**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and review of the facility's policies, it was determined the facility failed to have an effective system to ensure the Physician was notified when there was a significant change in condition and a need to alter treatment for one (1) of thirty (30) sampled residents (Resident #110). The facility admitted Resident #110, on [DATE], with diagnoses to include Chronic Pain; Contracture,Thoracic, Thoracolumbar, and Lumbosacral Intervertebral Disc Disorder. Resident #110 was hospitalized , on [DATE], with Altered Mental Status, Condition Decline, and Respiratory Failure. Prior to the [DATE] acute care hospitalization, the resident was receiving Oxycodone with Acetaminophen (a narcotic opioid pain reliever given for moderate to severe pain) on a every six (6) hour schedule. Review of Resident #110 medical record revealed the resident returned from the hospital to the facility, on [DATE]. The resident's discharge medication and the Physician's Orders included the same narcotic pain medication but it was ordered every six (6) hours as needed (PRN) instead of the routine administration of every six (6) hours. Moreover, the Physician's Order was for only (3) days, to start on [DATE] and end on [DATE]. However there was no documented evidence the Physician was notified that the order expired in three (3) days. Interviews with staff revealed Resident #110 continued to complain of pain. Interview with the resident revealed he/she was in constant pain and had made staff aware of his/her pain; however, no one was addressing the resident's pain. Interviews with Resident #110's Physician and Advanced Practice Registered Nurse (APRN) revealed they were aware the resident had chronic pain and had been on the narcotic pain reliever. However, they both stated they were unaware it had been discontinued as of [DATE]. In addition, the Physician stated he would have expected staff to notify him or the APRN that the resident was complaining of pain. Resident #110 was transferred to the Hospital Emergency Department (ED) on [DATE]. Review of the Admitting Physician's Note, dated [DATE], revealed the resident arrived at the ED in pain, lethargic, did not move his/her extremities, and moaned with discomfort. Per the ED record, the resident received Morphine (an opioid narcotic). The facility's failure to have an effective system to ensure the Physician was notified when there was a significant change in condition and a need to alter treatment provided to residents who required such services has caused or is likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) were identified in the area of 42 CFR 483.10 Resident Rights, on [DATE] and were determined to exist on [DATE]. The facility provided an acceptable Allegation of Compliance (AoC) on [DATE], with the facility alleging removal of the Immediate Jeopardy on [DATE]. The State Survey Agency validated removal of the Immediate Jeopardy as alleged on [DATE], prior to exit on [DATE], with the remaining non-compliance at a Scope and Severity of a D while the facility develops and implements a Plan of Correction and the facility's Quality Assurance (QA) monitors to ensure compliance with systemic changes. The findings include: Review of the facility's policy titled, Change in Condition: Notification Of, revised [DATE], revealed the center must immediately inform the resident, consult with the resident's Physician, and notify, consistent with his/her authority, the resident's Health Care Decision Maker (HCDM), where there was: a need to alter treatment significantly (that was, a need to discontinue or change from an existing form of treatment due to adverse consequences, or to commence a new form of treatment). Review of the facility's policy titled, Physician/Advanced Practice Provider (APP) Notification, revised [DATE], revealed the requirement to communicate a change in the resident's condition to the Physician/APP and initiate interventions as needed or ordered. Review of the facility's policy titled, Resident Rights and Dignity, revised [DATE], revealed each resident would be cared for in a manner that promoted an enhanced quality of life, dignity, respect, and individuality. Review of Resident #110's medical record revealed the facility admitted the resident, on [DATE], with diagnoses to include Chronic Pain; Contracture, Right Hand; Contracture, Left Hand; Contracture, Right Elbow; Thoracic, Thoracolumbar, and Lumbosacral Intervertebral Disc Disorder Review of Resident #110's Quarterly Minimum Data Set (MDS), dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) score of eleven (11), which indicated he/she had mild cognitive impairment. Continued review revealed the facility assessed Resident #110 as having pain during this assessment period and had received scheduled or as needed (PRN) pain medication. Review of Resident #110's Comprehensive Care Plan (CCP), initiated on [DATE], revealed Resident #110 was at risk for alterations in comfort related to Osteoarthritis, muscle weakness, right upper extremity edema, contracture, hemiplegia, obesity, and polyneuropathy. The goal was the resident would achieve an acceptable level of pain control. Further, interventions included but were not limited to, administer pain medication as ordered; elevate right upper extremities with pillow; observe pain characteristics: quality, severity, location, precipitating/relieving factors; medicate resident as ordered for pain and observe for effectiveness and side effects; report to Physician as indicated. Observation of Resident #110, on [DATE] at 9:05 AM, revealed the resident yelling for a nurse. Resident was moaning and groaning in pain. Further observation revealed, the resident was lying flat on his/her back, no pillow under the right arm. The resident's hands had contractures, and the resident was unable to use the call light related to his/her contractures. Per observation resident showed non-verbal ques of pain with grimacing. Further observation revealed no one responded to the resident until the State Survey Agency (SSA) Surveyor alerted staff that the resident needed assistance. However, there was no documented evidence the Physician was notified of the resident's complaints of pain. Interview with Resident #110, on [DATE] at 9:20 AM, revealed staff did not address his/her chronic pain, and while the resident had resided at the facility since the last readmission, on [DATE], he/she had not received pain medication as needed. Further interview revealed, the resident stated, I am miserable and I hurt all the time. Per interview the resident stated when he/she tells the nurse he/she was in pain, no one would help him/her. Review of Resident #110's Vital Sign Assessment, revealed, in the month of [DATE] the only pain assessments documented were on [DATE] at 1:00 PM, rated zero (0) out of ten (10), and on [DATE] at 10:00 PM, rated zero (0) out of ten (10), despite a diagnosis of Chronic Pain. Interview with State Registered Nurse Aide (SRNA) #11, on [DATE] at 1:50 PM, revealed Resident #110 hurt all the time, especially when he/she was moved. She stated the resident could not tolerate lying on his/her right side. Further interview revealed she would notify the nurse that the resident was in pain. Review of Resident #110's Hospital ED (emergency department) Admitting Physician Note, dated [DATE], revealed the resident arrived at the ED in pain lethargic, did not move his/her extremities, and moaned with discomfort. Per the ED record, Morphine (an opioid narcotic pain reliever for acute pain) Injection four (4) mg was ordered and given. Review of Resident #110's Hospital ED Face Sheet, dated [DATE], revealed Morphine Injection four (4) mg was added to the resident's hospital medications. Interview with Licensed Practical Nurse (LPN) #8, on [DATE] at 8:26 AM, revealed if a staff member reported to her that a resident was in pain, she would first review the orders and if a resident had unrelieved pain, the policy required the nurse to notify the Physician or APP (Advanced Practice Registered Nurse, APRN) to adjust the resident's pain medication regimen. However, she stated she could not recall notifying the Physician of the resident not having an order for his/her scheduled pain medication. Interview with Agency LPN #9, on [DATE] at 2:15 PM, revealed Resident #110 had experienced a recent change in condition (CIC) resulting in a decline. In addition, LPN #9 stated she readmitted the resident on [DATE] and recalled seeing the order for the narcotics for only three (3) days; however, she did not notify the Physician or APRN, nor reconcile orders with the medications the resident was ordered prior to the hospital admission. She stated she just assumed the Physician at the hospital did not want the resident on the pain medicaton after three (3) days. Furthermore, she did not notify the Physician that the resident was complaining of pain because she felt like that was the norm for the resident. Interview with the Unit Manager (UM), on [DATE] at 1:49 PM, revealed it was the responsibility of the nurse assigned to the resident to notify the Physician or APRN of any change of condition. Further interview revealed they should document the change on a Change of Condition form in the resident's medical record. She further stated if it was not documented, then it did not happen. Interview with the Assistant Director of Nursing (ADON), on [DATE] at 4:40 PM, revealed she was not made aware that nursing staff failed to notify the Physician or the APRN to reorder the resident's scheduled narcotic pain medication after the three (3) day order had expired on [DATE]. Further interview revealed she was also not aware the resident was crying out in pain. She stated it was her expectation for staff to follow the policies and notify the Physician or APRN when there was a change in a resident's condition. However, there was no documented evidence the nursing staff notified the Physician that the resident was no longer on scheduled Oxycodone with Acetaminophen after returning from the hospital. Furthermore, there was no documented evidence the nursing staff notified the Physician of a CIC related to pain, according to facility policy. Interview with the Regional Clinical Quality Specialist (RCQS), on [DATE] at 3:40 PM, revealed it was her expectation that nursing staff follow the facility's policies. The RCQS stated, with Resident #110's pain management, there was a communication breakdown because there was no documented evidence the nursing staff notified the Physician or the APRN of a CIC related to pain, according to facility policy. Interview with the APRN, on [DATE] at 2:30 PM, revealed she was aware the resident had chronic pain and mobility issues, used opioid medications, and took Oxycodone 10/325 mg (milligrams), one (1) tablet by mouth every six (6) hours, scheduled, prior to his/her admission to the hospital on [DATE]. Per interview, staff did not make her aware upon readmission of the order expiring in three (3) days. Per interview, if she had been made aware she would have reordered the medication. Further interview revealed, staff failed to notify her that the resident was in pain and was experiencing a change of condition. Interview with the Physician, on [DATE] at 10:15 AM, revealed it was his expectation for staff to notify him or the APRN if the resident was having a change of condition. Per interview, he was unaware the resident was in pain, and that the resident's pain medication order had expired. Interview with the Director of Nursing (DON), on [DATE] at 9:18 AM, revealed that follow-up on admission/readmission orders was important to address and treat the resident appropriately. Per interview, the DON stated there was no documented evidence the nursing staff notified the Physician that the resident was no longer on scheduled Oxycodone, after returning from the hospital. In addition, she stated there was no documented evidence the nursing staff notified the Physician or APRN of a CIC related to pain. Per interview, it was her expectation for staff to follow the facility's policies. Interview with the Administrator, on [DATE] at 5:28 PM, revealed the Change in Condition/Notification of Change policy was expected to be followed to ensure the Physician was notified of changes in a resident's condition per policy guidelines. Additionally, she stated any significant change in a resident's condition was expected to be documented in the medical record. The facility provided an acceptable credible Allegation of Compliance (AoC) on [DATE] alleging removal of the Immediate Jeopardy on [DATE]. Review of the AoC revealed the facility implemented the following: 1. An audit was conducted by the Assistant Director of Nursing (ADON), Nurse Practice Educator (NPE), and Unit Managers (UM) between [DATE] and [DATE] to determine if residents had pain, had pain medications ordered, if pain medications were effective, and if pain was not relieved. The Physician/Advanced Registered Nurse Practitioner (ARNP) were notified of unrelieved complaints of pain with new orders obtained if applicable. 2. Nineteen (19) of nineteen (19) residents identified with pain issues were reassessed on [DATE] by the Director of Nursing (DON), UM's, and/or Licensed Nurse (LN) Nurse Practitioner and/or Physician to determine if a change in condition had occurred regarding pain. Areas of concern were corrected upon discovery. 3. The DON, UM, ADON, NPE, and/or Clinical Quality Specialist (CQS) initiated reeducation, beginning on [DATE], with all facility staff to include contracted staff on the facility's policy and procedures regarding: (A) Change in Condition; (B) Pain Management, including observations; (C) Stop and Watch Tool; (D) Physician/Mid-Level Provider Notification of Change in a Resident's condition; and (E) Person Centered Care Plan. A post-test was administered at the time of the reeducation that required a passing score of 100% that will be graded by the DON, UM, ADON, NPE, and/or CQS to validate understanding. Facility staff and agency staff not available during the reeducation and post-test were to be provided reeducation including a post-test by the DON, UM, ADON, NPE, and/or CQS upon day of return to work prior to providing care. Newly hired staff and contracted staff were to be provided education and post-test during orientation by the DON, ADON, CQS, NPE, UM, and/or Licensed Nurse (LN). 4. Starting [DATE], clinical observation rounds will be conducted every shift, including interviews of ten (10) staff and five (5) residents who receive pain medication to identify any change in condition including a change in pain by the DON, ADON, UM, NPE, or LN to determine if residents have experienced a change in condition regarding pain. The Physician/NP were notified and the plan of care was reviewed to ensure it reflected the current needs of the resident daily until the Immediate Jeopardy is abated. 5. Starting [DATE], the Center Executive Director (CED) and/or LN would conduct ten (10) employee questionnaires daily to determine if staff were aware of the Center's process of the Stop and Watch Tool and reporting a change in condition, including reporting resident pain to a licensed nurse, to ensure prompt interventions when a resident experienced a change in condition, until the Immediate Jeopardy is abated. 6. The results of the observations, interviews, and audits will be reviewed daily by the CED or DON corrective actions taken upon discovery of deficiencies. 7. Beginning on [DATE], the DON, UM, ADON, NPE, CQS, and/or LNs initiated reeducation with all licensed nurses and agency nurses on the facility's policy and procedures regarding: (A) Pain management to include implementing person-centered care plan with individualized person centered interventions to include monitoring pain, administering pain medications as ordered, utilizing and documenting the pain scale, and observing for non-verbal signs/symptoms of pain; (B) Pressure Ulcer prevention to include developing/implementing the care plan; (C) Person-centered care plans; and (D) Physician/Mid-Level Provider Notification of Change in a resident's condition. 8. All admissions, readmissions, and residents with changes in respiratory status since [DATE] were reviewed on [DATE] by the DON, ADON, NPE, UM, and or LNs to determine if care plans reflected patient specific interventions to include interventions to monitor respiratory status to include residents with sleep apnea, COPD, acute respiratory failure, and asthma. Areas of concern were corrected upon discovery. 9. On [DATE], the DON, UM, ADON, NPE and or CQS initiated reeducation with all licensed nurses and agency nurses on the facility's policy and procedures regarding: (A) Revision of the care plan with all admissions, readmissions, and changes in respiratory status with diagnoses to include acute respiratory failure, sleep apnea, COPD, and asthma. A post-test was administered at the time of the reeducation that required a passing score of 100% that was graded by the DON, UM, ADON, NPE, and/or CQS to validate understanding. Licensed Nursing and Agency Licensed Nursing Staff not available will be provided reeducation, including a post-test, by the DON, UM, ADON, NPE, and/or Registered Nurse upon day of return to work before providing care. New licensed nursing hires and agency licensed nurses will be provided education and post-test during orientation by the DON, ADON, NPE and/or UM. 10. Care plan audits were completed for residents with diagnoses including acute respiratory failure, sleep apnea, COPD, and/or asthma and will be completed for new admissions, readmissions, and residents with a change in condition to include a change in respiratory status to determine the care plan has resident specific interventions including respiratory assessments; and, corrective actions were taken upon discovery of deficiencies. 11. Five (5) Licensed Nursing Staff interviews were completed by the CED, DON, UM, ADON, NPE, and/or CQS to determine if staff were aware of the process of a respiratory assessment when a resident's condition warranted the assessment and per the resident's plan of care will be conducted daily until the Immediate Jeopardy is abated. 12. The DON, UM, ADON, NPE, and/or CQS completed reeducation beginning on [DATE] with facility licensed staff to include agency staff on the facility's policy and procedures regarding: (A) Pain management to include implementing person-centered care plans with individualized person-centered interventions to include monitoring pain, administering pain medications as ordered, and utilizing and documenting pain scale assessments, and observe for non-verbal signs/symptoms of pain. A medication reconciliation process is in place to review discharge orders to current orders; (B) Physician/Mid-Level Provider Notification of Change in a resident's condition; and (C) Person Centered care plans regarding resident interventions for pain. A post-test was administered at the time of reeducation that required a passing score of 100% that was graded by the DON, UM, ADON, NPE, and or CQS to validate understanding. Facility licensed staff and agency staff not available will be provided reeducation including a post-test during orientation by the DON, ADON, NPE, UM, and/or LN, before allowed to work. 13. The CED and/or LN will conduct five (5) employee questionnaires daily to determine if staff were aware of the Center's process of reporting a change in condition including pain to a licensed nurse to ensure prompt intervention when a resident experienced a change in condition until Immediate Jeopardy is abated. 14. The UM's, ADON, NPE, and licensed nurses completed skin assessments on all residents on [DATE], to ensure residents, including residents with pressure ulcers, received care per Physician's orders to promote healing and prevent additional pressure ulcers with any needed corrective action taken upon discovery. 15. The CQS reeducated the Wound Nurse regarding the facility's policy, Wound Care, on [DATE]. A post-test was administered at the time of the reeducation to validate understanding. 16. The NPE, DON, UM's, and/or ADON reeducated all licensed staff, including agency staff, regarding the requirement that residents with pressure ulcers receive care to promote healing and prevent additional pressure ulcers, to include appropriate assessment of all wounds when a wound/abscess was identified, beginning on [DATE], with a posttest requiring 100% score to validate understanding. 17. The DON, ADON, NPE or UM will conduct observation rounds and treatment administration audits to ensure residents with pressure ulcers receive care to promote healing and prevent additional pressure ulcers as per Physician's Orders starting [DATE] daily until Immediate Jeopardy is abated. 