**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and review of the facility's policy, it was determined the facility failed to ensure residents, who required dialysis/hemodialysis received such services, consistent with professional standards of practice for four (4) of nineteen (19) sampled residents who received dialysis (Residents #242, #243, #244, and #11). In addition, the facility failed to ensure communication sheets, used to communicate information on the resident, were completed for each dialysis treatment. 1. The facility failded to secure and set-up Resident #243's dialysis treatments prior to admission to the facility on [DATE]. The facility failed to ensure Resident #243 received his/her dialysis treatment on 07/12/2023. The resident was discharged on 07/14/2023, and transported to the hospital for acute care dialysis. 2. The facility failed to ensure Resident #242 received his/her dialysis treatments on 04/23/2022, 04/26/2022, and on 04/28/2022. On 04/28/2022, when Resident #242 arrived to his/her dialysis appointment, the resident presented in the dialysis lobby slumped over, unresponsive, with his/her body twitching. The resident was immediately sent to the hospital for emergent care. Review of Resident #242's diagnoses when he/she presented to the hospital were Acute Metabolic Encephalopathy, from Uremia; Sepsis; End Stage Renal Disease; Hyperkalemia (high potassium); and Adult Neglect, concern for lack of hemodialysis for one (1) week. 3. The facility admitted Resident #244 on 02/23/2022. However, the facility failed to set up the resident's dialysis treatments prior to admission. On 02/25/2022, Resident #244 was readmitted to the hospital for acute care dialysis. 4. The facility failed to ensure Resident #11, who received out of facility dialysis on Tuesdays, Thursdays, and Saturday's, had communication sheets between the facility and the dialysis center, which were required for each treatment. The communication sheets were not completed from 05/17/2023 to 07/11/2023. The facility's failure to have an ongoing assessment of the resident before and after dialysis treatments, including monitoring the resident's condition for complications; and the failure to conduct ongoing communication and collaboration with the dialysis facility regarding residents' dialysis care and services; and failure to ensure residents had dialiysis appointments and failure to ensure residents were transported to their dialysis appointments is likely to cause serious injury, serious harm, serious impairment, or death to residents. Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) were identified on 07/21/2023 and determined to exist on 02/25/2022 in the area of 42 CFR 483.25(l) Quality of Care F698 Dialysis, at a Scope and Severity (S/S) of a K. The facility was notified of the Immediate Jeopardy on 07/21/2023, and the IJ is ongoing. The findings include: Review of the facility's policy titled, Community Hemodialysis (HD), effective and last revised date of 07/25/2019, revealed all residents admitted to the facility with the need for hemodialysis were to have coordination of services between the facility and the hemodialysis unit prior to admission. Per the policy, dialysis services were to be set up with the dialysis center by the hospital or community agency prior to the resident's admission to the facility. Continued review revealed when the dialysis schedule was determined, the facility would set up the transportation arrangements. The policy revealed a schedule would be provided to the nursing units for the resident's dialysis days, including the time and day of the week that the resident was to attend dialysis. Review revealed the facility was to obtain orders from the Physician for the resident's dialysis days, which was to be written on the Physician order sheet. In addition, a dialysis communication sheet was to return with the resident after the dialysis session to communicate to the facility information regarding the dialysis session. Further review revealed the facility was to continue to monitor the resident after dialysis for any signs and symptoms of disequilibrium syndrome (a serious and rare complication of dialysis that involves a range of neurological symptoms), nausea, vomiting, or bleeding from the dialysis access site. The policy review revealed changes in the resident's condition were to be documented and reported to the Physician. Review of the In-House Dialysis Company's policy titled, Patient Selection Criteria for Staff Assisted Home Hemodialysis in the Skilled Nursing Facility, dated 10/26/2021, revealed their clinical team reviewed patient (resident) records to ensure the patient could be safely dialyzed in a group environment, and the patient was not at risk of becoming unstable during treatment. Per the policy, the patient's services intake team was the central hub for all referral activity, returning patients, and admission related updates. Continued review revealed the admission items needed for acceptance were dialysis treatment records, lab reports within seven (7) days; a nephrology note including renal diagnosis, history and physical, face sheet with insurance information, hepatitis B surface antigen results within thirty (30) days, and chest x-ray or Purified Protein Derivative (PPD) test within 90 (ninety) days. The policy stated the patient services team would work with the facility to proactively reach out to hospitals to collect the necessary documents. Per the policy, it was helpful for the facility that wanted to admit the patient/resident to share relevant case worker contact information so the in-house clinic could support the facility's efforts to collect paperwork and admit residents/patients as quickly as possible. 