.m. There was no indication that CPR was provided. Staff revealed the resident should have received CPR. 3. Review of R#191's medical record indicated the resident did not have orders for code status. The resident was receiving hospice. A hospice Interdisciplinary Group (IDG) Comprehensive Assessment and Plan of care Update Report revealed the resident's code status as do not resuscitate, comfort measures only. A facility progress note dated [DATE] revealed the resident expired at approximately 5:45 a.m., no breathing noted. Skin warm and pink. No heartbeat noted upon auscultation. Hospice nurse pronounced time of death at 7:03 a.m. There was no indication that CPR was performed for this resident with no orders for code status. 4. Review of R#291's medical record indicated the resident was a full code. The resident was receiving hospice services. Coordination notes, dated [DATE] at 6:59 p.m., indicated the resident expired. A facility nursing progress note, dated [DATE] at 7:25 p.m., indicated staff was unable to obtain vitals on R#291. Additionally, R#291's chest did not rise or fall. There was no indication that CPR had been initiated. The time of death was pronounced at 7:46 p.m. on [DATE]. Immediate Jeopardy was identified on [DATE] and determined to have existed on [DATE] in the area of: F678: 483.24(a)(3) - Personnel provide basic life support, including cardiopulmonary resuscitation. (Scope/Severity [S/S]: K). Additionally, Substandard Quality of Care was identified with the requirements at 42 CFR 483.24(a)(3) - Personnel provide basic life support, including cardiopulmonary resuscitation. (Scope/Severity [S/S]: K). A Removal Plan (Credible Allegation of Compliance) was received on [DATE], related to 42 CFR 483.24(a)(3) - Personnel provide basic life support, including cardiopulmonary resuscitation. Based on observations, record review, interviews and review of facility policies as outlined in the Removal Plan, it was validated that the corrective action plans and the immediacy of the deficient practice as removed on [DATE]. The facility continues management level staff oversight as well as continues to develop and implement a Plan of Correction (POC). This oversight process includes the analysis of facility staff's conformance with the facility's policies and procedures governing the accurate acquiring of the necessary resident information, including cardiopulmonary resuscitation. In-service materials and records were reviewed. Observation and interviews were conducted with staff to ensure they demonstrated knowledge of the facility Policies and procedures governing when to provide cardiopulmonary resuscitation and what is required for fully implemented Advance Directives. Resident records were reviewed to ensure that resident care and treatment was current and accurate. Findings include: Review of the policy titled Cardiopulmonary Resuscitation (CPR) Policy, dated ,d+[DATE], revealed the policy of this center is to adhere to residents' rights to formulate advanced directives. In accordance to these rights, this center will implement guidelines regarding cardiopulmonary resuscitation (CPR). Policy Explanation and Implementation Guidelines: 1. If a resident experiences a cardiac arrest, center staff will provide basic life support, including CPR, prior to the arrival of emergency medical services, and: a. In accordance with the resident's advance directives, or b. In the absence of advance directives or a Do Not Resuscitate order, and c. If the resident does not show obvious signs of clinical death (e.g. rigor mortis, dependent lividity, decapitation, transection, or decomposition). 1. Review of the clinical record for R#243 revealed he was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was receiving Hospice care. The Admission Record included a code status sheet, printed on green paper with bold text indicating resident was a full code. The Advanced Directives Summary revealed the resident was a full code and the full code status was implemented on [DATE]. The Advanced Directive 2022 list, located in the facility's code status notebook, revealed R#243 was a full code. The Order Summary Report revealed an order dated [DATE], for full code status. Review of the POLST form for R#243, signed by resident and dated [DATE], revealed he had checked Attempt Resuscitation (CPR) in box A, which was for code status. In box B, which was for medical interventions, R#243 checked Full Treatment - In addition to treatment and care described above, use intubation, mechanical ventilation, and cardioversion as indicated. Transfer to hospital and/or intensive care unit if indicated. Review of the care plan, revised [DATE], revealed R#243's code status as Full Code. The care plan also indicated the resident was receiving hospice services for [CONDITION(S)]. The goal included, If my heart stops, or if I stop breathing, CPR will be initiated in honor of my wishes. Interventions included to flag the resident's chart and Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Hospice SN [Skilled Nurse] Routine Visit Summary, dated [DATE], revealed #243 was admitted to hospice with the primary diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The note also indicated the resident was an attempt to do CPR. Review of the Skilled Note, dated [DATE] at 11:05 p.m. written by Licensed Practical Nurse (LPN) JJ, revealed the resident was resting in bed. The nurse was unable to obtain vital signs for a full minute. The hospice nurse was notified. The resident was noted to be expired at that time, and a family member was noted by the bedside. The funeral home was notified by hospice for transport. Interview on [DATE] at 8:50 a.m. with the Director of Nursing (DON) revealed R#243 was a full code. She stated she could not remember what happened that day but did not believe the resident received CPR. Interview on [DATE] at 9:00 a.m. with Business Office Specialist (BOS) AA from the hospice agency revealed the note in the resident's chart indicated the resident was pronounced deceased by Registered Nurse (RN) BB, and the resident was a full code. Interview on [DATE] at 10:10 a.m. with Nurse Practitioner (NP) EE, stated R#243 had been on hospice services and she was surprised the resident was not made a DNR, stating it was the residents' choice to be a full code. She further stated whoever found the resident, and depending on the facility policy, CPR would have been initiated if the resident was a full code. Interview on [DATE] at 10:17 a.m. with LPN FF, stated if a resident was a full code, the facility would start CPR and another nurse would call hospice. Interview on [DATE] at 11:30 a.m. with the Director of Nursing (DON) revealed the facility kept hard charts to identify code status. She stated if the chart had a red dot on the outside, it meant the resident was a DNR. If there was no red dot, then the resident was a full code. During further interview, she acknowledged that if a resident was not a DNR, the nursing staff were expected to begin CPR. Telephone interview on [DATE] at 5:07 p.m. with LPN JJ, revealed R#243's family was visiting during the evening shift on [DATE] and was at his bedside as the resident transitioned. The family member notified the nurse and said, I think he is gone. LPN JJ confirmed when she went into the resident's room and assessed him, that he had no responses, so she notified hospice. During further interview, she stated if she found a resident unresponsive, she would check the electronic chart for orders, or the front of the hard charts for a green sheet of paper, which specified the resident's code status. She stated she did not recall if R#243 was a full code or DNR but stated he was on hospice. Interview on [DATE] at 9:43 a.m. with Hospice Registered Nurse (RN) BB, revealed the facility should have known the resident's code status. She stated if the resident was a full code, then CPR should have been initiated when the resident was found unresponsive. 2. Review of the clinical record for R#141 revealed she was readmitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident received hospice care. review of the resident's medical record revealed [MEDICAL RECORD OR PHYSICIAN ORDER] . The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the care plan, revised [DATE], revealed R#141 was a Full Code and was receiving hospice services. The goal included, If my heart stops, or if I stop breathing, CPR will be administration record (MAR) so that staff know I am a Full Code, inform all caregivers of resident's full code status, initiate CPR if resident was found without vital signs, and notify the MD (physician) and family as soon as possible of the resident's status and transfer to the hospital, send a copy of the full code status to the hospital if transferred. Review of the hospice Skilled Nurse (SN) Admission Visit Summary, dated [DATE], revealed the resident/responsible party was asked about preference regarding the use of cardiopulmonary resuscitation (CPR) during the visit and the answer indicated the resident was a full code. The resident/responsible party was also asked about preferences regarding life-sustaining treatments other than CPR and the answer indicated the resident was a full code. Review of the Progress Notes dated [DATE] at 4:30 a.m. written by LPN VV, indicated during morning rounds the resident was found to be without vital signs and hospice was notified. A note at 5:20 a.m., revealed the hospice nurse came to pronounce the resident and call the family to inform of the passing. Interview on [DATE] at 2:39 p.m. with LPN VV, revealed she found the resident without vital signs and, because the resident was on Hospice, she thought the resident was a DNR. She stated she looked at the admission sheet and thought the resident was a DNR. She further revealed when hospice came to pronounce R#141, they did not provide CPR. Interview on [DATE] at 4:49 p.m. with the DON, revealed when a resident was admitted , admissions reviewed the code status. She stated staff treated everyone as a full code unless they brought paperwork into the facility that stated otherwise. The DON indicated nursing had not reviewed the charts of expired residents to ensure the code status was correct. Interview on [DATE] at 9:53 a.m. with Hospice RN BB, stated that it was the facility's responsibility to know the resident's code status, and if they were a full code, the facility should provide CPR. 3. Review of the clinical record for R#291 revealed she was admitted to the facility on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was receiving Hospice care. The Advanced Directives Summary revealed the resident was a full code and the full code status was implemented on [DATE]. The Advanced Directive 2022 list, located in the facility's code status notebook, revealed R#291 was a full code. The Order Summary Report revealed an order dated [DATE], for full code status. Review of the care plan, initiated [DATE], revealed R#291 was a Full Code. The goal included, If my heart stops, or if I stop breathing, CPR will be initiated in honor of my wishes. Interventions included to flag the resident's chart and Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the POLST form for R#291, signed by R#291's responsible party and dated [DATE], revealed the responsible party checked box Attempt Resuscitation (CPR) in box A, which was for code status. In box B, which was for medical interventions, R#291's responsible party checked Full Treatment - In addition to treatment and care described above, use intubation, mechanical ventilation, and cardioversion as indicated. Transfer to hospital and/or intensive care unit if indicated. Review of the hospice Patient Information Report, revealed R#291 was admitted to hospice on [DATE] with the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of a coordination note dated [DATE] at 4:25 p.m., revealed the social worker met with the resident's representative to redo the POLST. The resident's representative confirmed they wanted staff to attempt CPR when the time came. An updated POLST form was turned into the office. Review of the Progress Notes, dated [DATE] at 7:25 p.m. written by LPN WW, revealed staff was unable to obtain vitals on R#291. Additionally, R#291's chest did not rise or fall, and the hospice nurse was notified to evaluate the resident. There was no evidence to indicate that CPR had been initiated. A telephone interview was attempted with LPN WW on [DATE] at 3:04 p.m., [DATE] at 9:54 a.m., and [DATE] at 10:47 a.m., but LPN WW did not return the calls. Interview on [DATE] at 8:47 a.m. with Social Worker XX, stated R#291 was a full code. She indicated she did not hear anything about CPR being done. 4. Review of the clinical record for R#191 revealed he was admitted to the [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no evidence regarding resident's Advance Directive or code status located in the medical record. The resident was receiving Hospice care. Review of a document titled Advanced Directive 2022 list, located in the facility's code status notebook, indicated R#191 had a designated durable power of attorney for healthcare (DPOAHC) and that the resident was a full code (indicating cardiopulmonary resuscitation/CPR would be provided if the resident was found without a pulse and/or respirations). Interview on [DATE] at 4:49 p.m. with the DON, revealed when a resident was admitted , admissions reviewed the code status. She stated staff treated everyone as a full code unless they brought paperwork into the facility that stated otherwise. The DON indicated nursing had not reviewed the charts of expired residents to ensure the code status was correct. Interview on [DATE] at 5:19 p.m. with the Administrator, revealed her expectation was if a resident on hospice had a full code status, the staff would administer CPR if the resident was unresponsive. Interview on [DATE] at 8:31 a.m. with the Medical Director (MD) stated he would expect to know a resident's code status on admission and that code status should be located on a POLST form and on the resident's face sheet just below the resident's picture. He stated if the resident had dementia, staff should discuss code status with the responsible party (RP). He further stated if a resident had a full code status and the staff found the resident unresponsive, the staff should initiate CPR. The MD stated hospice had a responsibility to revisit code status if the resident was a full code. He stated if R#191 was on hospice and was a full code, the staff should have begun CPR when the resident was found unresponsive. The facility implemented the following actions to remove the Immediate Jeopardy: 1. On [DATE], the Corporate Nurse Consultant provided education to Administrator, Director of Nursing, and Social Worker on the facility policy on Advanced Directives, Cardiopulmonary Resuscitation, and Do Not Resuscitate. 2. On [DATE], the Corporate Nurse Consultant and Director of Clinical Services reviewed the facility policy on Advanced Directives, Cardiopulmonary Resuscitation, and Do Not Resuscitate. No revisions were made. 3. On [DATE] at 4:30 p.m., the Licensed Nursing Home Administrator facilitated the Quality Assurance and Performance Improvement (QAPI) meeting with the QAPI Committee (Licensed Nursing Home Administrator, Director of Nursing, Dietary Manager, Social Service Director, Maintenance Director, Medical Records, Rehab Director, Business Office Manager, Unit Managers, Staff Development Coordinator, Infection Preventionist, Human Resource Director, Wound Care Nurse, Staffing Coordinator, Regional Dietary, Housekeeping and Nurse Consultants) to evaluate and review areas for improvement related to Advanced Directives and following resident Code Status. 4. On [DATE] at 12:20 p.m., the Licensed Nursing Home Administrator facilitated another Quality Assurance and Performance Improvement (QAPI meeting with the QAPI Committee, (Licensed Nursing Home Administrator, Director of Nursing, Dietary Manager, Social Service Director, Maintenance Director, Medical Records, Rehab Director, Business Office Manager, Unit Managers, Staff Development Coordinator, Infection Preventionist, Human Resource Director, Wound Care Nurse, Staffing Coordinator, Regional Dietary, Housekeeping and Nurse Consultants). The facility Medical Director was in attendance via telephone conference to discuss the noncompliance of tag F678. The QAPI Committee developed an action plan which include assigning a task force which includes Administrator, DON, Nurse Leadership team, and Social Services Director to conduct a 100 percent chart audit. Each member tracked for a signed DNR order, completed advanced directive summary, care plan documentation of code status and presence of code status in special instructions section of the chart. Ten charts were found to be without advanced directive summaries; two charts without supporting DNR orders were updated by uploading the signed documents into the miscellaneous section of the resident's chart. One chart had a Durable Power of Attorney for Healthcare that indicated the preference to be a DNR, but code status indicated Full Code. Do Not Resuscitate order faxed to resident's physician for signatures. Code status will be updated upon receipt of all applicable signatures. All other residents/patients had their code status added to the special instructions section of the chart. At the completion of the audit, 100% of the charts had all items necessary. 5. On [DATE], the Unit Manager, Infection Preventionist, Medical Records Clerk, Social Worker, and Director of Nursing, completed the facility wide review of code status of all residents and appropriate DNR forms are included in resident medical record. Identified issues in the audit included ten charts were found to be without advanced directive summaries. Two charts for residents without supporting DNR orders were updated with signed documents. All identified areas were addressed immediately. 6. On [DATE], the facility initiated comprehensive licensed nursing staff education on Advanced Directives and proper review of code status, to include that CPR must be initiated when a resident is a full code and there is no signed DNR in place at that time. The education was provided by the Staff Development Coordinator (SDC) and Regional Nurse Consultant. As of [DATE], the facility has a total of 71 facility employees, which 65 of the 71 employees have received facility education for a total of 92% educated. 7 out of 7 (2 Physical Therapist, 2 Physical Therapist Assistants, 1 Speech Therapist, 1 Occupational Therapist, 1 certified Occupational Therapist Assistant therapy staff, 3 out of 5 dietary staff, 4 out of 6 laundry/housekeeping staff, 22 out of 22 other staff. 13 out of 13 of the facility licensed nursing staff (4 RNs, 9 LPNs) have received the education. 16 (1 TNA, 15 CNAs) out of 18 nursing assistants (2 TNAs, 16 CNAs) have received the facility education. 2 (1 TNA, 1 CNA) out of 18 facility nursing assistants are not available to receive the education due to being off duty. There are 3 nursing staff, and 1 ancillary staff are currently on Family Medical Leave Act. The staff members who were unavailable will receive the education upon their return to work and prior to starting his/her duties. Newly hired CNAs and Nurses will be educated during the facility orientation and documentation will be maintained in the employee's education file. 7. On [DATE], two out of the three contract nurses assigned to Res #243, Res #141, Res #191, and Res #291 received education from the Director of Nursing on proper procedure for initiating CPR when a resident is a full code and when there is no signed DNR forms in place in the medical record. The third contract nurse stated to the Director of Nursing that she will not be returning to the facility. 8. On [DATE], the facility developed a monitoring system by which the Licensed Nursing Home Administrator, Social Worker, and/or the Director of Nursing would review advanced directives of new admissions once facility is back in compliance to ensure accuracy and proper DNR forms are signed and included in the resident medical records. The review will be discussed during the Morning Meeting Monday - Friday. The Licensed Nursing Home Administrator and/or Director of Nursing will send the list of new admissions, indicating their code status to Corporate Nurse Consultant on a weekly basis for 4 weeks for additional review and monitoring. 9. On [DATE], the facility revised the process in which the Director of Nursing and/or Nurse Managers will review incidents of death to ensure code status and/or resident advanced directives were followed during the Clinical Meetings. The Corporate Nurse Consultant provided re-education to the Director of Nursing on the process. 10. On [DATE], the facility implemented a procedure by which the results of the monitoring referenced above, and comprehensive staff education would be presented to the Quality Assurance and Performance Improvement (QAPI) Committee each month by the Licensed Nursing Home Administrator and/or Director of Nursing, to allow the QAPI Committee to monitor compliance with facility procedures in ensuring the rights of the residents related to advanced directives are respected and followed. 11. On [DATE], the Licensed Nursing Home Administrator and Cypress Regional Director of Scheduling sent communication to all contracted staffing agencies with instruction to direct their licensed nurses and certified nursing assistants to receive the facility education on Advanced Directives and Code Status from the facility designated educator prior to reporting to their work area. 12. As of [DATE], Total contract staff is 60. (1) RN, (8) LPN, (24) CNAs of contract staff have received the facility education. Facility utilizes 48 contracted CNAs and 12 contracted nurses. Contract staff will receive in-service before returning to duty. 13. All corrections were completed on [DATE]. 14. The facility alleges that we have achieved compliance as of [DATE]. Survey Agency validated removal of the Immediate Jeopardy as follows: The IJ was removed on [DATE] at 6:10 p.m., after the survey team performed an onsite verification to verify that the Removal Plan had been implemented. A chart audit, which included 100% of residents, was performed to ensure each resident's code status matched the resident's advanced directive, and the code status was clearly visible on the resident's face sheet. All charts included the necessary information. Nineteen interviews were conducted with staff to ensure staff had received training related to advanced directives and review of code status, including that CPR must be initiated when a resident was a full code and there was no signed DNR. The staff that were interviewed included the Administrator, Corporate Nurse Consultant, DON, Staff Development Coordinator, Registered Nurses, Licensed Practical Nurses, Certified Nursing Assistants, Physical Therapist, Social Services Director, Business Office Manager, Receptionist, Housekeeping, Dietary Manager, Activities Director, Admissions Coordinator, Human Resources Coordinator, Wound Nurse, and Infection Preventionist. The staff interviewed revealed knowledge on advanced directives and code status. In-service training records were reviewed, and the records verified that 65 facility staff and 33 contract staff received in-service training. Staff training was ongoing and those staff that were unavailable would receive education upon their return to work and prior to starting his/her duties, including contract agency staff. A monitoring system had been implemented and would be presented to the Quality Assurance and Performance Improvement Committee each month.