18. Quality Assurance/Performance Improvement (QAPI) meetings are occurring daily (Monday-Friday) beginning [DATE] with the interdisciplinary team, which consists of the CED, DOB, ADON, NPE, UM's, MDS, Dietary Manager, Social Services, Business Office Manager, Environmental Services, Medical Records, Maintenance, Human Resources, Registered Dietician, Activities Director, Central Supply, and Director of Rehabilitation, until Immediate Jeopardy is abated. During QAPI meetings, the current status of the AoC is discussed, including review of the audit tools, findings, and any needed corrective action. The State Survey Agency validated the implementation of the facility's AoC as follows: 1. Review of the facility's audit tool revealed the audits were reviewed, with all residents present as of [DATE]. Audits were conducted to determine the presence of pain, and the effectiveness of any pain medications ordered. Record review revealed nineteen (19) residents were identified with pain concerns, with most concerns identified consisting of pain medications not being effective, or not being effective for the length of time until the next dosage of pain medication was available. All of this information was emailed to the Nurse Practitioner (NP) by the CQS. Review of residents' medical records for residents identified, revealed residents had been reassessed by either the Physician or NP, with new orders provided as appropriate. 2. Review of nineteen (19) residents with identified pain issues revealed residents identified had been reassessed on [DATE] by the DON, UMs and/or Licensed Nurse (LN) to determine if a change in condition had occurred regarding pain. Interview with the NPE, on [DATE] at 1:30 PM, revealed, based on audits conducted by [DATE]; nineteen (19) residents were identified with pain issues. She revealed all residents had been reassessed, and staff were documenting changes in resident condition in nursing notes regarding effectiveness of pain medications. 3. Review of the facility's In-Service Sign In Sheets, dated [DATE] through [DATE], revealed all facility staff were educated in person or over the phone regarding: (A) Change in condition; (B) Pain management; (C) Stop and Watch Tool; (D) Provider notification of change; and (E) Person-centered care plans. Review of documents titled Post Test, revealed staff completed testing covering all identified areas, to include changes in resident condition, management of resident pain, Stop and Watch Tool, provider notification of change, and person-centered care plans. Interview with Admissions personnel, on [DATE] at 8:20 AM, revealed she had been educated to monitor residents for any new or worsening pain or any change in activity or changes in resident condition, the resident care plan. Admissions personnel was to report to the nurse and DON. She stated she was in-serviced on the use of the Stop and Watch tool. Interview with Laundry personnel, on [DATE] at 8:30 AM, revealed Laundry staff had been educated to monitor residents for pain or change in condition and to notify the nurse if any occurs. Laundry staff was to observe for any lack of care for the residents. Per interview Laundry personnel were in-serviced on the Stop and Watch tool. Interview with Physical Therapy Assistant (PTA) #1, on [DATE] at 8:15 AM, revealed PTA#1 had been educated to monitor for new or worsening pain and if a resident was participating less in activities or had a change in condition to report this to the nurse. Per interview, they had been in-serviced on the Stop and Watch tool. PTA #1 completed a posttest after the training. Interview with SRNA #8, on [DATE] at 8:35 AM and SRNA #27 at 8:45 AM, SRNA #25 at 8:50 AM and SRNA #28 at 9:00 AM revealed education was provided to monitor for any new or worsening pain, change in condition and the appropriate use of the resident's care plan. Any change was to be reported immediately to the nurse. Per interview, they had been in-serviced on the Stop and Watch tool and had taken a posttest after the education. Interview with the Activities Director on [DATE] at 3:40 PM revealed she had been educated in the Stop and Watch tool and the importance of the resident's care plan. She stated she was to watch for any new or worsening pain, or if a resident was participating less in activities. She stated she was to document and notify the nurse. 4. Review of AoC Audit Tool - [DATE], dated [DATE] through [DATE], revealed the facility was conducting observation rounds of ten (10) staff and five (5) residents every shift. Continued review revealed residents were interviewed to ensure they were receiving pain medications, with any changes in condition noted, assessments completed, notifications made as appropriate, and care plans updated as appropriate. Review of the staff portion for licensed staff revealed licensed staff were interviewed regarding the process for respiratory treatment, the process for reporting changes in condition, awareness of notification of the Physician or NP regarding resident pain issues and awareness of the care plan reflecting resident needs. Review of the staff portion for non-licensed staff revealed they were interviewed regarding awareness of the Stop and Watch Tool reporting of changes in resident condition regarding pain, respiratory status, or skin issues. Interview with RN #4 on [DATE] at 12:00 PM revealed she had audited nineteen (19) residents with pain. A tool called 'Stop and Watch' was used to educate staff on pain. All staff were educated and all tours of duty were included to assure no staff were missed. Interview with SRNA #8, on [DATE] at 8:35 AM, revealed education was done to monitor for any new or worsening pain or change in condition. Any change was to be reported immediately to the nurse. Per interview, she had been questioned during management rounds related to monitoring for pain and reporting to nursing staff. Interview with the Activities Director, on [DATE] at 3:40 PM, revealed she had been educated in the 'Stop and Watch' tool. She stated she was to watch for any new or worsening pain, or if a resident was participating less in activities. She stated she was to document and notify the nurse. Per interview, she had been asked during management rounds regarding awareness of the Stop and Watch Tool. 5. Review of the facility's AoC binders revealed completed documentation labeled F580 Test 2 All Staff except LN, completed by facility staff covering topics such as the Stop and Watch Tool, changes in resident condition, and person-centered resident care. 6. Interview with the DON, on [DATE] at 9:18 AM, revealed she reviewed the results of observations, interviews, and audits daily, and she ensured there was additional follow-up as needed. She stated audits had increased staff education and were helping management ensure staff followed-up with everything. She stated management had identified a need for staff improvement on documentation. 7. Review of the facility's In-Service Sign In Sheets, dated [DATE] through [DATE], revealed Licensed Nurses attended or were educated in person or over the phone regarding: (A) Pain management to include implementing person-centered care plan with individualized person centered interventions to include monitoring pain, administering pain medications as ordered, utilizing and documenting the pain scale, and observing for non-verbal signs/symptoms of pain; (B) Pressure Ulcer prevention to include developing/implementing the care plan; (C) Person-centered care plans; and (D) Physician/Mid-Level Provider Notification of Change in a resident's condition, Review of documents titled Post Test revealed licensed nursing staff completed testing covering all identified areas, to include changes in residents' condition, management of resident pain, Stop and Watch Tool, provider notification of change, and person-centered care plans. Interview with LPN #17, on [DATE] at 8:49 AM and with LPN #10 on [DATE] at 8:05 AM, LPN #3 at 9:05 AM and LPN #6 at 9:10 AM, revealed they had been educated to watch for any new or worsening pain, to implement a person centered care plan with individualized interventions, administer pain medications as ordered using the pain scale, pressure ulcers monitor and treatment and to notify the practitioner with all changes in resident conditions. Per interviews, a posttest to acknowledge understanding of the education was given. Interview with RN #4 on [DATE] at 12:00 PM revealed a tool called 'Stop and Watch' was used to educate staff on pain. All staff were educated and all tours of duty were included to assure no staff were missed. The education is to be ongoing. Staff were educated to be transparent and use open communication. RN#4 reported all staff were educated on notifying the practitioner if a resident was experiencing pain. For chronic pain, interventions were to be implemented. 8. Review of the facility's documentation revealed the NPE reviewed all residents on [DATE] that had been admitted , readmitted , or that had been identified with changes in respiratory status. The NPE identified any changes since [DATE], and ensured care plan changes were implemented as necessary. Interview with the NPE, on [DATE] at 1:30 PM, revealed she did review all residents on [DATE] that had been admitted , readmitted or identified with changes in respiratory status. 9. Review of the facility's In-Service Sign In Sheets, dated [DATE] through [DATE], revealed all licensed nurses, to include agency nurses, were educated in person or over the phone regarding revision of resident care plans for all admissions, readmissions, and changes in respiratory status for residents with diagnoses to include acute respiratory failure, sleep apnea, COPD, and asthma. Review of Clinical Competency Validation Respiratory Assessment, revealed licensed nursing staff completed testing following education. Interview with RN #4 on [DATE], LPN #17, on [DATE] at 8:49 AM and with LPN #10 on [DATE] at 8:05 AM, LPN #3 at 9:05 AM and LPN #6 at 9:10 AM, revealed they had been educated related to the revision of the resident care plan for all admissions, readmissions and changes in respiratory status for residents. Per interviews, a posttest to acknowledge understanding of the education was given. 10. Review of the AoC Audit Tool - [DATE], revealed care plan audits were conducted on new admissions, readmissions, and change in condition residents, to include a change in respiratory status, and were ongoing as of [DATE]. 11. Continued review of the AoC Audit Tool - [DATE], revealed five (5) licensed staff were interviewed d[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, review of the facility's policy, and review of the Centers for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) Manual Version 3.0, it was determined the facility failed to ensure Comprehensive Care Plans (CCP) for chronic pain and pressure risk with individualized person-centered interventions were followed for four (1) of thirty (30) sampled residents, Resident #110, #114, #36 and #102. The facility identified Resident #110 as at risk for alterations in comfort related to osteoarthritis (OA), muscle weakness, right upper extremity edema, contracture, hemiplegia, obesity, and polyneuropathy. Observation of Resident #110, on 04/21/2021 at 9:05 AM, revealed the resident yelled for a nurse for appoximately two (2) minutes. No one responded to the resident until the State Survey Agency (SSA) Surveyor alerted staff that the resident needed assistance. Interview with Resident #110, on 04/21/2021 at 9:20 AM, revealed staff did not address his/her chronic pain, and while the resident had resided at the facility since the last readmission, he/she had not received pain medication as needed. Resident #110's care plan, revised on 02/27/2021, identified the resident as being at risk for pressure injuries. Interviews and record review revealed the facility failed to implement pressure sore interventions. Resident #110 developed an open right gluteal abscess 2.0 cm (length) by 3.0 cm (width) by 0.4 cm (depth), with hard surrounding tissue and moderate amounts of purulent drainage. In addition, there was development of an unstageable sacral decubitus ulcer measuring 8.0 cm (length) by 2.0 cm (width). Furthermore, a Computed Tomography (CT) of the pelvis showed a chronic calcified posterior right gluteal region hematoma in the surrounding soft tissue infiltration indicating possible soft tissue infection from the right buttock ulcer. The facility's failure to have an effective system to ensure the facility developed care plans and implemented interventions in the care plans to address the resident's assessed needs, related to pain management and pressure ulcers, has caused or is likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy (IJ) was identified on 04/28/2021, in the area of 42 CFR 483.21(b)(1) Comprehensive Resident Centered Care Plans, Develop and Implement Care Plans, and was determined to exist on 04/04/2021. The facility provided an acceptable Allegation of Compliance (AoC) on 04/29/2021, with the facility alleging removal of the Immediate Jeopardy on 05/06/2021. The State Survey Agency validated removal of the Immediate Jeopardy as alleged on 05/06/2021, prior to exit on 05/14/2021, with the remaining non-compliance at a Scope and Severity of a D while the facility develops and implements a Plan of Correction and the facility's Quality Assurance (QA) monitors to ensure compliance with systemic changes. The findings include: Review of the facility's policy titled, Person-Centered Care Plan, revised 07/01/2019, revealed Comprehensive Care Plans were developed to help the resident attain or maintain his/her highest practicable physical, mental and psychosocial well-being and included measurable objectives and timetables to meet a resident's medical, nursing, nutrition, and mental and psychosocial needs that were identified in the comprehensive assessments. Review of the Centers for Medicare and Medicaid Services, Resident Assessment Instrument (RAI) Manual 3.0, dated October 2016, revealed the care plan was driven, not only by identified resident issues and/or conditions, but also by a resident's unique characteristics, strengths, and needs. Furthermore, a care plan, based on a thorough assessment and effective clinical decision making, was compatible with current standards of clinical practice that provided a strong basis for optimal approaches to quality of care and quality of life needs of individual residents. The manual stated a well-developed and executed assessment and care plan re-evaluated the resident's status at prescribed intervals (quarterly, annually, or if a significant change in status occurred) using the RAI and then modified the individualized care plan as appropriate and necessary. 1. Review of Resident #110's medical record revealed the resident was admitted by the facility, on 11/14/2017. The resident had current diagnoses of Obstructive Sleep Apnea (OSA), Chronic Obstructive Pulmonary Disease (COPD), Asthma, Dysphagia, Heart Failure (HF), and Chronic Kidney Disease (CKD). Further review revealed Resident #110 had been hospitalized , from 03/20/2021 to 04/01/2021, with Sepsis and Acute Respiratory Failure. Review of Resident #110's Quarterly Minimum Data Set (MDS), dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) score of eleven (11), which indicated he/she had mild cognitive impairment. Continued review revealed the facility assessed Resident #110 as having pain during this assessment period and had received scheduled or as needed (PRN) pain medication. Review of Resident #110's Comprehensive Care Plan (CCP), initiated on 05/01/2013 and last reviewed on 03/01/2021, revealed Resident #110 was at risk for alterations in comfort related to osteoarthritis (OA), muscle weakness, right upper extremity edema, contracture, hemiplegia, obesity, and polyneuropathy. The goal was the resident would achieve an acceptable level of pain control. Further, interventions included but were not limited to, administer pain medication as ordered; elevate right upper extremities with pillow; observe pain characteristics: quality, severity, location, precipitating/relieving factors, medicate resident as ordered for pain, observe for effectiveness and side effects, and report to the Physician as indicated. Observation of Resident #110, on 04/21/2021 at 9:05 AM, revealed the resident yelled for appoximately two (2) minutes. Resident was heard to moan and groan and observation of resident showed non-verbal ques of pain with grimacing. No one responded to the resident until the State Survey Agency (SSA) Surveyor alerted staff that the resident needed assistance. This surveyor went to the nursing station and made SRNA #11, aware that Resident needed assistance. SRNA #11 got up and went into the room. Interview with Resident #110, on 04/21/2021 at 9:20 AM, revealed staff did not address his/her chronic pain, and while the resident had resided at the facility since the last readmission, he/she had not received pain medication as needed. Interview with the resident revealed that he/she was in pain. The resident stated, I'm miserable and I hurt. I hurt all the time. Interview with Agency LPN #9, on 04/24/2021 at 2:15 PM and 04/25/2021 at 8:15 AM, revealed all staff was to follow and implement the residents' CCP to ensure they were receiving ordered care. LPN #9 stated Resident #110 was uncomfortable with positioning and would not tolerate it well. She stated the resident would cry out in pain when turned. LPN #9's interview revealed the resident verbalization pain, but stated if the resident had pain it was Only when moved. Further stated, She/he says she's in pain but she isn't. She stated the resident was incontinent, obese, and needed frequent skin assessments. Review of the facility's Roster Matrix (a cumulative record of residents on the census, their care needs, and identified health conditions), dated 04/20/2021, revealed no indication Resident #110 had any pressure ulcers. Further review of the Comprehensive Care Plan, last reviewed 03/01/2021, revealed Resident #110 was at risk for skin breakdown as evidenced by moisture/excessive perspiration, limited mobility, diabetes mellitus, peripheral vascular disease, incontinence of bowel and bladder, medications, history of pressure ulcers, obesity, hemiplegia, anemia, and an arterial ulcer to the right second digit. The goal was for the resident to show no signs of further skin breakdown. Further review revealed interventions were to apply barrier cream with each cleansing, assist with methods of reducing friction and shear, assist the resident with turning and repositioning every two (2) hours as tolerated, float heels while in bed as tolerated, provide a low air loss (LAL) mattress to the bed, perform [NAME]/Braden assessments per policy, observe skin risk factors per protocol, and observe for localized skin problems. Further review of the Comprehensive Care Plan, last reviewed 03/01/2021, revealed Resident #110 was at risk for skin breakdown or had actual skin breakdown. The healing goals were: 1) the resident would remain free of skin tear and bruising; 2) show no signs of skin breakdown; 3) the skin tear/bruise would heal; and 4) the wound/skin impairment would heal. Further review revealed interventions were to pat skin when drying, provide treatment to skin tear per Physician order, observe for signs of infection, assist resident with turning and repositioning, observe skin for signs/symptoms of skin breakdown, evaluate localized skin problems, utilize devices to assist with turning/positioning to reduce friction and shear, weekly skin assessments by a licensed nurse, weekly wound assessment to include measurements and description of the wound, and provide wound related pain management intervention (i.e. premedicate before wound care). Further review of the Comprehensive Care Plan, last reviewed 03/01/2021, revealed Resident #110 was incontinent of urine and was unable to participate cognitively or physically in a retraining program. The goals were to have incontinence care needs met by staff to maintain dignity and comfort, and to prevent incontinence related complications. Further review revealed interventions were to check and change every two (2) hours and as needed (PRN) and to observe for skin redness/irritation and report as indicated. Interview with Agency LPN #9, 04/25/2021 at 8:15 AM, stated the wound on the hip was an abscess with drainage, and she performed a culture and sensitivity on the drainage during a dressing change. She stated the wound abscess was tiny. LPN #9 stated the area on the right buttocks was healed. Further review Resident #110's medical record revealed, on 04/22/2021, Resident #110 was transferred to the hospital Emergency Department (ED) by Emergency Medical Services (EMS), and during the triage period, hospital staff and EMS identified a sacral wound. The hospital assessed the resident to have an open right gluteal abscess, 2.0 cm (length) by 3.0 cm (width) by 0.4 cm (depth), with hard surrounding tissue and moderate amounts of purulent drainage. In addition, the record stated staff identified an unstageable sacral decubitus ulcer measuring 8.0 cm (length) by 2.0 cm (width). Furthermore, a Computed Tomography (CT) of the pelvis showed a chronic calcified