1. Review of Resident #242's admission Record revealed the facility admitted the resident, on 04/21/2022, with diagnoses of End Stage Renal Disease (ESRD), Pain in Leg, and Hypotension. Review of Resident #242's admission Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of eleven (11) of fifteen (15), indicating moderate cognitive impairment. Review of Resident #242's Nursing Progress Note, dated 04/21/2022 at 9:04 PM, revealed the resident was total care for bed mobility and total care with transfers. Review of Resident #242's Nursing Progress Note, dated 04/23/2022 at 11:53 PM, revealed the resident had an arteriovenous (AV) fistula (a vascular access for hemodialysis) in the left upper arm. Further review of the 04/23/2022 Progress Note revealed the resident received hemodialysis three (3) times a week. Review of Resident #242's care plan initiated on 04/22/2022, revealed a potential for complications related to dialysis because of ESRD, with intervention which included dialysis treatment three (3) times a week on Tuesday, Thursday, Saturday at the dialysis clinic, pick up 2:00 PM, with no transport company listed, and make transportation arrangements for dialysis. Continued review of Resident #242's facility medical record revealed no documented evidence of the resident having a nursing assessment, progress note, or documentation of Physician/MD/NP notification of the missed HD treatment for 04/26/2022. Further review revealed a nursing assessment was performed on 04/23/2022; however, there was no documentation noting Resident #242 missing his/her HD or documented evidence of the Physician, Medical Director, or NP being notified of that information or of progress notes concerning the missed dialysis treatment. Review of the freestanding dialysis clinic progress notes dated 04/26/2022, revealed the clinic notified the NP of Resident #242's missed dialysis treatment. Continued review of the notes revealed on 04/28/2022, Resident #242 presented to the dialysis clinic lobby from the facility slumped over and unresponsive, with his/her body twitching. Further review revealed Emergency Medical Services (EMS) was called, and EMS transported the resident to the local Emergency Department (ED). Review of the EMS Run Sheet/Report dated 04/28/2022, revealed the EMS personnel arrived at the dialysis center and found Resident #242 seated in wheelchair. Per the report, Resident #242 was lethargic, difficult to arouse, and non-verbal when awakened. Continued review revealed the dialysis center staff told EMS staff the resident was discharged from the hospital on the previous Saturday and received his/her most recent dialysis treatment at that time. Per the report, EMS staff were informed Resident #242 was transferred to the facility from the hospital and had not been transported to dialysis until that day (04/28/2022), and upon arrival presented lethargic and non-verbal. Review revealed dialysis center staff, informed EMS staff, the skilled longterm care facility had requested Resident #242 receive only one (1) hour of the normal three (3) and a half hours of his/her dialysis treatment for every treatment because of scheduling convenience. Further review revealed the EMS assessment revealed no visible or palpable signs of trauma; all vital signs within normal limits; and blood glucose checked and was 105 mg/dl (normal). Review of Resident #242's hospital records of the History and Physical (H&P) dated 04/28/2022 at 10:30 PM, revealed the resident had admission diagnoses of Acute Metabolic Encephalopathy, likely multifactorial, Sepsis, ESRD, Hyperkalemia, Hyperthermia, Malnutrition, Decubitus Ulcer, and Adult Neglect. Continued revealed Resident #242 had a negative head Computed Tomography (CT) scan; had been febrile with a temperature of 100.7 degrees Fahrenheit; had a heart rate greater than ninety (90) beats per minute; and his/her chest X-ray noted possible inflammatory infiltrate. Per review, intravenous (IV) Vancomycin and Zosyn started (antibiotics) were initiated, and for the resident's ESRD dialysis was scheduled on a Tuesday, Thursday, Saturday schedule, and he/she received HD today in the ED. Review revealed cooling blankets were ordered for treatment of Resident #242's hyperthermia; and the resident's potassium level of 6.5 (normal range was 3.5-5) was noted as related to lack of receiving HD. Further review revealed Resident #242 had a basic metabolic