Based on clinical record review, staff interview, hospital History and Physical form review, hospital laboratory test report review, and hospital Discharge Summary review, the facility failed to provide care in a manner that prohibited neglect by failing to obtain a laboratory test as ordered by the physician to determine the blood level of [MEDICATION NAME] after an increase in the [MEDICATION NAME] dosage for one (1) resident (#1), of two (2) sampled residents receiving [MEDICATION NAME] drug therapy, on the total survey sample of nine (9) residents. After an increase in the daily [MEDICATION NAME] dosage for Resident #1 in accordance with a physician's orders [REDACTED]. Resident #1 was then hospitalized after a fall in the facility and admitted to the hospital Intensive Care Unit (ICU), with a hospital laboratory test documenting the resident to have toxic free [MEDICATION NAME] and total [MEDICATION NAME] levels of 3.43 micrograms per milliliter (mcg/ml) and 34.5 mcg/ml, respectively. This resulted in a situation in which the facility's noncompliance with the requirements of participation caused, or had the likelihood to cause, serious harm, injury, impairment, or death to residents. The facility's Administrator and Director of Nursing (DON) were informed of the immediate jeopardy on May 6, 2014 at approximately 12:00 p.m. The non-compliance related to the immediate jeopardy was identified to have existed on March 26, 2014 (the date the facility failed to obtain the [MEDICATION NAME] blood level for Resident #1 via the ordered laboratory test), continued through May 8, 2014, and was removed on May 9, 2014. On May 8, 2014, the facility implemented a credible allegation of jeopardy removal. During a May 7, 2014, 1:50 p.m. interview, the Administrator acknowledged that Resident #1's [MEDICATION NAME] level was not done as ordered, and during interview on May 7, 2014 at 5:00 p.m., the Administrator acknowledged that Resident #1 had experienced [MEDICATION NAME] toxicity. An allegation of jeopardy removal was received on May 8, 2014. Based on the corrective plans which had been developed and implemented by the facility, the immediacy of the deficient practice was determined to have been removed on May 9, 2014, and the facility remained out of compliance at a lower scope and severity of "D" while the process of evaluating modifications of the facility's laboratory services procedures, and of obtaining laboratory services as ordered, continued. In-service materials and records were reviewed. Interviews were conducted with staff to ensure they were knowledgeable about the facility's laboratory services procedures and obtaining resident laboratory tests as ordered by the physician. Resident records were reviewed to ensure that resident laboratory tests were obtained as ordered, including those laboratory tests ordered to monitor blood levels of drug therapy to ensure accurate drug dosage titration. Findings include: Resident #1's Quarterly Minimum Data Set assessment of 02/18/2014 documented in Section I - Active [DIAGNOSES REDACTED]. Resident #1's March 2014 physician's orders [REDACTED]. A Physician's Telephone Orders (PTO) form of 03/19/2014 then ordered to increase Resident #1's [MEDICATION NAME] dose to 200 mgs twice daily, and to check Resident #1's [MEDICATION NAME] level in one (1) week (03/26/2014) However, even though the 03/19/2014 PTO referenced above ordered that a [MEDICATION NAME] level be obtained for Resident #1 on 03/26/2014, further record review revealed no evidence to indicate that the laboratory test to obtain the [MEDICATION NAME] level had been done. A 04/08/2014, 7:03 p.m. Progress Notes Health Status Note then documented that on 04/07/2014, Resident #1 had fallen, and a 04/08/2014, 7:15 p.m. Progress Notes Health Status Note documented Resident #1's hospital ICU admission for [MEDICATION NAME] toxicity. A hospital History and Physical (H&P) form for Resident #1 documented that on 04/07/2014, the resident had been transferred to the emergency room . A 04/07/2014 hospital laboratory test report for Resident #1 documented the resident's Free [MEDICATION NAME] ([MEDICATION NAME]) level to be 3.43 mcg/ml, and the total [MEDICATION NAME] level to be 34.5 mcg/ml, with the listed Reference/Therapeutic ranges of [MEDICATION NAME] being 1.00-2.00 mcg/ml for free [MEDICATION NAME], and 10-20 mcg/ml for total [MEDICATION NAME]. The hospital H&P referenced above listed [MEDICATION NAME] toxicity as a referenced diagnosis, and indicated that Resident #1 would be admitted to ICU. Resident #1's hospital Discharge Summary documented that on 04/11/2014, Resident #1 was being discharged back to the nursing facility, and that the resident had [DIAGNOSES REDACTED]. During a 05/07/2014, 1:50 p.m. interview, the Administrator stated that nursing staff had failed to transcribe the physician's orders [REDACTED]. During a later interview with the DON on 05/07/2014 at 2:30 p.m., the DON also acknowledged that Resident #1 had been diagnosed with [REDACTED]. Based on the above, despite Resident #1 receiving [MEDICATION NAME] and the dosage having been increased from 300 mgs daily to 400 milligrams daily, and despite a physician's orders [REDACTED].#1 by failing to obtain the ordered laboratory test to monitor the blood level of the resident's [MEDICATION NAME]. Resident #1 later fell , was transferred to the hospital, and was found to have toxic free [MEDICATION NAME] and total [MEDICATION NAME] levels. She was admitted to the ICU with [DIAGNOSES REDACTED]. Cross refer to F329 for more information regarding Resident #1. The immediate jeopardy was removed on 05/09/2014, at which time the facility had implemented the following credible allegation of jeopardy removal to remove the immediacy of the deficient practice: 1. On May 6, 2014, the facility reviewed the existing laboratory policies and procedures and wrote a new Physician Accepting, Transcribing, and Implementing Orders Policy, and a new Receiving, Transcribing, and Implementing Laboratory Orders Policy. 2. On May 7, 2014, the facility conducted a complete audit of all resident records to ensure that all laboratory orders and all transcribed physicians' orders had been initiated as ordered. The results of this resident chart audit were documented on the audit tool form developed by the facility. 3. On May 7, 2014, the facility initiated a system process by which all new transcribed physicians' orders and laboratory orders would be reviewed daily, Monday through Friday, in the management morning report meeting which included the Administrator, the DON, the Assistant Director of Nursing (ADON), and all Unit Managers. This review also monitored inclusion of newly transcribed physicians' orders, including orders for laboratory testing intended to monitor resident drug therapy, on resident medication administration records, treatment administration records, and/or the laboratory book. On weekend days, the Weekend Supervisor would review all transcribed physicians' orders, including orders for laboratory testing related to resident drug therapy, to ensure both transcription and completion, with the Administrator, DON, or ADON to monitor each weekend day to ensure compliance. The review would be documented on the audit monitoring and completed tools form to ensure compliance with order transcription, and to ensure laboratory tests were completed as ordered. This process is to be a permanent procedure to allow the facility's management staff to monitor on a daily basis, and to ensure the accurate transcription and implementation of physicians' orders for resident care, including physicians' orders for laboratory testing related to resident drug therapy. 4. On May 8, 2014, the facility initiated a new procedure by which the DON, ADON, or Unit Manager would check selected resident clinical records weekly to ensure that all physicians' orders, to include physicians' orders for laboratory testing related to resident drug therapy, had been transcribed accurately. This process is to be a permanent procedure to allow management staff to conduct weekly audits to monitor for the accurate transcription and implementation of physicians' orders. 5. On May 8, 2014, the facility conducted staff in-service training for licensed nursing staff regarding the new Receiving, Transcribing, and Implementing Laboratory Orders Policy and Procedure. As of May 8, 2014, twenty-six (26), or seventy-six (76) percent, of the facility's thirty-four (34) licensed nursing staff had received this in-service training. The remaining eight (8) licensed nursing staff, who were unavailable for training at that time due to being off-duty or on leave, were to receive this in-service training upon their return to work; these licensed staff would not be allowed to provide direct resident care until completion of this in-service training. 6. On May 8, 2014, the facility implemented a procedure by which the results of the monitoring referenced above, to be documented on the audit monitoring and completed tools form, would be presented to the Quality Assurance (QA) Committee each month by the Administrator and/or the DON, to allow the QA Committee to monitor staff compliance with the facility's policies and procedures regarding the receipt, transcribing, and implementation of physicians' orders, including orders for laboratory testing, to ensure that these policies, procedures, and systems were in compliance. During this complaint survey, on the following referenced dates, each newly developed policy, procedure, and system included the facility's credible allegation of jeopardy removal was reviewed by survey staff to ensure completion and/or implementation, with the findings as follow: - On May 8, 2014, the new Physician Accepting, Transcribing, and Implementing Orders Policy and Receiving, Transcribing, and Implementing Laboratory Orders Policy were reviewed, and it was found that the facility had reviewed and modified its policies and procedures regarding physicians' orders and laboratory testing. - On May 8, 2014, the facility's resident record physicians' order/laboratory audit of May 7, 2014 was reviewed and found to have checked for resident laboratory orders and transcribed physicians' orders. - On May 8, 2014, a review was conducted of the facility's new system process, initiated on May 7, 2014 by the facility, involving the daily review of all newly transcribed physicians' orders and laboratory orders in the management morning report meeting. This review revealed monitoring of transcribed physicians' orders and their inclusion on resident medication administration records, treatment administration records, and/or the laboratory book, per the credible allegation of jeopardy removal. - On May 8, 2014, it was confirmed via procedural review that the facility had initiated a new procedure on May 8, 2014 by which DON/ADON/Unit Manager would audit selected resident records weekly to ensure accurate transcription and completion of physicians' orders. - On May 8, 2014, the licensed nursing staff in-service training for the facility's licensed nursing staff regarding the new Receiving, Transcribing, and Implementing Laboratory Orders Policy and Procedure was reviewed for completion, as indicated on the facility's credible allegation of jeopardy removal. - On May 8, 2014, it was confirmed via procedural review that the findings of clinical record audits documented on the audit monitoring and completed tools form would be reviewed at each monthly QA Committee meeting, and that the QA Committee would monitor staff compliance with the policies, procedures, and protocols for the receipt and implementation of physicians' orders. Based on the corrective actions which had been developed and implemented by the facility as outlined above, the immediacy of the deficient practice, related to the failure to obtain laboratory testing to ensure monitoring of the [MEDICATION NAME] blood level as ordered by the physician, was removed on May 9, 2014. However, the effectiveness of the corrective action plans could not be fully assessed to ensure ongoing application and completion. The facility had reviewed the existing laboratory policies and procedures and had written a new Physician Accepting, Transcribing, and Implementing Orders Policy, and a new Receiving, Transcribing, and Implementing Laboratory Orders Policy, and had initiated staff in-service training for the licensed nursing staff regarding these new Policies and Procedures. However, as of the May 9, 2014 exit date of this complaint survey, although twenty-six (26) licensed nursing staff had received this training, the remaining eight (8) licensed nursing staff had been unavailable and thus were to receive this in-service training upon their return to work. Also, on May 8, 2014, the facility initiated a new procedure by which the DON/ADON/Unit Manager would conduct selected weekly resident clinical record audits to ensure accurate transcription and implementation of physicians' orders, and the results of these audits were to be presented to the QA Committee monthly to allow the Committee to monitor facility staffs' conformance with the facility's policies, procedures, and protocols regarding the transcription and implementation of physicians' orders. However, this new audit procedure had only been implemented on May 8, 2014, with the first weekly audit scheduled to occur after the May 9, 2014 exit date of this complaint survey; therefore, the facility's ongoing compliance with this weekly monitoring procedure could not be fully assessed at the time of survey exit. Additionally, the QA Committee, which was to review the weekly clinical record audit results, had not convened at the time of survey exit, and was not scheduled to meet until the following week; thus, the Committee's ongoing process of procedural oversight regarding facility staffs' conformance with the transcription and implementation of physicians' orders, including physicians' orders for laboratory testing, could not be fully assessed at the time of survey completion. To allow for further evaluation of scheduled nursing staff in-service training regarding the new policies and procedures, supervisory staffs' weekly resident clinical record audits, and the QA Committee's ongoing oversight of conformance with physicians' orders, the noncompliance continues and the scope and severity is reduced to the "D" level.

Based on clinical record review, staff interview, hospital History and Physical form review, hospital Discharge Summary review, and review of the National Council of State Boards of Nursing Model Nursing Practice Act and Model Nursing Administrative Rules, the facility failed to ensure that services provided met professional standards of quality regarding blood level monitoring for the anticonvulsant drug [MEDICATION NAME] via laboratory testing as ordered by the physician after a [MEDICATION NAME] dosage increase for one (1) resident (#1), of two (2) sampled residents receiving [MEDICATION NAME] drug therapy, on the total survey sample of nine (9) residents. Resident #1's daily dose of the drug [MEDICATION NAME] was increased, in conformance with a physician's orders [REDACTED]. Resident #1 was later found to have fallen and was transported to the hospital. At the hospital, Resident #1 was noted with an elevated free [MEDICATION NAME] level of 3.43 micrograms per milliliter (mcg/ml) and an elevated total [MEDICATION NAME] level of 34.5 mcg/ml. She was admitted to the Intensive Care Unit (ICU) with [DIAGNOSES REDACTED]. The facility's failure to monitor the blood level of Resident #1's [MEDICATION NAME] drug therapy as ordered by the physician, and in accordance with professional standards of quality, resulted in a situation in which the facility's noncompliance with the requirements of participation caused, or had the likelihood to cause, serious harm, injury, impairment, or death to residents. The facility's Administrator and Director of Nursing (DON) were informed of the immediate jeopardy on May 6, 2014 at approximately 12:00 p.m. The non-compliance related to the immediate jeopardy was identified to have existed on March 26, 2014 (the date the facility failed to obtain the [MEDICATION NAME] blood level for Resident #1 via the ordered laboratory test), continued through May 8, 2014, and was removed on May 9, 2014. On May 8, 2014, the facility put into place a credible allegation of jeopardy removal. During an interview conducted on May 7, 2014 at 1:50 p.m., the Administrator acknowledged Resident #1's 04/07/2014 hospital transfer after a fall on that date, and that the facility had failed to obtain the [MEDICATION NAME] laboratory test as ordered. The Administrator also acknowledged, during a May 7, 2014, 5:00 p.m. interview, that Resident #1 had later been diagnosed with [REDACTED]. An allegation of jeopardy removal was received on May 8, 2014. Based on the corrective plans which had been developed and implemented by the facility, the immediacy of the deficient practice was determined to have been removed on May 9, 2014, and the facility remained out of compliance at a lower scope and severity of "D" while the process of evaluating modifications of the facility's laboratory services procedures and obtaining ordered laboratory services continued. In-service materials and records were reviewed. Interviews were conducted with staff to ensure they were knowledgeable about the facility's laboratory services procedures and obtaining resident laboratory tests as ordered by the physician. Resident records were reviewed to ensure that resident laboratory tests were obtained as ordered, including those laboratory tests ordered to monitor blood levels of drug therapy to ensure accurate drug dosage titration. Findings include: Review of the National Council of State Boards of Nursing Model Nursing Practice Act and Model Nursing Administrative Rules revealed that Chapter 2 - Standards of Nursing Practice, Section 2.2.2, Standards Related to Registered Nurse (RN) Responsibility for Nursing Practice Implementation, requires in Section 2.2.2(g) that the RN implement treatment; Section 2.2.4, Standards Related to RN Responsibility to Organize, Manage and Supervise the Practice of Nursing, requires in Section 2.2.4(j)(1) that the RN provide appropriate monitoring and surveillance of the care environment. Additionally, Section 2.3.2, Standards Related to Licensed Practical Nurse (LPN/VN) Responsibilities for Nursing Practice Implementation, requires in Section 2.3.2(i)(2) that the LPN implement treatments and procedures. Record review for Resident #1 revealed a Quarterly Minimum Data Set assessment of 02/18/2014 which documented diagnoses, in Section I - Active Diagnoses, which included, but were not limited to, Hypertension, Diabetes Mellitus, [MEDICAL CONDITION] and [MEDICAL CONDITION] Disorder. Resident #1's March 2014 physician's orders [REDACTED]. A 03/19/2014 Physician's Telephone Orders form for Resident #1 specified to discontinue the 300 mg daily [MEDICATION NAME] dose, to increase the daily dose of [MEDICATION NAME] to 200 mgs twice daily, and to check the [MEDICATION NAME] level in one (1) week (03/26/14). However, further record review for Resident #1 revealed no evidence to indicate that the laboratory test ordered for 03/26/2014 to check Resident #1's [MEDICATION NAME] level was done. A 04/08/2014, 7:03 p.m. Progress Notes Health Status (PNHS) Note documented that on 04/07/2014 at approximately 4:45 p.m., Resident #1 had fallen, and a subsequent 04/08/2014, 7:15 p.m. PNHS Note documented that she had been admitted to the hospital. A hospital History and Physical (H&P) form referenced Resident #1's 04/07/2014 hospital transfer, documented that Resident #1's [MEDICATION NAME] had been recently increased, and noted the [MEDICATION NAME] level was above the therapeutic level, documenting a free [MEDICATION NAME] level of 3.43 micrograms per milliliter (mcg/ml) and total [MEDICATION NAME] level of 34.5 mcg/ml. This H&P listed [MEDICATION NAME] toxicity as the first referenced diagnosis, and indicated that Resident #1 would be admitted to the ICU. Resident #1's hospital Discharge Summary documented that on 04/11/14, after treatment which included aggressive hydration, Resident #1 was discharged back to the nursing facility, and documented [DIAGNOSES REDACTED]. During a 05/07/2014, 1:50 p.m. interview, the Administrator acknowledged that the laboratory test ordered to check the Resident #1's [MEDICATION NAME] level on 03/26/2014 had not been done as ordered. The Administrator further stated that nursing staff had failed to transcribe the physician's orders [REDACTED].#1. Based on the above, despite Resident #1 having a [MEDICAL CONDITION] disorder and receiving the anticonvulsant drug [MEDICATION NAME], despite the resident's [MEDICATION NAME] dosage increase from 300 mgs to 400 mgs daily, despite a physician's orders [REDACTED]. [REDACTED].#1. Facility nursing staff then failed to ensure that this laboratory test related to the [MEDICATION NAME] blood level of Resident #1 was obtained as ordered. Resident #1 later fell , was transferred to the hospital, was found to have toxic free [MEDICATION NAME] and total [MEDICATION NAME] levels, and was admitted to the ICU with [DIAGNOSES REDACTED]. The facility thus failed to ensure that Resident #1 received care in accordance with professional standards of nursing quality, regarding the monitoring of the resident's blood level of [MEDICATION NAME] as specified by the physician's orders [REDACTED]. Cross refer to F329 for more information regarding Resident #1. The immediate jeopardy was removed on 05/09/2014, at which time the facility had implemented the following credible allegation of jeopardy removal to remove the immediacy of the deficient practice: 1. On May 6, 2014, the facility reviewed the existing laboratory policies and procedures and wrote a new Physician Accepting, Transcribing, and Implementing Orders Policy, and a new Receiving, Transcribing, and Implementing Laboratory Orders Policy. 2. On May 7, 2014, the facility conducted a complete audit of all resident records to ensure that all laboratory orders and all transcribed physicians' orders had been initiated as ordered. The results of this resident chart audit were documented on the audit tool form developed by the facility. 3. On May 7, 2014, the facility initiated a system process by which all new transcribed physicians' orders and laboratory orders would be reviewed daily, Monday through Friday, in the management morning report meeting which included the Administrator, the DON, the Assistant Director of Nursing (ADON), and all Unit Managers. This review also monitored inclusion of newly transcribed physicians' orders, including orders for laboratory testing intended to monitor resident drug therapy, on resident medication administration records, treatment administration records, and/or the laboratory book. On weekend days, the Weekend Supervisor would review all transcribed physicians' orders, including orders for laboratory testing related to resident drug therapy, to ensure both transcription and completion, with the Administrator, DON, or ADON to monitor each weekend day to ensure compliance. The review would be documented on the audit monitoring and completed tools form to ensure compliance with order transcription, and to ensure laboratory tests were completed as ordered. This process is to be a permanent procedure to allow the facility's management staff to monitor on a daily basis, and to ensure the accurate transcription and implementation of physicians' orders for resident care, including physicians' orders for laboratory testing related to resident drug therapy. 4. On May 8, 2014, the facility initiated a new procedure by which the DON, ADON, or Unit Manager would check selected resident clinical records weekly to ensure that all physicians' orders, to include physicians' orders for laboratory testing related to resident drug therapy, had been transcribed accurately. This process is to be a permanent procedure to allow management staff to conduct weekly audits to monitor for the accurate transcription and implementation of physicians' orders. 5. On May 8, 2014, the facility conducted staff in-service training for licensed nursing staff regarding the new Receiving, Transcribing, and Implementing Laboratory Orders Policy and Procedure. As of May 8, 2014, twenty-six (26), or seventy-six (76) percent, of the facility's thirty-four (34) licensed nursing staff had received this in-service training. The remaining eight (8) licensed nursing staff, who were unavailable for training at that time due to being off-duty or on leave, were to receive this in-service training upon their return to work; these licensed staff would not be allowed to provide direct resident care until completion of this in-service training. 6. On May 8, 2014, the facility implemented a procedure by which the results of the monitoring referenced above, to be documented on the audit monitoring and completed tools form, would be presented to the Quality Assurance (QA) Committee each month by the Administrator and/or the DON, to allow the QA Committee to monitor staff compliance with the facility's policies and procedures regarding the receipt, transcribing, and implementation of physicians' orders, including orders for laboratory testing, to ensure that these policies, procedures, and systems were in compliance. During this complaint survey, on the following referenced dates, each newly developed policy, procedure, and system included the facility's credible allegation of jeopardy removal was reviewed by survey staff to ensure completion and/or implementation, with the findings as follow: - On May 8, 2014, the new Physician Accepting, Transcribing, and Implementing Orders Policy and Receiving, Transcribing, and Implementing Laboratory Orders Policy were reviewed, and it was found that the facility had reviewed and modified its policies and procedures regarding physicians' orders and laboratory testing. - On May 8, 2014, the facility's resident record physicians' order/laboratory audit of May 7, 2014 was reviewed and found to have checked for resident laboratory orders and transcribed physicians' orders. - On May 8, 2014, a review was conducted of the facility's new system process, initiated on May 7, 2014 by the facility, involving the daily review of all newly transcribed physicians' orders and laboratory orders in the management morning report meeting. This review revealed monitoring of transcribed physicians' orders and their inclusion on resident medication administration records, treatment administration records, and/or the laboratory book, per the credible allegation of jeopardy removal. - On May 8, 2014, it was confirmed via procedural review that the facility had initiated a new procedure on May 8, 2014 by which DON/ADON/Unit Manager would audit selected resident records weekly to ensure accurate transcription and completion of physicians' orders. - On May 8, 2014, the licensed nursing staff in-service training for the facility's licensed nursing staff regarding the new Receiving, Transcribing, and Implementing Laboratory Orders Policy and Procedure was reviewed for completion, as indicated on the facility's credible allegation of jeopardy removal. - On May 8, 2014, it was confirmed via procedural review that the findings of clinical record audits documented on the audit monitoring and completed tools form would be reviewed at each monthly QA Committee meeting, and that the QA Committee would monitor staff compliance with the policies, procedures, and protocols for the receipt and implementation of physicians' orders. Based on the corrective actions which had been developed and implemented by the facility as outlined above, the immediacy of the deficient practice, related to the failure to obtain laboratory testing to ensure monitoring of the [MEDICATION NAME] blood level as ordered by the physician, was removed on May 9, 2014. However, the effectiveness of the corrective action plans could not be fully assessed to ensure ongoing application and completion. The facility had reviewed the existing laboratory policies and procedures and had written a new Physician Accepting, Transcribing, and Implementing Orders Policy, and a new Receiving, Transcribing, and Implementing Laboratory Orders Policy, and had initiated staff in-service training for the licensed nursing staff regarding these new Policies and Procedures. However, as of the May 9, 2014 exit date of this complaint survey, although twenty-six (26) licensed nursing staff had received this training, the remaining eight (8) licensed nursing staff had been unavailable and thus were to receive this in-service training upon their return to work. Also, on May 8, 2014, the facility initiated a new procedure by which the DON/ADON/Unit Manager would conduct selected weekly resident clinical record audits to ensure accurate transcription and implementation of physicians' orders, and the results of these audits were to be presented to the QA Committee monthly to allow the Committee to monitor facility staffs' conformance with the facility's policies, procedures, and protocols regarding the transcription and implementation of physicians' orders. However, this new audit procedure had only been implemented on May 8, 2014, with the first weekly audit scheduled to occur after the May 9, 2014 exit date of this complaint survey; therefore, the facility's ongoing compliance with this weekly monitoring procedure could not be fully assessed at the time of survey exit. Additionally, the QA Committee, which was to review the weekly clinical record audit results, had not convened at the time of survey exit, and was not scheduled to meet until the following week; thus, the Committee's ongoing process of procedural oversight regarding facility staffs' conformance with the transcription and implementation of physicians' orders, including physicians' orders for laboratory testing, could not be fully assessed at the time of survey completion. To allow for further evaluation of scheduled nursing staff in-service training regarding the new policies and procedures, supervisory staffs' weekly resident clinical record audits, and the QA Committee's ongoing oversight of conformance with physicians' orders, the noncompliance continues and the scope and severity is reduced to the "D" level.