posterior right gluteal region hematoma in the surrounding soft tissue infiltration indicating possible soft tissue infection from the right buttocks ulcer. Further review revealed a surgical consult revealed the abscess and sacral ulcer would require surgical debridement of necrotic tissue. Then, a palliative care (care primarily focused on alleviating pain) consult was requested by the provider because the patient has no quality of life. The resident was transferred back to the facility under Hospice Care on 04/30/2021 and expired on 04/30/2021. Review of a Braden Scale (a scale used to determine the degree of risk a resident had for developing pressure ulcers) Assessment and Skin Check dated, 04/08/2021 at 5:27 PM, revealed Resident #110's score as ten (10), which indicated high risk. Review of the Skin Check, dated 04/08/2021, revealed the nurse identified wounds to the right, second toe; right buttocks; and forehead. Review of a CIC follow-up Progress Note, dated 04/11/2021 at 9:43 AM, revealed Resident #110's skin was warm with one-plus (1+) pitting edema in bilateral feet. Review of the Skin Check, performed on 04/15/2021 at 5:27 PM, revealed no documented assessment, skin injuries, or wounds. Review of the Skin Assessment Grid, dated 04/20/2021, revealed the only remaining wounds documented as assessed, was the buttocks/right hip abscess. There was no documentation of the right first toe, second toe, or third toe. There was no documentation of the medial forehead wound. There was no documentation or description of an unstageable sacral decubitus ulcer. Interview with SRNA #18, on on 04/25/2021 at 8:20 AM, revealed when aides found a skin issue on a resident, the process was to document the finding on the Skin Assessment sheet and make the nurse aware. She further stated it was important to follow the resident's CCP. Interview with SRNA #26, on 04/26/2021 at 5:15 PM, revealed Resident #110 was a total assist, but not bedridden. She stated the resident did not refuse care, but she would have to be very gentle when providing care. She used a pillow for elevation of the right arm. However, the SSA Surveyor observations, on 04/21/2021, revealed no pillow under the resident's right arm as directed by the resident's CCP. SRNA #26 further stated it was important to follow the resident's CCP so that residents' needs were met. She stated she had performed incontinent care for Resident #110, but she did not recall seeing a wound. Interview with Agency LPN #15, on 04/26/2021 at 5:05 PM, revealed she cared for Resident #110. She stated he/she was bedridden and had skin breakdown in abdominal folds. She did not recall any other skin breakdown. She stated Resident #110 would occasionally not want to be changed. LPN #15 stated her focus was on acute residents, so the SRNA's were her eyes and ears to alert her to potential problems. She stated person-centered care plans should be implemented. Additional interview with LPN #9, on 04/27/2021 at 11:13 AM, revealed Resident #110's right buttocks area had purulent drainage like an abscess. She stated she notified the Wound Care Nurse (WCN), obtained a wound culture and sensitivity, and notified the Physician for treatment orders. She stated she did not measure the wound and estimated it to be the size of a nickel. She stated no other skin issues were present. LPN #9 stated, on 4/22/2021, the abscess was open and draining, and she had to pack it. She recalled the resident flinched during treatment and stated it was uncomfortable. She further stated that Resident #110 did not want to be disturbed. LPN #9 stated she did not document the resident's care or his/her verbal or non-verbal reactions to treatment. Interview with Registered Nurse (RN) #3, on 04/25/2021 at 8:30 AM, revealed Resident #110's had an abscess to the right buttock. Per interview, RN #3 stated SRNA's only changed the resident two (2) times or less a shift because it was too uncomfortable for the resident. RN #3 stated the resident's CCP should have be implemented. Interview with RN #2, Nurse Educator/Wound Care Nurse (WCN), on 04/25/2021 at 9:00 AM, revealed she was following Resident #110 for a wound on the toe, forehead, and shearing on the right buttock; however, she was not following the resident's abdominal fold wounds. RN #2 stated the shearing wound on the right buttock was healed, but a new wound abscess was found on the right hip area. She stated that LPN #9 did culture and dress the wound. In addition, the WCN stated the resident would grimace and moan when touched, and staff had to be gentle and procede slowing during the resident's wound care treatments. She stated she did not document Resident #110's pain level or non-verbal cues. She further stated if there was an order to do so, she would generally premedicate residents prior to wound care. Per interview, she stated it was important to follow the resident's CCP. Furthermore, she stated she should have premedicated Resident #110, per the CCP. She stated it would have been important to prevent any additional discomfort to the resident. Continued interview with the WCN, on 04/25/2021 at 9:00 AM, revealed it was her expectation that staff assessed skin, bathed, checked and changed, and turned the resident per the CCP. She stated the importance of CCP was to ensure the Resident #110 was turned a minimum of every two (2) hours, and if he/she required, more frequently to prevent pressure injuries. She stated CCP's should be personalized and updated. Further interview revealed there was currently no widespread education on newly identified skin issues. The WCN stated the facility process was to let Unit Managers know about new skin issues. She stated not all staff had been educated on Pressure Ulcer Prevention (PUP) and PUP protocols were not in place. The WCN stated the plan was to implement new training regarding the turn schedule so nursing staff and SRNA's were educated on the importance of turning residents. Additional interview with the WCN, on 04/25/2021 at 4:35 PM, revealed Agency staff was trained prior to coming to the facility on basic resident care. She stated the facility had processes to ensure competencies, which were not yet in place, for new hires, but new hires were paired with a trainer for one (1) to two (2) days, which she did not think was an adequate period of time. In addition, the WCN stated, during orientation, new staff was educated about using the CCP to personalize care, and trainers reported if there were any issues with competencies. Per interview, she stated she relied on other staff to check that agency staff was competent. Furthermore, she stated there was no follow-up from the Educator to assure competent care was provided according to the CCP and facility policies. She stated her goal was to spend one-on-one time with all staff, but for right now the process is broken. Additional interview with the WCN, on 04/27/2021 at 11:52 AM, revealed during the last treatment she did on Resident #110, she only concentrated on the abscess to the hip. She recalled documenting assessment findings on a piece of paper. She stated she received an order to pack the wound with Silvadene covered gauze. Per interview, she stated the wound was an abscess and not something that could be staged. She stated she did not measure the wound, and per policy, no photographs were obtained. The WCN stated a full skin assessment was not done. Further interviewed revealed she focused on the acute areas of skin breakdown, and nurses did a weekly skin assessment. Interview with the Regional Clinical Quality Specialist (RCQS), on 04/24/2021 at 03:40 PM, revealed it was her expectation that nursing staff utilize skilled charting to document She stated, If it was not charted, it didn't happen. RCQS stated, Stated there is a breakdown in communication. here was no documented evidence the nursing followed the resident's care plan, according to facility policy. Interview with the Director of Nursing (DON), on 05/14/2021 at 9:18 AM, revealed it was her expectation staff followed the resident's CCP, and if a resident had a pressure injury, it should be addressed in the CPC. She stated she expected nursing staff to provide the correct level of care per the person-centered care plan and as ordered by the Physician. Further interview revealed full skin assessments should be completed by nursing staff when weekly skin assessments were due. Per interview, the DON stated all residents at risk for skin breakdown should be checked, changed, and turned every two (2) hours. The DON stated SRNA's should notify the nurse of any change in the resident's condition. 2. Based on observation, interview, and record review, it was determined the facility failed to follow the individualized care plan relating to bathing and grooming of Resident #114. Record review revealed the facility admitted Resident #114 on 08/10/2021 with multiple diagnoses to include Hemiplegia Affecting the Left Dominant Side, Dysphagia, History of TIA, Cognitive-Communication Deficit, Epilepsy, Vascular Dementia with Behavioral Disturbance, Major Depressive Disorder, Generalized Anxiety Disorder, Unspecified Mood Disorder, Congestive Heart Failure (CHF), Acquired Absence of Left Leg Above Knee (LAKA), Repeated Falls, etc. Review of the Annual Minimum Data Set (MDS) dated [DATE] revealed the facility assessed the resident with a Brief Interview for Mental Status (BIMS) exam score of eight (8) of fifteen (15), and determined the resident to be moderately cognitively impaired. Review of Resident #114 Comprehensive Care Plan, last reviewed on 04/13/2021, revealed the resident required assistance with, and was dependent for Activities of Daily Living (ADL) care in bathing, grooming, personal hygiene, dressing, eating, bed mobility, transfer, locomotion, and toileting related to Limited Mobility, Cognitive Loss and Behaviors, Hemiplegia, and Left Above-Knee Amputation (LAKA), with the goal that ADL care needs will be anticipated and met throughout the next review period. Target date was 07/12/2021. Interventions included providing Resident #114 with extensive assist for toileting, dressing, and bathing. Observation of Resident #114, on 04/21/2021 at around 2:00 PM, revealed Resident #114 lying in bed with a urinal containing urine hanging on his bed rail. There was an odor detected coming from the resident's side of the room. Resident #114 also had a full beard, and his clothes and hair were disheveled. Attempts to have a conversation with Resident #114 regarding his care needs were unsuccessful. He commented that he liked pretty women. Interview with the Manager on 200 Hall (LPN #1), on 04/21/2021 at 2:15 PM, revealed residents received showers on a routine assigned schedule and as often as staff deemed necessary. In addition, the manager stated the nurse aides complete shower sheets when showers were given to their assigned residents. The shower sheets were placed in a shower book at the nurses' station. Resident #114 was assigned to receive a shower on Tuesdays and Fridays during the evening shift. Continued interview with LPN #1 (Unit Manager), revealed that based on the shower sheets in the book, she could not determine when the last time Resident #114 received a shower, or that ADL care needs were being provided as per care plan. Observation of the Shower Binder, on 04/21/2021 at 2:30 PM, located at the nurses' station, revealed Resident #114 did not have any shower sheets in the book for April. Interview with the manager again revealed she did not know why the sheets were not in the book. She stated that this was a new process, and she realized the process needed improvement. Continued interview revealed that perhaps the sheets were removed and sent to medical records already, and she would check to find out. However, no sheets were located in medical records. Interview with SRNA #22, on 04/24/2021 at 9:00 AM, employed sixteen (16) years, revealed she usually worked weekends from 7 AM-11 PM on the 200 Hall. On a good day, staffing was four (4) nurse aides; today, there were three aides working the 200 Hall. Continued interview revealed each aide was assigned two to three showers each. During the shower, the nurse aide noted any skin issues and reported any findings to the nurse. Afterward, a shower sheet was completed, and placed in the shower binder located at the nurses' station. If the shower sheet was not found in the shower book, either the nurse aide did not do the shower, or the aide failed to complete the sheet; The nurse was supposed to verify that the nurse aide conducted the shower by checking the shower sheets. She stated that the facility has been in a staffing crisis lately, and most of the staff are Agency. Interview with SRNA #19 on 04/24/2021 at 9:30 AM, employed 25 years at the facility, revealed she primarily works weekends on the 300 Hall and works typically with three to four aides. She revealed she normally was assigned two showers on her shift. She said the aides completed the shower sheets and reported any skin issues to the nurse; they then put the sheets in the shower book. Continued interview revealed that she would assume it was not done if she did not see the shower sheet in the book. Interview with LPN #11, on 04/25/2021 at 8:49 AM, employed seventeen (17) years, revealed that aides were responsible for performing resident's showers on the days the showers were due. Aides bring the shower sheets to the nurse upon completion. The aides were supposed to inform nurses if the resident refuses their shower. The nurse would then go to the resident and try to convince the resident to take a shower. If the resident continued to refuse a shower, it should be documented in the medical record. Interview again with LPN #1, on 04/22/2021 at approximately 10:00 AM, revealed Resident #114 received a good shower last evening. She revealed more attention would be given to make sure resident's care plans were implemented as outlined in their individualized care plan. 3. Record review revealed the facility admitted Resident #36 on 02/27/2019 with diagnoses to include Anoxic Brain Damage, Hemiplegia Affecting Unspecified Side, Chronic Obstructive Pulmonary Disease, Encephalopathy, Unspecified Convulsions, Dysphagia, Hypothyroidism, Congenital Deformities, Irritability and Anger, Mood Disorder, Bipolar Disorder, Unspecified Psychosis, etc. Review of the Annual Minimum Data Set (MDS), dated [DATE], revealed the facility assessed the resident with a Brief Interview for Mental Status (BIMS) exam score of three (3) of fifteen (15), and determined the resident to be moderately cognitively impaired. The resident required one person physical assist with mobility and extensive assistance with transfers due to impairment on one side. In addition, the resident was dependent for toileting, hygiene, and requires substantial/maximum assistance with shower/bath. Resident #36 was incontinent of urine. Review of Resident #36's Comprehensive Care Plan (CCP), last reviewed on 03/09/2021, revealed the resident required extensive to dependent care for all Activities of Daily Living (ADL) in bathing, grooming, personal hygiene, dressing, eating, bed mobility, transfer, locomotion, and toileting related to Anoxia and Hemiplegia. Review of Resident #36's CCP, last reviewed on 03/09/2021, revealed the resident required extensive to dependent care for all Activities of Daily Living (ADL) care in bathing, grooming, personal hygiene, dressing, eating, bed mobility, transfer, locomotion, and toileting related to Anoxia and Hemiplegia. The goal of Resident #36 ADL care was to maintain the highest capable level of ADL ability throughout the next review period. Initiated date was 03/01/2018. Target date was 06/07/2021. Interventions included providing extensive assist for personal hygiene (grooming), and bathing. Review of Resident #36's CCP, last reviewed on 03/09/2021, revealed the resident was at risk for skin breakdown as evidenced by incontinence, limited mobility, hemiplegia, and cognitive loss and decreased safety awareness, convulsions, diagnosis of herpes labialis. The goal of Resident #36 interventions were the resident would not show signs of skin breakdown for the next ninety (90) days. Initiated date was 03/01/2018. Target date was 06/07/2021. Interventions included applying barrier cream with each cleansing, assist resident with repositioning, observe for localized skin problems, observe for skin risk factors per protocol, observe skin conditions with ADL care, observe skin for signs/symptoms of skin breakdown, provide pericare/incontinence care as needed, perform a weekly skin assessment by a licensed nurse. Observation of Resident #36, on 04/21/21 at 9:30 AM, revealed the resident to have greasy, uncombed hair. The Resident's had food stuck between his/her teeth and they appeared dirty. Resident #36 reported to SSA Surveyor that he/she was in pain. Resident #36 pointed to the groin area and stated, It hurts and burns. Observation noted a strong smell of urine. Resident stated he/she was wet, and the brief under slacks appeared saturated. When asked how often he/she was changed during the day, Resident #36 replied, he/she sat in the wheelchair and was not changed until he/she was put back to bed. SSA Surveyor reported Resident #36's condition to the Unit Manager, LPN #6. Medical Records review, on 04/21/2021 at 11:10 AM, revealed a Skin Assessment was performed after SSA Surveyor alerted nursing staff that the resident was wet and uncomfortable. On 4/20/2021 at 2:12 PM, LPN #9 documented a red fungal rash to vaginal folds. Continued review of medical records revealed a Nursing Note, dated 4/21/2021 at 2:25 PM, for a change in condition (CIC). Review of the CIC notes revealed, LPN #9 assessed Resident #36 as having a rash area covering vaginal labias. The physician was notified and new orders received. Observation, on 5/11/2021 at 4:00 PM, of perineal care on Resident #36, revealed labial area was excoriated with a small amount of thick, white drainage note. Observation on 5/13/2021 at 8:30 AM, revealed Resident #36 sitting in his/her in room in a wheelchair. Resident #36 pointed to his/her groin. Per interview, Resident stated he/she had not been changed. Resident stated he/she was wet. Observation revealed a strong smell of urine and briefs were full. SSA Surveyor asked if the staff changed his/her briefs when asked, he/she replied, Not very much. When asked if staff takes him/her to the bathroom during the day, he/she stated, No. I sit all day. The resident began to cry. Staff came in and changed the resident. Review of the 300 Hall Shower Binder, on 04/21/2021 at 2:50 PM, located at the nurses' station, revealed Resident #36 had only two (2) document shower sheets, dated 03/28/21 and 04/21/2021. There was no document evidence Resident #36 received his/her showers as care planned and per facility policy for resident to receive a bath/shower at least twice weekly. Interview with the Unit Clerk, SRNA #11, on 04/28/2021 at 1:50 PM, revealed she did not know why the sheets were not in the book. She stated the nurse was responsible for making sure the shower or bed bath was completed, and should sign each shower sheet when the shower wa completed. She stated aides do a skin check with each change. Continued interview revealed Resident #36 was changed in the morning, per the Care Plan, then changed and repositioned every two (2) hours thereafter on even hours. However, further interview revealed, Resident #36 was placed in his/her wheelchair after breakfast and not changed until after lunch. Interview with SRNA #19, on 04/25/2021 at 3:43 PM, revealed she worked the 300 Unit. She stated the facility was frequently short staffed. Per interview, SRNA #19 stated she did not have enough time on some days to do job. On days when there were not enough aides, she revealed she tried to check and change each residents every two (2) hours. SRNA #19 stated, however, check and change were usually done every three (3) hours. She state aides completed shower sheets, documented skin issues, and reported to the nurse to sign. Continued interview revealed that she would assume it was not done if shower sheet were not in the shower binder. On 04/24/2021 at 2:15 PM,Interview with LPN #9, revealed showers were given every two (2) days. The policy was for the aide to report to the nurse, if a resident refused a shower so the nurse could talk with the resident. If the resident refused a second time, the Unit Manager would speak to and educate the resident on the benefits of taking regular showers. If after a third refusal, the nurse was to document the refusal on the shower sheet, and as a nursing note. LPN #9 stated that was not always the case, and shower sheets were not always completed. Interview with RN #2, Nurse Educator/Wound Care Nurse, on 4/25/2021 at 9:00 AM revealed incontinent residents should be checked and changed every two (2) hours. RN #2 stated the importance of following the Care Plan (CP) was to ensure the Resident was turned minimally every two (2) hours, [TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, review