**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to check the pacemaker function as ordered for discharged Resident #428, Resident #11, and Resident #93, three of seven sampled residents identified by the facility as having a pacemaker. Resident #428 had a physician's order to check the function of their pacemaker (a small electronic device, implanted in the chest to regulate the heart's rhythm) every month. The facility did not have evidence to indicate the resident's pacemaker was checked monthly as ordered by the physician from April of 2021 until after discharge on [DATE]. On [DATE], Resident #428 was found unresponsive, pale in color, with a heart rate of 38 beats per minutes (a normal resting heart rate range for adults range from 60 to 100 beats per minute). The resident was transferred to the local hospital for further evaluation. At the hospital, Resident #428 was profoundly bradycardic (heart rate slower than 60 beats per minute) and his/her pacemaker not functioning properly. Resident #11 and Resident #93 also had physician's orders to check the function of their pacemaker. Interviews with facility staff revealed these resident's pacemaker was not checked as ordered by the physician. It was determined the facility's non-compliance with one or more requirements of participation had caused or was likely to cause serious injury, harm, impairment, or death to residents. The Immediate Jeopardy (IJ) was related to State Operations Manual, Appendix PP, 483.25 (Quality of Care) at a scope and severity of K. On [DATE] at 1:00 PM, the Administrator, Regional Administrator, Regional Nurse Consultant, and the Director of Nursing (DON) were provided the IJ template and notified of the findings at substandard quality of care at the immediate jeopardy level in the area of Quality of Care at F684-Quality of Care. The IJ began on [DATE] and continued until [DATE] when survey team verified onsite that corrective actions had been implemented. On [DATE] the immediate jeopardy was removed, F684 was lowered to the lower severity of no actual harm with a potential for more than minimal harm that was not immediate jeopardy, to allow the facility time to monitor and/or revise their corrective actions as necessary to achieve substantial compliance. Findings included: Cross Reference F867 QAPI/QAA Improvement Activities and F726 Competent Nursing Staff. 1. A review of Resident #428's Face Sheet revealed the facility admitted the resident on [DATE]. Resident #428 had diagnoses that included Atrial Fibrillation (an abnormal rhythm of the heart) and Presence of a Cardiac Pacemaker. Resident #428 was discharged on [DATE]. A review of Resident #428's annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of [DATE], indicated the resident had a Brief Interview for Mental Status (BIMS) score of four, which indicated Resident #428 had severe cognitive impairment. A review of Resident #428's Care Plan(s), with a review date of [DATE], indicated the resident had a potential for alteration in their cardiac function related to a pacemaker. The goal was for no complications related to the pacemaker as evidenced by a heart rate within normal limits. Interventions directed staff to check the pacemaker per schedule. A review of Resident #428's Physician Orders, for [DATE], indicated an order dated [DATE] to check the resident's pacemaker every month. A review of Resident #428's Departmental Notes, dated [DATE] - [DATE], revealed no evidence the resident's pacemaker was checked. A review of Resident #428's Departmental Notes, dated [DATE] at 2:39 PM, indicated the resident was found sitting on the side of their bed with their eyes closed and breathing through his/her mouth. The resident did not respond to sternal (chest) rub, was pale in color and had a heart rate of 38 beats per minute (normal range is 60 beats to 100 beats per minute). Per the note, the resident was transferred to the hospital for further evaluation. A review of the hospital Emergency Department Note, dated [DATE], indicated Resident #428's chief complaint as arrhythmia (abnormal heart rhythm)/palpitations (the perceived abnormality of the heartbeat characterized by hard, fast, or irregular beats). Per the note, the resident's heart rate was 37 bpm. The Medical Decision Making (MDM) indicated, Resident #428 arrived at the hospital profoundly bradycardic. The MDM further specified, a doctor evaluated the resident and found the resident's pacemaker did not function properly. A telephone interview was held with a family member (FM) of Resident #428 on [DATE] at while a resident of the facility. The FM stated on [DATE], the facility called and informed them Resident #428 had been found unconscious and would be sent to the hospital. The FM said when they arrived at the hospital, the resident's heart rate was 30 beats