Based on clinical record review, staff interview, hospital History and Physical form review, hospital laboratory test report review, and hospital Discharge Summary review, the facility failed to ensure that care was provided in accordance with the written plan of care, related to laboratory testing ordered by the physician to determine the blood level of the anticonvulsant drug [MEDICATION NAME], for one (1) resident (#1), of two (2) sampled residents receiving [MEDICATION NAME] drug therapy, on the total survey sample of nine (9) residents. For Resident #1, whose Care Plan identified the resident's use of [MEDICAL CONDITION] medication and specified that laboratory/diagnostic work be provided as ordered, the facility failed to obtain a laboratory test ordered by the physician to determine the blood level of the [MEDICATION NAME] anticonvulsant drug therapy. Resident #1 later fell and was transported to the hospital and admitted to the hospital Intensive Care Unit (ICU) with a toxic free [MEDICATION NAME] level of 3.43 micrograms per milliliter (mcg/ml) and a toxic total [MEDICATION NAME] level of 34.5 mcg/ml. The facility's failure to obtain the ordered laboratory test, as specified by the Care Plan, to monitor Resident #1's [MEDICATION NAME] blood level, and the resident then experiencing a toxic blood level of [MEDICATION NAME], resulted in a situation in which the facility's noncompliance with the requirements of participation caused, or had the likelihood to cause, serious harm, injury, impairment, or death to residents. The facility's Administrator and Director of Nursing (DON) were informed of the immediate jeopardy on May 6, 2014 at approximately 12:00 p.m. The non-compliance related to the immediate jeopardy was identified to have existed on March 26, 2014 (the date the facility failed to obtain the [MEDICATION NAME] blood level for Resident #1 via the ordered laboratory test), continued through May 8, 2014, and was removed on May 9, 2014. On May 8, 2014, the facility put into place a credible allegation of jeopardy removal. During an interview conducted on May 7, 2014 at 1:50 p.m., the Administrator acknowledged Resident #1's hospital transfer of 04/07/2014, and acknowledged that the [MEDICATION NAME] level was not done as ordered. During a later interview of May 7, 2014 at 5:00 p.m., the Administrator also acknowledged that Resident #1 had been diagnosed with [REDACTED]. An allegation of jeopardy removal was received on May 8, 2014. Based on the corrective plans which had been developed and implemented by the facility, the immediacy of the deficient practice was determined to have been removed on May 9, 2014, and the facility remained out of compliance at a lower scope and severity of "D" while the process of evaluating modifications of the facility's laboratory services procedures, and of obtaining laboratory services as ordered, continued. In-service materials and records were reviewed. Interviews were conducted with staff to ensure they were knowledgeable about the facility's laboratory services procedures and obtaining resident laboratory tests as ordered by the physician. Resident records were reviewed to ensure that resident laboratory tests were obtained as ordered, including those laboratory tests ordered to monitor blood levels of drug therapy to ensure accurate drug dosage titration. Findings include: Record review for Resident #1 revealed a Minimum Data Set (MDS) assessment of 02/18/2014 which documented in Section I - Active [DIAGNOSES REDACTED]. Review of Resident #1's Care Plan revealed a Focus area, dated as having been initiated on 02/24/2014, which identified, as had the 02/18/2014 MDS referenced above, that the resident had a [MEDICAL CONDITION] disorder. Interventions on this Care Plan related to Resident #1's [MEDICAL CONDITION] disorder identified the resident's use of [MEDICAL CONDITION] medication, and specified to obtain and monitor Resident #1's laboratory and diagnostic work as ordered by the physician. Review of Resident #1's March 2014 physician's orders [REDACTED].#1's [MEDICATION NAME] dose to 200 mgs twice daily, and specified to check the [MEDICATION NAME] level in one (1) week (03/26/2014). However, further review of Resident #1's clinical record revealed that, even though the Care Plan referenced above specified to obtain laboratory/diagnostic work as ordered by the physician as related to the resident's [MEDICAL CONDITION] drug therapy, there was no evidence to indicate that the laboratory test ordered for 03/26/2014 to check Resident #1's [MEDICATION NAME] level was done. A Progress Notes Health Status Note entry of 04/08/2014 at 7:03 p.m. documented that on 04/07/2014 at approximately 4:45 p.m., Resident #1 had fallen, and a 04/08/2013, 7:15 p.m. Progress Notes Health Status Note documented that the resident had been admitted to the hospital for [MEDICATION NAME] toxicity. A hospital History and Physical (H&P) form documented Resident #1's hospital transfer, and documented that the [MEDICATION NAME] level was above the therapeutic level, listed [MEDICATION NAME] toxicity as the a diagnosis, and indicated that Resident #1 would be admitted to the ICU. A hospital laboratory test report of 04/07/2014 documented Resident #1 to have a Free [MEDICATION NAME] ([MEDICATION NAME]) level of 3.43 mcg/ml, and a total [MEDICATION NAME] level of 34.5 mcg/ml; the listed the Reference/Therapeutic ranges of [MEDICATION NAME] were 1.00-2.00 mcg/ml for free [MEDICATION NAME], and 10-20 mcg/ml for total [MEDICATION NAME]. A hospital Discharge Summary (DS) for Resident #1 documented that the resident was discharged back to the nursing facility on 04/11/2014, and listed [DIAGNOSES REDACTED]. During a 05/07/2014, 1:50 p.m. interview, the Administrator acknowledged that the ordered 03/26/2014 laboratory test to check Resident #1's [MEDICATION NAME] level had not been done, and during a 05/07/2014, 2:30 p.m., the DON acknowledged that Resident #1 had been diagnosed with [REDACTED]. Based on the above, despite Resident #1 having an order for [REDACTED].#1 was later transferred to the hospital after a fall and found to have a toxic free [MEDICATION NAME] level of 3.43 mcg/ml and a toxic total [MEDICATION NAME] level of 34.5 mcg/ml. Resident #1 was admitted to the ICU with [DIAGNOSES REDACTED]. Cross refer to F329 for more information regarding Resident #1. The immediate jeopardy was removed on 05/09/2014, at which time the facility had implemented the following credible allegation of jeopardy removal to remove the immediacy of the deficient practice: 1. On May 6, 2014, the facility reviewed the existing laboratory policies and procedures and wrote a new Physician Accepting, Transcribing, and Implementing Orders Policy, and a new Receiving, Transcribing, and Implementing Laboratory Orders Policy. 2. On May 7, 2014, the facility conducted a complete audit of all resident records to ensure that all laboratory orders and all transcribed physicians' orders had been initiated as ordered. The results of this resident chart audit were documented on the audit tool form developed by the facility. 3. On May 7, 2014, the facility initiated a system process by which all new transcribed physicians' orders and laboratory orders would be reviewed daily, Monday through Friday, in the management morning report meeting which included the Administrator, the DON, the Assistant Director of Nursing (ADON), and all Unit Managers. This review also monitored inclusion of newly transcribed physicians' orders, including orders for laboratory testing intended to monitor resident drug therapy, on resident medication administration records, treatment administration records, and/or the laboratory book. On weekend days, the Weekend Supervisor would review all transcribed physicians' orders, including orders for laboratory testing related to resident drug therapy, to ensure both transcription and completion, with the Administrator, DON, or ADON to monitor each weekend day to ensure compliance. The review would be documented on the audit monitoring and completed tools form to ensure compliance with order transcription, and to ensure laboratory tests were completed as ordered. This process is to be a permanent procedure to allow the facility's management staff to monitor on a daily basis, and to ensure the accurate transcription and implementation of physicians' orders for resident care, including physicians' orders for laboratory testing related to resident drug therapy. 4. On May 8, 2014, the facility initiated a new procedure by which the DON, ADON, or Unit Manager would check selected resident clinical records weekly to ensure that all physicians' orders, to include physicians' orders for laboratory testing related to resident drug therapy, had been transcribed accurately. This process is to be a permanent procedure to allow management staff to conduct weekly audits to monitor for the accurate transcription and implementation of physicians' orders. 5. On May 8, 2014, the facility conducted staff in-service training for licensed nursing staff regarding the new Receiving, Transcribing, and Implementing Laboratory Orders Policy and Procedure. As of May 8, 2014, twenty-six (26), or seventy-six (76) percent, of the facility's thirty-four (34) licensed nursing staff had received this in-service training. The remaining eight (8) licensed nursing staff, who were unavailable for training at that time due to being off-duty or on leave, were to receive this in-service training upon their return to work; these licensed staff would not be allowed to provide direct resident care until completion of this in-service training. 6. On May 8, 2014, the facility implemented a procedure by which the results of the monitoring referenced above, to be documented on the audit monitoring and completed tools form, would be presented to the Quality Assurance (QA) Committee each month by the Administrator and/or the DON, to allow the QA Committee to monitor staff compliance with the facility's policies and procedures regarding the receipt, transcribing, and implementation of physicians' orders, including orders for laboratory testing, to ensure that these policies, procedures, and systems were in compliance. During this complaint survey, on the following referenced dates, each newly developed policy, procedure, and system included the facility's credible allegation of jeopardy removal was reviewed by survey staff to ensure completion and/or implementation, with the findings as follow: - On May 8, 2014, the new Physician Accepting, Transcribing, and Implementing Orders Policy and Receiving, Transcribing, and Implementing Laboratory Orders Policy were reviewed, and it was found that the facility had reviewed and modified its policies and procedures regarding physicians' orders and laboratory testing. - On May 8, 2014, the facility's resident record physicians' order/laboratory audit of May 7, 2014 was reviewed and found to have checked for resident laboratory orders and transcribed physicians' orders. - On May 8, 2014, a review was conducted of the facility's new system process, initiated on May 7, 2014 by the facility, involving the daily review of all newly transcribed physicians' orders and laboratory orders in the management morning report meeting. This review revealed monitoring of transcribed physicians' orders and their inclusion on resident medication administration records, treatment administration records, and/or the laboratory book, per the credible allegation of jeopardy removal. - On May 8, 2014, it was confirmed via procedural review that the facility had initiated a new procedure on May 8, 2014 by which DON/ADON/Unit Manager would audit selected resident records weekly to ensure accurate transcription and completion of physicians' orders. - On May 8, 2014, the licensed nursing staff in-service training for the facility's licensed nursing staff regarding the new Receiving, Transcribing, and Implementing Laboratory Orders Policy and Procedure was reviewed for completion as indicated on the facility's credible allegation of jeopardy removal. - On May 8, 2014, it was confirmed via procedural review that the findings of clinical record audits documented on the audit monitoring and completed tools form would be reviewed at each monthly QA Committee meeting, and that the QA Committee would monitor staff compliance with the policies, procedures, and protocols for the receipt and implementation of physicians' orders. Based on the corrective actions which had been developed and implemented by the facility as outlined above, the immediacy of the deficient practice, related to the failure to obtain laboratory testing to ensure monitoring of the [MEDICATION NAME] blood level as ordered by the physician, was removed on May 9, 2014. However, the effectiveness of the corrective action plans could not be fully assessed to ensure ongoing application and completion. The facility had reviewed the existing laboratory policies and procedures and had written a new Physician Accepting, Transcribing, and Implementing Orders Policy, and a new Receiving, Transcribing, and Implementing Laboratory Orders Policy, and had initiated staff in-service training for the licensed nursing staff regarding these new Policies and Procedures. However, as of the May 9, 2014 exit date of this complaint survey, although twenty-six (26) licensed nursing staff had received this training, the remaining eight (8) licensed nursing staff had been unavailable and thus were to receive this in-service training upon their return to work. Also, on May 8, 2014, the facility initiated a new procedure by which the DON/ADON/Unit Manager would conduct selected weekly resident clinical record audits to ensure accurate transcription and implementation of physicians' orders, and the results of these audits were to be presented to the QA Committee monthly to allow the Committee to monitor facility staffs' conformance with the facility's policies, procedures, and protocols regarding the transcription and implementation of physicians' orders. However, this new audit procedure had only been implemented on May 8, 2014, with the first weekly audit scheduled to occur after the May 9, 2014 exit date of this complaint survey; therefore, the facility's ongoing compliance with this weekly monitoring procedure could not be fully assessed at the time of survey exit. Additionally, the QA Committee, which was to review the weekly clinical record audit results, had not convened at the time of survey exit, and was not scheduled to meet until the following week; thus, the Committee's ongoing process of procedural oversight regarding facility staffs' conformance with the transcription and implementation of physicians' orders, including physicians' orders for laboratory testing, could not be fully assessed at the time of survey completion. To allow for further evaluation of scheduled nursing staff in-service training regarding the new policies and procedures, supervisory staffs' weekly resident clinical record audits, and the QA Committee's ongoing oversight of conformance with physicians' orders, the noncompliance continues and the scope and severity is reduced to the "D" level.

Based on clinical record review, staff interview, hospital History and Physical form review, hospital laboratory test report review, hospital Medical Charts with Audits form review, hospital Patient Results form review, and hospital Discharge Summary review, the facility failed to ensure monitoring as ordered by the physician, via ordered laboratory testing, of the blood level of the anticonvulsant drug [MEDICATION NAME] after an increase in the daily [MEDICATION NAME] dosage, to thus ensure the safe titration of the [MEDICATION NAME] dosage for one (1) resident (#1), of two (2) sampled residents receiving [MEDICATION NAME] drug therapy, on the total survey sample of nine (9) residents. For Resident #1, the facility increased the daily dose of [MEDICATION NAME] drug therapy in conformance with a physician's orders [REDACTED]. Subsequently, Resident #1 experienced a fall and was transported to the hospital where she was noted with [MEDICAL CONDITION] and lethargy. A hospital laboratory test revealed Resident #1 to have an elevated free [MEDICATION NAME] level of 3.43 micrograms per milliliter (mcg/ml) and an elevated total [MEDICATION NAME] level of 34.5 mcg/ml, and she was admitted to the Intensive Care Unit (ICU) in guarded condition with [DIAGNOSES REDACTED]. The facility's failure to monitor the blood level of Resident #1's [MEDICATION NAME] drug therapy as ordered, with the resident subsequently becoming [MEDICATION NAME] toxic, resulted in a situation in which the facility's noncompliance with the requirements of participation caused, or had the likelihood to cause, serious harm, injury, impairment, or death to residents. The facility's Administrator and Director of Nursing (DON) were informed of the immediate jeopardy on May 6, 2014 at approximately 12:00 p.m. The non-compliance related to the immediate jeopardy was identified to have existed on March 26, 2014 (the date the facility failed to obtain the [MEDICATION NAME] blood level for Resident #1 via the ordered laboratory test), continued through May 8, 2014, and was removed on May 9, 2014. On May 8, 2014, the facility implemented a credible allegation of jeopardy removal. During an interview conducted on May 7, 2014 at 1:50 p.m., the Administrator stated that he had been aware of Resident #1 being transferred to the hospital after experiencing a fall on 04/07/2014, and acknowledged, during a later interview of May 7, 2014 at 5:00 p.m., that he had been made aware on 04/08/2014 of Resident #1 having been diagnosed with [REDACTED]. However, the Administrator further stated, during the May 7, 2014, 1:50 p.m. interview referenced above, that he had not been aware, prior to being informed during this complaint survey, that the facility had failed to obtain the [MEDICATION NAME] laboratory test ordered for Resident #1, but acknowledged that the [MEDICATION NAME] level was not done as ordered. An allegation of jeopardy removal was received on May 8, 2014. Based on the corrective plans which had been developed and implemented by the facility, the immediacy of the deficient practice was determined to have been removed on May 9, 2014, and the facility remained out of compliance at a lower scope and severity of "D" while the process of evaluating modifications of the facility's laboratory services procedures, and of obtaining laboratory services as ordered, continued. In-service materials and records were reviewed. Interviews were conducted with staff to ensure they were knowledgeable about the facility's laboratory services procedures and obtaining resident laboratory tests as ordered by the physician. Resident records were reviewed to ensure that resident laboratory tests were obtained as ordered, including those laboratory tests ordered to monitor blood levels of drug therapy to ensure accurate drug dosage titration. Findings include: Record review for Resident #1 revealed a Quarterly Minimum Data Set (MDS) assessment having an Assessment Reference Date of 02/18/2014 which documented in Section C - Cognitive Patterns that the resident had a Brief Interview for Mental Status Summary Score of 03, indicating that the resident had severe cognitive impairment. Section I - Active [DIAGNOSES REDACTED].#1 had [DIAGNOSES REDACTED]. Review of Resident #1's March 2014 physician's orders [REDACTED]. A subsequent Physician's Telephone Orders (PTO) form dated 03/19/2014 for Resident #1 specified to discontinue the resident's current 300 milligram (mg) daily dose of [MEDICATION NAME] drug therapy, and to increase the dose of [MEDICATION NAME] to 200 mgs twice daily. This 03/19/2014 PTO form also specified to check Resident #1's [MEDICATION NAME] level in one (1) week (03/26/2014); however, clinical record review revealed no evidence to indicate that the laboratory test, ordered via the 03/19/2014 PTO referenced above, to check Resident #1's [MEDICATION NAME] level was done. During an interview with the Administrator conducted on 05/07/2014 at 1:50 p.m., the Administrator stated that the physician's orders [REDACTED]. level on 03/26/2014 had therefore not been done. A Progress Notes Health Status Note entry for Resident #1 dated 04/08/2014, timed at 7:03 p.m. and indicated to be a late entry note for 04/07/2014, documented that on 04/07/2014 at approximately 4:45 p.m., the resident had fallen to the floor. This Note documented that Resident #1 was yelling and thrashing about, with an elevated pulse rate of 109 and a oxygen pulse oximetry of ninety (90) percent. A Progress Notes Health Status Note of 04/08/2014, timed at 7:15 p.m., then documented that Resident #1 had been admitted to the hospital into the ICU for [MEDICATION NAME] toxicity. The hospital History and Physical (H&P) form for Resident #1 which referenced the resident's 04/07/2014 hospital transfer documented, in the History of Present Illness section, that the resident had been transferred to the emergency room for evaluation after she was found on the floor in the room. This H&P form documented that Resident #1's [MEDICATION NAME] dose had been recently increased in the nursing facility, and further noted that the [MEDICATION NAME] level was above the therapeutic level. The Laboratory and Ancillary Results section of this hospital H&P specifically documented that the [MEDICATION NAME] level was as follows: free [MEDICATION NAME] level of 3.43 (mcg/ml), and total [MEDICATION NAME] level of 34.5 (mcg/ml). The hospital laboratory test report for Resident #1, dated as having been completed on 04/07/2014 and timed 6:03 p.m., documented the resident's total [MEDICATION NAME]/Free [MEDICATION NAME] laboratory test results, as indicated on the H&P referenced above, to be a Free [MEDICATION NAME] ([MEDICATION NAME]) level of 3.43 mcg/ml, and a total [MEDICATION NAME] level of 34.5 mcg/ml. This hospital laboratory report listed the Reference/Therapeutic ranges of [MEDICATION NAME] to be 1.00-2.00 mcg/ml for Free [MEDICATION NAME], and 10-20 mcg/ml for Total [MEDICATION NAME]. The Physical Examination section of the hospital H&P referenced above for Resident #1 documented an assessment had revealed vital signs which included a low pulse rate of forty-seven (47). The resident was documented as being lethargic and briefly arousable, but falling asleep easily. The Assessment and Plan section of this H&P listed [MEDICATION NAME] toxicity as the first referenced diagnosis, and indicated that Resident #1 would be admitted to the hospital ICU with aggressive hydration and close monitoring of the [MEDICATION NAME] level. Review of a hospital Medical Charts with Audits form dated 04/07/2014, timed at 6:03 p.m., for Resident #1 revealed the physician documented, in the Disposition section, that Resident #1 was being admitted to the hospital in guarded condition. The physician also referenced the resident's [MEDICATION NAME] level to be "quite elevated with a free level of 3.4," indicated that Resident #1 was "profoundly bradycardic", and further indicated that the elevated free [MEDICATION NAME] level "certainly could be accounting for her [MEDICAL CONDITION]." A hospital Patient Results form for Resident #1 documented that, after the 04/07/2014 hospital ICU admission and the initiation of treatment for [REDACTED]. This Patient Results form also documented that by 04/11/2014, Resident #1's Free [MEDICATION NAME] level had declined further to 2.71 mcg/ml, and the total [MEDICATION NAME] level had declined to 21.6 mcg/ml. The hospital Discharge Summary (DS) for Resident #1 documented a hospital discharge date of [DATE]. This hospital DS documented that Resident #1 was aggressively hydrated, and sodium [MEDICATION NAME] was added to intravenous fluids in order to increase the alkalinity of the urine and promote [MEDICATION NAME] drug elimination. This DS documented that Resident #1's [MEDICATION NAME] level had shown a slow tendency of clearance from the initial level of 3.43 mcg/ml, but that as of 04/11/2014, the [MEDICATION NAME] level had declined to 2.71 mcg/ml, and the pulse rate had increased to fifty-five (55) beats per minute. This DS further documented that Resident #1 would be discharged to the nursing facility as of that time, with [DIAGNOSES REDACTED]. During an interview with the DON conducted on 05/07/2014 at 2:30 p.m., the DON acknowledged that Resident #1 had returned to the nursing facility after the hospital transfer of 04/07/2014, and acknowledged awareness of Resident #1 having been diagnosed with [REDACTED]. The DON stated that when Resident #1 was readmitted to the nursing facility after hospital discharge, the DON had not been aware that the resident's [MEDICATION NAME] level had been missed, and had not become aware of the omitted laboratory test to check Resident #1's [MEDICATION NAME] blood level until she was made aware during this complaint survey. The DON could present no evidence of any investigative or corrective actions, related to Resident #1's omitted [MEDICATION NAME] laboratory test of 03/26/2014 or to the resident's [DIAGNOSES REDACTED]. Based on the above, despite Resident #1's [MEDICATION NAME] dosage having been increased from 300 mgs daily to 400 milligrams daily, and despite a physician's orders [REDACTED]. drug therapy. Resident #1 was subsequently transferred to the hospital after experiencing a fall, was noted to have [MEDICAL CONDITION] and lethargy, was found to have a toxic free [MEDICATION NAME] level of 3.43 mcg/ml and a toxic total [MEDICATION NAME] level of 34.5 mcg/ml, and was admitted to the ICU with [DIAGNOSES REDACTED]. The facility thus failed to ensure adequate monitoring of Resident #1's [MEDICATION NAME] drug therapy by failing to obtain the laboratory test ordered by the physician to determine the resident's [MEDICATION NAME] blood level. The immediate jeopardy was removed on 05/09/2014, at which time the facility had implemented the following credible allegation of jeopardy removal to remove the immediacy of the deficient practice: 1. On May 6, 2014, the facility reviewed the existing laboratory policies and procedures and wrote a new Physician Accepting, Transcribing, and Implementing Orders Policy, and a new Receiving, Transcribing, and Implementing Laboratory Orders Policy. 