of the facility's policy, and review of the Centers for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) Manual Version 3.0, it was determined the facility failed to ensure Comprehensive Care Plans (CCP) were reviewed and revised to address the need for additional interventions to monitor and maintain sufficient respiratory status for one (1) of thirty (30) sampled residents (Resident #110). The facility admitted Resident #110, on [DATE] with current diagnoses of Chronic Obstructive Pulmonary Disease (COPD), Asthma, Dysphasia, Heart Failure (HF), and Chronic Kidney Disease (CKD). Resident #110 had been hospitalized , from [DATE] to [DATE] with Sepsis and Acute Respiratory Failure. In addition, Resident #110 had been sent to the hospital Emergency Department (ED), on [DATE], for edema and was returned to the facility five (5) hours later, on [DATE]. However, there was no documented evidence the facility identified the resident's risks and revised the Comprehensive Care Plan (CCP) to give direction for staff to monitor and maintain sufficient respiratory status for the resident. On [DATE], Resident #110 experienced a change in condition (CIC) with his/her respiratory status. Resident #110 was transferred to the hospital's ED (Emergency Department), on [DATE] at 5:52 PM, via Emergency Medical Services (EMS) and was admitted . Resident #110 presented to the ED in pain, lethargic and moaning with diminished lung sounds bilaterally (both sides), bilateral upper and lower extremity swelling and edema, febrile, and with an altered mental status. Resident #110 returned to the facility under Hospice Care, on [DATE], and expired on [DATE]. The facility's failure to revise the resident's care plan to address the resident's respiratory status has caused or is likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy (IJ) was identified on [DATE] in the area of 42 CFR 483.21(b)(2) Comprehensive Resident Centered Care Plans, Timing and Revision of Care Plans, and was determined to exist on [DATE]. The facility provided an acceptable Allegation of Compliance (AoC) on [DATE], with the facility alleging removal of the Immediate Jeopardy on [DATE]. The State Survey Agency validated removal of the Immediate Jeopardy as alleged on [DATE], prior to exit on [DATE], with the remaining non-compliance at a Scope and Severity of a D while the facility develops and implements a Plan of Correction and the facility's Quality Assurance (QA) monitors to ensure compliance with systemic changes. Refer to F695 The findings include: Review of the facility's policy titled, Person-Centered Care Plan, revised [DATE], revealed Comprehensive Care Plans were developed to help the resident attain or maintain his/her highest practicable physical, mental and psychosocial well-being and included measurable objectives and timetables to meet a resident's medical, nursing, nutrition, and mental and psychosocial needs that were identified in the comprehensive assessments. Review of the Centers for Medicare and Medicaid Services, Resident Assessment Instrument (RAI) Manual 3.0, dated [DATE], revealed the care plan must be reviewed and revised periodically, and the services provided or arranged should be consistent with each resident's written plan of care. Continued review of the manual, revealed the care plan was driven, not only by identified resident issues and/or conditions, but also by a resident's unique characteristics, strengths, and needs. Furthermore, a care plan, based on a thorough assessment and effective clinical decision making, was compatible with current standards of clinical practice that provided a strong basis for optimal approaches to quality of care and quality of life needs of individual residents. The manual stated a well-developed and executed assessment and care plan re-evaluated the resident's status at prescribed intervals (quarterly, annually, or if a significant change in status occurred) using the RAI and then modified the individualized care plan as appropriate and necessary. Record review revealed the facility admitted Resident #110 on [DATE]. The resident had diagnoses of Obstructive Sleep Apnea (OSA), Chronic Obstructive Pulmonary Disease (COPD), Asthma, Dysphagia, Heart Failure (HF), and Chronic Kidney Disease (CKD). Further review revealed, Resident #110 had been hospitalized , from [DATE] to [DATE], with Sepsis and Acute Respiratory Failure. Review of Resident #110's CCP, initiated on [DATE], revealed a focus of the resident was at risk for the potential alteration in fluid balance and he/she was at risk for fluid volume excess because of Heart Failure and Chronic Kidney Disease. The goal revealed the resident would not experience any signs/symptoms of fluid overload as evidenced by the absence of peripheral edema and dyspnea. Continued review of the CCP revealed interventions, initiated on [DATE], included staff was to observe for symptoms of edema, shortness of air (SOA) and weight gain. Further review revealed the CCP was not revised when the resident experienced a change in condition on [DATE]. Continued review of Resident #110's CCP, initiated on [DATE], revealed the resident was at risk for complications related to OSA, COPD, Asthma, and Dysphagia. The goal stated the resident would not have sign/symptoms of respiratory distress or aspiration. Further review of the CCP revealed some interventions were to administer aerosol medications as ordered/indicated; administer BiPAP as ordered; observe and report SpO2 (blood oxygen saturation) levels via pulse oximetry as ordered and as needed; and observe respiratory rate, signs/symptoms of dyspnea, abnormal breath sounds, cyanosis, and use of accessory muscles. Review of Resident #110's hospital records, dated [DATE], revealed the resident was admitted to the hospital, on [DATE], for sepsis and acute respiratory failure. Resident #110 was discharged from the hospital and returned to the facility on [DATE]. However, there was no documented evidence the CCP was revised to address the resident's respiratory status. Further review of Resident #110's medical record revealed a Physician's Order, with a start date of [DATE], to use a BiPAP machine with two (2) liters of oxygen at bedtime. In addition, the record showed an order for two (2) liters of oxygen, via nasal cannula, every shift to keep oxygen saturation levels above ninety (90) percent. Observation and interview with Resident #110, on [DATE] at 9:20 AM, revealed the resident in bed lying on his/her left side with his/her heels pressed against the mattress. There was generalized edema observed over the lower extremities, bilateral hands, and upper extremities; the left hand had an indentation where it rested against the bed. Further observation revealed the resident was on two (2) liters/minute of oxygen via nasal cannula, but the oxygen tubing was not labeled with a date or initialed. Additional observation showed the resident's BIPAP mask and tubing were on the floor. Interview with Registered Nurse (RN) #3, on [DATE] at 8:30 AM, revealed Resident #110 was in no respiratory distress throughout the evening of [DATE], until about 5:30 AM on [DATE]. Continued interview revealed at 6:30 AM, a State Registered Nurse Aide (SRNA) observed the resident with thick phlegm coming from the mouth. RN #3 stated she notified the Physician. Per interview, the Physician examined the resident that morning and ordered lab work and a chest x-ray. Further interview revealed she did not update the care plan, and she left for the day. However, she stated any licensed nurse could update care plans. RN #3 stated the care plan should have been revised to include increased monitoring for Resident #110 when he/she had the change of condition. Interview with the Physician, on [DATE] at 10:12 AM, revealed he examined Resident #110 on the morning of [DATE]. Per interview, he assessed the resident with fluid overload caused by his/her recent intravenous (IV) antibiotic therapy, and it was his intent to diurese (remove fluid) the resident. The Physician stated he gave a verbal order to the Director of Nursing (DON) directly to place an indwelling catheter, give one (1) dose of Furosemide (a diuretic used to remove excess fluid from the body) sixty (60) mg IV (intravenous), monitor lung sounds, and document strict I&O's (fluid intake and output). The Physician stated he gave the order specifically to the DON because, as an RN (Registered Nurse), she was the only nurse in the building, who could push IV Furosemide. Additionally, he stated he ordered strict I&O's and the monitoring of the resident's lung sounds to assess the resident's response to the treatment. However review of the resident's CCP revealed no documented evidence the care plan was revised to reflect these new orders. Continued review of Resident #110's Nursing Progress Note, dated [DATE] at 3:09 PM, revealed the first CIC follow-up note by LPN #9. The note stated the resident's condition had declined, and the Physician was notified. Furthermore, the note stated new orders were received to continue to hold PO (oral) medications, insert a Foley catheter for strict I&O's, and provide comfort care; there was not a specific time given for receipt of the orders. However, the resident's CCP was not revised to reflect these changes to the resident's plan of care. Interview with Agency State Registered Nurse Aide (SRNA) #21, on [DATE] at 3:04 PM, revealed she was assigned to Resident #110 on [DATE]. Per interview, she stated that when she cared for the resident, he/she was crying and complained of having no air (SOA). Per interview, SRNA #21 stated she reported this to the nurse, but did not recall if the nurse assessed the resident. She further stated no one made her aware of any revisions to the resident's care plan. She stated all she knew was the resident was sent to the hospital later that day. Review of Resident #110's Hospital ED Admitting Physician Note, dated [DATE], revealed the resident arrived at the ED in pain, lethargic, did not move his/her extremities, and moaned with discomfort. Resident #110 was admitted to the hospital with diminished lung sounds bilaterally (both sides), bilateral upper and lower extremity swelling and edema, febrile, and with an altered mental status. Resident #110 returned to the facility under Hospice Care, on [DATE], and expired on [DATE]. Interview with LPN #9, on [DATE] at 8:15 AM, revealed she was assigned to Resident #110, on [DATE] from 6:00 AM to 6:00 PM. She stated the resident was noted to have a CIC during the night shift, which was documented and reported to her at shift change. LPN # 9 stated she was up and down the hall ensuring the resident was responsive, and she monitored his/her vital signs throughout the day. However, she stated she did not revise the care plan to include increased monitoring and to include strict intake and outputs, as ordered by the Physician. She further stated she should have updated the care plan, so Resident #110 could obtain the best possible outcome and so all staff would know how to care for the resident. Telephone Interview with the Minimum Data Set (MDS) Coordinator, [DATE] at 4:20 PM, revealed every nurse had the ability to access and update the CCP, and she would expect to see updates on acute changes as they happened. Interview with the Assistant Director of Nursing/Infection Preventionist (ADON/IP), on [DATE] at 10:00 AM, revealed she was made aware of the change of condition with Resident #110 on the morning of [DATE]. She stated she expected the care plans to be revised according to the resident's condition to prevent further decline. She further stated the care plans must be accurate in order for all staff to know what care needs were to be provided. Interview with the DON, on [DATE] at 9:15 AM, revealed it was her expectation that nursing staff provide the correct level of care per the care plan and as ordered by the Physician. Per interview, it was the DON's expectation that nurses did resident assessments and charted accordingly. She further stated it was her expectation for the care plans to be revised to reflect the resident's plan of care. Interview with the Regional Clinical Quality Specialist (RCQS), on [DATE] at 3:40 PM, revealed it was her expectation that care plans were updated, when there was a CIC. Furthermore, nursing staff was to assess the resident as ordered and as in the CCP. Interview with the Administrator, on [DATE] at 2:15 PM, revealed it was her expectation for care plans to be revised when there was a change of condition. The facility provided an acceptable credible Allegation of Compliance (AoC) on [DATE] alleging removal of the Immediate Jeopardy on [DATE]. Review of the AoC revealed the facility implemented the following: 1. An audit was conducted by the Assistant Director of Nursing (ADON), Nurse Practice Educator (NPE), and Unit Managers (UM) between [DATE] and [DATE] to determine if residents had pain, had pain medications ordered, if pain medications were effective, and if pain was not relieved. The Physician/Advanced Registered Nurse Practitioner (ARNP) were notified of unrelieved complaints of pain with new orders obtained if applicable. 2. Nineteen (19) of nineteen (19) residents identified with pain issues were reassessed on [DATE] by the Director of Nursing (DON), UM's, and/or Licensed Nurse (LN) Nurse Practitioner and/or Physician to determine if a change in condition had occurred regarding pain. Areas of concern were corrected upon discovery. 3. The DON, UM, ADON, NPE, and/or Clinical Quality Specialist (CQS) initiated reeducation, beginning on [DATE], with all facility staff to include contracted staff on the facility's policy and procedures regarding: (A) Change in Condition; (B) Pain Management, including observations; (C) Stop and Watch Tool; (D) Physician/Mid-Level Provider Notification of Change in a Resident's condition; and (E) Person Centered Care Plan. A post-test was administered at the time of the reeducation that required a passing score of 100% that will be graded by the DON, UM, ADON, NPE, and/or CQS to validate understanding. Facility staff and agency staff not available during the reeducation and post-test were to be provided reeducation including a post-test by the DON, UM, ADON, NPE, and/or CQS upon day of return to work prior to providing care. Newly hired staff and contracted staff were to be provided education and post-test during orientation by the DON, ADON, CQS, NPE, UM, and/or Licensed Nurse (LN). 4. Starting [DATE], clinical observation rounds will be conducted every shift, including interviews of ten (10) staff and five (5) residents who receive pain medication to identify any change in condition including a change in pain by the DON, ADON, UM, NPE, or LN to determine if residents have experienced a change in condition regarding pain. The Physician/NP were notified and the plan of care was reviewed to ensure it reflected the current needs of the resident daily until the Immediate Jeopardy is abated. 5. Starting [DATE], the Center Executive Director (CED) and/or LN would conduct ten (10) employee questionnaires daily to determine if staff were aware of the Center's process of the Stop and Watch Tool and reporting a change in condition, including reporting resident pain to a licensed nurse, to ensure prompt interventions when a resident experienced a change in condition, until the Immediate Jeopardy is abated. 6. The results of the observations, interviews, and audits will be reviewed daily by the CED or DON corrective actions taken upon discovery of deficiencies. 7. Beginning on [DATE], the DON, UM, ADON, NPE, CQS, and/or LNs initiated reeducation with all licensed nurses and agency nurses on the facility's policy and procedures regarding: (A) Pain management to include implementing person-centered care plan with individualized person centered interventions to include monitoring pain, administering pain medications as ordered, utilizing and documenting the pain scale, and observing for non-verbal signs/symptoms of pain; (B) Pressure Ulcer prevention to include developing/implementing the care plan; (C) Person-centered care plans; and (D) Physician/Mid-Level Provider Notification of Change in a resident's condition. 8. All admissions, readmissions, and residents with changes in respiratory status since [DATE] were reviewed on [DATE] by the DON, ADON, NPE, UM, and or LNs to determine if care plans reflected patient specific interventions to include interventions to monitor respiratory status to include residents with sleep apnea, COPD, acute respiratory failure, and asthma. Areas of concern were corrected upon discovery. 9. On [DATE], the DON, UM, ADON, NPE and or CQS initiated reeducation with all licensed nurses and agency nurses on the facility's policy and procedures regarding: (A) Revision of the care plan with all admissions, readmissions, and changes in respiratory status with diagnoses to include acute respiratory failure, sleep apnea, COPD, and asthma. A post-test was administered at the time of the reeducation that required a passing score of 100% that was graded by the DON, UM, ADON, NPE, and/or CQS to validate understanding. Licensed Nursing and Agency Licensed Nursing Staff not available will be provided reeducation, including a post-test, by the DON, UM, ADON, NPE, and/or Registered Nurse upon day of return to work before providing care. New licensed nursing hires and agency licensed nurses will be provided education and post-test during orientation by the DON, ADON, NPE and/or UM. 10. Care plan audits were completed for residents with diagnoses including acute respiratory failure, sleep apnea, COPD, and/or asthma and will be completed for new admissions, readmissions, and residents with a change in condition to include a change in respiratory status to determine the care plan has resident specific interventions including respiratory assessments; and, corrective actions were taken upon discovery of deficiencies. 11. Five (5) Licensed Nursing Staff interviews were completed by the CED, DON, UM, ADON, NPE, and/or CQS to determine if staff were aware of the process of a respiratory assessment when a resident's condition warranted the assessment and per the resident's plan of care will be conducted daily until the Immediate Jeopardy is abated. 12. The DON, UM, ADON, NPE, and/or CQS completed reeducation beginning on [DATE] with facility licensed staff to include agency staff on the facility's policy and procedures regarding: (A) Pain management to include implementing person-centered care plans with individualized person-centered interventions to include monitoring pain, administering pain medications as ordered, and utilizing and documenting pain scale assessments, and observe for non-verbal signs/symptoms of pain. A medication reconciliation process is in place to review discharge orders to current orders; (B) Physician/Mid-Level Provider Notification of Change in a resident's condition; and (C) Person Centered care plans regarding resident interventions for pain. A post-test was administered at the time of reeducation that required a passing score of 100% that was graded by the DON, UM, ADON, NPE, and or CQS to validate understanding. Facility licensed staff and agency staff not available will be provided reeducation including a post-test during orientation by the DON, ADON, NPE, UM, and/or LN, before allowed to work. 13. The CED and/or LN will conduct five (5) employee questionnaires daily to determine if staff were aware of the Center's process of reporting a change in condition including pain to a licensed nurse to ensure prompt intervention when a resident experienced a change in condition until Immediate Jeopardy is abated. 14. The UM's, ADON, NPE, and licensed nurses completed skin assessments on all residents on [DATE], to ensure residents, including residents with pressure ulcers, received care per Physician's orders to promote healing and prevent additional pressure ulcers with any needed corrective action taken upon discovery. 15. The CQS reeducated the Wound Nurse regarding the facility's policy, Wound Care, on [DATE]. A post-test was administered at the time of the reeducation to validate understanding. 16. The NPE, DON, UM's, and/or ADON reeducated all licensed staff, including agency staff, regarding the requirement that residents with pressure ulcers receive care to promote healing and prevent additional pressure ulcers, to include appropriate assessment of all wounds when a wound/abscess was identified, beginning on [DATE], with a posttest requiring 100% score to validate understanding. 17. The DON, ADON, NPE or UM will conduct observation rounds and treatment administration audits to ensure residents with pressure ulcers receive care to promote healing and prevent additional pressure ulcers as per Physician's Orders starting [DATE] daily until Immediate Jeopardy is abated. 