index (BMI) of 17.5 (underweight), appeared cachectic (wasting away), and nutrition was consulted. Review further revealed Resident #242's Stage 3 Decubitus Ulcer which was noted on his/her last admission, appeared to have increased in size. In addition, review revealed documentation noting there was concern for neglect given the patient's nutrition status, lack of HD for one (1) week, and Stage 3 Decubitus Ulcer; and Hypertension. In an interview on 07/11/2023 at 3:23 PM, the Social Worker, from the out of facility freestanding dialysis center, stated Resident #242 had been a no call/no show on 04/23/2022 for his/her dialysis treatment. She stated, on 04/26/2022, the resident was sent back to the facility from the dialysis center without receiving a dialysis treatment. According to the Social Worker, the resident's transportation arrived after 3:00 PM and would only pick up the resident at 5:00 PM or earlier. She stated Resident #242 would not have been able to get a full dialysis treatment as ordered due to the transportation issue. In an interview with the former Assistant Director of Nursing (ADON) on 07/13/2023 at 12:11 PM, she stated when Resident #242 was accepted by the facility the transport should have been set up for dialysis by the facility prior to the resident coming. She said it was the responsibility of the facility. She stated Resident #242's missed treatment on 04/23/2022 (Saturday) happened on a weekend, and the facility could not get transport because it had not been scheduled yet. She stated the referrals went to the Business Office Manager (BOM) and then to the Director of Nursing (DON), prior to the resident's admission. The former ADON stated if the facility decided to accept the resident, facility staff corresponded with the liaison (facilitator of communication of information between the hospital or outside facility and the facility). She stated then the BOM set up dialysis transport for the resident. In an interview on 07/25/2023 at 8:38 AM, with the Director of Nursing (DON), she stated the facility did not have the Physician/Medical Director (MD) communication book sheets from April 2022 because the facility had changed medical providers since then. The DON further stated the scheduler and not the BOM set up transport for dialysis residents to the dialysis clinic. 2. Review of Resident #243's facility admission Record revealed the facility admitted the resident from a hospital, on 07/11/2023, with diagnoses of ESRD, Diabetes, and Abnormal Findings of Blood Chemistry. Review further revealed Resident #243 was discharged from the facility on 07/14/2023; prior to the facility being able to assess the resident's BIMS score for cognition. Review of an email to the facility's Liaison #1 from the in-house dialysis clinic, dated 07/10/2023 at 12:51 PM, revealed Resident #243's name was on the in-house dialysis clinic's waitlist. Review of the hospital record Dialysis Notes for Resident #243, dated 07/10/2023 at 7:00 AM, revealed dialysis was in progress. Continued review of the Dialysis Notes at 10:00 AM on 07/10/2023, revealed Resident #243's dialysis session was completed. Further review of Resident 243's hospital record revealed laboratory results dated [DATE] at 6:46 AM, revealed a Potassium level of 5.3 millimoles per liter (mmol/L, normal value 3.5-5.1 mmol/L), BUN 83 milligram per deciliter (mg/dL, normal value 8 to 26 mg/dL), and Creatinine-Blood 6.01 mg/dL (normal 0.73 to 1.18 mg/dL). Review of Resident #243's care plan, initiated by the facility on 07/11/2023, revealed care plan interventions which included to monitor/document/report as needed (PRN) signs and/or symptoms of renal insufficiency such as: changes in level of consciousness; changes in skin turgor or oral mucosa; and changes in heart and lung sounds. Continued review revealed additional interventions included: check and change dressing daily at dialysis access site and document; and do not draw blood or take Blood Pressure (BP) in the arm with graft; however, no site was listed. Review further revealed no documented evidence of dialysis clinic, frequency of treatment, or days of treatment listed in the care plan. Continued review of Resident #243's facility medical record revealed a Physician's order dated 07/12/2023, for the resident to receive in house dialysis three (3) times per week, on Monday-Wednesday-Friday. Review of a Nurse Progress Note for Resident #243, dated 07/14/2023 at 3:55 PM, documented by Registered Nurse (RN) #3, revealed the resident had received no dialysis since Monday (07/10/2023), and the Physician had been notified. Per review of the Note, Resident #243 was transported to a local Emergency Department (RD) via medical transport. Continued review revealed facility staff accompanied Resident #243 to the ED, and the resident was alert and oriented when transported and displayed no signs and/or symptoms of distress or discomfort. Additional review of the 07/14/2023 Nurse Progress Note documented by RN #3 revealed the documentation had been struck through (a line drawn through the text) by RN #3 on 