2. On May 7, 2014, the facility conducted a complete audit of all resident records to ensure that all laboratory orders and all transcribed physicians' orders had been initiated as ordered. The results of this resident chart audit were documented on the audit tool form developed by the facility. 3. On May 7, 2014, the facility initiated a system process by which all new transcribed physicians' orders and laboratory orders would be reviewed daily, Monday through Friday, in the management morning report meeting which included the Administrator, the DON, the Assistant Director of Nursing (ADON), and all Unit Managers. This review also monitored inclusion of newly transcribed physicians' orders, including orders for laboratory testing intended to monitor resident drug therapy, on resident medication administration records, treatment administration records, and/or the laboratory book. On weekend days, the Weekend Supervisor would review all transcribed physicians' orders, including orders for laboratory testing related to resident drug therapy, to ensure both transcription and completion, with the Administrator, DON, or ADON to monitor each weekend day to ensure compliance. The review would be documented on the audit monitoring and completed tools form to ensure compliance with order transcription, and to ensure laboratory tests were completed as ordered. This process is to be a permanent procedure to allow the facility's management staff to monitor on a daily basis, and to ensure the accurate transcription and implementation of physicians' orders for resident care, including physicians' orders for laboratory testing related to resident drug therapy. 4. On May 8, 2014, the facility initiated a new procedure by which the DON, ADON, or Unit Manager would check selected resident clinical records weekly to ensure that all physicians' orders, to include physicians' orders for laboratory testing related to resident drug therapy, had been transcribed accurately. This process is to be a permanent procedure to allow management staff to conduct weekly audits to monitor for the accurate transcription and implementation of physicians' orders. 5. On May 8, 2014, the facility conducted staff in-service training for licensed nursing staff regarding the new Receiving, Transcribing, and Implementing Laboratory Orders Policy and Procedure. As of May 8, 2014, twenty-six (26), or seventy-six (76) percent, of the facility's thirty-four (34) licensed nursing staff had received this in-service training. The remaining eight (8) licensed nursing staff, who were unavailable for training at that time due to being off-duty or on leave, were to receive this in-service training upon their return to work; these licensed staff would not be allowed to provide direct resident care until completion of this in-service training. 6. On May 8, 2014, the facility implemented a procedure by which the results of the monitoring referenced above, to be documented on the audit monitoring and completed tools form, would be presented to the Quality Assurance (QA) Committee each month by the Administrator and/or the DON, to allow the QA Committee to monitor staff compliance with the facility's policies and procedures regarding the receipt, transcribing, and implementation of physicians' orders, including orders for laboratory testing, to ensure that these policies, procedures, and systems were in compliance. During this complaint survey, on the following referenced dates, each newly developed policy, procedure, and system included the facility's credible allegation of jeopardy removal was reviewed by survey staff to ensure completion and/or implementation, with the findings as follow: - On May 8, 2014, the new Physician Accepting, Transcribing, and Implementing Orders Policy and Receiving, Transcribing, and Implementing Laboratory Orders Policy were reviewed, and it was found that the facility had reviewed and modified its policies and procedures regarding physicians' orders and laboratory testing. - On May 8, 2014, the facility's resident record physicians' order/laboratory audit of May 7, 2014 was reviewed and found to have checked for resident laboratory orders and transcribed physicians' orders. - On May 8, 2014, a review was conducted of the facility's new system process, initiated on May 7, 2014 by the facility, involving the daily review of all newly transcribed physicians' orders and laboratory orders in the management morning report meeting. This review revealed monitoring of transcribed physicians' orders and their inclusion on resident medication administration records, treatment administration records, and/or the laboratory book, per the credible allegation of jeopardy removal. - On May 8, 2014, it was confirmed via procedural review that the facility had initiated a new procedure on May 8, 2014 by which DON/ADON/Unit Manager would audit selected resident records weekly to ensure accurate transcription and completion of physicians' orders. - On May 8, 2014, the licensed nursing staff in-service training for the facility's licensed nursing staff regarding the new Receiving, Transcribing, and Implementing Laboratory Orders Policy and Procedure was reviewed for completion, as indicated on the facility's credible allegation of jeopardy removal. - On May 8, 2014, it was confirmed via procedural review that the findings of clinical record audits documented on the audit monitoring and completed tools form would be reviewed at each monthly QA Committee meeting, and that the QA Committee would monitor staff compliance with the policies, procedures, and protocols for the receipt and implementation of physicians' orders. Based on the corrective actions which had been developed and implemented by the facility as outlined above, the immediacy of the deficient practice, related to the failure to obtain laboratory testing to ensure monitoring of the [MEDICATION NAME] blood level as ordered by the physician, was removed on May 9, 2014. However, the effectiveness of the corrective action plans could not be fully assessed to ensure ongoing application and completion. The facility had reviewed the existing laboratory policies and procedures and had written a new Physician Accepting, Transcribing, and Implementing Orders Policy, and a new Receiving, Transcribing, and Implementing Laboratory Orders Policy, and had initiated staff in-service training for the licensed nursing staff regarding these new Policies and Procedures. However, as of the May 9, 2014 exit date of this complaint survey, although twenty-six (26) licensed nursing staff had received this training, the remaining eight (8) licensed nursing staff had been unavailable and thus were to receive this in-service training upon their return to work. Also, on May 8, 2014, the facility initiated a new procedure by which the DON/ADON/Unit Manager would conduct selected weekly resident clinical record audits to ensure accurate transcription and implementation of physicians' orders, and the results of these audits were to be presented to the QA Committee monthly to allow the Committee to monitor facility staffs' conformance with the facility's policies, procedures, and protocols regarding the transcription and implementation of physicians' orders. However, this new audit procedure had only been implemented on May 8, 2014, with the first weekly audit scheduled to occur after the May 9, 2014 exit date of this complaint survey; therefore, the facility's ongoing compliance with this weekly monitoring procedure could not be fully assessed at the time of survey exit. Additionally, the QA Committee, which was to review the weekly clinical record audit results, had not convened at the time of survey exit, and was not scheduled to meet until the following week; thus, the Committee's ongoing process of procedural oversight regarding facility staffs' conformance with the transcription and implementation of physicians' orders, including physicians' orders for laboratory testing, could not be fully assessed at the time of survey completion. To allow for further evaluation of scheduled nursing staff in-service training regarding the new policies and procedures, supervisory staffs' weekly resident clinical record audits, and the QA Committee's ongoing oversight of conformance with physicians' orders, the noncompliance continues and the scope and severity is reduced to the "D" level.

Based on clinical record review, staff interview, and hospital document review, facility administration failed to ensure the provision of laboratory testing as ordered by the physician. This failure resulted in the omission of a laboratory test ordered by the physician to check the [MEDICATION NAME] blood level of one (1) resident (#1), who received [MEDICATION NAME] drug therapy and whose daily [MEDICATION NAME] dose had recently been increased, of two (2) sampled residents receiving [MEDICATION NAME] drug therapy, on the total survey sample of nine (9) residents. Specifically, Resident #1 received daily the [MEDICATION NAME] drug therapy in conformance with the physician's orders [REDACTED]. Resident #1 later experienced a fall requiring hospital transfer, and at the hospital the resident was noted with [MEDICAL CONDITION], lethargy, and toxic free [MEDICATION NAME] and total [MEDICATION NAME] levels of 3.43 micrograms per milliliter (mcg/ml) and 34.5 mcg/ml, respectively. Resident #1 was admitted to the Intensive Care Unit (ICU) with [DIAGNOSES REDACTED]. This failure resulted in a situation in which the facility's noncompliance with the requirements of participation caused, or had the likelihood to cause, serious harm, injury, impairment, or death to residents. The facility's Administrator and Director of Nursing (DON) were informed of the immediate jeopardy on May 6, 2014 at approximately 12:00 p.m. The non-compliance related to the immediate jeopardy was identified to have existed on March 26, 2014 (the date the facility failed to obtain the [MEDICATION NAME] blood level via the ordered laboratory test), continued through May 8, 2014, and was removed on May 9, 2014. The facility enacted a credible allegation of jeopardy removal on May 8, 2014. During an interview conducted on May 7, 2014 at 1:50 p.m., the Administrator acknowledged awareness of Resident #1's fall and hospital transfer of 04/07/2014, but further acknowledged being unaware, prior to this complaint survey, of the failure of facility staff to obtain the ordered laboratory test related to the [MEDICATION NAME] drug therapy of Resident #1. An allegation of jeopardy removal was received on May 8, 2014. Based on the corrective plans which had been developed and implemented by the facility, the immediacy of the deficient practice was determined to have been removed on May 9, 2014, and the facility remained out of compliance at a lower scope and severity of "D" while the process of evaluating modifications of the facility's laboratory services procedures, and of obtaining laboratory services as ordered, continued. In-service materials and records were reviewed. Interviews were conducted with staff to ensure they were knowledgeable about the facility's laboratory services procedures and obtaining resident laboratory tests as ordered by the physician. Resident records were reviewed to ensure that resident laboratory tests were obtained as ordered, including those laboratory tests ordered to monitor blood levels of drug therapy to ensure accurate drug dosage titration. Findings include: Cross refer to F329. Based on record review, staff interview, and hospital document review, the facility failed to ensure monitoring of the [MEDICATION NAME] drug therapy, by failing to obtain laboratory testing as ordered by the physician, for one (1) resident (#1) who received the anticonvulsant drug [MEDICATION NAME], of two (2) sampled residents receiving [MEDICATION NAME] drug therapy, on the total survey sample of nine (9) residents. After increasing the daily dose of [MEDICATION NAME] drug therapy for Resident #1 as specified by the physician, the facility then failed to obtain the ordered laboratory test regarding the resident's [MEDICATION NAME] blood level. Resident #1 then fell , was transported to the hospital, was found to have a toxic free [MEDICATION NAME] level of 3.43 micrograms per milliliter (mcg/ml) and a toxic total [MEDICATION NAME] level of 34.5 mcg/ml, and was admitted to the ICU with [DIAGNOSES REDACTED]. During an interview with the Administrator conducted on 05/07/2014 at 1:50 p.m., the Administrator was questioned regarding the facility's failure to obtain the laboratory test for Resident #1 as ordered by the physician to check the resident's [MEDICATION NAME] drug level, and of any actions he had taken in response to this facility failure. The Administrator acknowledged the incident involving Resident #1's hospitalization of 04/07/2014 after having fallen, but stated he had been unaware that the resident's [MEDICATION NAME] blood level had not been checked as ordered prior to this complaint survey. The Administrator stated that when a resident was readmitted to the facility after a hospitalization , the facility's protocol had specified that the readmitting nurse was responsible for identifying the reason for the resident's hospital admission; this information would be included in the Twenty-Four Hour Report, and would be brought to the daily morning meeting (which would include the Administrator and the DON) for discussion. The Administrator stated, in reference to the incident involving Resident #1's hospitalization of 04/07/2014, that there had been no discussion in the morning meetings since this incident regarding Resident #1's hospital [DIAGNOSES REDACTED]. However, during an interview conducted later in the afternoon of 05/07/2014 at 5:00 p.m., the Administrator stated that upon review of the morning meeting notes of 04/08/2014 (the morning meeting conducted after Resident #1's 04/07/2014 hospital transfer and admission with [DIAGNOSES REDACTED].#1's fall and hospital transfer of 04/07/2014, and also of Resident #1 having been diagnosed with [REDACTED]. However, the Administrator acknowledged that he had taken no action, or put into place any corrective measures, after having been informed on 04/08/2014 of the Resident #1 having [MEDICATION NAME] toxicity, prior to the April 30, 2014 entrance date of this complaint survey. Based on the above, despite having knowledge on 04/08/2014 of Resident #1, who received [MEDICATION NAME] anticonvulsant drug therapy, being transferred and admitted to the hospital on [DATE] with [DIAGNOSES REDACTED]. Rather, actions were not taken to investigate the incident and begin corrective actions until after the 04/30/2014 entrance date of this complaint survey. The immediate jeopardy was removed on 05/09/2014, at which time the facility had implemented the following credible allegation of jeopardy removal to remove the immediacy of the deficient practice: 1. On May 6, 2014, the facility reviewed the existing laboratory policies and procedures and wrote a new Physician Accepting, Transcribing, and Implementing Orders Policy, and a new Receiving, Transcribing, and Implementing Laboratory Orders Policy. 2. On May 7, 2014, the facility conducted a complete audit of all resident records to ensure that all laboratory orders and all transcribed physicians' orders had been initiated as ordered. The results of this resident chart audit were documented on the audit tool form developed by the facility. 3. On May 7, 2014, the facility initiated a system process by which all new transcribed physicians' orders and laboratory orders would be reviewed daily, Monday through Friday, in the management morning report meeting which included the Administrator, the DON, the Assistant Director of Nursing (ADON), and all Unit Managers. This review also monitored inclusion of newly transcribed physicians' orders, including orders for laboratory testing intended to monitor resident drug therapy, on resident medication administration records, treatment administration records, and/or the laboratory book. On weekend days, the Weekend Supervisor would review all transcribed physicians' orders, including orders for laboratory testing related to resident drug therapy, to ensure both transcription and completion, with the Administrator, DON, or ADON to monitor each weekend day to ensure compliance. The review would be documented on the audit monitoring and completed tools form to ensure compliance with order transcription, and to ensure laboratory tests were completed as ordered. This process is to be a permanent procedure to allow the facility's management staff to monitor on a daily basis, and to ensure the accurate transcription and implementation of physicians' orders for resident care, including physicians' orders for laboratory testing related to resident drug therapy. 4. On May 8, 2014, the facility initiated a new procedure by which the DON, ADON, or Unit Manager would check selected resident clinical records weekly to ensure that all physicians' orders, to include physicians' orders for laboratory testing related to resident drug therapy, had been transcribed accurately. This process is to be a permanent procedure to allow management staff to conduct weekly audits to monitor for the accurate transcription and implementation of physicians' orders. 5. On May 8, 2014, the facility conducted staff in-service training for licensed nursing staff regarding the new Receiving, Transcribing, and Implementing Laboratory Orders Policy and Procedure. As of May 8, 2014, twenty-six (26), or seventy-six (76) percent, of the facility's thirty-four (34) licensed nursing staff had received this in-service training. The remaining eight (8) licensed nursing staff, who were unavailable for training at that time due to being off-duty or on leave, were to receive this in-service training upon their return to work; these licensed staff would not be allowed to provide direct resident care until completion of this in-service training. 6. On May 8, 2014, the facility implemented a procedure by which the results of the monitoring referenced above, to be documented on the audit monitoring and completed tools form, would be presented to the Quality Assurance (QA) Committee each month by the Administrator and/or the DON, to allow the QA Committee to monitor staff compliance with the facility's policies and procedures regarding the receipt, transcribing, and implementation of physicians' orders, including orders for laboratory testing, to ensure that these policies, procedures, and systems were in compliance. During this complaint survey, on the following referenced dates, each newly developed policy, procedure, and system included the facility's credible allegation of jeopardy removal was reviewed by survey staff to ensure completion and/or implementation, with the findings as follow: - On May 8, 2014, the new Physician Accepting, Transcribing, and Implementing Orders Policy and Receiving, Transcribing, and Implementing Laboratory Orders Policy were reviewed, and it was found that the facility had reviewed and modified its policies and procedures regarding physicians' orders and laboratory testing. - On May 8, 2014, the facility's resident record physicians' order/laboratory audit of May 7, 2014 was reviewed and found to have checked for resident laboratory orders and transcribed physicians' orders. - On May 8, 2014, a review was conducted of the facility's new system process, initiated on May 7, 2014 by the facility, involving the daily review of all newly transcribed physicians' orders and laboratory orders in the management morning report meeting. This review revealed monitoring of transcribed physicians' orders and their inclusion on resident medication administration records, treatment administration records, and/or the laboratory book, per the credible allegation of jeopardy removal. - On May 8, 2014, it was confirmed via procedural review that the facility had initiated a new procedure on May 8, 2014 by which DON/ADON/Unit Manager would audit selected resident records weekly to ensure accurate transcription and completion of physicians' orders. - On May 8, 2014, the licensed nursing staff in-service training for the facility's licensed nursing staff regarding the new Receiving, Transcribing, and Implementing Laboratory Orders Policy and Procedure was reviewed for completion, as indicated on the facility's credible allegation of jeopardy removal. - On May 8, 2014, it was confirmed via procedural review that the findings of clinical record audits documented on the audit monitoring and completed tools form would be reviewed at each monthly QA Committee meeting, and that the QA Committee would monitor staff compliance with the policies, procedures, and protocols for the receipt and implementation of physicians' orders. Based on the corrective actions which had been developed and implemented by the facility as outlined above, the immediacy of the deficient practice, related to the failure to obtain laboratory testing to ensure monitoring of the [MEDICATION NAME] blood level as ordered by the physician, was removed on May 9, 2014. However, the effectiveness of the corrective action plans could not be fully assessed to ensure ongoing application and completion. The facility had reviewed the existing laboratory policies and procedures and had written a new Physician Accepting, Transcribing, and Implementing Orders Policy, and a new Receiving, Transcribing, and Implementing Laboratory Orders Policy, and had initiated staff in-service training for the licensed nursing staff regarding these new Policies and Procedures. However, as of the May 9, 2014 exit date of this complaint survey, although twenty-six (26) licensed nursing staff had received this training, the remaining eight (8) licensed nursing staff had been unavailable and thus were to receive this in-service training upon their return to work. Also, on May 8, 2014, the facility initiated a new procedure by which the DON/ADON/Unit Manager would conduct selected weekly resident clinical record audits to ensure accurate transcription and implementation of physicians' orders, and the results of these audits were to be presented to the QA Committee monthly to allow the Committee to monitor facility staffs' conformance with the facility's policies, procedures, and protocols regarding the transcription and implementation of physicians' orders. However, this new audit procedure had only been implemented on May 8, 2014, with the first weekly audit scheduled to occur after the May 9, 2014 exit date of this complaint survey; therefore, the facility's ongoing compliance with this weekly monitoring procedure could not be fully assessed at the time of survey exit. Additionally, the QA Committee, which was to review the weekly clinical record audit results, had not convened at the time of survey exit, and was not scheduled to meet until the following week; thus, the Committee's ongoing process of procedural oversight regarding facility staffs' conformance with the transcription and implementation of physicians' orders, including physicians' orders for laboratory testing, could not be fully assessed at the time of survey completion. To allow for further evaluation of scheduled nursing staff in-service training regarding the new policies and procedures, supervisory staffs' weekly resident clinical record audits, and the QA Committee's ongoing oversight of conformance with physicians' orders, the noncompliance continues and the scope and severity is reduced to the "D" level.