18. Quality Assurance/Performance Improvement (QAPI) meetings are occurring daily (Monday-Friday) beginning [DATE] with the interdisciplinary team, which consists of the CED, DOB, ADON, NPE, UM's, MDS, Dietary Manager, Social Services, Business Office Manager, Environmental Services, Medical Records, Maintenance, Human Resources, Registered Dietician, Activities Director, Central Supply, and Director of Rehabilitation, until Immediate Jeopardy is abated. During QAPI meetings, the current status of the AoC is discussed, including review of the audit tools, findings, and any needed corrective action. The State Survey Agency validated the implementation of the facility's AoC as follows: 1. Review of the facility's audit tool revealed the audits were reviewed, with all residents present as of [DATE]. Audits were conducted to determine the presence of pain, and the effectiveness of any pain medications ordered. Record review revealed nineteen (19) residents were identified with pain concerns, with most concerns identified consisting of pain medications not being effective, or not being effective for the length of time until the next dosage of pain medication was available. All of this information was emailed to the Nurse Practitioner (NP) by the CQS. Review of residents' medical records for residents identified, revealed residents had been reassessed by either the Physician or NP, with new orders provided as appropriate. 2. Review of nineteen (19) residents with identified pain issues revealed residents identified had been reassessed on [DATE] by the DON, UMs and/or Licensed Nurse (LN) to determine if a change in condition had occurred regarding pain. Interview with the NPE, on [DATE] at 1:30 PM, revealed, based on audits conducted by [DATE]; nineteen (19) residents were identified with pain issues. She revealed all residents had been reassessed, and staff were documenting changes in resident condition in nursing notes regarding effectiveness of pain medications. 3. Review of the facility's In-Service Sign In Sheets, dated [DATE] through [DATE], revealed all facility staff were educated in person or over the phone regarding: (A) Change in condition; (B) Pain management; (C) Stop and Watch Tool; (D) Provider notification of change; and (E) Person-centered care plans. Review of documents titled Post Test, revealed staff completed testing covering all identified areas, to include changes in resident condition, management of resident pain, Stop and Watch Tool, provider notification of change, and person-centered care plans. Interview with Admissions personnel, on [DATE] at 8:20 AM, revealed she had been educated to monitor residents for any new or worsening pain or any change in activity or changes in resident condition, the resident care plan. Admissions personnel was to report to the nurse and DON. She stated she was in-serviced on the use of the Stop and Watch tool. Interview with Laundry personnel, on [DATE] at 8:30 AM, revealed Laundry staff had been educated to monitor residents for pain or change in condition and to notify the nurse if any occurs. Laundry staff was to observe for any lack of care for the residents. Per interview Laundry personnel were in-serviced on the Stop and Watch tool. Interview with Physical Therapy Assistant (PTA) #1, on [DATE] at 8:15 AM, revealed PTA#1 had been educated to monitor for new or worsening pain and if a resident was participating less in activities or had a change in condition to report this to the nurse. Per interview, they had been in-serviced on the Stop and Watch tool. PTA #1 completed a posttest after the training. Interview with SRNA #8, on [DATE] at 8:35 AM and SRNA #27 at 8:45 AM, SRNA #25 at 8:50 AM and SRNA #28 at 9:00 AM revealed education was provided to monitor for any new or worsening pain, change in condition and the appropriate use of the resident's care plan. Any change was to be reported immediately to the nurse. Per interview, they had been in-serviced on the Stop and Watch tool and had taken a posttest after the education. Interview with the Activities Director on [DATE] at 3:40 PM revealed she had been educated in the Stop and Watch tool and the importance of the resident's care plan. She stated she was to watch for any new or worsening pain, or if a resident was participating less in activities. She stated she was to document and notify the nurse. 4. Review of AoC Audit Tool - [DATE], dated [DATE] through [DATE], revealed the facility was conducting observation rounds of ten (10) staff and five (5) residents every shift. Continued review revealed residents were interviewed to ensure they were receiving pain medications, with any changes in condition noted, assessments completed, notifications made as appropriate, and care plans updated as appropriate. Review of the staff portion for licensed staff revealed licensed staff were interviewed regarding the process for respiratory treatment, the process for reporting changes in condition, awareness of notification of the Physician or NP regarding resident pain issues and awareness of the care plan reflecting resident needs. Review of the staff portion for non-licensed staff revealed they were interviewed regarding awareness of the Stop and Watch Tool reporting of changes in resident condition regarding pain, respiratory status, or skin issues. Interview with RN #4 on [DATE] at 12:00 PM revealed she had audited nineteen (19) residents with pain. A tool called 'Stop and Watch' was used to educate staff on pain. All staff were educated and all tours of duty were included to assure no staff were missed. Interview with SRNA #8, on [DATE] at 8:35 AM, revealed education was done to monitor for any new or worsening pain or change in condition. Any change was to be reported immediately to the nurse. Per interview, she had been questioned during management rounds related to monitoring for pain and reporting to nursing staff. Interview with the Activities Director, on [DATE] at 3:40 PM, revealed she had been educated in the 'Stop and Watch' tool. She stated she was to watch for any new or worsening pain, or if a resident was participating less in activities. She stated she was to document and notify the nurse. Per interview, she had been asked during management rounds regarding awareness of the Stop and Watch Tool. 5. Review of the facility's AoC binders revealed completed documentation labeled F580 Test 2 All Staff except LN, completed by facility staff covering topics such as the Stop and Watch Tool, changes in resident condition, and person-centered resident care. 6. Interview with the DON, on [DATE] at 9:18 AM, revealed she reviewed the results of observations, interviews, and audits daily, and she ensured there was additional follow-up as needed. She stated audits had increased staff education and were helping management ensure staff followed-up with everything. She stated management had identified a need for staff improvement on documentation. 7. Review of the facility's In-Service Sign In Sheets, dated [DATE] through [DATE], revealed Licensed Nurses attended or were educated in person or over the phone regarding: (A) Pain management to include implementing person-centered care plan with individualized person centered interventions to include monitoring pain, administering pain medications as ordered, utilizing and documenting the pain scale, and observing for non-verbal signs/symptoms of pain; (B) Pressure Ulcer prevention to include developing/implementing the care plan; (C) Person-centered care plans; and (D) Physician/Mid-Level Provider Notification of Change in a resident's condition, Review of documents titled Post Test revealed licensed nursing staff completed testing covering all identified areas, to include changes in residents' condition, management of resident pain, Stop and Watch Tool, provider notification of change, and person-centered care plans. Interview with LPN #17, on [DATE] at 8:49 AM and with LPN #10 on [DATE] at 8:05 AM, LPN #3 at 9:05 AM and LPN #6 at 9:10 AM, revealed they had been educated to watch for any new or worsening pain, to implement a person centered care plan with individualized interventions, administer pain medications as ordered using the pain scale, pressure ulcers monitor and treatment and to notify the practitioner with all changes in resident conditions. Per interviews, a posttest to acknowledge understanding of the education was given. Interview with RN #4 on [DATE] at 12:00 PM revealed a tool called 'Stop and Watch' was used to educate staff on pain. All staff were educated and all tours of duty were included to assure no staff were missed. The education is to be ongoing. Staff were educated to be transparent and use open communication. RN#4 reported all staff were educated on notifying the practitioner if a resident was experiencing pain. For chronic pain, interventions were to be implemented. 8. Review of the facility's documentation revealed the NPE reviewed all residents on [DATE] that had been admitted , readmitted , or that had been identified with changes in respiratory status. The NPE identified any changes since [DATE], and ensured care plan changes were implemented as necessary. Interview with the NPE, on [DATE] at 1:30 PM, revealed she did review all residents on [DATE] that had been admitted , readmitted or identified with changes in respiratory status. 9. Review of the facility's In-Service Sign In Sheets, dated [DATE] through [DATE], revealed all licensed nurses, to include agency nurses, were educated in person or over the phone regarding revision of resident care plans for all admissions, readmissions, and changes in respiratory status for residents with diagnoses to include acute respiratory failure, sleep apnea, COPD, and asthma. Review of Clinical Competency Validation Respiratory Assessment, revealed licensed nursing staff completed testing following education. Interview with RN #4 on [DATE], LPN #17, on [DATE] at 8:49 AM and with LPN #10 on [DATE] at 8:05 AM, LPN #3 at 9:05 AM and LPN #6 at 9:10 AM, revealed they had been educated related to the revision of the resident care plan for all admissions, readmissions and changes in respiratory status for residents. Per interviews, a posttest to acknowledge understanding of the education was given. 10. Review of the AoC Audit Tool - [DATE], revealed care plan audits were conducted on new admissions, readmissions, and change in condition residents, to include a change in respiratory status, and were ongoing as of [DATE]. 11. Continued review of the AoC Audit Tool - [DATE],&q[TRUNCATED]

Based on interview, record review, and review of the facility's policy, it was determined the facility failed to ensure the discharge summary process included reconciliation of all pre-discharge medications with the resident's post-discharge medications, both prescription and over-the-counter, and the resident was discharged with the correct medications for one (1) of thirty (30) sampled residents (Resident #81). The facility admitted Resident #81, on 03/12/2021, for short-term rehabilitation. On 05/05/2021, the Physician ordered to discharge Resident #81 home with medications. Licensed Practical Nurse (LPN) #3, Resident #81's nurse, reviewed the Discharge Instructions/Summary with Resident #81, and sent his/her medications from the medication cart home with the resident on 05/05/2021. On 05/07/2021, Resident #81 informed a family member that the medications he/she received from the facility at discharge included a medication that he/she did not take, Risperdal (an antipsychotic used to treat schizophrenia and other psychiatric disorders). The resident sent the family member a picture of a medication box that was labeled Risperdal 0.25 milligram (mg), with Resident #80's name on it. Resident #81 stated he/she took two (2) doses of Risperdal 0.25 mg and experienced lethargy, mental status changes, dizziness, and difficulty with memory after taking the medication. The facility's Pharmacist stated the medication, Risperdal (generic name Risperidone) could pose a moderate risk of interaction with the other prescribed medications for Resident #81. Resident #81's Attending Physician stated Resident #81 was a high-risk resident, and if the Risperdal had been taken at a higher dosage than 0.25 milligrams per day, it could cause increased sedation and a heart arrhythmia. The facility's failure to have an effective system in place to ensure each resident received the correct medications during medication reconciliation in the discharge summary process has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy (IJ) was identified, in the area of 42 CFR 483.21(c)(2) Comprehensive Resident Centered Care Plan, Discharge Summary, on 05/14/2021 and was determined to exist on 05/05/2021 and is ongoing. The findings include: Review of the facility's policy titled, Discharge Planning Process, review date 02/01/2019, revealed the discharge summary should include a reconciliation of all pre-discharge medications with the patient's (resident's) post-discharge medications (both prescription and over-the-counter). No further details were found in the policy regarding medication reconciliation. Review of Resident #81's medical record revealed the resident was admitted to the facility, on 03/12/2021, for short-term rehabilitation upon discharge from an acute care hospital episode for Alcoholic Hepatitis with Ascites, Generalized Weakness, Difficulty with Walking, and Chronic Pancreatitis. Review of Resident #81's initial Minimum Data Set (MDS) Assessment, dated 03/18/2021, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of fifteen (15) out of fifteen (15), indicating the resident was cognitively intact. Review of Resident #81's initial care plan indicated the need for assistance with Activities of Daily Living (ADLs) including bathing, grooming, personal hygiene, dressing, transfers, locomotion and toileting related to a recent hospitalization resulting in fatigue. Discharge documents showed the need for a rolling walker for ambulation and independence in all ADLs. Further review of the record revealed initial medication orders, dated 03/12/2021, as well as changes to the orders, as indicated, throughout the course of Resident #81's stay at the facility. However, the record revealed no order for Risperidone at any time during the course of care for Resident #81. In addition, the record revealed the Physician ordered Resident #81 to be discharged home with medications, on 05/05/2021. Continued review revealed the resident was discharged per the order by LPN #3. However, there was no documented evidence of specific reconciliation of medications on the Order Summary, which was supposed to include all discharge medications and directions for administration. Further, the paper copies of Resident #81's record, kept in the hardback chart at the Nurse's Station revealed an Order Summary, including the form Medication List, but the form was blank. There was no documented list of Resident #81's discharge medications for review. Interview with Resident #81's Family Member, on 05/11/2021 at 2:12 PM, revealed, on 05/07/2021, Resident #81 called to inform her that he/she had discovered a medication box that was given to him/her from the facility. The Family Member stated Resident #81 told her the box contained a medication that was not ordered for him/her. She stated the box had thirty (30) pills of Risperdal 0.25 mg, take one (1) tablet daily. In addition, the resident told the Family Member the box was labeled with Resident #80's name, and he/she had taken two (2) doses. She stated Resident #81 reported to her that after taking the Risperdal tablets, he/she was feeling lethargic, had mental status changes, dizziness, difficulty with memory, some disorientation, and was very upset because he/she could not process thoughts or finish a sentence. The Family Member stated Resident #81 felt so bad that he/she was not able to visit with her, on 05/07/2021 or 05/08/2021; and, the resident was scheduled to see his/her primary care provider, on 05/11/2021 or 05/12/2021. Per interview, Resident #81 took photos of the medication box labeled with Resident #80's name and forwarded it to her. The Family Member stated she verified the picture of the medication box in Resident #81's possession that had Resident #80's name and was labeled Risperdal 0.25 mg, take one (1) tablet daily. Review of Resident #80's medical record revealed an order for Risperidone, 0.25 mg, with instructions to be administered by mouth one (1) time a day. Interview with LPN #3, on 05/12/2021 at 10:20 AM, revealed when a nurse discharged a resident, they sent what was in the resident's medication drawer with the resident. LPN #3 stated the actual medication boxes were sent home with the resident. Further interview revealed the face sheet and medication list were printed, and the nurse used them to instruct the resident on the discharge medications prior to his/her departure. Additional interview with LPN #3, on 05/12/2021 at 4:00 PM, revealed she discharged Resident #81, sometime after 10:00 AM on 05/05/2021. LPN #3 stated she and Resident #81 went over the medication list together with education on his/her medications. She stated, for Resident #81, she printed the facesheet and the order summary, which included all of the resident's medications and how to take them. LPN #3 stated she had been over the whole process in her memory and did not know how Resident #81 received Resident #80's medication, other than human error. She also stated that prior to Covid, the Pharmacy came through at regular intervals and reviewed all medications and stocked the medication carts. However, with current Covid restrictions, LPN #3 stated Pharmacy depended on nursing to report medication needs. Continued interview on 05/12/2021 at 4:00 PM, with LPN #3 revealed since Resident #80 was transferred from another unit in the facility, there initially must have been enough medications from his/her previous order to provide the Risperdal he/she was ordered. Review of the medication cart showed a newly delivered box of Risperidone (Risperdal) as of 05/12/2021 for Resident #80. Interview with LPN #2, on 05/12/2021 at 10:00 AM, revealed that a resident who was to be discharged received a discharge summary with upcoming appointments, a printed medication list, and a summary of care at the facility. He/she stated, We are allowed to send any non-narcotic medications home with the resident and, narcotics if there was a specific order for it. The resident would be asked about pain medication availability already at home. Residents are discharged with medications in the original boxes. Telephone interview with the Pharmacist in charge, on 05/13/2021 at 9:09 AM, revealed that the Pharmacy was not involved with discharge medications. The Pharmacist stated additional drowsiness, lethargy, and inability to concentrate would be likely side effects of Risperidone use, in combination with Resident #81's own medication regimen and/or heavy alcohol use. Interview with Resident #81's Attending Physician, on 05/13/2021 at 1:20 PM, revealed he was not knowledgeable of the discharge process, but he expected the process to be managed safely, which included sending the correct discharge medications home with the resident. The Physician stated Resident #81 was a high risk for medication administration due to potential side effects; consequently, he stated he always weighed the risk of the medication versus the benefit before prescribing medications for Resident #81. In addition, the Physician stated there would probably be no serious adverse reactions from Resident #81 taking Risperidone, with his/her other medications, if he/she only took it for two (2) days as reported, but if it were taken longer or abused, there could be increased lethargy and even a heart arrhythmia (abnormal heart rhythm). Interview with the Director of Nursing (DON), on 05/14/2021 at 9:18 AM, revealed with a resident to be discharged , the nurse would go over information about his/her care needs and what medications went home with the resident; the resident would receive whatever medications the doctor ordered. In addition, the resident signed the care summary and a copy went in the hard chart. Per interview, with medication reconciliation, she expected the nurse to compare the written list, prescription by prescription, with the actual medications to be sent home. She stated the facility followed these recommendations from Pharmacy about how the nursing staff should manage the discharge process for medications. The DON stated, in the incident with Resident #81 where an incorrect medication was sent home with the resident, the only answer she had was it involved human error. Furthermore, she stated the discharge education given to a resident was computer generated and was based on previously entered information for the resident. Interview with the Administrator, on 05/12/2021 at 2:20 PM, revealed she expected at discharge, the nurse would provide a list of medications and would go over those with the resident prior to discharge. She stated there should be printed copies, one (1) given to the resident, and one (1) placed in the resident's hard copy chart. The Administrator stated the nurse would gather the resident's medications and give them to the resident at departure. She further stated that medications were supposed to be in order in the medication cart by resident room, and she expected each resident's medications to be in the correct slot. In addition, the Administrator stated she expected nurses to reconcile the physical medication with the printed list.