per minute and the resident immediately received a new pacemaker due to one of the pacemaker's leads not functioning. The FM stated the resident expired about a week after she was hospitalized and during that time developed blood clots in her legs and lungs. In an interview on [DATE] at 8:10 AM, Registered Nurse (RN) #15/Unit Manager, stated a resident's pacemaker was ordered by the physician to be checked either once a month or every three months. RN #15 stated checking a resident's pacemaker was the responsibility of the assigned nurse or the unit manager. RN #15 stated she expected the resident's pacemaker check to be recorded in the nurse's note. RN #15 reviewed the orders for Resident #428 and stated since the resident's order had a specific date of the 8th of the month and a time, the order should have been transferred to the MAR for the 8th of every month on the 7-3 shift. RN #15 reviewed Resident #428's Medication Administration Record (MAR) and the nurse's (departmental) notes for [DATE], [DATE], and [DATE] and stated she was unable to find any information that indicated the resident's pacemaker had been checked. Licensed Practical Nurse (LPN) #14 was interviewed on [DATE] at 10:17 AM. She stated she worked with Resident #428 as the resident's primary nurse at least five days a week for six years. LPN #14 stated she did not check Resident #428's pacemaker function. In an interview on [DATE] at 1:20 PM the Director of Nursing (DON) stated she was unable to find any information in Resident #428's medical record to support the facility completed pacemaker checks for the resident. A telephone interview was conducted on [DATE] at 4:30 PM with the Device RN from Resident #428's cardiologist office. The RN stated he expected all physician orders to check pacemakers to be followed. He stated it was not acceptable for the facility to not check Resident #428's pacemaker after the last cardiology visit in April of 2021 and until the [DATE] hospitalization. The RN stated a pacemaker malfunction could be detected during a pacemaker check. The Device RN also stated, any traumatic event or fall could damage or break a pacemaker wire and result in an immediate problem with the pacemaker. He stated there were no documented falls for Resident #428, so one would believe the wires on the resident's pacemaker were worn. The RN stated a resident could maintain a normal pulse range and still have a worn pacemaker lead or a malfunctioning pacemaker. Per the RN, it was possible if Resident #428 had regular pacemaker checks the malfunction could have been detected and Resident #428's emergent pacemaker replacement and accompanying problems could have been avoided. In a follow-up interview on [DATE] at 8:00 AM, the DON stated the facility did not have a policy on pacemakers. The DON reported she was not aware the resident's pacemaker was not checked as ordered. The DON explained she could not answer why the resident's pacemaker was not checked as ordered and care planned. Per the DON, the last time the resident's pacemaker was checked was in [DATE], when the resident's family took to resident to see the cardiologist (a doctor who specialized in treating diseases of the cardiovascular system, mainly the heart and blood vessels). In another interview on [DATE] at 9:20 AM, the DON stated she expected staff to follow through on all physician's orders. The DON stated was unable to recall any details about Resident #428's transfer to the hospital on [DATE]. The Administrator was interviewed on [DATE] at 9:59 AM, the Administrator stated she expected physician's orders to be followed. During an interview on [DATE] at 10:36 AM, Resident #428's primary physician stated he expected physician's orders to be followed. 2. A review of Resident #11's Face Sheet indicated the facility admitted the resident on [DATE] with diagnoses that included Thoracic Aortic Aneurysm, Chronic Systolic (Congestive) Heart Failure, Hypertensive Heart Disease, and a Cardiac Pacemaker. A review of Resident #11's quarterly MDS, with an ARD of [DATE], indicated Resident #11 had a Brief Interview for Mental Status BIMS score of 14, which indicated the resident was cognitively intact. A review of Resident #11's Care Plan (s) with a start date of [DATE] and a review date of [DATE], indicated the resident had an alteration in cardiac function related to a pacemaker. Interventions directed staff to check the pacemaker per schedule. A review of Resident #11's Physician Orders, for [DATE], indicated an order dated [DATE] to check the resident's pacemaker every three months in June, September, December, and March. During an interview on [DATE] at 9:13 AM, Resident #11 stated it had been a while since their pacemaker was checked. RN #15/Unit Manager stated she was unsure when the resident's pacemaker was checked. 