Based on clinical record review, staff interview, hospital History and Physical form review, hospital laboratory test report review, and hospital Discharge Summary review, the facility failed to provide laboratory services which met the needs of one (1) resident (#1), regarding a laboratory test ordered to monitor the resident's blood level of the anticonvulsant drug [MEDICATION NAME], of two (2) sampled residents receiving [MEDICATION NAME] drug therapy, on the total survey sample of nine (9) residents. The facility failed to check Resident #1's [MEDICATION NAME] blood level via an ordered laboratory test; Resident #1 was later transported to the hospital after a fall and found to have an elevated free [MEDICATION NAME] level of 3.43 micrograms per milliliter (mcg/ml) and an elevated total [MEDICATION NAME] level of 34.5 mcg/ml. She was admitted to the Intensive Care Unit (ICU) with [DIAGNOSES REDACTED]. The facility's failure to provide this laboratory test as ordered resulted in a situation in which the facility's noncompliance with the requirements of participation caused, or had the likelihood to cause, serious harm, injury, impairment, or death to residents. The facility's Administrator and Director of Nursing (DON) were informed of the immediate jeopardy on May 6, 2014 at approximately 12:00 p.m. The non-compliance related to the immediate jeopardy was identified to have existed on March 26, 2014 (the date the facility failed to obtain the [MEDICATION NAME] blood level for Resident #1 via the ordered laboratory test), continued through May 8, 2014, and was removed on May 9, 2014. The facility put into place a credible allegation of jeopardy removal on May 8, 2014. During an interview with the Administrator conducted on May 7, 2014 at 1:50 p.m., the Administrator acknowledged that the laboratory test ordered by the physician to check the blood [MEDICATION NAME] level of Resident #1 had not been done as ordered. An allegation of jeopardy removal was received on May 8, 2014. Based on the corrective plans which had been developed and implemented by the facility, the immediacy of the deficient practice was determined to have been removed on May 9, 2014, and the facility remained out of compliance at a lower scope and severity of "D" while the process of evaluating modifications of the facility's laboratory services procedures, and of obtaining laboratory services as ordered, continued. In-service materials and records were reviewed. Interviews were conducted with staff to ensure they were knowledgeable about the facility's laboratory services procedures and obtaining resident laboratory tests as ordered by the physician. Resident records were reviewed to ensure that resident laboratory tests were obtained as ordered, including those laboratory tests ordered to monitor blood levels of drug therapy to ensure accurate drug dosage titration. Findings include: Resident #1's Minimum Data Set assessment of 02/18/2014 documented diagnoses, in Section I - Active Diagnoses, which included Hypertension, Diabetes Mellitus, [MEDICAL CONDITION] and [MEDICAL CONDITION] Disorder. Resident #1's March 2014 physician's orders [REDACTED].#1's [MEDICATION NAME] dose to 200 mgs twice daily, and to check the resident's [MEDICATION NAME] level in one (1) week; but, further record review revealed no evidence to indicate that this laboratory test, which was ordered to be completed on 03/26/2014, was done. During a 05/07/2014, 1:50 p.m. interview, the Administrator acknowledged that the laboratory test ordered to check Resident #1's [MEDICATION NAME] level on 03/26/2014 had not been done. A Progress Notes Health Status (PNHS) Note entry of 04/08/2014 at 7:03 p.m. documented that Resident #1 had fallen on 04/07/2014, and a subsequent 04/08/2014, 7:15 p.m. PNHS Note documented Resident #1's hospital admission related to [MEDICATION NAME] toxicity. Resident #1's hospital History and Physical form for the resident's 04/07/2014 hospital transfer documented that the [MEDICATION NAME] level was above the therapeutic level, listed [MEDICATION NAME] toxicity as the first referenced diagnosis, and indicated that the resident would be admitted to the ICU for monitoring of the [MEDICATION NAME] level. Resident #1's hospital laboratory test report of 04/07/2014 documented the resident to have a Free [MEDICATION NAME] ([MEDICATION NAME]) level of 3.43 mcg/ml and a total [MEDICATION NAME] level of 34.5 mcg/ml (Reference/Therapeutic ranges, 1.00-2.00 mcg/ml for free [MEDICATION NAME], and 10-20 mcg/ml for total [MEDICATION NAME]). Resident #1's hospital Discharge Summary documented the resident's 04/11/2014 discharge back to the nursing facility, and documented discharge [DIAGNOSES REDACTED]. Based on the above, despite Resident #1 receiving [MEDICATION NAME] drug therapy and despite a physician's orders [REDACTED]. blood level. Later, Resident #1 fell and was transferred to the hospital, was found to have a toxic free [MEDICATION NAME] level of 3.43 mcg/ml and a toxic total [MEDICATION NAME] level of 34.5 mcg/ml, and was admitted to ICU with [DIAGNOSES REDACTED]. The facility thus failed to provide laboratory services which met the needs of Resident #1 by failing to obtain the laboratory test ordered by the physician to monitor the [MEDICATION NAME] blood level. Cross refer to F329 for more information regarding Resident #1. The immediate jeopardy was removed on 05/09/2014, at which time the facility had implemented the following credible allegation of jeopardy removal to remove the immediacy of the deficient practice: 1. On May 6, 2014, the facility reviewed the existing laboratory policies and procedures and wrote a new Physician Accepting, Transcribing, and Implementing Orders Policy, and a new Receiving, Transcribing, and Implementing Laboratory Orders Policy. 2. On May 7, 2014, the facility conducted a complete audit of all resident records to ensure that all laboratory orders and all transcribed physicians' orders had been initiated as ordered. The results of this resident chart audit were documented on the audit tool form developed by the facility. 3. On May 7, 2014, the facility initiated a system process by which all new transcribed physicians' orders and laboratory orders would be reviewed daily, Monday through Friday, in the management morning report meeting which included the Administrator, the DON, the Assistant Director of Nursing (ADON), and all Unit Managers. This review also monitored inclusion of newly transcribed physicians' orders, including orders for laboratory testing intended to monitor resident drug therapy, on resident medication administration records, treatment administration records, and/or the laboratory book. On weekend days, the Weekend Supervisor would review all transcribed physicians' orders, including orders for laboratory testing related to resident drug therapy, to ensure both transcription and completion, with the Administrator, DON, or ADON to monitor each weekend day to ensure compliance. The review would be documented on the audit monitoring and completed tools form to ensure compliance with order transcription, and to ensure laboratory tests were completed as ordered. This process is to be a permanent procedure to allow the facility's management staff to monitor on a daily basis, and to ensure, the accurate transcription and implementation of physicians' orders for resident care, including physicians' orders for laboratory testing related to resident drug therapy. 4. On May 8, 2014, the facility initiated a new procedure by which the DON, ADON, or Unit Manager would check selected resident clinical records weekly to ensure that all physicians' orders, to include physicians' orders for laboratory testing related to resident drug therapy, had been transcribed accurately. This process is to be a permanent procedure to allow management staff to conduct weekly audits to monitor for the accurate transcription and implementation of physicians' orders. 5. On May 8, 2014, the facility conducted staff in-service training for licensed nursing staff regarding the new Receiving, Transcribing, and Implementing Laboratory Orders Policy and Procedure. As of May 8, 2014, twenty-six (26), or seventy-six (76) percent, of the facility's thirty-four (34) licensed nursing staff had received this in-service training. The remaining eight (8) licensed nursing staff, who were unavailable for training at that time due to being off-duty or on leave, were to receive this in-service training upon their return to work; these licensed staff would not be allowed to provide direct resident care until completion of this in-service training. 6. On May 8, 2014, the facility implemented a procedure by which the results of the monitoring referenced above, to be documented on the audit monitoring and completed tools form, would be presented to the Quality Assurance (QA) Committee each month by the Administrator and/or the DON, to allow the QA Committee to monitor staff compliance with the facility's policies and procedures regarding the receipt, transcribing, and implementation of physicians' orders, including orders for laboratory testing, to ensure that these policies, procedures, and systems were in compliance. During this complaint survey, on the following referenced dates, each newly developed policy, procedure, and system included the facility's credible allegation of jeopardy removal was reviewed by survey staff to ensure completion and/or implementation, with the findings as follow: - On May 8, 2014, the new Physician Accepting, Transcribing, and Implementing Orders Policy and Receiving, Transcribing, and Implementing Laboratory Orders Policy were reviewed, and it was found that the facility had reviewed and modified its policies and procedures regarding physicians' orders and laboratory testing. - On May 8, 2014, the facility's resident record physicians' order/laboratory audit of May 7, 2014 was reviewed and found to have checked for resident laboratory orders and transcribed physicians' orders. - On May 8, 2014, a review was conducted of the facility's new system process, initiated on May 7, 2014 by the facility, involving the daily review of all newly transcribed physicians' orders and laboratory orders in the management morning report meeting. This review revealed monitoring of transcribed physicians' orders and their inclusion on resident medication administration records, treatment administration records, and/or the laboratory book, per the credible allegation of jeopardy removal. - On May 8, 2014, it was confirmed via procedural review that the facility had initiated a new procedure on May 8, 2014 by which DON/ADON/Unit Manager would audit selected resident records weekly to ensure accurate transcription and completion of physicians' orders. - On May 8, 2014, the licensed nursing staff in-service training for the facility's licensed nursing staff regarding the new Receiving, Transcribing, and Implementing Laboratory Orders Policy and Procedure was reviewed for completion, as indicated on the facility's credible allegation of jeopardy removal. - On May 8, 2014, it was confirmed via procedural review that the findings of clinical record audits documented on the audit monitoring and completed tools form would be reviewed at each monthly QA Committee meeting, and that the QA Committee would monitor staff compliance with the policies, procedures, and protocols for the receipt and implementation of physicians' orders. Based on the corrective actions which had been developed and implemented by the facility as outlined above, the immediacy of the deficient practice, related to the failure to obtain laboratory testing to ensure monitoring of the [MEDICATION NAME] blood level as ordered by the physician, was removed on May 9, 2014. However, the effectiveness of the corrective action plans could not be fully assessed to ensure ongoing application and completion. The facility had reviewed the existing laboratory policies and procedures and had written a new Physician Accepting, Transcribing, and Implementing Orders Policy, and a new Receiving, Transcribing, and Implementing Laboratory Orders Policy, and had initiated staff in-service training for the licensed nursing staff regarding these new Policies and Procedures. However, as of the May 9, 2014 exit date of this complaint survey, although twenty-six (26) licensed nursing staff had received this training, the remaining eight (8) licensed nursing staff had been unavailable and thus were to receive this in-service training upon their return to work. Also, on May 8, 2014, the facility initiated a new procedure by which the DON/ADON/Unit Manager would conduct selected weekly resident clinical record audits to ensure accurate transcription and implementation of physicians' orders, and the results of these audits were to be presented to the QA Committee monthly to allow the Committee to monitor facility staffs' conformance with the facility's policies, procedures, and protocols regarding the transcription and implementation of physicians' orders. However, this new audit procedure had only been implemented on May 8, 2014, with the first weekly audit scheduled to occur after the May 9, 2014 exit date of this complaint survey; therefore, the facility's ongoing compliance with this weekly monitoring procedure could not be fully assessed at the time of survey exit. Additionally, the QA Committee, which was to review the weekly clinical record audit results, had not convened at the time of survey exit, and was not scheduled to meet until the following week; thus, the Committee's ongoing process of procedural oversight regarding facility staffs' conformance with the transcription and implementation of physicians' orders, including physicians' orders for laboratory testing, could not be fully assessed at the time of survey completion. To allow for further evaluation of scheduled nursing staff in-service training regarding the new policies and procedures, supervisory staffs' weekly resident clinical record audits, and the QA Committee's ongoing oversight of conformance with physicians' orders, the noncompliance continues and the scope and severity is reduced to the "D" level.

Based on clinical record review, staff interview, and hospital document review, the facility failed to have an effective Quality Assessment and Assurance (QA) Committee which developed a process to ensure the provision of resident laboratory tests as ordered by the physician. This resulted in the failure of the facility to obtain a laboratory test ordered by the physician to check the [MEDICATION NAME] blood level of one (1) resident (#1), who received [MEDICATION NAME] drug therapy and whose daily [MEDICATION NAME] dose had recently been increased, of two (2) sampled residents receiving [MEDICATION NAME] drug therapy, on the total survey sample of nine (9) residents. Resident #1 received daily [MEDICATION NAME] drug therapy for which the daily dose had been increased per physician's orders [REDACTED]. Resident #1 was then transferred to the hospital after a fall, was found to have toxic free [MEDICATION NAME] and total [MEDICATION NAME] levels of 3.43 micrograms per milliliter (mcg/ml) and 34.5 mcg/ml, respectively, and was admitted to the Intensive Care Unit (ICU) with [DIAGNOSES REDACTED]. This failure resulted in a situation in which the facility's noncompliance with the requirements of participation caused, or had the likelihood to cause, serious harm, injury, impairment, or death to residents. The facility's Administrator and Director of Nursing (DON) were informed of the immediate jeopardy on May 6, 2014 at approximately 12:00 p.m. The non-compliance related to the immediate jeopardy was identified to have existed on March 26, 2014 (the date the facility failed to obtain the [MEDICATION NAME] blood level for Resident #1 via the ordered laboratory test), continued through May 8, 2014, and was removed on May 9, 2014. The facility implemented a credible allegation of jeopardy removal related to the immediate jeopardy on May 8, 2014. During a May 7, 2014, 1:50 p.m. interview, the Administrator acknowledged the incident involving Resident #1 having a fall and subsequent hospital transfer, and acknowledged the resident's [DIAGNOSES REDACTED].#1's [MEDICATION NAME] laboratory testing and [MEDICATION NAME] toxicity. An allegation of jeopardy removal was received on May 8, 2014. Based on the corrective plans which had been developed and implemented by the facility, the immediacy of the deficient practice was determined to have been removed on May 9, 2014, and the facility remained out of compliance at a lower scope and severity of "D" while the process of evaluating modifications of the facility's laboratory services procedures, and of obtaining laboratory services as ordered, continued. In-service materials and records were reviewed. Interviews were conducted with staff to ensure they were knowledgeable about the facility's laboratory services procedures and obtaining resident laboratory tests as ordered by the physician. Resident records were reviewed to ensure that resident laboratory tests were obtained as ordered, including those laboratory tests ordered to monitor blood levels of drug therapy to ensure accurate drug dosage titration. Findings include: Cross refer to F329. Based on record review, staff interview, and hospital document review, the facility failed to obtain laboratory testing regarding [MEDICATION NAME] drug therapy as ordered by the physician for one (1) resident (#1) who received the anticonvulsant [MEDICATION NAME], of two (2) sampled residents receiving [MEDICATION NAME] drug therapy, on the total survey sample of nine (9) residents. Resident #1 received [MEDICATION NAME] drug therapy; however, the facility failed to obtain a laboratory test ordered to determine the resident's [MEDICATION NAME] blood level. Resident #1 then fell , was transferred to the hospital, was found to have a toxic free [MEDICATION NAME] level of 3.43 mcg/ml and a toxic total [MEDICATION NAME] level of 34.5 mcg/ml, and was admitted to the ICU with [DIAGNOSES REDACTED]. An interview was conducted with the DON on 05/07/2014 at 2:30 p.m. regarding the facility's QA Committee. During this interview, the DON acknowledged Resident #1 having been admitted to the hospital and being diagnosed with [REDACTED]. When asked about the QA Committee's involvement in the corrective action plan (which had included a new Physician Accepting, Transcribing, and Implementing Orders Policy, a new Receiving, Transcribing, and Implementing Laboratory Orders Policy, and a system process involving the review of all new transcribed physicians' orders and laboratory orders during morning management report meetings Monday through Friday, and by the Weekend Supervisor on weekend days), the DON stated that the QA Committee had not been informed of the incident involving facility staffs' failure to obtain ordered laboratory testing related to Resident #1's [MEDICATION NAME] drug therapy and the resident being subsequently diagnosed with [REDACTED]. laboratory testing. The DON stated that the QA Committee would be informed of the incident involving Resident #1 the following Wednesday (05/14/2014). Based on the above, the facility failed to ensure the involvement of, and input by, the QA Committee in the development and implementation of the corrective action plan developed by the facility in response to an incident whereby the facility failed to obtain laboratory testing ordered by the physician to monitor the [MEDICATION NAME] blood level of Resident #1, with the resident then hospitalized and diagnosed with [REDACTED].#1. The facility thus failed to ensure oversight by the QA Committee of the implementation of, and facility staff's conformance with, the corrective action plan, and failed to ensure the Committee's evaluation of the effectiveness of this corrective action plan. The immediate jeopardy was removed on 05/09/2014, at which time the facility had implemented the following credible allegation of jeopardy removal to remove the immediacy of the deficient practice: 1. On May 6, 2014, the facility reviewed the existing laboratory policies and procedures and wrote a new Physician Accepting, Transcribing, and Implementing Orders Policy, and a new Receiving, Transcribing, and Implementing Laboratory Orders Policy. 2. On May 7, 2014, the facility conducted a complete audit of all resident records to ensure that all laboratory orders and all transcribed physicians' orders had been initiated as ordered. The results of this resident chart audit were documented on the audit tool form developed by the facility. 3. On May 7, 2014, the facility initiated a system process by which all new transcribed physicians' orders and laboratory orders would be reviewed daily, Monday through Friday, in the management morning report meeting which included the Administrator, the DON, the Assistant Director of Nursing (ADON), and all Unit Managers. This review also monitored inclusion of newly transcribed physicians' orders, including orders for laboratory testing intended to monitor resident drug therapy, on resident medication administration records, treatment administration records, and/or the laboratory book. On weekend days, the Weekend Supervisor would review all transcribed physicians' orders, including orders for laboratory testing related to resident drug therapy, to ensure both transcription and completion, with the Administrator, DON, or ADON to monitor each weekend day to ensure compliance. The review would be documented on the audit monitoring and completed tools form to ensure compliance with order transcription, and to ensure laboratory tests were completed as ordered. This process is to be a permanent procedure to allow the facility's management staff to monitor on a daily basis, and to ensure, the accurate transcription and implementation of physicians' orders for resident care, including physicians' orders for laboratory testing related to resident drug therapy. 4. On May 8, 2014, the facility initiated a new procedure by which the DON, ADON, or Unit Manager would check selected resident clinical records weekly to ensure that all physicians' orders, to include physicians' orders for laboratory testing related to resident drug therapy, had been transcribed accurately. This process is to be a permanent procedure to allow management staff to conduct weekly audits to monitor for the accurate transcription and implementation of physicians' orders. 5. On May 8, 2014, the facility conducted staff in-service training for licensed nursing staff regarding the new Receiving, Transcribing, and Implementing Laboratory Orders Policy and Procedure. As of May 8, 2014, twenty-six (26), or seventy-six (76) percent, of the facility's thirty-four (34) licensed nursing staff had received this in-service training. The remaining eight (8) licensed nursing staff, who were unavailable for training at that time due to being off-duty or on leave, were to receive this in-service training upon their return to work; these licensed staff would not be allowed to provide direct resident care until completion of this in-service training. 6. On May 8, 2014, the facility implemented a procedure by which the results of the monitoring referenced above, to be documented on the audit monitoring and completed tools form, would be presented to the Quality Assurance (QA) Committee each month by the Administrator and/or the DON, to allow the QA Committee to monitor staff compliance with the facility's policies and procedures regarding the receipt, transcribing, and implementation of physicians' orders, including orders for laboratory testing, to ensure that these policies, procedures, and systems were in compliance. During this complaint survey, on the following referenced dates, each newly developed policy, procedure, and system included the facility's credible allegation of jeopardy removal was reviewed by survey staff to ensure completion and/or implementation, with the findings as follow: - On May 8, 2014, the new Physician Accepting, Transcribing, and Implementing Orders Policy and Receiving, Transcribing, and Implementing Laboratory Orders Policy were reviewed, and it was found that the facility had reviewed and modified its policies and procedures regarding physicians' orders and laboratory testing. - On May 8, 2014, the facility's resident record physicians' order/laboratory audit of May 7, 2014 was reviewed and found to have checked for resident laboratory orders and transcribed physicians' orders. - On May 8, 2014, a review was conducted of the facility's new system process, initiated on May 7, 2014 by the facility, involving the daily review of all newly transcribed physicians' orders and laboratory orders in the management morning report meeting. This review revealed monitoring of transcribed physicians' orders and their inclusion on resident medication administration records, treatment administration records, and/or the laboratory book, per the credible allegation of jeopardy removal. - On May 8, 2014, it was confirmed via procedural review that the facility had initiated a new procedure on May 8, 2014 by which DON/ADON/Unit Manager would audit selected resident records weekly to ensure accurate transcription and completion of physicians' orders. - On May 8, 2014, the licensed nursing staff in-service training for the facility's licensed nursing staff regarding the new Receiving, Transcribing, and Implementing Laboratory Orders Policy and Procedure was reviewed for completion, as indicated on the facility's credible allegation of jeopardy removal. - On May 8, 2014, it was confirmed via procedural review that the findings of clinical record audits documented on the audit monitoring and completed tools form would be reviewed at each monthly QA Committee meeting, and that the QA Committee would monitor staff compliance with the policies, procedures, and protocols for the receipt and implementation of physicians' orders. Based on the corrective actions which had been developed and implemented by the facility as outlined above, the immediacy of the deficient practice, related to the failure to obtain laboratory testing to ensure monitoring of the [MEDICATION NAME] blood level as ordered by the physician, was removed on May 9, 2014. However, the effectiveness of the corrective action plans could not be fully assessed to ensure ongoing application and completion. The facility had reviewed the existing laboratory policies and procedures and had written a new Physician Accepting, Transcribing, and Implementing Orders Policy, and a new Receiving, Transcribing, and Implementing Laboratory Orders Policy, and had initiated staff in-service training for the licensed nursing staff regarding these new Policies and Procedures. However, as of the May 9, 2014 exit date of this complaint survey, although twenty-six (26) licensed nursing staff had received this training, the remaining eight (8) licensed nursing staff had been unavailable and thus were to receive this in-service training upon their return to work. Also, on May 8, 2014, the facility initiated a new procedure by which the DON/ADON/Unit Manager would conduct selected weekly resident clinical record audits to ensure accurate transcription and implementation of physicians' orders, and the results of these audits were to be presented to the QA Committee monthly to allow the Committee to monitor facility staffs' conformance with the facility's policies, procedures, and protocols regarding the transcription and implementation of physicians' orders. However, this new audit procedure had only been implemented on May 8, 2014, with the first weekly audit scheduled to occur after the May 9, 2014 exit date of this complaint survey; therefore, the facility's ongoing compliance with this weekly monitoring procedure could not be fully assessed at the time of survey exit. Additionally, the QA Committee, which was to review the weekly clinical record audit results, had not convened at the time of survey exit, and was not scheduled to meet until the following week; thus, the Committee's ongoing process of procedural oversight regarding facility staffs' conformance with the transcription and implementation of physicians' orders, including physicians' orders for laboratory testing, could not be fully assessed at the time of survey completion. To allow for further evaluation of scheduled nursing staff in-service training regarding the new policies and procedures, supervisory staffs' weekly resident clinical record audits, and the QA Committee's ongoing oversight of conformance with physicians' orders, the noncompliance continues and the scope and severity is reduced to the "D" level.