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to ensure skin assessments were completed to identify/monitor for skin breakdown along pressure ulcer prevention interventions according to standards of practice to prevent further decline for one (1) of thirty (30) sampled residents, Resident #110. On [DATE], Resident #110 was transferred to the hospital by Emergency Medical Services (EMS) and during the triage period hospital staff and EMS identified a sacral wound. The hospital assessed the resident to have an open right gluteal abscess measuring three (3.0) centimeters (cm) and draining copious amounts of purulent material. There was an unstageable sacral decubitus ulcer measuring eight (8.0) cm (length) by two (2.0) cm (width). Surgical consult revealed the abscess and sacral ulcer would require surgical debridement of necrotic tissue. Review of Infectious Disease (ID) Consult, on [DATE], revealed ID was consulted for evaluation of sepsis and antibiotic management. Possible causes for the infectious etiology included Bacteremia and soft tissue infection from right buttocks ulcer. A Computed Tomography (CT) of the pelvis showed a chronic calcified posterior right gluteal region hematoma in the surrounding soft tissue infiltration indicating possible soft tissue infections. Wound culture of right buttock showing gram negative rods. Review of the facility's Skin Assessment Grids, revealed the Wound Nurse assessed Resident #110's wounds on [DATE] and identified a new Right Hip/Buttock Abscess that measured 2.0 cm (length) by 3.0 cm (width) by 0.4 cm (depth), with hard surrounding tissue and moderate amounts of purulent drainage. However, interview and record review revealed the Wound Nurse nor other nursing staff had not identified the unstageable sacral decubitus ulcer that was assessed and identified during hospital triage. Review of the Acute Care Hospital record, dated [DATE], revealed a palliative care (treatment focused on prevention of suffering and improving quality of life) consult was requested on [DATE]. Continued review revealed the provider noted, Patient has no quality of life. Review of the Nurses Notes, dated [DATE], revealed the resident was readmitted back to the facility under Hospice Care, on [DATE], and later expired on [DATE]. The facility's failure to provide care consistent with professional standards of practice, to care for and prevent pressure ulcers has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) were identified on [DATE], in the area of 42 CFR 483.25(b)(1) Quality of Care, Treatment/Services to Prevent/Heal Pressure Ulcers, and were determined to exist on [DATE]. The facility provided an acceptable Allegation of Compliance (AoC) on [DATE], with the facility alleging removal of the Immediate Jeopardy on [DATE]. The State Survey Agency validated removal of the Immediate Jeopardy as alleged on [DATE], prior to exit on [DATE], with the remaining non-compliance at a Scope and Severity of a D while the facility develops and implements a Plan of Correction and the facility's Quality Assurance (QA) monitors to ensure compliance with systemic changes. The findings include: Review of the facility's policy titled, Skin Integrity Management revised on [DATE], revealed the purpose was to provide safe and effective care to prevent the occurrence of pressure ulcers, manage treatment, and promote healing of all wounds. Per the policy, staff was to continually observe and monitor residents for changes and implement revisions to the plan of care. Nursing staff was to follow Standards of Practice, which included: 1) Review pre-admission information to plan for resident's needs; 2) Complete comprehensive evaluation of the resident upon admission/readmission; 3) Identify resident's skin integrity status and need for prevention interventions or treatment modalities through review of all assessment information; 4) Develop comprehensive, interdisciplinary plan of care including prevention and wound treatments, as indicated; 5) Review co-morbid conditions that may affect healing; 6) Notify Dietician and Rehabilitation Services as indicated; 7) Notify Physician/Advance Practice Provider (APP); Review care plan weekly and revise as indicated; 8) Document daily monitoring of ulcer site, with or without dressing. Daily monitoring should include status of dressing, status of tissue surrounding dressing, and adequate control of wound pain. On [DATE] at 9:05 AM, observation of Resident #110, revealed the resident yelled for a nurse, moaned and groaned as if in pain. Further observation revealed the resident was lying flat on his/her back, no pillow under the right arm, as per the care plan. In addition, the resident did not have the care planned boots on his/her feet, the residents' hands had contractures, and the resident was unable to use the call light related to his/her contractures. Per observation, the resident showed non-verbal cues of pain with grimacing. No one responded to the resident until the State Survey Agency (SSA) Surveyor alerted staff that the resident needed assistance. Further observation revealed the resident smelled of the strong odor of urine. Observation of Resident #110, on [DATE] at 1:15 PM, approximately four (4) hours later, revealed the resident lying in the same position as earlier, however there was a pillow under his/her right arm. Interview with Resident #110, on [DATE] at 9:20 AM, revealed staff did not address his/her chronic pain, and while the resident had resided at the facility since the last readmission, on [DATE], he/she had not received pain medication as needed. Further interview revealed, the resident stated I am miserable and I hurt all the time. Per interview, the resident stated when he/she told the nurse he/she was in pain, no one would help him/her. Resident #110 stated he/she was unable to turn and reposition related to the amount of pain he/she was experiencing. He/she was unaware of the last time he/she had been changed and stated he/she was wet and smelled. The resident further stated it hurt to be touched. Interview with Registered Nurse (RN) #3, on [DATE] at 8:30 AM, revealed Resident #110 used to get showers, and now, she was unaware of the last shower the resident had taken. She stated the resident refused showers because he/she was in too much pain to move. Interview with LPN #13, on [DATE] at 3:55 PM, revealed she cared for Resident #110. She stated the facility policy was to check User Defined Assessments (UDA) in the Electronic Health Record (EHR), which directed/prompted nursing staff when to assess residents. LPN #13 stated nurses charted by exception, except with change in condition. She stated UDA had a Change in Condition/Situation, Background, Assessment, and Recommendation (CIC/SBAR) alert, which prompted the user to follow-up. She stated some sections of the EHR would not allow for free-hand charting, but nursing could use the progress note section. LPN #13 stated it was important to do resident assessments and document to ensure quality care. Interview with LPN #11, on [DATE] at 8:49 AM, revealed resident weekly skin assessments were assigned to each nurse. She stated the nurses routinely has two (2) to three (3) assessments per shift. Skin assessments were documented in the medical record. Further interview revealed, the Wound Care physician came weekly and reviewed findings. She stated staff looked for skin issues during routine care and showers/baths. Further interview revealed Resident #110 was being followed by Wound Care every week for skin issues. Record review revealed the facility admitted Resident #110 on [DATE], with diagnoses to include Chronic Pain; Contracture, Right Hand; Contracture, Left Hand; Contracture, Right Elbow; Thoracic, Thoracolumbar, and Lumbosacral Intervertebral Disc Disorder. Review of the Social Services Assessment, dated [DATE], revealed Resident #110 scored an eleven (11) on the Brief Interview for Mental Status (BIMS) evaluation. Further review revealed the resident was able to express ideas and wants and was able to understand verbal content. Review of the Quarterly Minimum Data Set (MDS) assessment, dated [DATE], revealed the facility assessed Resident #110's Functional Abilities as needing substantial/maximal assistance. Resident was dependent on staff to roll left and right in the bed. Further review revealed the resident had one (1) Stage 2 ulcer, one (1) venous and arterial ulcer, and was receiving pressure ulcer/injury care. Review of the Braden Scale for Predicting Pressure Sore Risk, dated [DATE], revealed the facility assessed Resident #110 to be a severe risk for skin breakdown, with a score of eight (8). Review of the Comprehensive Care Plan (CCP), last updated [DATE], revealed Resident #110 was at risk for skin breakdown as evidenced by moisture/excessive perspiration limited mobility, Diabetes, Peripheral Vascular Disease, incontinence of bowel and bladder, medications, history of pressure ulcers, obesity, hemiplegia, arterial ulcer to right second digit. The goals were to show no signs of further skin breakdown. Further review revealed interventions directed staff to apply barrier cream with each cleansing, assist with methods of reducing friction and shear, assist the resident with turning and repositioning every two (2) hours as tolerated. In addition, staff were to float resident's heels while in bed as tolerated, provide a low air loss (LAL) mattress to bed, perform [NAME]/Braden assessments per policy, observe skin risk factors per protocol, and observe for localized skin problems. Further review revealed, Resident #110 was at risk for skin breakdown or had actual skin breakdown. The healing goals were: 1) the resident would remain free of skin tear and bruising; 3) show no signs of skin breakdown; 3) the skin tear/bruise would heal; and 4) the wound/skin impairment would heal. Further review revealed interventions to pat skin when drying, provide treatment to skin tear per physician order, observe for signs of infection, assist resident with turning and repositioning, observe skin for signs/symptoms of skin breakdown, evaluate localized skin problems, utilize devices to assist with turning/positioning to reduce friction and shear, weekly skin assessments by licensed nurse, weekly wound assessment to include measurements and description of wound, and provide wound related pain management intervention (i.e. pre-medicate). Continued review of the CCP, last updated [DATE], revealed Resident #110 was incontinent of urine and was unable to participate cognitively or physically in a retraining program. The goals were to have incontinence care needs met by staff to maintain dignity and comfort, and to prevent incontinence related complications. Further review revealed interventions were to check and change every two (2) hours and as needed (PRN), observe for skin redness/irritation and report as indicated, observe for odor, color, consistency, and amount, use absorbent products PRN. Review of the Specialty Physician's Wound Evaluation and Management Summary, revealed the Wound Physician assessed Resident #110's wounds, on [DATE], and it identified a shear wound to the Right Buttock which measured 0.2 cm (length) by 0.3 cm (width) by 0.2 cm (depth), with light serous exudate, twenty percent (20%) slough, one hundred percent (100%) granulation tissue. Abnormal granulation present within wound margins. Wound progress improved. The summary stated to apply a Primary dressing and Silver Sulfadiazine once daily for thirty (30) days; Secondary dressing - apply gauze island once daily for sixteen (16) days; Apply House barrier cream to Peri-wound three (3) times daily for twenty-three (23) days. Off-load wound; reposition per facility protocol; turn side to side and front to back in bed every one to two hours if able. Review of the Specialty Physician's Wound Evaluation and Management Summary, revealed the Wound Physician assessed Resident #110's wounds, on [DATE], and it identified a shear wound to the Right Buttock - 0.4 cm (length) by 0.6 cm (width) by 0.2 cm (depth), with light serous exudate, twenty percent (20%) slough, eighty percent (80%) granulation tissue. Wound progress deteriorated. Treatment: Primary dressing - Silver Sulfadiazine apply once daily for twenty (23) days; Secondary dressing - apply gauze island once daily for nine (9) days; Apply House barrier cream to Peri-wound three (3) times daily for sixteen (16) days. Off-load wound; reposition per facility protocol; turn side to side and front to back in bed every 1-2 hours if able. Review of the Specialty Physician's Wound Evaluation and Progress Note, revealed the [DATE] visit was rescheduled. Review of the Specialty Physician's Progress Note, revealed the [DATE] visit was rescheduled due to Resident #110 hospitalization unrelated to wounds. Review of a Nursing Note, dated [DATE] at 5:27 PM, revealed Resident #110 was readmitted to the facility after a hospitalization for Sepsis and Acute Respiratory Failure, from [DATE] to [DATE]. Review of skin check, dated [DATE], revealed the nurse identified the following skin injury/wounds: Mild bruising from intravenous (IV) to right upper chest and hands from hospital stay. Other wounds included an old, healed right buttocks scar; and scab areas to toes on right foot. No further descriptions were documented. Review of a Change in Condition (CIC) note, dated [DATE] at 1:35 AM, revealed a skin check was performed and noted the previously identified right buttock wound with treatment in place. The note did not include a description of the wound or surrounding tissue. However, the CIC note did include new orders to apply Z-Guard. Review of the Specialty Physician's Wound Evaluation and Management Summary, revealed the Wound Physician assessed Resident #110's wounds, on [DATE], and it stated the shear wound to the Right Buttock was resolved. The summary directed staff to continue to off-load wound; reposition per facility protocol; turn side to side and front to back in bed every 1-2 hours if able. A Braden Scale Assessment and Skin Check dated, [DATE] at 5:27 PM, revealed Resident #110's score as ten (10), indicating the resident was at high risk for pressure ulcer development. Review of Skin Check revealed the nurse identified wounds, including one to the Right Buttock. Review of the Specialty Physician's Progress Note, revealed the [DATE] visit was rescheduled. Review of Nursing Progress Notes, dated [DATE] at 7:00 PM, revealed Resident #110 was sent to the local emergency room for evaluation related to generalized peripheral edema and inability to obtain a blood pressure. Review of CIC follow-up Progress Note, dated [DATE] at 9:43 AM, revealed Resident #110's skin was warm with one-plus (1+) pitting edema in bilateral feet. Review revealed no evidence nursing assessed the resident for pressure wounds after identification of CIC. Interview with Licensed Practical Nurse (LPN) #9, on [DATE] at 8:15 AM, revealed she readmitted the resident on [DATE], however she failed to assess the residents skin as per policy. Review of Nursing Skin Assessment Note, dated [DATE], revealed nursing failed to assess Resident #110's skin, per policy, as evidenced by the form/document being blank. Interview with LPN #9, on [DATE] at 8:15 AM, revealed she could not recall not documenting skin assessments for Resident #110 that she was assigned to perform. She stated there were times she was unable to get assessments completed on her shifts. Review of the facility's Skin Assessment Grids, revealed the Wound Nurse assessed Resident #110's wounds on [DATE] and identified a new Buttocks Right/Hip Abscess that measured 2.0 cm (length) by 3.0 cm (width) by 0.4 cm (depth), with hard surrounding tissue and moderate amounts of purulent drainage. The Skin Assessment Grid had no identification or assessment of the sacral area. Review of the Physician's Order revealed, staff were to treat the abscess with Silvadene covered packing gauze with dry dressing daily and PRN. Review of the [DATE] TAR, revealed staff continued to cleanse Right Buttocks area with wound wash, pat dry, and apply Medihoney Wound/Burn Dressing Gel every day shift, except for [DATE] and [DATE], for shearing from start date of [DATE] until the end date of the order on [DATE], even though the wound was documented as resolved from the Specialty Physician's Wound Evaluation and Management Summary, dated [DATE]. Review of Late Entry Progress Note, dated [DATE] at 3:00 PM, revealed a change in condition (CIC) related to a skin wound or ulcer. Resident #110's vital signs were obtained and were the following: oral temperature was 97.8 degrees Fahrenheit (ºF), respirations 18 breaths per minute; pulse was 62 beats per minute and regular; blood pressure was 102/56, and oxygen saturation 98%. The resident's blood sugar was 190. The CIC note did not contain an assessment or identfication of a sacral wound. Review of Late Entry Progress Note, dated [DATE] at 11:45 PM, revealed nursing performed a skin check and identified the previous right buttock wound. However, there was no description of the wound or surrounding tissue. Review of the Nurses Progress note, dated [DATE], revealed a nickel size wound abscess to right buttocks with thick white exudate. Further review revealed there were no measurements obtained. Additional review of the note revealed new orders received to: obtain wound culture; clean site with wound cleanser; pack opening with non-medicated Iodoform gauze with Silvadene; and dry dressing BID. Interview with LPN #9, on [DATE] at 8:15 AM, revealed she assessed the resident's hip wound as an abscess, on [DATE]. She stated she did not measure the abscess; she only performed a swab of the abscess to send for culture and sensitivity. Further interview revealed the facility's policy prohibited her from taking pictures of the wound. Review of Progress Notes, dated [DATE] at 3:09 PM, revealed a decline in Resident #110's health. Resident #110's vital signs were obtained and were the following: oral temperature: 99.3 ºF; respirations 22; pulse 59 and regular; blood pressure 126/59, and oxygen saturation: 98%. Per the note, the Physician was notified and new orders were received to hold oral medications. Further review of the Progress Notes, dated [DATE] at 7:31 PM, revealed after further monitoring and review of Resident #110's declining condition, a new order was received to transport the resident to the Emergency Department (ED). Emergency Medical Services (EMS) was dispatched at 5:52 PM. Review of the EMS Run Sheet, dated [DATE] at 6:04 PM, revealed that no nurse was present in the resident's room, and no transfer information was available from the facility when Resident #110 was picked up for transport to the hospital ED. Further review revealed EMS crew stated the resident was alert to pain and felt warm. A temperature of 103.0 degrees Fahrenheit (ºF) was obtained while still in the facility. Review of ED Notes, dated [DATE] at 6:19 PM, revealed Resident #110 presented to the ED with atrial fibrillation (A-fib), generalized swelling, a fever of 101.6 degrees Fahrenheit, altered mental status, diminished lung sounds bilaterally, and faint heart tones. Lab results revealed an elevated [NAME] Blood Count (WBC) at 15.7 (reference range is 3.7 - 10.3 x 10(3)/mcl. X-ray results were positive for bilateral parenchymal opacities, which could represent edema or infection and computed tomography (CT) results showed bilateral pleural effusion. Further review revealed, Resident #110 was admitted to the hospital, on [DATE], with diagnoses, which included Sepsis, Unstageable Pressure Ulcer of Sacral Region and Right Gluteal Abscess, Morbid Obesity, and Healthcare Associated Pneumonia (HCAP). Continued review of ED Physician notes, dated [DATE], revealed Resident #110 met the criteria for Sepsis. Wound cultures were obtained from the sacral decubitus ulcer and the right gluteal abscess. Review of Surgical Consult, dated [DATE], revealed a stat consult was requested to evaluate Resident #110's wounds. Per the notes, the resident's right gluteal abscess was actively draining, likely with necrotic tissue in the base, which could use further opening and debridement. Further review of the progress note revealed the resident had an unstageable sacral decubitus ulcer measuring 8 cm (length) by 2 cm (width), which required surgical debridement. The provider wrote, Patient has no quality of life. Review of Infectious Disease (ID) Consult, on [DATE], revealed ID was consulted for evaluation of Sepsis and antibiotic management; possible causes for the infectious etiology included Bacteremia, HCAP, and soft tissue infection from right buttock ulcer. A Computed Tomography (CT) of the pelvis showed