3. A review of Resident #93's Face Sheet revealed the facility admitted the resident on [DATE] with diagnoses of Vascular Dementia and Encounter for Checking and Testing of Cardiac Pacemaker Pulse Generator. A review of Resident #93's quarterly MDS, with an ARD of [DATE], revealed Resident #93 had a BIMS score of three, which indicated the resident had severe cognitive impairment. A review of Resident #93's Care Plan(s), with a start date of [DATE], revealed the resident had potential for alteration in cardiac function related to a pacemaker. Care plan interventions directed the staff to the resident's pacemaker per schedule. A review of Resident #93's Physician Orders, for [DATE] revealed an order dated [DATE] to check the resident's pacemaker every month. A review of Resident #93's Departmental Notes, from [DATE] to [DATE] revealed no evidence of documentation denoting the resident's pacemaker was checked. During an interview on [DATE] at 7:37 AM, LPN #8 revealed when Resident #93 was admitted to the facility in [DATE] the resident did not have a cardiologist and Resident #93 had not had a cardiologist since admission. LPN #8 further revealed she had never checked the pacemaker and thought the Registered Nurses checked the pacemaker but could not find any documentation the pacemaker had ever been checked. During an interview on [DATE] at 4:31 PM, Licensed Practical Nurse LPN #2 revealed she knew Resident #93 had a pacemaker, but she had never checked the function of the resident's pacemaker. In an interview on [DATE] at 2:48 PM, LPN #7, Unit Manager, stated she was not aware Resident #93 had a pacemaker. LPN #7 continued to say that there was not a task to check the pacemaker on the resident's MAR so she would not know to check it. During an interview on [DATE] at 4:35 PM, RN #3 stated she had never checked the function of a resident's pacemaker. On [DATE] at 2:50 pm a follow-up interview was conducted with LPN #14, Unit Coordinator. LPN #14 said the facility did not have a way to check residents' pacemakers. LPN #14 stated the only way staff would know that the resident needed a pacemaker check was if the cardiologist had called to schedule the check. During an interview on [DATE] at 2:55 PM, the Assistant Director of Nursing (ADON) stated she never noticed the resident's pacemaker was not checked every month. The ADON said she did not know why the order for a pacemaker to be checked every month did not come up on the MAR as a task. The nurses on the floor could not see the order and did not know to check the pacemaker monthly. The ADON said there was an issue with the pacemaker checks orders not being added to the MAR. In a follow-up interview on [DATE] at 9:11 AM, the DON stated the facility had quarterly care plan meetings in which staff reviewed the resident's physician's orders and care plan. Per the DON, in these meetings, nursing staff should have identified the physician's orders were not being completed. In an interview on [DATE] at 10:10 AM, the Administrator revealed the electronic MAR was not showing the physician's order to check the pacemaker monthly. The Administrator stated quarterly meetings are held with staff from all disciplines and during the meeting monthly orders should be checked to assure the orders were being implemented. The Administrator said staff missed that the pacemaker was not being checked and acknowledged the facility missed the fact Resident #93's pacemaker was not checked monthly. ********************************************** On [DATE] the facility submitted the following acceptable Removal Plan: 1. Registered Nurse Unit Managers, Director of Nursing and/or Assistant Director of Nursing notified the cardiologist/physician for the [three] residents identified to verify orders for monitoring of pacemaker checks and specific equipment needed. Registered Nurse Unit Managers initiated contact with three equipment companies on [DATE] to obtain pacemaker monitoring device. The necessary equipment has been ordered for eight residents whose pacemakers cannot be checked remotely. If the equipment does not arrive, Registered Nurse Unit Manager or Director of Nursing or Assistant Director of Nursing/Designee, will contact the specific pacemaker device company to complete an onsite pacemaker check. All pacemakers were checked between [DATE] - [DATE]. All were found to be in good working order. The physician indicated to check the resident's pacemaker function again, monthly, or quarterly, as indicated per physician orders based on the residents' specific needs. 