Based on record review, facility staff interview, resident interview, Wound Care Specialist Evaluation review, and Employee Statement of Events form review, the facility failed to provide care in a manner which prohibited neglect, related to warm moist compress application and resident monitoring after compress application, for one (1) resident ("A") from a survey sample of thirteen (13) residents. This failure resulted in neglect for Resident "A", when a warm moist compress was applied to the resident's left knee without nursing staff checking the compress temperature to ensure safety, and without nursing staff frequently monitoring the resident after application, per facility Procedure. Resident "A" sustained left knee blisters in an area approximately six (6) centimeters (cms) by ten (10) cms in size which required debridement, and left thigh blisters measuring approximately 0.5 cm by 0.8 cm, and 0.5 cm by 1.0 cm. in size. This resulted in a situation in which the facility's non-compliance with the requirements of participation caused, or had the likelihood to cause, serious harm, injury, impairment or death to residents. The facility's Administrator, Director of Nursing (DON), and Risk Manager were informed of the immediate jeopardy on February 3, 2014, at 11:30 a.m. The non-compliance related to the immediate jeopardy was identified to have existed on December 17, 2013 (the date a moist heat compress which had been heated in a microwave oven was applied to the left knee of Resident "A" without staff determining the temperature of the moist heat compress or frequently monitoring the resident's skin under the compress, per facility Procedure, resulting in the resident sustaining second [MEDICAL CONDITION] blistering to the left knee and thigh), continued through February 3, 2014, and was removed on February 4, 2014. The facility implemented a credible allegation of jeopardy removal related to the immediate jeopardy on February 3, 2014. During a 01/15/2014, 3:30 p.m. interview, the Administrator and Director of Nursing (DON) acknowledged that after the application of the warm moist compress to Resident "A"'s knee on 12/17/2013, the nurse should have monitored Resident "A" more frequently, as specified by the facility's Procedure regarding warm moist compress application. An allegation of jeopardy removal was received on February 3, 2014. Based on the corrective plans which had been developed and implemented by the facility, the immediacy of the deficient practice was determined to have been removed on February 3, 2014, and the facility remained out of compliance at a lower scope and severity of "D" while the facility completed a process which involved the retraining, via staff in-service, of nursing staff related to a new Policy and Procedure regarding warm moist compress use to ensure the safe use of warm moist compresses. All available nursing staff had received this in-service training, however, the training process continued as staff who were initially unavailable received this in-service training as they reported to work. In-service materials and records were reviewed. Interviews were conducted with staff to ensure they were knowledgeable about the use and application of warm moist compresses, and observations were made to assess staffs' performance of care. Findings include: Record review for Resident "A" revealed a 12/10/2013 Minimum Data Set in which Section C - Cognitive Patterns documented that the resident was cognitively intact, having a Brief Interview for Mental Status score of fifteen. Section I - Active [DIAGNOSES REDACTED]. A 12/16/2013 Physician's Telephone Orders form for Resident "A" specified application of warm moist heat to the left knee every shift for three (3) days for pain and swelling, and a 12/17/2013, 9:09 a.m. Progress Notes (PN) entry documented the 1:00 a.m., 12/17/2013 application of warm moist heat to the top the left knee using a towel in a plastic bag, wrapped in a pillowcase. Neither this PN, nor any additional medical record documentation, reflected any evidence to indicate that nursing staff determined the actual temperature of the warm moist compress prior to its placement on Resident "A"'s knee. A 12/17/2013, 9:30 a.m. PN for Resident "A" documented that at around 3:15 a.m. that morning, it was reported to Licensed Practical Nurse (LPN) "BB" that the resident had blisters on the left knee, which were confirmed on assessment. A 12/17/2013, 2:30 p.m. PN more specifically documented that Resident "A" had intact, fluid-filled left knee blisters of various sizes in an area of approximately six (6) cms by ten (10) cms, and left thigh blisters approximately 0.5 cm by 0.8 cm, and 0.5 cm by 1.0 cm. in size. Further record review for Resident "A", however, revealed no evidence to indicate that nursing staff observed Resident "A", or monitored the resident's status, after the 1:00 a.m. warm moist compress application, as documented in the 12/17/2013, 9:09 a.m. PN above, until approximately 3:15 a.m., as indicted in the 12/17/2013, 9:30 a.m. PN above. Following this two-plus hour period during which nursing staff failed to monitor Resident "A", the resident was found to have the burned, blistered areas to both the left knee and left thigh. A 12/30/2013 Wound Care Specialist Evaluation (WCSE) which documented a wound care physician's treatment of [REDACTED]. This WCSE also documented a left thigh burn wound having a total surface area of 8 cms, requiring blister roof removal. A 12/20/2013 Employee Statement of Events (ESE) written by LPN "BB" indicated that on 12/17/2013 at 1:00 a.m., she and Certified Nursing Assistant (CNA) "CC" had gone to Resident "A"'s room to apply a warm moist compress, per the resident's request. LPN "BB" indicated that once in the room, Resident "A" held the warm compress in the hand and stated it was too hot, but that at the resident's request, the warm compress was placed on the resident's knee. At 4:30 a.m., LPN "BB" went to Resident "A"'s room, after the resident called for assistance, and observed blistering. In a 12/20/2013 ESE statement, CNA "CC" indicated that on 12/17/2013 after Resident "A" requested the warm moist compress, and after the CNA heated the compress in a microwave oven for three (3) minutes, she informed LPN "BB" of heating the compress via the microwave, and she and LPN "BB" then went to the resident's room. However, CNA "CC" indicated that even though Resident "A" stated the compress was too hot, LPN "BB" touched the heated compress, stated that the compress was "fine", and allowed placement of the compress on the resident's knee. During a 12/23/2013, 12:30 p.m. interview, Resident "A" acknowledged that on 12/17/2013, he/she had informed LPN "BB" that the heated compress was too hot, but that the compress was placed on the knee anyway, and caused the burns. During a later interview conducted on 02/03/2014 at 12:45 p.m., Resident "A" also confirmed that after the warm moist compress had been applied to his/her knee on 12/17/2013, no staff, either licensed nursing staff or CNA staff, had come to check on his/her status for "two to three hours". During a 02/03/2014, 10:30 a.m. interview, the Administrator and DON acknowledged that LPN "BB" and CNA "CC" had not provided care to Resident "A" in conformance with facility policy, related to the process used for heating the warm moist compress and to monitoring the resident once the compress was applied to the knee. During an interview conducted on 02/04/2014 at 11:20 a.m. in the presence of the Administrator, DON, and Risk Manager, the DON and Risk Manager further stated that, per the facility's General Guidelines for Clean - Warm Compress Procedure, the water temperature for a warm compress was not supposed to exceed 100 degrees Fahrenheit (F), and that the nurse was supposed to frequently monitor a resident when a compress was applied. Based on the above, even though facility Procedure specified that water utilized for a warm moist compress was not to exceed 100 degrees F, and even though Procedure specified that the nurse was to check a resident frequently after the application of a heated compress, facility nursing staff neglected Resident "A" during the application of a warm moist compress. LPN "BB" allowed the application of the warm moist compress to Resident "A"'s knee after having been informed by CNA "CC" that the compress had been heated for three (3) minutes in a microwave oven, and after having been informed by Resident "A" that the heated compress was too hot to the touch. There was no evidence to indicate that the actual temperature of the heated compress was checked to ensure that it did not exceed 100 degrees F, as specified by facility Procedure, prior to application of the compress to Resident "A"'s knee. There was also no evidence to indicate that nursing staff monitored Resident "A", once the compress was applied, for a period of over two (2) hours, even though facility Procedure specified frequent monitoring. This failure by facility staff resulted in Resident "A" sustaining areas of left knee blistering approximately six (6) cms by ten (10) cms, requiring debridement, and left thigh blistering measuring approximately 0.5 cm by 0.8 cm, and 0.5 cm by 1.0 cm. Cross refer to F323 for more information regarding Resident "A". The immediate jeopardy was determined to have been removed on February 4, 2014, at which time the facility had presented and implemented an allegation of jeopardy removal which included the following corrective actions: 1.On December 17, 2013, treatment for [REDACTED]. 2.On December 17, 2013, the facility evaluated the Procedure being utilized by the facility for the use of warm moist compresses, and implemented a new Policy and Procedure, the Hot Packs/Moist Heat Standard of Practice Policy and Procedure, related to warm moist compress use. 3.On December 17, 2013, the DON, Assistant Director of Nursing (ADON), and Unit Manager reviewed residents for physicians' orders related to warm moist compresses. 4.On December 20, 2013, the LPN involved in the burn incident of Resident "A" was terminated, as the facility's investigation for neglect was substantiated. 5.On January 7, 2014, the facility modified protocol to require that the application of warm moist compresses would be accomplished through the facility's Therapy Department. 6.On January 7, 2014, the facility's Performance Improvement (PI) Committee evaluated and approved the new protocol involving the application of warm moist compresses through the Therapy Department. 7.On January 7, 2014, the facility modified facility protocol to require the Maintenance Director to check the [MEDICATION NAME] monthly regarding its operation and temperatures to ensure operation per manufacturer's specifications. This monitoring was to be documented utilizing the [MEDICATION NAME] Temperature Log Form, which will be audited monthly by the Administrator to ensure compliance. The results of these audits will be presented to the PI Committee monthly for review and any necessary corrective action. 8.On January 15, 2014, the facility modified protocol to include the Restorative Nursing staff, under the supervision of the Therapy Department, in the provision of care regarding warm moist compress application. 9.On January 15, 2014, the PI Committee reviewed the modified protocol which included Restorative Nursing staff, under the supervision of the Therapy Department, in the application of warm moist compresses to be heated via the [MEDICATION NAME]. 10.On January 15, 2014, the facility initiated a procedure by which the DON, Risk Manager, ADON, Unit Manager, or Restorative Nurse would audit the Restorative Care Flow Record bimonthly to monitor compliance with warm moist compress application and documentation, and the results of these audits will be presented to the PI Committee monthly for review and any necessary corrective action. 11.On February 3, 2014, the facility modified the Restorative Care Flow Record form to allow for the documentation of warm moist compresses which, as indicated above, had on January 15, 2014 been assigned to the Restorative Nursing staff, under the supervision of the Therapy Department. Warm compress application would be documented on the Restorative Care Flow Record, and would include the documentation of skin checks every five minutes and a twenty-minute maximum time of application. 12.On February 3, 2014, the PI Committee met and approved the Restorative Care Flow Record as the monitoring tool to be utilized during warm moist compress application. 13.On February 3, 2014, the facility continued the process of providing staff in-service training to nursing staff regarding the new Hot Packs/Moist Heat Standard of Practice Policy and Procedure, and the procedural modification of allowing only Restorative Nursing staff, under the direction of the Therapy Department, to apply warm moist compresses to residents. As of that date, the one (1) Restorative LPN, and all seven (7) Restorative Aides, had received this in-service training. A total of forty-one (41) of forty-six (46) facility CNAs (89%) had received in-service training, and thirty-four (34) of forty-two (42) licensed nursing staff (81%), both Registered Nurses and LPNs, had received this in-service training. The remaining eight (8) licensed nursing staff and five (5) CNAs were to receive this in-service training as they returned to work, and prior to providing direct resident care, to ensure compliance. Based on these corrective actions which had been developed and implemented by the facility as outlined above, the immediacy of the deficient practice was removed on February 4, 2013. However, at the time of survey exit, the effectiveness of these corrective action plans could not be fully assessed to ensure ongoing application and completion. On December 17, 2013, the facility implemented the new the Hot Packs/Moist Heat Standard of Practice Policy and Procedure. On January 7, 2014, the facility modified its protocol to require monthly [MEDICATION NAME] temperature checks by the Maintenance Director via the [MEDICATION NAME] Temperature Log Form, which was to be audited monthly by the Administrator and the audit results to be submitted to the PI Committee. On January 15, 2014, the facility specified that Restorative Nursing staff, under the supervision of the Therapy Department, would provide warm moist compress application, and the DON/Risk Manager/ADON/Unit Manager would audit the Restorative Care Flow Record bimonthly to monitor compliance and report the audit results to the PI Committee monthly. As of February 3, 2014, all eight (8) Restorative Nursing staff had received in-service training on the new Hot Packs/Moist Heat Standard of Practice Policy and Procedure, the procedural modification specifying that only Restorative Nursing staff provide warm moist compress therapy, and the use of the [MEDICATION NAME] Temperature Log. Additionally, forty-one (41) of forty-six (46) facility CNAs, and thirty-four (34) of forty-two (42) licensed nursing staff had received this in-service training, regarding the new Policy and Procedure as referenced above, as of that date. However, eight (8) licensed nursing staff and five (5) CNAs had not yet received this in-service training, due to their having been unavailable, and would therefore be required to receive this training as they returned to work to ensure competency. Therefore, the training of these remaining nursing staff members could not be evaluated at the time of survey completion and will need to be evaluated at a future time. In addition, the facility had implemented routine auditing by administrative staff of nursing staffs' conformance related to the new Policy and Procedure, utilizing the [MEDICATION NAME] Temperature Log and the Restorative Care Flow Record, with the results of these audits to be submitted to the PI Committee for their review and development of any needed corrective actions. The PI Committee had met on January 7, 2014 and February 3, 2014 to review and approve the newly-implemented Policy and Procedure changes as referenced above, but the PI Committee's ongoing oversight, via reports of administrative staff audits, of facility nursing staffs' compliance with these new procedural changes will need to be evaluated after subsequent monthly PI Committee meetings, and thus could not be evaluated at the time of survey completion. Therefore, the non-compliance continues, but the scope and severity is reduced to the "D" level.