a chronic calcified posterior right gluteal region hematoma in the surrounding soft tissue infiltration indicating possible soft tissue infections. Wound culture of right buttock showing gram negative rods. Interview with State Registered Nurse Aide (SRNA) #18, on [DATE] at 8:20 AM, revealed when aides found a skin issue on a resident, the process was to document the findings on the Skin Assessment sheet, and make the nurse aware. She further stated residents were assessed every Friday by the Wound Care Nurse. She further stated Resident #110 had some areas on her toes, abdominal folds and right buttock. She stated the resident was being followed by wound care. Interview with Licensed Practical Nurse (LPN) #9, on [DATE] at 8:15 AM, revealed she was assigned to Resident #110, on [DATE]. She stated Registered Nurse (RN) #3 observed a CIC in the resident during the night shift. RN #3 documented the CIC and reported the resident's condition to her at shift change. LPN # 9 stated she was up and down the hall insuring he/she was responsive, and monitored vital signs throughout the day. LPN #9 stated vital signs were within normal limits, and the plan was to wait for labs to see what to do next; however, she added Resident #110 did not improve, was not verbally responsive, and his/her temperature was elevated. The Physician was notified, and new orders were received to send the Resident to the ED. EMS was dispatched and Resident was transferred to the hospital's ED via EMS at 5:52 PM. Interview with SRNA #19, on [DATE] at 3:43 PM, revealed she cared for Resident #110 and stated, I try to check and change residents every two hours, but it's usually more like every three hours. Further interview revealed when she was providing care to the resident on [DATE] she noticed the area to the residents right hip she notified the nurse on duty. She stated the area was red and open with white drainage coming out of area. SRNA #19 stated she did not observe the resident's buttocks, because once she identified the right hip wound she stopped providing care and got the nurse. Interview with Agency LPN #9, on [DATE] at 8:15 AM, revealed Resident #110 was incontinent, obese, and needed frequent skin assessments. LPN #9 identified the wound on the hip as an, abscess with drainage, on [DATE], and stated she performed a culture and sensitivity on the drainage during a dressing change. She stated the wound abscess was tiny. She stated she did not perform an additional skin assessment once the area to right hip was located, she only assessed that area, she did not look any further on the resident's sacral area. She stated the plan was to wait for labs to see what to do next; however, she added Resident #110 did not improve, was not verbally responsive, and his/her temperature was elevated. LPN #9 stated the resident was uncomfortable with positioning and would not tolerate it well. She stated the resident would cry out in pain when turned. The Physician was notified, and new orders were received to send the resident to the ED. Further interview with LPN #9, on [DATE] at 11:13 AM, revealed Resident #110's right buttock area had purulent drainage like an abscess. She stated she notified the Wound Care Nurse, obtained a wound culture, and notified the Physician for treatment orders. She stated she did not measure the wound and estimated it to be the size of a nickel. Further interview revealed she monitored the wound for drainage and checked for further deterioration during dressing changes, and charted when care was completed. Per interview, she stated no other skin issues were present. LPN #9 stated, on [DATE], the abscess was open and draining, and she had to pack it. She recalled that he/she flinched during treatment and stated it was uncomfortable. She further stated, Resident #110 didn't want to be bothered. LPN #9 stated she did not the document care or the resident's verbal or non-verbal reactions to treatment. Interview with Agency LPN #15, on [DATE] at 5:05 PM, revealed she cared for Resident #110. She stated he/she was bedridden and had skin breakdown in abdominal folds. She did not recall Resident #110 having any other skin breakdown and stated the SRNA's were her eyes and ears regarding identifying new skin issues. Interview with RN #3, on [DATE] at 8:30 AM, revealed wound shear on Resident #110's right buttock had healed; however, the resident did have an abscess to right buttock. RN #3 stated she did not do a full skin assessment because she only treated the wound areas she was assigned. RN #3 stated, Aides changed Resident #110 no more than two times a shift due to it being too uncomfortable for the resident. Interview with RN #2, Nurse Educator/Wound Care Nurse, on [DATE] at 9:00 AM, revealed nursing had identified a new wound abscess to Resident #110's right hip area. She stated, LPN #9 did the culture and dressing. She stated resident would, grimace and moan when touched, and staff had to go very slowly, and gently during the resident's wound care treatments. She stated staff nurses would follow-up with Resident #110's weekly skin checks and he/she was followed by the Wound Care Physician. She stated Wound Care Physician rescheduled in-house appointments with Resident #110 due to his/her hospitalization. She could not recall why the wound consult visit on [DATE] was rescheduled. RN #2 stated she notified the physician about the new abscess. RN #2 was not aware Resident was refusing care. Per interview, he/she was care planned (CP) to be turned per facility schedule. She stated it was her expectation that staff assess skin and turn resident per the CP. Further interview revealed there was currently no widespread education on newly identified skin issues. She stated the facility process was to let Unit Managers know about new skin issues. She stated not all staff had been education on Pressure Ulcer Prevention (PUP) and PUP protocols were not in place. RN #2 stated the plan was to implement new education regarding turn schedule. Subsequent interview with RN #2, on [DATE] at 4:35 PM revealed that Agency staff was trained prior to coming to facility on basic resident care. She stated the facility had processes to ensure competencies, which were not yet in place, for new hires. New hires were paired with a trainer for one to two days, which she stated, Personally, I don't believe that was enough time. Trainers report if there were any issues with competencies. She relied on other staff to check that staff was competent. There was no follow-up from the Educator to assure competent care was provided according facility policies. She stated that her goal was to spend one-on-one time with all staff, but for right now, The process is broken. Additional interview with RN #2, on [DATE] at 11:52 AM, revealed during Resident #110's last treatment, done on [DATE], she only concentrated on the abscess to the hip. She recalled documenting her assessment on a piece of paper and was did not recall she failed to document her assessment in the chart. She received an order to pack with Silvadene covered gauze. She stated the wound was an abscess and not something that could be staged. She stated she did not measure the wound, as directed per the policy. RN #2 stated, We didn't do a full skin assessment. Further interview revealed it was her process to focus on the acute area, and nurses did a weekly skin assessment. Interview with Assistant Director of Nursing (ADON), on [DATE] at 4:40 PM, revealed it was her expectation that nurses assess and document what they did. She stated, If you didn't document, it didn't happen. She further stated nursing staff should fully assess using the CIC Tool. She stated she was aware of Resident #110's abscess and knew it was assessed by the Wound Care Nurse. ADON stated it was not an expectation that nursing did a full skin assessment when made aware of a new skin condition; however, she stated it would be important to fully exam the entire area to determine full extent of wound. Interview with the Director of Nursing (DON), on [DATE] at 9:18 AM, revealed it was her expectation staff followed the resident's comprehensive care plan, and care plans should be updated if any type of pressure injury was found. It was the DON's expectation that nursing staff provide the correct level of care per the care plan and as ordered by the physician Further interview revealed it was her expectation that full skin assessments were completed by nursing staff when weekly skin assessment were due. Interview with the Regional Clinical Quality Specialist (RCQS), on [DATE] at 3:40 PM, revealed it was her expectation that staff followed care plans, and updated as needed, when there was a CIC or a new pressure/wound was identified. Furthermore, nursing staff was to assess the resident and chart findings. She stated, If it was not charted, it didn't happen. The facility provided an acceptable credible Allegation of Compliance (AoC) on [DATE] alleging removal of the Immediate Jeopardy on [DATE]. Review of the AoC revealed the facility implemented the following: 1. An audit was conducted by the Assistant Director of Nursing (ADON), Nurse Practice Educator (NPE), and Unit Managers (UM) between [DATE] and [DATE] to determine if residents had pain, had pain medications ordered, if pain medications were effective, and if pain was not relieved. The Physician/Advanced Registered Nurse Practitioner (ARNP) were notified of unrelieved complaints of pain with new orders obtained if applicable. 2. Nineteen (19) of nineteen (19) residents identified with pain issues were reassessed on [DATE] by the Director of Nursing (DON), UM's, and/or Licensed Nurse (LN) Nurse Practitioner and/or Physician to determine if a change in condition had occurred regarding pain. Areas of concern were corrected upon discovery. 3. The DON, UM, ADON, NPE, and/or Clinical Quality Specialist (CQS) initiated reeducation, beginning on [DATE], with all facility staff to include contracted staff on the facility's policy and procedures regarding: (A) Change in Condition; (B) Pain Management, including observations; (C) Stop and Watch Tool; (D) Physician/Mid-Level Provider Notification of Change in a Resident's condition; and (E) Person Centered Care Plan. A post-test was administered at the time of the reeducation that required a passing score of 100% that will be graded by the DON, UM, ADON, NPE, and/or CQS to validate understanding. Facility staff and agency staff not available during the reeducation and post-test were to be provided reeducation including a post-test by the DON, UM, ADON, NPE, and/or CQS upon day of return to work prior to providing care. [TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and review of the facility's policies, it was determined the facility failed to have an effective system to ensure residents' respiratory care needs were consistently met for one (1) of thirty (30) sampled residents (Resident #110). The facility admitted Resident #110 on [DATE]. The resident had current diagnoses of Obstructive Sleep Apnea (OSA), Chronic Obstructive Pulmonary Disease (COPD), Asthma, Dysphagia, Heart Failure (HF), and Chronic Kidney Disease (CKD). Resident #110 had been hospitalized , from [DATE] to [DATE] with Sepsis and Acute Respiratory Failure. In addition, Resident #110 had been sent to the hospital Emergency Department (ED), on [DATE], for edema and returned to the facility five (5) hours later, on [DATE]. On [DATE], Resident #110 experienced a change in condition (CIC) with his/her respiratory status. Interview and record review revealed nursing staff did not implement respiratory care interventions for the resident on [DATE], as ordered by the Physician. Nursing staff failed to administer the resident's ordered Furosemide (a diuretic used to remove excess fluid from the body) sixty (60) mg intravenously (IV), monitor lung sounds; failed to perform strict fluid intake and output (I&O), and, failed to monitor the resident for his/her deteriorating condition. Record review and interview revealed staff failed to notify the Physician that Resident #110 refused to wear his/her mask that delivered Bi-level Positive Airway Pressure (BiPAP), a mask with tubing attached to a machine that delivered bi-level positive airway pressure while sleeping to keep the airway open and improve oxygenation, used to treat OSA) at night. Resident #110 was transferred to the hospital's ED (Emergency Department), on [DATE] at 5:52 PM, via Emergency Medical Services (EMS) and was admitted . According to the hospital ED records, the resident arrived lethargic and moaning with diminished lung sounds bilaterally (both sides), bilateral upper and lower extremity swelling and edema, febrile, and with an altered mental status. Resident #110 returned to the facility under Hospice Care, on [DATE], and expired on [DATE]. The facility's failure to provide respiratory care to meet the needs of the resident, has caused or is likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) were identified on [DATE], in the area of 42 CFR 483.25(i) Quality of Care, Respiratory Care, and determined to exist on [DATE]. The facility provided an acceptable Allegation of Compliance (AoC) on [DATE], with the facility alleging removal of the Immediate Jeopardy on [DATE]. The State Survey Agency validated removal of the Immediate Jeopardy as alleged on [DATE], prior to exit on [DATE], with the remaining non-compliance at a Scope and Severity of a D while the facility develops and implements a Plan of Correction and the facility's Quality Assurance (QA) monitors to ensure compliance with systemic changes. The findings include: Review of the facility's policy titled, Respiratory Management, revised on [DATE], revealed the purpose of the policy was to provide appropriate respiratory services. Further review revealed residents would be assessed for the need for respiratory services as part of the nursing assessment process. If respiratory care was needed it would be performed by a licensed nurse who had been trained. Furthermore, the nurse would consult with the Physician/Advanced Practice Provider (APP) when a resident was not responding to treatment provided by nursing; or, a resident's condition worsened. Review of the facility's policy titled, Bi-level Positive Airway Pressure, revised [DATE], revealed this treatment was used and provided via a mask connected to a machine that delivered positive airway pressure therapy for the treatment of OSA and to augment ventilation as a non-invasive positive pressure ventilator (NIPPV). Review of the facility's policy titled, Change in Condition (CIC): Notification Of, revised on [DATE], revealed the facility must immediately consult with the resident's Physician and notify him/her when there was a need to change an existing form of treatment or start a new form of treatment. Review of the facility's policy titled, Physician/Advanced Practice Provider (APP) Notification, revised on [DATE], revealed if the resident had a CIC, the Physician or APP must be notified to address new or changed interventions as needed. Per policy, if a resident had a CIC, a licensed nurse must observe and collect information about the resident's condition and report these findings to the Physician or APP (Advanced Practice Registered Nurse/APRN). Review of the facility's policy titled, Nursing Documentation, revised on [DATE], revealed the purpose of nursing documentation was to communicate the resident's status and provide complete, comprehensive, and accessible accounting of care and monitoring provided. Further review revealed the resident's record would specify what nursing interventions were performed. Review of the facility's policy titled, Assessment: Nursing, revised on [DATE], revealed the purpose of a nursing assessment was to determine the resident's condition and clinical needs. Further review revealed the assessment process must include direct observation and communication with the resident, as well as communication with licensed and non-licensed direct care staff on all shifts. Per facility policy, the Physician or APRN was to be notified of all CIC assessment results. Review of the facility's policy titled, Intake and Output, revised on [DATE], revealed the purpose was to ensure nursing staff recorded total fluid intake and output to track the resident's fluid balance. Per policy, nursing staff was to record all intake amounts including fluids taken by mouth and the amount of IV (intravenous) fluids infused; and nursing staff was to record all output amounts including urine in milliliters (ml). Further review of the policy revealed intake and output (I&O) totals were to be recorded in the resident's medical record. Review of the facility's policy titled, Taking Medication and Treatment Orders, revised on [DATE], revealed verbal orders were given face-to-face to a nurse by a practitioner who was in the facility, and verbal orders were not an accepted standard of practice and could only be used in an emergency situation. Continued review revealed the person taking the orders could only take the order from a credentialed physician or other authorized practitioner, as allowed by state regulations. Further review of the policy revealed the person obtaining orders must document verbal orders, with the prescriber's name and title, name and title of the person receiving the order, date, month, year, and time. The prescriber's signature must be obtained per state regulation. Review of Resident #110's medical record revealed the facility admitted the resident, on [DATE]. Further review revealed the resident had current diagnoses, which included Obstructive Sleep Apnea (OSA), Chronic Obstructive Pulmonary Disease (COPD), Asthma, Dysphagia, Heart Failure (HF), and Chronic Kidney Disease (CKD). Review of Resident #110's Social Services Assessment, dated [DATE], revealed the resident scored an eleven (11) out of fifteen (15) on the Brief Interview for Mental Status (BIMS) evaluation, indicating the resident was cognitively intact. Further review revealed the resident was able to express ideas and wants, and was able to understand verbal content. Review of Resident #110's Plan of Care (POC), initiated on [DATE], revealed the resident was at risk for complications related to OSA, COPD, Asthma, and Dysphagia. The goal stated the resident would not have signs/symptoms of respiratory distress or aspiration. Further review of the POC revealed interventions included to administer aerosol medications as ordered/indicated; administer BiPAP as ordered; observe and report SpO2 (blood oxygen saturation) levels via pulse oximetry as ordered and as needed; and observe respiratory rate, signs/symptoms of dyspnea, abnormal breath sounds, cyanosis, and use of accessory muscles. Continued review of the care plan revealed the resident had the potential for alteration in fluid balance and impaired renal function with interventions to include observing for symptoms of edema, shortness of air (SOA), and weight gain. Review of Resident #110's Nursing Notes, dated [DATE] at 8:59 AM, revealed the resident was tachycardia, pulse one-hundred eighty (180) beats/minute; 02 sat 89% with 02/NC at two (2) liters per minute. Further review revealed Resident #110 complained of left sided chest pain. Resident denied nausea/vomiting, his/her skin was warm and dry to touch. But the resident stated he/she was feeling hot during night hours. Continued review revealed the resident was alert, oriented, and verbally responsive x 2; with no difficulty in breathing; and, the resident denied shortness of breath. The APRN was notified with new orders to send the resident to the emergency room. Review of Resident #110's hospital records, dated [DATE], revealed the resident was admitted to the hospital, on [DATE], for sepsis (widespread infection) and acute respiratory failure. Resident #110 was discharged from the hospital and returned to the facility on [DATE]. Review of Resident #110's Physician's Orders, dated [DATE], revealed orders for the use of a BiPAP machine with two (2) liters of oxygen at bedtime. In addition, the order stated for the resident to use two (2) liters of oxygen, via nasal cannula, every shift to keep oxygen levels above ninety (90) percent. Continued review revealed a Physician's Order for Advair Diskus Aerosol Powder Breath, Activated (an inhaler used to treat COPD, Asthma) 250-50 micrograms (mcg) per dose, inhale one (1) puff orally two (2) times a day for Asthma, with a start date of [DATE]. Further review of Resident #110's medical record revealed a Treatment Order, dated [DATE], to change oxygen tubing weekly, and label each component with date and initials, every day shift, every Thursday. Review of Resident #110's Nursing Notes, dated [DATE] at 7:00 PM, revealed the on call APRN was notifie of resident's generalized peripheral edema and not being able to obtain a blood pressure on the resident. Further review revealed new orders obtain to send the resident to the emergency room for furrther evaluation. Review of Resident #110's hospital records, dated [DATE], revealed