2. To ensure all pacemakers were checked as ordered while awaiting the ordered equipment, the Administrator contacted a Medtronic pacemaker representative via phone on [DATE], and the representative made a facility visit to check pacemakers for 10 residents whose pacemakers cannot be checked remotely on [DATE]. The remaining three residents had their pacemakers checked onsite, with the results sent to the facility on [DATE]. The Administrator verified all residents with pacemakers had their devices checked, either onsite or remotely, on [DATE]. No concerns were identified with the pacemakers or the residents during the checks. 3. Registered Nurse Unit Managers reviewed the medical record and identified nine additional residents within the facility with pacemakers, for a total of 13 current residents with pacemakers. This review was completed by the Registered Nurse Unit Managers on [DATE]. 4. The facility has developed and implemented, on [DATE], a pacemaker policy related to the checking of pacemakers and documenting the pacemaker checks on the resident's medication administration record to ensure pacemakers are monitored at prescribed frequency. 5. Licensed nurses will be responsible for completion of the pacemaker checks per the care plan, documenting the pacemaker checks on the medication administration record per the care plan and the Registered Nurse Unit Manager or Director of Nursing or Assistant Director of Nursing/Designee will verify the checks have been completed. 6. The Director of Nursing, Assistant Director of Nursing, and Registered Nurse Unit Managers will be educated on [DATE] by the Regional Nurse Consultant/designee regarding following physician orders related to monitoring of pacemaker checks and obtaining necessary equipment when needed. 7. All licensed staff, to include contract nurses, will be educated by the Director of Nursing/designee regarding following physician orders related to monitoring of pacemaker checks and necessary equipment needed. This education will be initiated on [DATE]. This education will be provided to staff prior to their next scheduled shift. In addition, education will be added to new licensed staff orientation. As of [DATE] at 5:00 PM, 14 of 21 LPNs and 12 of 16 RNs have received the education. Licensed nurses working the night shift and weekends will be educated by the Director of Nursing or Assistant Director of Nursing or Registered Nurse Unit Managers/Designee prior to their next shift. 8. New admissions/readmissions will be reviewed daily, seven days a week by the Registered Nurse Unit Manager or Director of Nursing or Assistant Director of Nursing/Designee, to ensure Physician orders are initiated for residents with pacemakers to include how to perform specific device pacemaker checks and ensure necessary equipment is available. After review, any resident admitted with pacemaker will have orders obtained for monitoring and needed equipment. 9. Based on the actions listed above the completion date of this plan is [DATE]. The immediacy of the IJ was removed on [DATE]. ******************** On [DATE], after reviewing the facility's information provided in their Removal Plan and verifying the immediate actions had been implemented, the scope/severity level of F684 was lowered to E, to allow the facility time to monitor and/or revise their corrective actions as necessary to achieve substantial compliance.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record review, and review of the facility policy, the facility's Quality Assurance Performance Improvement (QAPI) committee failed to thoroughly review all factors related to Resident #428 emergent discharge to the hospital on [DATE]. The facility QAPI committee further failed to develop and implement corrective action. Resident #428 had a physician's order to check the function of their pacemaker (a small electronic device, usually placed in the chest to help regulate slow electrical problems with the heart) every month. The facility did not have evidence to indicate the resident's pacemaker was checked as ordered by the physician after [DATE]. On [DATE], Resident #428 was found unresponsive, pale in color, with a heart rate of 38 beats per minutes (a normal resting heart rate range for adults range from 60 to 100 beats per minute). The resident was transferred to the local hospital for further evaluation and found the resident's pacemaker did not function properly. Following Resident #428's emergent discharge QAPI committee failed to identify his/her pacemaker had not been checked as ordered. Resident #11 and Resident #93 were found to have a pacemaker, orders to check the pacemakers, and no evidence the pacemakers were being checked as ordered. This failure to investigate and implement corrective actions to ensure resident's pacemakers were checked as ordered had the potential to affect the remaining six sampled residents who had a pacemaker and currently resided in the facility. It was determined the facility's non-compliance with one or more requirements of participation had caused or was likely to cause serious