Based on record review, facility staff interview, facility General Guidelines For Clean-Warm Compress Procedure review, and Employee Statement of Events form review, the facility failed to review and revise the Care Plan of one (1) resident ("A"), related to an order specifying the application of a warm moist compress, from a survey sample of thirteen (13) residents. For Resident "A", the resident's Care Plan was not revised, as specified by facility Procedure, to reflect the receipt of a physician's orders [REDACTED]. This failure resulted in a certified nursing assistant, rather than a licensed nurse as specified by facility Procedure, applying a warm moist compress to the left knee of Resident "A", and nursing staff then failing to monitor Resident "A"'s skin after application of the compress for over two (2) hours. Resident "A" was found to have left knee blisters in an area approximately six (6) centimeters (cms) by ten (10) cms, and left thigh blisters measuring approximately 0.5 cm by 0.8 cm, and 0.5 cm by 1.0 cm. This resulted in a situation in which the facility's non-compliance with the requirements of participation caused, or had the likelihood to cause, serious harm, injury, impairment or death to residents. The facility's Administrator, Director of Nursing (DON), and Risk Manager were informed of the immediate jeopardy on February 3, 2014, at 11:30 a.m. The non-compliance related to the immediate jeopardy was identified to have existed on December 17, 2013 (the date a moist heat compress which had been heated in a microwave oven was applied to the left knee of Resident "A", without staff checking the temperature of the moist heat compress or frequently monitoring the resident's skin under the compress, per Procedure, resulting second [MEDICAL CONDITION] blistering to the left knee and thigh), continued through February 3, 2014, and was removed on February 4, 2014. The facility implemented a credible allegation of jeopardy removal related to the immediate jeopardy on February 3, 2014. During a 01/15/2014, 3:30 p.m. interview, the Administrator and Director of Nursing (DON) acknowledged the incident of 12/17/2013 during which Resident"A" [MEDICAL CONDITION] application of a warm moist compress by Certified Nursing Assistant (CNA) "CC". During an interview with the Administrator, DON, and Risk Manager conducted on 02/03/2014 at 11:30 a.m., the DON stated that staff were expected to follow facility policy regarding warm moist compress application, including compress temperature and monitoring. However, during a later interview conducted on 02/04/2014 at 11:20 a.m. with the Administrator, DON, and Risk Manager, the DON and the Risk Manager acknowledged that facility Procedure did not give clear instructions regarding heating and monitoring warm moist compresses, and thus failed to instruct staff as to the method by which to use compresses. An allegation of jeopardy removal was received on February 3, 2014. Based on the corrective plans which had been developed and implemented by the facility, the immediacy of the deficient practice was determined to have been removed on February 3, 2014, and the facility remained out of compliance at a lower scope and severity of "D" while the facility completed a process which involved the retraining, via staff in-service, of nursing staff related to a new Policy and Procedure regarding warm moist compress use to ensure the safe use of warm moist compresses. All available nursing staff had received this in-service training, however, the training process continued as staff who were initially unavailable received this in-service training as they reported to work. In-service materials and records were reviewed. Interviews were conducted with staff to ensure they were knowledgeable about the use and application of warm moist compresses, and observations were made to assess staffs' performance of care. Findings include: The facility's General Guidelines for Clean-Warm Compress Procedure specified, in the Care Plan Documentation Guideline section, that when a warm compress was to be used, the use of the compress would be listed as an Approach (Intervention) under the appropriate Care Plan Problem (Focus area). This Guideline section also specified that the Care Plan Approaches should list instructions for the application of the compress which were unique to each resident, and should include the discipline responsible for application. This Procedure also specified that only licensed nurses were to apply warm moist compresses. Record review for Resident "A" revealed a Minimum Data Set of 12/10/2013 which documented in Section C - Cognitive Patterns a Brief Interview for Mental Status score of 15, indicating the resident was cognitively intact, and documented in Section I - Active [DIAGNOSES REDACTED]. A 12/16/2013 Physician's Telephone Orders form for Resident "A" specified the application of warm moist heat to the left knee every shift for three (3) days for pain and swelling. Resident "A"'s current Care Plan referenced a Focus area, originally dated 10/28/2011 and dated as last reviewed on 12/10/2013, which indicated that the resident had chronic pain related to a chronic physical disability, and listed multiple Interventions to address this identified problem. However, even though the Physician's Telephone Orders form of 12/16/2013 referenced above specified the application of warm moist heat to Resident "A"'s left knee every shift for three days for pain and swelling, and even though the facility's General Guidelines for Clean - Warm Compress Procedure specified that the warm compress and instructions for its use would be listed on the Care Plan, further review of Resident "A"'s Care Plan revealed no evidence to indicate that the Care Plan had been reviewed and revised to reflect the use of the warm moist compress and the instructions for its use. A 12/17/2013, 9:09 a.m. Progress Notes (PN) entry for Resident "A" documented that at 1:00 a.m. on that date, warm moist heat had been applied by a CNA (instead of a licensed nurse, per facility Procedure) to the resident's left knee. A 12/17/2013, 9:30 a.m. PN then documented that at around 3:15 a.m. on that date, staff reported that Resident "A" had blisters to the left knee, requiring physician notification, and a 12/17/2013, 2:30 p.m. PN documented fluid-filled blisters to the left knee in an area measuring approximately six (6) cms by ten (10) cms, and thigh blisters measuring approximately 0.5 cm by 0.8 cm, and 0.5 cm by 1.0 cm. In a 12/20/2013 Employee Statement of Events, Licence Practical Nurse (LPN) "BB" indicated that on 12/17/2013 at 1:00 a.m., CNA "CC" informed her that Resident "A" requested the application of a warm compress to the left knee. LPN "BB" indicated that she had gone to Resident "A"'s room and the warm compress was placed on the resident's knee. LPN "BB" indicated that at 4:30 a.m., Resident "A" called and CNA "CC" first responded, then LPN "BB" went to Resident "A"s room to observe left knee blisters. In a 12/20/13 Employee Statement of Events, CNA "CC" indicated that on 12/17/13 at 1:00 a.m., when Resident "A" requested a warm compress, she had asked another CNA how to heat the compress because she had not performed that procedure before for this resident. CNA "CC" indicated that she was told by the other CNA to heat the compress in the microwave oven for three (3) minutes, which she had done before the compress was placed on the resident's knee. CNA "CC" indicated that she next checked Resident "A" at 4:00 a.m. and found blistering on the resident's knee. During a 01/15/2014, 3:30 p.m. interview with the Administrator and DON, these staff members acknowledged that Resident "A" had not received care, as per facility policy, related to the application of the warm moist compress, further stating that CNA "CC" should not have been involved in the application of the knee compress. Based on the above, the facility failed to include in the Care Plan of Resident "A", per facility Procedure, the use of a warm moist compress to the left knee, the instructions for the preparation and use of the warm moist compress, and the discipline responsible for application of the warm moist compress, to ensure that nursing staff had instructions for the safe use of warm moist compresses. A moist compress was then heated in a microwave by CNA "CC", after she consulted another CNA about the procedure for heating the compress due to CNA "CC"'s stated lack of knowledge, and lack of instructions for preparation and use, regarding the process. CNA "CC" then applied the heated warm moist compress to the knee of Resident "A", against facility Procedure, and nursing staff then failed to monitor the resident for a period which exceeded two (2) hours. Resident "A" was later found to have left knee fluid-filled blisters in an area approximately six (6) cms by ten (10) cms, which required debridement, and left thigh blisters measuring approximately 0.5 cm by 0.8 cm, and 0.5 cm by 1.0 cm. Cross refer to F323 for more information regarding Resident "A". The immediate jeopardy was determined to have been removed on February 4, 2014, at which time the facility had presented and implemented an allegation of jeopardy removal which included the following corrective actions: 1. On December 17, 2013, treatment for [REDACTED]. 2. On December 17, 2013, the facility evaluated the Procedure being utilized by the facility for the use of warm moist compresses, and implemented a new Policy and Procedure, the Hot Packs/Moist Heat Standard of Practice Policy and Procedure, related to warm moist compress use. 3. On December 17, 2013, the DON, Assistant Director of Nursing (ADON), and Unit Manager reviewed residents for physicians' orders related to warm moist compresses. 4. On December 20, 2013, the LPN involved in the burn incident of Resident "A" was terminated, as the facility's investigation for neglect was substantiated. 5. On January 7, 2014, the facility modified facility protocol to indicate that the application of warm moist compresses would be accomplished through the facility's Therapy Department. 6. On January 7, 2014, the facility's Performance Improvement (PI) Committee evaluated and approved the new protocol involving the application of warm moist compresses through the Therapy Department. 7. On January 7, 2014, the facility modified facility protocol to require the Maintenance Director to check the [MEDICATION NAME] monthly regarding its operation and temperatures to ensure operation per manufacturer's specifications. This monitoring was to be documented utilizing the [MEDICATION NAME] Temperature Log Form, which will be audited monthly by the Administrator to ensure compliance. The results of these audits will be presented to the PI Committee monthly for review and any necessary corrective action. 8. On January 15, 2014, the facility modified protocol to include the Restorative Nursing staff, under the supervision of the Therapy Department, in the provision of care regarding warm moist compress application. 9. On January 15, 2014, the PI Committee reviewed the modified protocol which included Restorative Nursing staff, under the supervision of the Therapy Department, in the application of warm moist compresses to be heated via the [MEDICATION NAME]. 10. On January 15, 2014, the facility initiated a procedure by which the DON, Risk Manager, ADON, Unit Manager, or Restorative Nurse would audit the Restorative Care Flow Record bimonthly to monitor compliance with warm moist compress application and documentation, and the results of these audits will be presented to the PI Committee monthly for review and any necessary corrective action. 11. On February 3, 2014, the facility modified the Restorative Care Flow Record form to allow for the documentation of warm moist compresses which, as indicated above, had on January 15, 2014 been assigned to the Restorative Nursing staff, under the supervision of the Therapy Department. Warm compress application would be documented on the Restorative Care Flow Record, and would include the documentation of skin checks every five minutes and a twenty-minute maximum time of application. 12. On February 3, 2014, the PI Committee met and approved the Restorative Care Flow Record as the monitoring tool to be utilized during warm moist compress application. 13. On February 3, 2014, the facility continued the process of providing staff in-service training to nursing staff regarding the new Hot Packs/Moist Heat Standard of Practice Policy and Procedure, and the procedural modification of allowing only Restorative Nursing staff, under the direction of the Therapy Department, to apply warm moist compresses to residents. As of that date, the one (1) Restorative LPN, and all seven (7) Restorative Aides, had received this in-service training. A total of forty-one (41) of forty-six (46) facility CNAs (89%) had received in-service training, and thirty-four (34) of forty-two (42) licensed nursing staff (81%), both Registered Nurses and LPNs, had received this in-service training. The remaining eight (8) licensed nursing staff and five (5) CNAs were to receive this in-service training as they returned to work, and prior to providing direct resident care, to ensure compliance. Based on these corrective actions which had been developed and implemented by the facility as outlined above, the immediacy of the deficient practice was removed on February 4, 2013. However, at the time of survey exit, the effectiveness of these corrective action plans could not be fully assessed to ensure ongoing application and completion. On December 17, 2013, the facility implemented the new the Hot Packs/Moist Heat Standard of Practice Policy and Procedure. On January 7, 2014, the facility modified is protocol to require monthly [MEDICATION NAME] temperature checks by the Maintenance Director via the [MEDICATION NAME] Temperature Log Form, which was to be audited monthly by the Administrator and the audit results to be submitted to the PI Committee. On January 15, 2014, the facility specified that Restorative Nursing staff, under the supervision of the Therapy Department, would provide warm moist compress application, and the DON/Risk Manager/ADON/Unit Manager would audit the Restorative Care Flow Record bimonthly to monitor compliance and report the audit results to the PI Committee monthly. As of February 3, 2014, all eight (8) Restorative Nursing staff had received in-service training on the new Hot Packs/Moist Heat Standard of Practice Policy and Procedure, the procedural modification specifying that only Restorative Nursing staff provide warm moist compress therapy, and the use of the [MEDICATION NAME] Temperature Log. Additionally, forty-one (41) of forty-six (46) facility CNAs, and thirty-four (34) of forty-two (42) licensed nursing staff had received this in-service training, regarding the new Policy and Procedure as referenced above, as of that date. However, eight (8) licensed nursing staff and five (5) CNAs had not yet received this in-service training, due to their having been unavailable, and would therefore be required to receive this training as they returned to work to ensure competency. Therefore, the training of these remaining nursing staff members could not be evaluated at the time of survey completion and will need to be evaluated at a future time. In addition, the facility had implemented routine auditing by administrative staff of nursing staffs' conformance related to the new Policy and Procedure, utilizing the [MEDICATION NAME] Temperature Log and the Restorative Care Flow Record, with the results of these audits to be submitted to the PI Committee for their review and development of any needed corrective actions. The PI Committee had met on January 7, 2014 and February 3, 2014 to review and approve the newly-implemented Policy and Procedure changes as referenced above, but the PI Committee's ongoing oversight, via reports of administrative staff audits, of facility nursing staffs' compliance with these new procedural changes will need to be evaluated after subsequent monthly PI Committee meetings, and thus could not be evaluated at the time of survey completion. Therefore, the non-compliance continues, but the scope and severity is reduced to the "D" level.

Based on record review, facility staff interview, National Council of State Boards of Nursing Model Nursing Practice Act and Model Nursing Administrative Rules review, facility General Guidelines for Clean-Warm Compress Procedure review, and Employee Statement of Events form review, the facility failed to ensure that services were provided in accordance with professional standards of quality, related to the monitoring of a warm moist compress for one (1) resident ("A") from a survey sample of thirteen (13) residents. This failure to provide services in accordance with professional quality standards resulted in nursing staff failing to monitor Resident "A" for over two (2) hours after the application of a warm moist compress to the resident's left knee. Resident "A" was then found to have a cluster of left knee blisters in an area approximately six (6) centimeters (cms) by ten (10) cms, which required debridement, and left thigh blisters measuring approximately 0.5 cm by 0.8 cm, and 0.5 cm by 1.0 cm. This resulted in a situation in which the facility's non-compliance with the requirements of participation caused, or had the likelihood to cause, serious harm, injury, impairment or death to residents. The facility's Administrator, Director of Nursing (DON), and Risk Manager were informed of the immediate jeopardy on February 3, 2014, at 11:30 a.m. The non-compliance related to the immediate jeopardy was identified to have existed on December 17, 2013 (the date a warm moist compress which had been heated in a microwave oven was applied to the left knee of Resident "A", without staff determining the actual temperature of the moist heat compress or frequently monitoring the resident's skin under the compress, per facility Procedure and in accordance with Nursing Standards of Practice, resulting in the resident sustaining second [MEDICAL CONDITION] blistering to the left knee and thigh), continued through February 3, 2014, and was removed on February 4, 2014. The facility implemented a credible allegation of jeopardy removal related to the immediate jeopardy on February 3, 2014. During a 01/15/2014, 3:30 p.m. interview, the Administrator and Director of Nursing (DON) acknowledged the 12/17/2013 incident which resulted in Resident"A" sustaining from the application of a warm moist compress by Certified Nursing Assistant (CNA) "CC". The Administrator and DON acknowledged that the facility's Procedure required that Licensed Practical Nurse (LPN) "BB", who should have applied the warm moist compress, to provide more frequent monitoring of Resident "A" once the compress was applied. An allegation of jeopardy removal was received on February 3, 2014. Based on the corrective plans which had been developed and implemented by the facility, the immediacy of the deficient practice was determined to have been removed on February 3, 2014, and the facility remained out of compliance at a lower scope and severity of "D" while the facility completed a process which involved the retraining, via staff in-service, of nursing staff related to a new Policy and Procedure regarding warm moist compress use to ensure the safe use of warm moist compresses. All available nursing staff had received this in-service training, however, the training process continued as staff who were initially unavailable received this in-service training as they reported to work. In-service materials and records were reviewed. Interviews were conducted with staff to ensure they were knowledgeable about the use and application of warm moist compresses, and observations were made to assess staffs' performance of care. Findings include: Review of the National Council of State Boards of Nursing Model Nursing Practice Act and Model Nursing Administrative Rules revealed that Chapter 2 - Standards of Nursing Practice, Section 2.3.2, Standards Related to Licensed Practical Nurse (LPN/VN) Responsibilities for Nursing Practice Implementation, requires in Section 2.3.2(c) that the nurse demonstrates attentiveness and provides client surveillance and monitoring. Review of Resident "A"'s clinical record revealed that Section C - Cognitive Patterns of the 12/10/2013 Minimum Data Set documented a Brief Interview for Mental Status score of 15, indicating that the resident was cognitively intact, and Section I - Active [DIAGNOSES REDACTED]. A 12/16/2013 Physician's Telephone Orders form specified the application of warm moist heat to Resident "A"'s left knee every shift for three (3) days. A 12/17/2013, 9:09 a.m. Progress Notes (PN) entry documented that at 1:00 a.m. on that date, LPN "BB" had been informed of the application of warm moist heat by a CNA to Resident "A"'s left knee. However, additional record review revealed no evidence to indicate that LPN "BB", or any licensed nursing staff, provided frequent monitoring of Resident "A" on 12/17/2013 after the 1:00 a.m. application of the warm moist heat pack to the resident's left knee, even though the facility's General Guidelines for Clean-Warm Compress Procedure specified that nursing staff check the resident's skin beneath a compress frequently, and even though the National Council of State Boards of Nursing Model Nursing Practice Act and Model Nursing Administrative Rules required that the nurse provide attentiveness and monitoring to the resident. Instead, a 12/17/2013, 9:30 a.m. PN documented that at around 3:15 a.m. (over two hours after application of the most heat pack), it was reported to the nurse that Resident "A" had left knee blisters. A subsequent 12/17/2013, 2:30 p.m. PN documented that Resident "A" had sustained fluid-filled blisters on the left knee in a clustered area approximately six (6) centimeters (cms) by ten (10) cms, and thigh blisters approximately 0.5 cm by 0.8 cm, and 0.5 cm by 1.0 cm. In a 12/20/2013 Employee Statement of Events written statement, LPN "BB" (the licensed nurse referenced in the 12/17/2013, 9:09 a.m. and 9:30 a.m. PNs above) indicated that on 12/17/2013 at 1:00 a.m., she had been told by CNA "CC" that Resident "A" requested a warm compress to the left knee, and went to the resident's room to observe the resident holding the warm pad in his/her hand. LPN "BB" indicated that Resident "A" told her that the warm compress was too hot, but further indicated that because the resident requested for the warm compress be placed on the knee, it was placed on the knee. Nowhere in this written statement did LPN "BB" indicate that she provided frequent monitoring, or any monitoring, of Resident "A" (as specified by facility Procedure, and by the Standards of Nursing Practice referenced above) after the warm compress was put into place on 12/17/2013 at approximately 1:00 a.m. In fact, instead of providing frequent monitoring of Resident "A" upon application of the warm moist compress, LPN "BB" indicated in this written statement that she instructed the resident to call when the warm moist compress got cool. LPN "BB" further indicated that at 4:30 a.m., Resident "A" did call, and at that time, the LPN went to Resident "A"s room and observed the blisters. In a 12/20/2013 Employee Statement of Events statement, CNA "CC" indicated that on 12/17/2013 at 1:00 a.m., she told LPN "BB" that she had warmed Resident "A"'s warm moist compress in the microwave. CNA "CC" further indicated that once she and LPN "BB" had gone to Resident "A"'s room, Resident "A" had told LPN "BB" that the heated compress was too hot as the resident held the compress in his/her hand, but that LPN "BB" felt of the heated compress and stated that the compress was "fine, the hotter the better", and the heated warm compress was then placed on Resident "A"'s knee. During an interview conducted on 12/23/2013 at 1:30 p.m., the Administrator acknowledged that on the evening when Resident "A" [MEDICAL CONDITION] the heated compress, LPN "BB" had allowed the placement of the warm moist compress even after Resident "A" had told LPN "BB" that the compress was too hot when touched with his/her hand. During a subsequent interview with the Administrator and Director of Nursing conducted on 02/03/2014 at 10:30 a.m., these staff members stated that LPN "BB" should have checked the status of Resident "A"'s warm compress immediately upon application to the knee, then every ten (10) minutes thereafter, allowing the compress to stay on for a maximum of twenty (20) minutes. Based on the above, even though professional standards of practice specified that a nurse demonstrate attentiveness and provide client surveillance and monitoring, and even though facility Procedure specified frequent monitoring upon the application of a moist heat pack to a resident, a warm moist compress was applied to Resident "A"'s knee even though the resident stated it was too hot, and then LPN "BB" failed to monitor the resident for a period exceeding two (2) hours. Thus, facility licensed nursing staff failed to demonstrate attentiveness and provide monitoring to Resident "A", in accordance with the Standards of Nursing Practice referenced above. As a result, Resident "A" was found to have left knee fluid-filled blisters in a clustered area approximately six (6) cms by ten (10) cms, which required debridement, and left thigh blisters measuring approximately 0.5 cm by 0.8 cm, and 0.5 cm by 1.0 cm. Cross refer to F323 for more information regarding Resident "A". The immediate jeopardy was determined to have been removed on February 4, 2014, at which time the facility had presented and implemented an allegation of jeopardy removal which included the following corrective actions: 1. On December 17, 2013, treatment for [REDACTED]. 2. On December 17, 2013, the facility evaluated the Procedure being utilized by the facility for the use of warm moist compresses, and implemented a new Policy and Procedure, the Hot Packs/Moist Heat Standard of Practice Policy and Procedure, related to warm moist compress use. 3. On December 17, 2013, the DON, Assistant Director of Nursing (ADON), and Unit Manager reviewed residents for physicians' orders related to warm moist compresses. 4. On December 20, 2013, the LPN involved in the burn incident of Resident "A" was terminated, as the facility's investigation for neglect was substantiated. 5. On January 7, 2014, the facility modified facility protocol to indicate that the application of warm moist compresses would be accomplished through the facility's Therapy Department. 6. On January 7, 2014, the facility's Performance Improvement (PI) Committee evaluated and approved the new protocol involving the application of warm moist compresses through the Therapy Department. 7. On January 7, 2014, the facility modified facility protocol to require the Maintenance Director to check the [MEDICATION NAME] monthly regarding its operation and temperatures to ensure operation per manufacturer's specifications. This monitoring was to be documented utilizing the [MEDICATION NAME] Temperature Log Form, which will be audited monthly by the Administrator to ensure compliance. The results of these audits will be presented to the PI Committee monthly for review and any necessary corrective action. 8. On January 15, 2014, the facility modified protocol to include the Restorative Nursing staff, under the supervision of the Therapy Department, in the provision of care regarding warm moist compress application. 9. On January 15, 2014, the PI Committee reviewed the modified protocol which included Restorative Nursing staff, under the supervision of the Therapy Department, in the application of warm moist compresses to be heated via the [MEDICATION NAME]. 10. On January 15, 2014, the facility initiated a procedure by which the DON, Risk Manager, ADON, Unit Manager, or Restorative Nurse would audit the Restorative Care Flow Record bimonthly to monitor compliance with warm moist compress application and documentation, and the results of these audits will be presented to the PI Committee monthly for review and any necessary corrective action. 11. On February 3, 2014, the facility modified the Restorative Care Flow Record form to allow for the documentation of warm moist compresses which, as indicated above, had on January 15, 2014 been assigned to the Restorative Nursing staff, under the supervision of the Therapy Department. Warm compress application would be documented on the Restorative Care Flow Record, and would include the documentation of skin checks every five minutes and a twenty-minute maximum time of application. 12. On February 3, 2014, the PI Committee met and approved the Restorative Care Flow Record as the monitoring tool to be utilized during warm moist compress application. 13. On February 3, 2014, the facility continued the process of providing staff in-service training to nursing staff regarding the new Hot Packs/Moist Heat Standard of Practice Policy and Procedure, and the procedural modification of allowing only Restorative Nursing staff, under the direction of the Therapy Department, to apply warm moist compresses to residents. As of that date, the one (1) Restorative LPN, and all seven (7) Restorative Aides, had received this in-service training. A total of forty-one (41) of forty-six (46) facility CNAs (89%) had received in-service training, and thirty-four (34) of forty-two (42) licensed nursing staff (81%), both Registered Nurses and LPNs, had received this in-service training. The remaining eight (8) licensed nursing staff and five (5) CNAs were to receive this in-service training as they returned to work, and prior to providing direct resident care, to ensure compliance. Based on these corrective actions which had been developed and implemented by the facility as outlined above, the immediacy of the deficient practice was removed on February 4, 2013. However, at the time of survey exit, the effectiveness of these corrective action plans could not be fully assessed to ensure ongoing application and completion. On December 17, 2013, the facility implemented the new the Hot Packs/Moist Heat Standard of Practice Policy and Procedure. On January 7, 2014, the facility modified is protocol to require monthly [MEDICATION NAME] temperature checks by the Maintenance Director via the [MEDICATION NAME] Temperature Log Form, which was to be audited monthly by the Administrator and the audit results to be submitted to the PI Committee. On January 15, 2014, the facility specified that Restorative Nursing staff, under the supervision of the Therapy Department, would provide warm moist compress application, and the DON/Risk Manager/ADON/Unit Manager would audit the Restorative Care Flow Record bimonthly to monitor compliance and report the audit results to the PI Committee monthly. As of February 3, 2014, all eight (8) Restorative Nursing staff had received in-service training on the new Hot Packs/Moist Heat Standard of Practice Policy and Procedure, the procedural modification specifying that only Restorative Nursing staff provide warm moist compress therapy, and the use of the [MEDICATION NAME] Temperature Log. Additionally, forty-one (41) of forty-six (46) facility CNAs, and thirty-four (34) of forty-two (42) licensed nursing staff had received this in-service training, regarding the new Policy and Procedure as referenced above, as of that date. However, eight (8) licensed nursing staff and five (5) CNAs had not yet received this in-service training, due to their having been unavailable, and would therefore be required to receive this training as they returned to work to ensure competency. Therefore, the training of these remaining nursing staff members could not be evaluated at the time of survey completion and will need to be evaluated at a future time. In addition, the facility had implemented routine auditing by administrative staff of nursing staffs' conformance related to the new Policy and Procedure, utilizing the [MEDICATION NAME] Temperature Log and the Restorative Care Flow Record, with the results of these audits to be submitted to the PI Committee for their review and development of any needed corrective actions. The PI Committee had met on January 7, 2014 and February 3, 2014 to review and approve the newly-implemented Policy and Procedure changes as referenced above, but the PI Committee's ongoing oversight, via reports of administrative staff audits, of facility nursing staffs' compliance with these new procedural changes will need to be evaluated after subsequent monthly PI Committee meetings, and thus could not be evaluated at the time of survey completion. Therefore, the non-compliance continues, but the scope and severity is reduced to the "D" level.