07/22/2023 at 3:52 PM. The State Survey Agency (SSA) Surveyor attempted a telephone interview with RN #3 on 07/25/2023 at 3:07 PM; however, no answer was received. The SSA Surveyor left RN #3 a message requesting a return call. In an interview on 07/25/2023 at 4:01 PM with Registered Nurse (RN) #3, she stated she had only taken care of Resident #243 once. She stated on 07/14/2023, she was told in report that Resident #243 was an Hemodialysis (HD) patient, and was told by the ADON the resident needed to go to the hospital. RN #3 stated the ADON said it was something about Resident #243's HD and that the resident had missed a few days of his/her HD. She stated she struck through her Nurse Progress Note from that date because it had not been an accurate note. The RN stated she made a mistake by charting an assumption on the time frame. According to RN #3, she had just been employed at the facility within the last month. She stated she received education on dialysis; however, every facility was different regarding residents' weights, such as if staff at the facility weighed the resident or if the staff at the dialysis clinic weighed the resident. RN #3 further stated if a resident missed a dialysis treatment, the resident usually was sent to the ED to get the missed treatment. Review of Resident #243's facility medical record revealed the resident had one (1) nursing assessment completed on 07/11/2023, while residing in the facility. Further review revealed for 07/12/2023, there was no documented evidence of a Nurse Progress Note, assessment of Resident #243, or documentation of notification to the Physician or Nurse Practitioner (NP) of the missed dialysis treatment on 07/12/2023. In an interview with the Unit Manager (UM) on 07/27/2023 at 2:05 PM, she stated she put the change of condition note in for Resident #243, dated 07/14/2023, due to the resident having behaviors and needing dialysis. She further stated she was unsure about Resident #243's missing HD treatment on 07/12/2023. In an interview on 07/19/2023 at 2:10 PM, with the in-house dialysis RN, she stated Resident #243 was never accepted by the in-house dialysis clinic when the SSA Surveyor requested the resident's missed HD documentation. The RN stated Resident #243 had been on the in-house dialysis clinic's pending list, and the Medical Director had not yet accepted Resident #243. She stated before acceptance, the DON and Medical Director of the in-house dialysis clinic met and determined, by doing a medical review, whether the patient/resident would be accepted into the dialysis clinic. She reiterated that Resident #243 had not been accepted into the in-house dialysis clinic. In an interview on 07/25/2023 at 9:30 AM, with Licensed Practical Nurse (LPN) #2, she stated it was not communicated to her that Resident #243 had an HD order placed. She stated if she had known the resident had a dialysis treatment due on 07/12/2023, she would have taken Resident #243 to dialysis. In an interview on 07/25/2023 at 9:49 AM, with the Staff Development Coordinator (SDC), she stated she placed the order on 07/12/2023 for Resident #243 to have dialysis three (3) times per week on Monday, Wednesday, and Friday, and for it to be done by the in-house dialysis clinic. She stated she put the order in during the Interdisciplinary (IDT) meeting because Resident #243 was a new admission and needed dialysis orders. She stated the members of the IDT were Therapy, Nursing, the Social Services Direct, the Activity Director, the Minimum Data Set (MDS) Coordinator, the Dietary Director, and the Staff Development Coordinator (SDC). She stated the IDT clinical meeting was held every Monday through Friday. However, there was no documented evidence the order was followed-up. In an interview with the Director of Nursing (DON), on 07/19/2023 at 2:26 PM, she stated there was a Pending Outpatient list for residents until a dialysis chair became open, and there was currently one (1) resident on that list, Resident #243. In an additional interview on 07/25/2023 at 9:55 AM with the DON, she stated it was her understanding the in-house dialysis clinic had approved Resident #243. She stated she was not aware the resident was on a waiting list. The DON stated two (2) facility residents that were on dialysis were in the hospital, and she did not understand why the in-house dialysis clinic could not put Resident #243 in one (1) of those dialysis chairs. The DON stated there would not be anything in the Physician/MD communication book about a missed dialysis treatment on 07/12/2023 for Resident #243, because staff should have completed a change of condition form. She stated the change of condition form for 07/12/2023 was not entered. She stated Nurse Practitioner (NP) #3 was aware of the missed dialysis for Resident #243, but there was no documented evidence the facility notified NP #3. The DON stated for in-house dialysis, the facility must have approval by Liaison #1, who coordinated treatments between the facility and the in-house dialysis clinic. In an interview on 07/25/2023 at 2:42 PM, with NP #3 she stated she worked on Tuesdays and Thursdays; however, had been on call 07/12/2023 (Wednesday). She stated she did not recall receiving a call about Resident #243. The NP stated if a resident missed dialysis, she expected a nursing assessment and stat (immediate) labs (laboratory work) drawn on the resident. She stated she would want the nurse to monitor for lethargy; vital signs, especially low or high blood pressure; increased confusion; seizure activity; and high potassium, blood urea nitrogen (BUN), creatinine, and sodium. NP #3 stated she always ordered lab work on new admissions; however, had covered for another NP at another facility on Thursday, 07/13/2023, so she had not seen Resident #243. She further stated Resident #243 had been seen by the Medical Director on 07/14/2023. In an interview on 07/25/2023 at 3:17 PM with the facility's Liaison #1, he stated for dialysis residents he sent all the information to the in-house dialysis clinic. He stated he and the facility would get an approval email and then admit the resident. He stated he received an email that said Resident #243 was accepted. When the SSA Surveyor asked for the email and previous emails dealing with that subject, or the email thread, he stated there was only an email with Resident #243's approval for the waitlist. In an interview on 07/25/2023 at 4:33 PM, with Liaison #2, she stated Resident #243 did come from her account, she had sent information to the in-house dialysis clinic, and they went through an authorization saying Resident #243 was good to go. She stated she received an email from the in-house dialysis clinic saying Resident #243 was approved for the waitlist, and they had seventeen (17) chairs. She stated when she gave this information to the facility's Admissions office, she was told the facility was good to accept the resident. In an interview on 07/25/2023 at 4:08 PM, with the Admissions Coordinator, she stated for outpatient dialysis the hospital set up the HD center or clinic for the resident, and the facility set up the transport. She stated once that was verified the facility could admit the resident. The Admissions Coordinator stated for in-house dialysis the facility sent information to the in-house dialysis clinic for approval for a chair, and the clinic was supposed to open more chairs on 07/10/2023. She stated she messaged the Administrator who responded that the in-house dialysis clinic was not opening more chairs. She stated the hospital had been holding Resident #243 for acceptance to the facility. She stated the DON spoke to the in-house dialysis clinic, who stated since the facility had two (2) residents at the hospital, the in-house dialysis clinic would accept Resident #243. The Admissions Coordinator stated she told the hospital the facility could accept Resident #243. However, the facility provided no documented evidence to corroborate the Admissions Coordinator's statement. In an interview with the in-house Dialysis Clinic Manager (DCM) on 07/26/2023 at 3:47 PM, she stated the clinical liaisons were updated regularly, and the facility was previously told the in-house dialysis clinic was at full capacity. The DCM stated an email was sent on 07/10/2023 at 12:51 PM, that informed the facility that Resident #243 had been waitlisted. She stated the clinic advised the facility not to admit the resident for their (in-house clinic) dialysis. The DCM stated they did allow one (1) extra spot because of the closure of two (2) other nearby facilities in June 2023. She stated the in-house dialysis clinic's RN had access to the facility's charting, and the RN noted Resident #243 was residing in the facility and had not had his/her HD. The DCM stated the facility then brought Resident #243 to them for HD on 07/14/2023; however, the in-house dialysis clinic did not have specific dialysis orders as they had not accepted Resident #243 at that point. The DCM stated the facility could admit a resident on dialysis that had not been accepted by the in-house dialysis clinic; however, the resident would have to go to an outpatient dialysis clinic to receive treatment. In an interview on 07/25/2023 at 2:56 PM, with the Medical Director, he stated the facility had many residents on dialysis with multiple co-morbidities. The Medical Director stated he would not send a resident to the hospital unless he/she missed multiple dialysis days. He stated he or the NP should be notified if a resident missed their dialysis. He further stated he had only been the facility's Medical Director for a month, but if resident rwuiring dialysis di not recieve the dialysis as ordered it could greatly affect the resident's renal staus. 