injury, harm, impairment, or death to residents. The Immediate Jeopardy was related to State Operations Manual, Appendix PP, 483.75 (Quality Assurance and Performance Improvement) at a scope and severity of K. On [DATE] at 1:00 PM, the Administrator, Regional Administrator, Regional Nurse Consultant, and the Director of Nursing (DON) were informed of the Immediate Jeopardy (IJ) situation. On [DATE] at 1:00 PM, the Administrator, Regional Administrator, Regional Nurse Consultant, and the Director of Nursing (DON) were provided the IJ template and notified of the findings at the immediate jeopardy level in the area of Quality Assurance and Performance Improvement at F867-QAPI/QAA Improvement Activities. The IJ began on [DATE] and continued until [DATE] when the survey team verified onsite that corrective actions had been implemented. On [DATE] the immediate jeopardy was removed, F867 remained at the lower severity of no actual harm with a potential for more than minimal harm that was not immediate jeopardy, to allow the facility time to monitor and/or revise their corrective actions as necessary to achieve substantial compliance. Findings included: Cross Reference F684 Quality of Care and F726 Competent Nursing Staff. Review of a facility policy titled, Quality Assurance/Quality Assurance Performance Improvement, effected [DATE], indicated Policy: Our purpose is to provide excellent quality resident/guest services. Quality is defined as meeting or exceeding the needs, expectations and requirements of the resident/guest cost effectively while maintaining good resident/guest outcomes and perceptions of resident/guest care . The policy specified, .QAPI Plan address: a. Clinical Care - Monitor existing QM [quality measures] results, [corporation name] infonet monitors for . incident reports, infection reports, discharges . Per the policy, .Administration is responsible and accountable for developing, leading and closely monitoring of QAPI program . A review of Resident #428's Face Sheet revealed the facility admitted the resident on [DATE] with diagnoses that included Atrial Fibrillation and Presence of a Cardiac Pacemaker. Resident #428 was discharged on [DATE]. A review of Resident #428's Care Plan(s), with a review date of [DATE], revealed interventions that directed staff to check the pacemaker per schedule. A review of Resident #428's Physician Orders, revealed an order dated [DATE] to check the resident's pacemaker every month. A review of Resident #428's Departmental Notes, dated [DATE] - [DATE], revealed no evidence of documentation denoting the resident's pacemaker was checked. A review of Resident #428's Departmental Notes, dated [DATE] at 2:39 PM, indicated Resident #428 was unresponsive and had a heart rate of 38 beats per minute (normal range is 60 beats to 100 beats per minute). Per the note, the resident was transferred to the hospital for further evaluation. A review of the hospital Emergency Department Note, dated [DATE], indicated Resident #428's had a heart rate of 37. The Medical Decision Making (MDM) indicated; Resident #428 arrived at the hospital profoundly bradycardic. The MDM further specified, a doctor evaluated the resident and found the resident's pacemaker did not function properly. A review of Resident #428's Departmental Notes, dated [DATE] 12:03 AM, indicated Registered Nurse (RN) #52 received an update from the hospital the hospital regarding Resident #428's condition and was notified the resident had a diagnosis to include pacemaker lead failure. Per the note, the hospital staff notified the RN, Resident #428 had received a new pacemaker. A telephone interview was held with a family member (FM) of Resident #428 on [DATE] at 9:20 AM. The FM stated the entire time Resident #428 lived in the facility, they had no knowledge of the resident's pacemaker was checked. The FM stated the resident expired about a week after she was hospitalized and during that time developed blood clots in her legs and lungs. During an interview on [DATE] at 2:55 PM, the Assistant Director of Nursing (ADON) stated she never noticed the resident's pacemaker was not checked every month. The ADON said she did not know why the order for a pacemaker to be checked every month did not come up on the MAR (Medication Administration Record) as a task. The nurses on the floor could not see the order and did not know to check the pacemaker monthly. The ADON said there was an issue with the pacemaker checks orders not being added to the MAR. In an interview on [DATE] at 1:20 PM the Director of Nursing (DON) stated she was unable to find any information in Resident #428's medical record to support the facility completed pacemaker checks for the resident. A telephone interview was conducted on [DATE] at 4:30 PM with the Device RN from Resident #428's cardiologist office. Per