the resident was sent to the ED, on [DATE], for edema and lab tests. The resident returned to the facility on [DATE], after spending approximately five (5) hours in the ED as an outpatient. Observation and interview with Resident #110, on [DATE] at 9:20 AM, revealed the resident in bed lying on his/her left side with his/her legs crossed, one over the other, with his/her heels pressed against the mattress. There was generalized edema observed over the lower extremities, bilateral hands, and upper extremities; the left hand had an indentation where it rested against the bed. Further observation revealed the resident was on two (2) liters/minute of oxygen via nasal cannula, but the oxygen tubing was not labeled with a date or initialed, which was not according to the treatment order. Additional observation revealed the resident's BIPAP mask and tubing were on the floor, and the resident stated, My life is miserable. Record review revealed Resident #110's lung sounds were assessed on [DATE] at 6:00 AM. However, there was no documented evidence that nursing monitored the resident's lung sounds throughout the day to assess for the resident's worsening condition. Further review revealed there was no documented evidence the nurses assessed an apical pulse on the resident even though the resident had a diagnosis of AFIB. Interview with Licensed Practical Nurse (LPN) #9, on [DATE] at 8:15 AM, revealed Resident #110 routinely refused his/her BiPAP treatment. She stated nurses should document refusals on the MAR (Medication Administration Record). Per interview, she could not recall if the Physician was aware of the resident's repeated refusals to wear the BiPAP. Record review revealed no documentation of notification to the Physician of the resident's refusal to wear the BiPAP. Interview with Registered Nurse (RN) #3, on [DATE] at 8:30 AM, revealed Resident #110 refused the BiPAP and wanted it off most nights because it was noisy and interfered with sleep. She stated she did not recall if the Physician had been notified of the resident's refusal to wear BiPAP. Interview with the Physician, on [DATE] at 9:23 AM, revealed the nurses did not make him aware of Resident #110's non-compliance with wearing the BIPAP at night. He further stated it would have helped the resident with his/her respiratory illness. Record review revealed Resident #110 refused to wear the BIPAP on ten (10) out of twenty (20) nights in the month of [DATE]. However, there was no documented evidence nursing staff provided encouragement and education related to the refusal of care related to wearing the BIPAP at night. Continued review of Resident #110's Nursing Progress Note, dated [DATE] at 6:05 AM, revealed Registered Nurse (RN) #3 observed Resident #110 with frothy, thick mucous in his/her mouth and throat. RN #3 noted the resident's oxygen saturation (SpO2) was ninety-two (92) percent on two (2) liters/minute of oxygen via nasal cannula. Per the Note, a nursing assessment at 6:00 AM, revealed the resident had abnormal lung sounds (rales, rhonchi, wheezing) and complained of chest pain. Further review revealed the assessment of the resident showed a resting pulse rate of one-hundred fifteen (115) beats per minute (BPM), respirations of eighteen (18) per minute, temperature of 97.6 degrees Fahrenheit, and a blood pressure (BP) of 95/48 millimeters of mercury (mmHg). The note stated Resident #110 was not wearing his/her BIPAP. In addition, the note stated RN #3 notified the Physician of Resident #110's condition and new orders were given for lab work and a chest x-ray. Continued interview with RN #3, on [DATE] at 8:30 AM, revealed Resident #110 was normal until about 5:30 AM, and at 6:30 AM, a State Registered Nurse Aide (SRNA) observed the resident with thick phlegm coming from his/her mouth. RN #3 stated she notified the Physician. Per interview, the Physician examined the resident that morning and ordered lab work and a chest x-ray. Interview with the Physician, on [DATE] at 10:12 AM, revealed he examined Resident #110 on the morning of [DATE]. Per interview, he assessed the resident with fluid overload caused by his/her recent IV antibiotic therapy, and it was his intent to diurese (remove fluid) the resident. The Physician stated he gave a verbal order to the Director of Nursing (DON) directly to place an indwelling Foley (brand of indwelling catheter) catheter, give one (1) dose of Furosemide sixty (60) mg IV, monitor lung sounds, and document strict I&O's. The Physician stated he gave the order specifically to the DON because, as an RN, she was the only nurse in the building, who could push IV Furosemide. Additionally, he stated he ordered strict I&O's and the monitoring of the resident's lung sounds to assess the resident's response to the treatment. Further, the Physician stated a staff nurse informed him that following the ordered treatment, Resident #110 was diuresed of approximately two (2) liters of fluid. Per interview, when the resident's condition did not improve, he transferred him/her to the ED for more aggressive measures. Record review revealed Resident #110 was transferred to the hospital, via EMS, on [DATE] at 5:52 PM. Interview with the DON, on [DATE] at 9:15 AM, revealed she assessed Resident #110, on [DATE], in the morning, and told the unit LPN to call the doctor to send the resident out. She stated she documented the assessment; in addition, she stated, according to the facility's policy verbal orders were given in emergency situations by the Physician to an RN. Per interview, the facility's policy dictated that verbal orders were transcribed on an order sheet and signed by the Physician. When asked if she had ever taken a verbal order from a Physician, she replied, No. When asked if Furosemide had been taken out of the emergency box (e-Box), she replied, No. The DON further stated that no one gave Resident #110 Furosemide IV on [DATE], as ordered. She stated the unit LPN was given the order to give Furosemide. In addition, the DON stated the Physician also gave the unit LPN verbal orders to place an indwelling Foley catheter, monitor lung sounds, and document strict I&O's. The DON indicated she first heard about the Physician's orders in the afternoon, however she could not recall the exact time. Additional interviews with the DON on [DATE] at 9:15 AM and review of the resident's records revealed no documented Physician's Orders for Furosemide sixty (60) mg IV, Foley catheter placement, monitoring and assessing lung sounds, strict I&Os, or to provide comfort care. Furthermore, continued review of the Nursing Progress Notes, dated [DATE], revealed no documented nursing assessment by the DON, as stated per interview. Continued review of Resident #110's Nursing Progress Note, dated [DATE] at 3:09 PM, revealed the first CIC follow-up note by LPN #9. The note stated the resident's condition had declined, and the Physician was notified. Furthermore, the note stated new orders were received to continue to hold PO (oral) medications, insert a Foley catheter for strict I&O's, and provide comfort care. However, there was not a specfic time given for receipt of the orders. Interview with LPN #9, on [DATE] at 8:15 AM, revealed RN #3 observed a CIC in Resident #110 during the night shift, which was documented and reported to her at shift change. LPN # 9 stated she was up and down the hall ensuring the resident was responsive and monitored his/her vital signs throughout the day. LPN #9 stated the plan was to wait for lab results to see what to do next; however, she added Resident #110 did not improve, was not verbally responsive, and his/her temperature was elevated. LPN #9 stated the Physician gave orders regarding Resident #110 to the DON, not the LPN's on the unit. In addition, she stated she was not aware whether or not the resident had received Furosemide sixty (60) mg IV or that the Physician wanted the resident diuresed. She stated she did not perform any IV diuresis, but a catheter was placed in the morning to monitor strict I&O's and for comfort care. She recalled the resident's urine output was about fourteen hundred (1400) ml's. Per interview, she stated she did not document any I&Os, was unaware of any chest pain for the resident, and did not document any abnormal lung sounds because they were clear based on the night shift nurse's finding. According to LPN #9, around 11:00 AM, Resident #110 complained he/she could not swallow, so the Physician ordered nothing by mouth and to hold oral medications. The LPN stated Resident #110 was very edematous. She stated she assessed the resident and auscultated clear lung sounds; however, she did not document her assessment. LPN #9 stated the assessment should have been documented to keep an accurate record of the resident's condition. Further interview revealed LPN #9 continued to monitor the resident's mental status, provide comfort care, and monitor his/her status of distress for a further decline in condition. Again, LPN #9 revealed she did not document the assessments and stated the facility needed a better tool for documentation because it could be overwhelming. She recalled she documented a general note later in the afternoon. LPN #9 stated the resident required a higher level of care, which the facility could not provide, and she wanted the resident sent to the hospital. She stated the UM called the Physician, and she received an order to transfer the resident to the hospital. Record review revealed there were no documented assessments for lung sounds, strict I&Os or monitoring of Resident #110's condition, on [DATE] from 6:00 AM to 3:09 PM to ensure the resident's care needs were identified. In addition, there was no documented evidence LPN #9 performed the ordered care. Interview with the Pharmacist on, [DATE] at 3:31 PM, revealed if a needed medication was not on hand, it was pulled from the e-Box. Per interview, two (2) vials of Furosemide (forty) 40 mg were kept in the e-Box, and to audit what was used from the e-Box, nursing staff must fill out a requisition form and fax it to Pharmacy. According to the Pharmacist, the Pharmacy delivered the facility an e-Box, on [DATE], and picked it up, on [DATE]. The Pharmacist stated the e-Box was missing two (2) Furosemide (forty) 40 mg/4 ml vials; however, Pharmacy did not receive a faxed inventory form requesting replacement. However, interview with the DON revealed she did not administer the Furosemide. Review of the Hospital Emergency Department (ED) Notes, dated [DATE] at 6:19 PM, revealed Resident #110 presented to the ED with Atrial Fibrillation, Generalized Edema, Altered Mental Status, a fever of 101.6 degrees Fahrenheit, diminished lung sounds bilaterally, and faint heart tones. Lab results revealed an elevated [NAME] Blood Cell (WBC) count at 15.7 (reference range is 3.7 to 10.3). Further review revealed chest x-ray results were positive for bilateral parenchymal opacities, which could represent edema or infection, and the computed tomography (CT) results of the lungs showed bilateral pleural effusions. Review of the Hospital History and Physical (H&P) for Resident #110, dated [DATE] at 11:19 PM, revealed Resident #110's principal problems were Sepsis (widespread infection of the blood stream), Atrial Fibrillation, Healthcare-Associated Pneumonia (HCAP), Anemia, and Cor Pulmonale (an abnormal enlargement of the right side of the heart as a result of lung disease). A broad spectrum antibiotic and diuretic were ordered. Interview with Agency State Registered Nurse Aide (SRNA) #21, on [DATE] at 3:04 PM, revealed she had cared for Resident #110 and stated he/she required total assist for everything due to contractures. SRNA #21 stated Resident #110 usually had swollen extremities. She stated that when she cared for the resident recently, he/she was crying, complained of no air, and slept all day. Per interview, SRNA #21 stated that she reported the resident's condition to the nurse but did not recall if the nurse assessed the resident. Interview with Agency LPN #10, on [DATE] at 9:40 AM, revealed she was aware Resident #110 had bilateral edema in all extremities. However, there was no documented evidence that nursing staff assessed the resident's edema during the skin assessment on [DATE]. Interview with the Assistant Director of Nursing/Infection Preventionist (ADON/IP), on [DATE]at 10:00 AM, revealed resident assessments should be completed and documented according to policy. She stated it was her expectation that if a resident had a change of condition related to respiratory, that an assessment should be completed and documented in the clinical record. Further, the ADON stated the provider was to be notified. Continued interview with the DON, on [DATE] at 9:15 AM, revealed she expected nursing staff to provide the correct level of care. Per interview, it was the DON's expectation that nurses did resident assessments and charted accordingly. Interview with the RCQS, on [DATE] at 3:40 PM, revealed it was her expectation that when a resident had a change of condition, it was her expectation for it to be documented in the resident's clinical record; furthermore she expected the staff to follow the resident's plan of care and notify the Physician. Furthermore, nursing staff was to assess the resident and document the results. Interview with Administrator, on [DATE] at 2:15 PM, revealed it was her expectation for staff to follow the facility's policy related to assessments and follow the Physician's Orders, as per policy. The facility provided an acceptable credible Allegation of Compliance (AoC) on [DATE] alleging removal of the Immediate Jeopardy on [DATE]. Review of the AoC revealed the facility implemented the following: 1. An audit was conducted by the Assistant Director of Nursing (ADON), Nurse Practice Educator (NPE), and Unit Managers (UM) between [DATE] and [DATE] to determine if residents had pain, had pain medications ordered, if pain medications were effective, and if pain was not relieved. The Physician/Advanced Registered Nurse Practitioner (ARNP) were notified of unrelieved complaints of pain with new orders obtained if applicable. 2. Nineteen (19) of nineteen (19) residents identified with pain issues were reassessed on [DATE] by the Director of Nursing (DON), UM's, and/or Licensed Nurse (LN) Nurse Practitioner and/or Physician to determine if a change in condition had occurred regarding pain. Areas of concern were corrected upon discovery. 3. The DON, UM, ADON, NPE, and/or Clinical Quality Specialist (CQS) initiated reeducation, beginning on [DATE], with all facility staff to include contracted staff on the facility's policy and procedures regarding: (A) Change in Condition; (B) Pain Management, including observations; (C) Stop and Watch Tool; (D) Physician/Mid-Level Provider Notification of Change in a Resident's condition; and (E) Person Centered Care Plan. A post-test was administered at the time of the reeducation that required a passing score of 100% that will be graded by the DON, UM, ADON, NPE, and/or CQS to validate understanding. Facility staff and agency staff not available during the reeducation and post-test were to be provided reeducation including a post-test by the DON, UM, ADON, NPE, and/or CQS upon day of return to work prior to providing care. Newly hired staff and contracted staff were to be provided education and post-test during orientation by the DON, ADON, CQS, NPE, UM, and/or Licensed Nurse (LN). 4. Starting [DATE], clinical observation rounds will be conducted every shift, including interviews of ten (10) staff and five (5) residents who receive pain medication to identify any change in condition including a change in pain by the DON, ADON, UM, NPE, or LN to determine if residents have experienced a change in condition regarding pain. The Physician/NP were notified and the plan of care was reviewed to ensure it reflected the current needs of the resident daily until the Immediate Jeopardy is abated. 5. Starting [DATE], the Center Executive Director (CED) and/or LN would conduct ten (10) employee questionnaires daily to determine if staff were aware of the Center's process of the Stop and Watch Tool and reporting a change in condition, including reporting resident pain to a licensed nurse, to ensure prompt interventions when a resident experienced a change in condition, until the Immediate Jeopardy is abated. 6. The results of the observations, interviews, and audits will be reviewed daily by the CED or DON corrective actions taken upon discovery of deficiencies. 7. Beginning on [DATE], the DON, UM, ADON, NPE, CQS, and/or LNs initiated reeducation with all licensed nurses and agency nurses on the facility's policy and procedures regarding: (A) Pain management to include implementing person-centered care plan with individualized person centered interventions to include monitoring pain, administering pain medications as ordered, utilizing and documenting the pain scale, and observing for non-verbal signs/symptoms of pain; (B) Pressure Ulcer prevention to include developing/implementing the care plan; (C) Person-centered care plans; and (D) Physician/Mid-Level Provider Notification of Change in a resident's condition. 8. All admissions, readmissions, and residents with changes in respiratory status since [DATE] were reviewed on [DATE] by the DON, ADON, NPE, UM, and or LNs to determine if care plans reflected patient specific interventions to include interventions to monitor respiratory status to include residents with sleep apnea, COPD, acute respiratory failure, and asthma. Areas of concern were corrected upon discovery. 9. On [DATE], the DON, UM, ADON, NPE and or CQS initiated reeducation with all licensed nurses and agency nurses on the facility's policy and procedures regarding: (A) Revision of the care plan with all admissions, readmissions, and changes in respiratory status with diagnoses to include acute respiratory failure, sleep apnea, COPD, and asthma. A post-test was administered at the time of the reeducation that required a passing score of 100% that was graded by the DON, UM, ADON, NPE, and/or CQS to validate understanding. Licensed Nursing and Agency Licensed Nursing Staff not available will be provided reeducation, including a post-test, by the DON, UM, ADON, NPE, and/or Registered Nurse upon day of return to work before providing care. New licensed nursing hires and agency licensed nurses will be provided education and post-test during orientation by the DON, ADON, NPE and/or UM. 10. Care plan audits were completed for residents with diagnoses including acute respiratory failure, sleep apnea, COPD, and/or asthma and will be completed for new admissions, readmissions, and residents with a change in condition to include a change in respiratory status to determine the care plan has resident specific interventions including respiratory assessments; and, corrective actions were taken upon discovery of deficiencies. 11. Five (5) Licensed Nursing Staff interviews were completed by the CED, DON, UM, ADON, NPE, and/or CQS to determine if staff were aware of the process of a respiratory assessment when a resident's condition warranted the assessment and per the resident's plan of care will be conducted daily until the Immediate Jeopardy is abated. 12. The DON, UM, ADON, NPE, and/or CQS completed reeducation beginning on [DATE] with facility licensed staff to include agency staff on the facility's policy and procedures regarding: (A) Pain management to include implementing person-centered care plans with individualized person-centered interventions to include monitoring pain, administering pain medications as ordered, and utilizing and documenting pain scale assessments, and observe for non-verbal signs/symptoms of pain. A medication reconciliation process is in place to review discharge orders to current orders; (B) Physician/Mid-Level Provider Notification of Change in a resident's condition; and (C) Person Centered care plans regarding resident interventions for pain. A post-test was administered at the time of reeducation that required a passing score of 100% that was graded by the DON, UM, ADON, NPE, and or CQS to validate understanding. Facility licensed staff and agency staff not available will be provided reeducation including a post-test during orientation by the DON, ADON, NPE, UM, and/or LN, before allowed to work. 13. The CED and/or LN will conduct five (5) employee questionnaires daily to determine if staff were aware of the Center's process of reporting a change in condition including pain to a licensed nurse to ensure prompt intervention when a resident experienced a change in condition until Immediate Jeopardy is abated. 14. The UM's, ADON, NPE, and licensed nurses completed skin assessments on all residents on [DATE], to ensure residents, including residents with pressure ulcers, received care per Physician's orders to promote healing and prevent additional pressure ulcers with any needed corrective action taken upon discovery. 15. The CQS reeducated the Wound Nurse regarding the facility's policy, Wound Care, on [DATE]. A post[TRUNCATED]