Based on observation, record review, facility staff interview, resident interview, Wound Care Physician interview, facility General Guidelines For Clean-Warm Compress Procedure review, Wound Care Specialist Evaluation review, and Employee Statement of Events form review, the facility failed to ensure the application of a warm moist compress by licensed nursing staff, per facility Procedure, failed to check the temperature of the heated warm moist compress prior to application, per facility Procedure, and failed to ensure frequent monitoring after the application of the warm moist compress, per facility Procedure, for one (1) resident ("A") from a survey sample of thirteen (13) residents. This failure resulted in a certified nursing assistant applying a warm moist compress to the left knee of Resident "A", with staff then failing to assess the condition of the resident's skin after the application of the compress for over two (2) hours. Resident "A" was then found to have sustained left knee blisters in a clustered area measuring approximately six (6) centimeters (cms) by ten (10) cms which required debridement, and left thigh blisters measuring approximately 0.5 cm by 0.8 cm, and 0.5 cm by 1.0 cm. This resulted in a situation in which the facility's non-compliance with the requirements of participation caused, or had the likelihood to cause, serious harm, injury, impairment or death to residents. The facility's Administrator, Director of Nursing (DON), and Risk Manager were informed of the immediate jeopardy on February 3, 2014, at 11:30 a.m. The non-compliance related to the immediate jeopardy was identified to have existed on December 17, 2013 (the date a moist heat compress which had been heated in a microwave oven was applied to the left knee of Resident "A", without staff ascertaining the temperature of the moist heat compress or frequently monitoring the resident's skin under the compress, per facility Procedure, resulting in the resident sustaining second degree burns and blistering to the left knee and thigh), continued through February 3, 2014, and was removed on February 4, 2014. The facility implemented a credible allegation of jeopardy removal related to the immediate jeopardy on February 3, 2014. During a 01/15/2014, 3:30 p.m. interview, the Administrator and Director of Nursing (DON) acknowledged the incident of 12/17/2013 during which Resident"A" sustained burns after application of a warm moist compress by Certified Nursing Assistant (CNA) "CC" after the CNA had heated the compress in a microwave oven. The Administrator and DON stated that, per facility Procedure, a licensed nurse, not a CNA, should have applied the compress, and that nursing staff should have monitored Resident "A" more frequently after the application of the heated compress, per facility Protocol, and that facility Procedure related to Resident "A"'s warm moist compress application had not been followed. An allegation of jeopardy removal was received on February 3, 2014. Based on the corrective plans which had been developed and implemented by the facility, the immediacy of the deficient practice was determined to have been removed on February 3, 2014, and the facility remained out of compliance at a lower scope and severity of "D" while the facility completed a process which involved the retraining, via staff in-service, of nursing staff related to a new Policy and Procedure regarding warm moist compress use to ensure the safe use of warm moist compresses. All available nursing staff had received this in-service training, however, the training process continued as staff who were initially unavailable received this in-service training as they reported to work. In-service materials and records were reviewed. Interviews were conducted with staff to ensure they were knowledgeable about the use and application of warm moist compresses, and observations were made to assess staffs' performance of care. Findings include: The facility's General Guidelines for Clean-Warm Compress Procedure specified that a licensed nurse was responsible for the application of a warm moist compress. This Procedure specified that the temperature of the water or prescribed solution utilized for a warm compress was not to exceed 100 degrees Fahrenheit (F). The Procedure also specified that nursing staff were to check a resident's skin beneath the compress frequently for tenderness, pain, and extreme redness, and that treatment was to be discontinued if these complications occurred. Record review for Resident "A" revealed that the Quarterly Minimum Data Set (MDS) assessment having an Assessment Reference Date of 12/10/2013 documented in Section C - Cognitive Patterns that the resident had a Brief Interview for Mental Status score of 15, indicating that the resident was cognitively intact. Section I - Active [DIAGNOSES REDACTED]. Section G - Functional Status documented that Resident "A" required supervision/oversight with eating, but was totally dependent on staff for all other Activities of Daily Living. Review of Resident "A"'s clinical record revealed a Physician's Telephone Orders form of 12/16/2013 which specified the application of warm moist heat to the resident's left knee every shift for three (3) days for pain and swelling. A Progress Notes (PN) entry dated 12/17/2013, timed at 9:09 a.m. and labeled as a Status Note, documented that at 1:00 a.m. on 12/17/2013, a CNA had applied warm moist heat to the top of Resident "A"'s left knee, per the resident's request. This PN documented that a towel placed inside a plastic bag, and then wrapped in a pillowcase cover, had been applied to the resident's left knee, and that the resident had been instructed to call for staff when the heat pack got cool. However, the application of the warm moist compress to Resident "A"'s knee by a CNA, as documented in the 12/17/2013 9:09 a.m. PN referenced above, was in violation of the facility's General Guidelines for Clean-Warm Compress Procedure, as referenced above, which specified that the compress was to be applied by a licensed nurse. Additionally, review of Resident "A"'s clinical record, to include review of this PN, revealed no evidence to indicate that nursing staff checked the temperature of the warm moist compress, before application of the compress, to ensure that the temperature did not exceed 100 degrees F, as specified by the General Guidelines for Clean-Warm Compress Procedure. A later PN entry of 12/17/2013, timed at 9:30 a.m. and labeled as a Skin/Wound Note, for Resident "A" documented that earlier on 12/17/2013 at around 3:15 a.m., staff had reported to the nurse that Resident "A" had blisters from the heat which had been applied to the left knee. This PN documented that assessment at that time revealed blisters and redness on the resident's left knee, and that the physician, when contacted, had ordered the application of antibiotic ointment to the blisters. A 12/17/2013 Physician's Telephone Orders form for Resident "A" specified that Triple Antibiotic Ointment be applied to the blisters, and another 12/17/2013 Physician's Telephone Order's form specified a skin preparation to the intact blisters on Resident "A"'s left knee, then the application of Silvadene (silver sulfadiazine) Ointment twice daily to the left knee blisters when opened until healed. A PN entry of 12/17/2013, timed at 2:30 p.m. and labeled as a Skin/Wound Note, for Resident "A" documented that assessment of the resident had revealed intact, fluid-filled blisters of various sizes on the left knee, in a total clustered area measuring approximately six (6) cms by ten (10) cms. This PN also documented intact blisters measuring approximately 0.5 cm by 0.8 cm, and 0.5 cm by 1.0 cm, with a red area surrounding the blisters approximately 5 cms in size, to the resident's left thigh above the knee. However, despite the facility's General Guidelines for Clean-Warm Compress Procedure referenced above which specified that the nurse was to check a resident's skin beneath a warm compress frequently after application for tenderness/pain/extreme redness, further record review for Resident "A" revealed no evidence to indicate that a nurse, or any staff member, checked the status of the warm moist compress after application to Resident "A"'s left knee on 12/17/2013 at 1:00 a.m. (as documented in the 12/17/2013, 9:09 a.m. PN referenced above) until approximately 3:15 a.m. on 12/17/2013 (as documented in the 12/17/2013, 9:30 a.m. PN referenced above). This represented a period in excess of two (2) hours after moist heat pack application to Resident "A"'s knee during which facility nursing staff failed to monitor the status of the moist heat pack and the resident's skin. When facility staff finally checked Resident "A" over two (2) hours after moist heat pack application, blistering to the resident's left knee and thigh was discovered. A Wound Care Specialist Evaluation (WCSE) report of 12/30/2013 for Resident "A" documented, in the History of Present Illness section, a Chief Complaint indicating wound care physician consultation for a left knee wound. This WCSE documented, in the Burn Wound of the Left Knee section, that the left knee burn wound measured 7.5 cms. in length, 10 cms. in width, and 0.1 cm. in depth, for a total surface area of 75 cms, and that the knee wound had thick adherent devitalized necrotic tissue of 70 percent. This WCSE documented, in the Procedure section, that Resident "A"'s left knee burn wound was debrided via surgical excision, with removal of necrotic tissue and subcutaneous tissue, with a post-debridement depth of two (2) centimeters. In addition, this 12/30/2013 WCSE for Resident "A" documented, in the Burn Wound to the Left, Distal Thigh section, that the left thigh burn wound measured 4 cms. in length, 2 cms in width, and was of an unmeasurable depth, for a total survey area of 8 cms. This WCSE documented that the roof of the thigh wound blisters was removed. This WCSE specified that both Resident "A"'s left knee and left thigh burn wounds were to be treated with silver sulfadiazine and a dry protective dressing once daily. A WCSE report of 01/08/2014 documented the Wound Care Physician's evaluation and treatment of [REDACTED]. This WCSE documented that at that time, the resident's left knee burn wound measured 6.6 cms by 9.5 cms by 0.1 cm, with sixty (60) percent devitalized necrotic tissue, and that the thigh burn wound measured 2.7 cms by 1.7 cms by 0.1 cms. This WCPE also documented debridement of the left knee burn wound, with removal of necrotic tissue. This WCSE continued to specify the application of silver sulfadiazine ointment with a dry protective dressing once daily to both burn wounds. During an interview with the Wound Care Physician conducted on 01/15/2014 at 11:30 a.m., the physician stated, in reference to Resident "A"'s burn wounds, that the wounds would be categorized as second degree burns. In a 12/20/2013 Employee Statement of Events written statement of Licensed Practical Nurse (LPN) "BB" obtained by the facility during the facility's investigation into the burn wounds of Resident "A", LPN "BB" indicated that on 12/17/2013 at 1:00 a.m., CNA "CC" informed her that Resident "A" had requested that the CNA put a warm compress on the left knee. LPN "BB" indicated that Resident "A" had asked the CNA to warm a towel, place it inside a plastic bag, and put it into a pillow case. LPN "BB" indicated that she then went to Resident "A"'s room and initially observed the resident holding the warm compress in the palm of the hand, at which time the resident stated that the warm moist pad was too hot for his/her hand, but requested that the warm pad be placed on the knee. LPN "BB" further documented that she then pulled Resident "A"'s gown over the resident's left knee, and the warm pad was placed on the resident's knee and the resident was instructed to call when the warm pad got cool. LPN "BB" indicated that at 4:30 a.m., when Resident "A" called via the call light, CNA "CC" answered and then came to inform the LPN that the resident said he/she had blisters on the left knee. LPN "BB" indicated that she then went to Resident "A"s room, observed the blisters, and placed a telephone call to the nurse practitioner. In a 12/20/2013 written Employee Statement of Events statement of CNA "CC" obtained by the facility during its investigation into Resident "A"s burns, CNA "CC" indicated that on 12/17/2013 at 1:00 a.m., Resident "A" requested that the CNA warm a towel inside of a plastic bag, which were both inside of a pillow case, to help with knee pain. CNA "CC" indicated that she had not utilized a warm compress for Resident "A" before, and so she had asked another CNA how to heat the warm compress and had been told to place the compress in a microwave oven for three (3) minutes for heating. CNA "CC" indicated that after she had warmed the compress in the microwave, she had informed LPN "BB" of the resident's request regarding the warm compress and of how she had been told to heat the warm compress. CNA "CC" indicated that she and LPN "BB" then went to Resident "A"'s room and the CNA placed the warm compress in the resident's hand, and the resident stated that the warm compress was too hot. CNA "CC" indicated that LPN "BB" felt of the heated warm compress and stated that the compress was "fine". CNA"CC" indicated that the heated warm compress was then placed on Resident "A"'s knee. CNA "CC" indicated that she went back at 4:00 a.m. to check Resident "A", noted the towel compress to still be on the resident's knee, and removed the compress to find the resident's knee blistered. During an interview with Resident "A" conducted on 12/23/2013 at 12:30 p.m., Resident "A" was asked about the burn incident involving the application of the warm compress to the knee on 12/17/2013. Resident "A" stated that on 12/17/2013, before application of the compress heated in the microwave to his/her knee, he/she had informed LPN "BB" that the compress was too hot, but that the compress had been placed on the knee and had caused the burn. Resident "A" further stated that he/she had experienced some pain. During an observation of Resident "A"'s knee on 12/23/2013 at 12:30 p.m., conducted at the time of the resident interview referenced above, an area of scattered, intact fluid-filled blisters measuring approximately six (6) cms by ten (10) cms was observed to the knee. During interview with the Administrator and Director of Nursing (DON) conducted on 01/15/2014 at 3:30 p.m., these staff members acknowledged that Resident"A"'s burn had occurred after the warm moist compress had been heated in the microwave oven, and that facility protocol did not indicate the compress was to be heated in the microwave. They stated that CNA "CC" had heated and been involved in applying the warm moist compress, which was not considered within the duties of a CNA. It was also stated once the heated warm moist compress had been applied to Resident "A"s knee, staff should have checked the status of the compress approximately five (5) minutes after application. The Administrator and DON acknowledged that facility policy had not been followed. During a later interview conducted on 02/03/2014 at 10:30 a.m. with the Administrator and DON, these staff members again stated (as in the 01/15/2014, 3:30 p.m. interview referenced above) that CNA "CC", who had applied the warm moist compress to Resident "A"'s knee on 12/17/2013, should not have been involved in this procedure. These staff stated that only a licensed nurse should have applied the resident's warm moist compress, per facility Procedure. These staff members also again stated (as in the 01/15/2014, 3:30 p.m. interview above) that the water utilized for a warm moist compress should not have been heated in the microwave, further stating that warm water from the tap was to be used in the preparation of a compress. During a subsequent interview conducted on 02/04/2014 at 11:20 a.m. with the Administrator, DON, and Risk Manager, the facility's General Guidelines for Clean-Warm Compress Procedure (the Procedure in place on 12/17/2013 when Resident "A" sustained the burn wounds to the left knee and thigh) referenced above was reviewed. During this interview and Procedure review with these staff, the DON and Risk Manager acknowledged that, while the Procedure had specified that the temperature of water or prescribed solution utilized for a warm compress was not to exceed 100 degrees F., the Procedure had failed to specify that staff were to utilize only faucet tap water for a warm moist compress, and thus did not instruct staff on how to heat water when preparing a warm moist compress. The DON and Risk Manager further acknowledged that, while this Procedure had specified that nursing staff were to check a resident's skin beneath a compress frequently, the Procedure did not specify the actual frequency that nursing staff were to check, and therefore failed to instruct staff how often to monitor a resident once a warm moist compress had been applied. Based on the above, even though facility Procedure specified that only licensed nursing staff were to apply warm moist compresses, even though the Procedure specified that water or solution utilized in the preparation of warm moist compresses was not to exceed 100 degrees F, and even though the Procedure specified that nursing staff were to check a resident's skin beneath a compress frequently for tenderness/pain/extreme redness after compress application, CNA "CC", instead of a licensed nurse, heated a warm moist compress for Resident "A" for three (3) minutes utilizing a microwave oven and applied the warm moist compress to the resident's knee, without nursing staff ascertaining the temperature of the compress and even though the resident stated that the warm moist compress was too hot. Then, nursing staff failed to frequently check Resident "A" after the application of the warm moist compress for a period exceeding two (2) hours. Resident "A" was found to have left knee fluid-filled blisters in a clustered area approximately six (6) cms by ten (10) cms, which required debridement, and left thigh blisters measuring approximately 0.5 cm by 0.8 cm, and 0.5 cm by 1.0 cm. The immediate jeopardy was determined to have been removed on February 4, 2014, at which time the facility had presented and implemented an allegation of jeopardy removal which included the following corrective actions: 1. On December 17, 2013, treatment for [REDACTED]. 2. On December 17, 2013, the facility evaluated the Procedure being utilized by the facility for the use of warm moist compresses, and implemented a new Policy and Procedure, the Hot Packs/Moist Heat Standard of Practice Policy and Procedure, related to warm moist compress use. 3. On December 17, 2013, the DON, Assistant Director of Nursing (ADON), and Unit Manager reviewed residents for physicians' orders related to warm moist compresses. 4. On December 20, 2013, the LPN involved in the burn incident of Resident "A" was terminated, as the facility's investigation for neglect was substantiated. 5. On January 7, 2014, the facility modified facility protocol to indicate that the application of warm moist compresses would be accomplished through the facility's Therapy Department. 6. On January 7, 2014, the facility's Performance Improvement (PI) Committee evaluated and approved the new protocol involving the application of warm moist compresses through the Therapy Department. 7. On January 7, 2014, the facility modified facility protocol to require the Maintenance Director to check the hydrocollator monthly regarding its operation and temperatures to ensure operation per manufacturer's specifications. This monitoring was to be documented utilizing the Hydrocollator Temperature Log Form, which will be audited monthly by the Administrator to ensure compliance. The results of these audits will be presented to the PI Committee monthly for review and any necessary corrective action. 8. On January 15, 2014, the facility modified protocol to include the Restorative Nursing staff, under the supervision of the Therapy Department, in the provision of care regarding warm moist compress application. 9. On January 15, 2014, the PI Committee reviewed the modified protocol which included Restorative Nursing staff, under the supervision of the Therapy Department, in the application of warm moist compresses to be heated via the hydrocollator. 10. On January 15, 2014, the facility initiated a procedure by which the DON, Risk Manager, ADON, Unit Manager, or Restorative Nurse would audit the Restorative Care Flow Record bimonthly to monitor compliance with warm moist compress application and documentation, and the results of these audits will be presented to the PI Committee monthly for review and any necessary corrective action. 11. On February 3, 2014, the facility modified the Restorative Care Flow Record form to allow for the documentation of warm moist compresses which, as indicated above, had on January 15, 2014 been assigned to the Restorative Nursing staff, under the supervision of the Therapy Department. Warm compress application would be documented on the Restorative Care Flow Record, and would include the documentation of skin checks every five minutes and a twenty-minute maximum time of application. 12. On February 3, 2014, the PI Committee met and approved the Restorative Care Flow Record as the monitoring tool to be utilized during warm moist compress application. 13. On February 3, 2014, the facility continued the process of providing staff in-service training to nursing staff regarding the new Hot Packs/Moist Heat Standard of Practice Policy and Procedure, and the procedural modification of allowing only Restorative Nursing staff, under the direction of the Therapy Department, to apply warm moist compresses to residents. As of that date, the one (1) Restorative LPN, and all seven (7) Restorative Aides, had received this in-service training. A total of forty-one (41) of forty-six (46) facility CNAs (89%) had received in-service training, and thirty-four (34) of forty-two (42) licensed nursing staff (81%), both Registered Nurses and LPNs, had received this in-service training. The remaining eight (8) licensed nursing staff and five (5) CNAs were to receive this in-service training as they returned to work, and prior to providing direct resident care, to ensure compliance. Based on these corrective actions which had been developed and implemented by the facility as outlined above, the immediacy of the deficient practice was removed on February 4, 2013. However, at the time of survey exit, the effectiveness of these corrective action plans could not be fully assessed to ensure ongoing application and completion. On December 17, 2013, the facility implemented the new the Hot Packs/Moist Heat Standard of Practice Policy and Procedure. On January 7, 2014, the facility modified is protocol to require monthly hydrocollator temperature checks by the Maintenance Director via the Hydrocollator Temperature Log Form, which was to be audited monthly by the Administrator and the audit results to be submitted to the PI Committee. On January 15, 2014, the facility specified that Restorative Nursing staff, under the supervision of the Therapy Department, would provide warm moist compress application, and the DON/Risk Manager/ADON/Unit Manager would audit the Restorative Care Flow Record bimonthly to monitor compliance and report the audit results to the PI Committee monthly. As of February 3, 2014, all eight (8) Restorative Nursing staff had received in-service training on the new Hot Packs/Moist Heat Standard of Practice Policy and Procedure, the procedural modification specifying that only Restorative Nursing staff provide warm moist compress therapy, and the use of the Hydrocollator Temperature Log. Additionally, forty-one (41) of forty-six (46) facility CNAs, and thirty-four (34) of forty-two (42) licensed nursing staff had received this in-service training, regarding the new Policy and Procedure as referenced above, as of that date. However, eight (8) licensed nursing staff and five (5) CNAs had not yet received this in-service training, due to their having been unavailable, and would therefore be required to receive this training as they returned to work to ensure competency. Therefore, the training of these remaining nursing staff members could not be evaluated at the time of survey completion and will need to be evaluated at a future time. In addition, the facility had implemented routine auditing by administrative staff of nursing staffs' conformance related to the new Policy and Procedure, utilizing the Hydrocollator Temperature Log and the Restorative Care Flow Record, with the results of these audits to be submitted to the PI Committee for their review and development of any needed corrective actions. The PI Committee had met on January 7, 2014 and February 3, 2014 to review and approve the newly-implemented Policy and Procedure changes as referenced above, but the PI Committee's ongoing oversight, via reports of administrative staff audits, of facility nursing staffs' compliance with these new procedural changes will need to be evaluated after subsequent monthly PI Committee meetings, and thus could not be evaluated at the time of survey completion. Therefore, the non-compliance continues, but the scope and severity is reduced to the "D" level.