the RN, it was possible if Resident #428 had regular pacemaker checks the malfunction could have been detected and Resident #428's emergent pacemaker replacement and accompanying problems could have been avoided. In an interview on [DATE] at 8:00 AM, the DON reported she was not aware the resident's pacemaker was not checked as ordered. The DON explained she could not answer why the resident's pacemaker was not checked as ordered and care planned. Per the DON, the last time the resident's pacemaker was checked was in [DATE], when the resident's family took to resident to see the cardiologist (a doctor who specialized in treating diseases of the cardiovascular system, mainly the heart and blood vessels). The DON reported the facility did not have a policy on pacemakers. In a follow-up interview on [DATE] at 2:57 PM, the Administrator stated residents who were discharged /transferred were discussed in the facility's morning meetings to determine the reason for discharge/transfer. She stated the QAPI committee discussed specifics about each resident discharge/transfer. The Administrator indicated she was not the administrator at the time and the DON might have the QAPI review of Resident #428's transfer to the hospital. On [DATE] at 3:18 PM, the DON stated Resident #428's discharge was reviewed, but she was unable to recall anything that was discussed about the resident's discharge. The DON stated residents' discharges were reviewed each Monday, and the information discussed included an attempt to determine if the resident's discharge could have been prevented. The DON stated they tried to determine root cause and if the transfer could have prevented. The DON stated there were no changes implemented as a result of Resident #428's emergent transfer to the hospital. On [DATE] at 4:02 PM, the Administrator stated pacemakers were not discussed in the facility's QAPI meetings. ************************************************************************************************************************************************************************************************ On [DATE] at 10:22 AM, a Removal Plan was submitted by the facility and accepted by the state survey agency. The Removal Plan read as follows: 1. Those likely to suffer are the facility residents with the potential for any adverse reaction due to the failure to meet, discuss, and institute the collection of data and monitoring of other residents and processes. An emergency Quality Assurance and Performance Improvement (QAPI) meeting was held on [DATE] to address failure to meet, discuss, and institute collection of data and monitoring of other residents and processes related to an adverse event involving Resident #428 and failure to have a policy in place or defined process for pacemakers or checking pacemakers. It was determined that the root cause related to no pacemaker policy. The policy was developed and implemented on [DATE]. Those in attendance included the Regional Administrator, Regional Nurse Consultant, Regional Quality Assurance Nurse, Administrator, Director of Nursing, and Medical Director. 2. The Quality Assurance Committee (Administrator, Director of Nursing, Assistant Director of Nursing, Medical Director, and Infection Control Preventionist) were reeducated on [DATE] by the Regional Director on policy and procedures of the QAPI meeting for consistent monitoring of QAPI programs to include Diagnostics, Event Reporting, Customer Relations, Policy and Procedure Review/Approval, Compliance/Regulatory, Rehospitalization, Other items Reviewed, Facility Assessment Results/Revisions/Annual Review, Action Plans, Survey Related Monitoring, Performance Improvement Project (PIP), and Emergency QAPI meeting minutes to ensure adverse events and quality deficiencies are identified, corrected, and monitored. 3. The Quality Assurance Committee (Administrator, Director of Nursing, Assistant Director of Nursing, Medical Director, and Infection Control Preventionist) will monthly review the QAPI program to ensure quality deficiencies and adverse events are corrected and monitored. Findings will be submitted monthly, for three months, to the Regional Administrator, Regional Nurse Consultant, and Regional Quality Assurance Nurse for review and revision. Any concerns identified will be immediately addressed and education will be provided. 4. Based on the actions listed above, the completion date of this plan is [DATE]. The immediacy of the IJ was removed on [DATE]. *************************** On [DATE], after reviewing the facility's information provided in their Removal Plan and verifying the immediate actions had been implemented, the scope/severity level of F867 was lowered to E, to allow the facility time to monitor and/or revise their corrective actions as necessary to achieve substantial compliance.