3. Review of Resident #244's admission Record revealed the facility admitted the resident on 02/23/2022, with diagnoses of Chronic Kidney Disease Stage 4, Hypertension, and Diabetes. The resident was only in the facility for a short time, and a BIMS score was not assessed. Review of the facility's Nursing admission assessment dated [DATE], revealed Resident #244 received hemodialysis and had a tunnel catheter (dialysis access) in the right upper chest. Per review of the Assessment, Resident #244 received dialysis treatments on Monday-Wednesday-Friday, and the resident's last treatment was on Wednesday, 02/23/2022. Continued review of Resident #244's medical record revealed the facility admitted Resident #244 without an outpatient dialysis clinic order to receive his/her HD. Review revealed Resident #244 was sent back to the acute care hospital two (2) days later (on 02/25/2022) to receive his/her HD. Per the record, Resident #244 did not return to the facility. Review of Resident #244's care plan dated 02/25/2022, revealed the resident had a potential for complications related to dialysis related to ESRD and dialysis treatments three (3) times a week. Continued review revealed interventions which included: make transport arrangements for dialysis; protect shunt (dialysis access) site from injury; and avoid constriction on affected arm, such as BP cuff, carrying purse, constrictive clothing. However, further review revealed no documented evidence of a dialysis clinic listed, times listed, or a transport company listed. Review of the Nurse's Note dated 02/25/2022 at 11:11 AM, documented by the former ADON, revealed Resident #244 was being transported to a local ED. Continued review revealed the former ADON notified the ED nurse that Resident #244 needed to have dialysis, and upon return to the facility, a dialysis center needed to be assigned on a regular schedule. In an interview with the former Assistant Director of Nursing (ADON) on 07/13/2023 at 12:11 PM, she stated she could not remember anything about Resident #244. 4. Review of Resident #11's admission Record revealed the facility admitted the resident on 10/26/2022, with diagnoses of ESRD, Diabetes, and Hypertension. Review of Resident #11's Quarterly MDS assessment dated [DATE], revealed the facility assessed the resident to have a BIMS score of fifteen (15) of fifteen (15), indicating no cognitive impairment. Continued review of Resident #11's Point-Click-Care (PCC, software used by the facility) Physician's order, dated 06/28/2023, revealed the resident received out of facility dialysis on Tuesday, Thursday, and Saturday. Further review, on 07/11/2023 at 2:56 PM, revealed the communication sheets between the dialysis center and the facility, provided by the facility, showed the last communication sheet was dated 05/17/2023. Review of Resident #11's care plan revealed interventions initiated on 10/27/2022, which included: to communicate with dialysis center regarding medication, diet, and lab results; protect shunt (dialysis) site from injury; avoid constriction on affected arm, such as BP cuff, carrying purse, constrictive clothing; avoid any possible injury to the arm with the fistula; and monitor for bleeding of the right upper chest and left upper arm fistula. In an interview with Licensed Practical Nurse (LPN) #12 on 07/23/2023 at 8:15 AM, she stated she just started working at the facility a month ago and had not received any education on dialysis. She stated she knew to watch a resident's vital signs and change the resident's access bandage after HD. However, she stated she was not sure about ongoing monitoring or what to do if a resident missed HD. LPN #12 stated some residents got weighed every morning; however she was not sure about how residents receiving HD were to be weighed. She further stated the care plans and orders told staff how to care for residents. In an interview with the DON on 07/19/2023 at 2:26 PM, she stated the hospital had the responsibility to set-up HD for residents. She stated if not, the facility made sure transportation for the dialysis treatments was set up prior to the resident coming to the facility. The DON stated the facility did not accept a resident until HD and the transport was set up. The DON stated sometimes the hospital set up transport also, and sometimes it was the facility that set it up. She stated the HD schedule was posted at the nurse's station, and it was also written in the Physician's orders. According to the DON, the communication sheet utilized did not have an area for monitoring residents after their HD. However, she stated Physician's orders stated to monitor the fistula and remove the bandage over the fistula after four (4) hours. The DON stated the process for when a resident missed an HD treatment was for the Physician, Medical Director, or NP to be notified to send the resident to the ED to get dialysis, and for the resident to be monitored for fluid overload, shortness of air, and respiratory failure. She stated the Admissions Liaison talked to the hospital about admitting a resident that required dialysis. The DON stated the resident's hospital Discharge Summary was where dialysis orders were located, such as the chair time and the days of the week for the dialysis treatment. The DON stated the facility currently had no transportation issues regarding dialysis. She stated there was a Pending Outpatient list for residents until a dialysis chair became open. In an additional interview with the DON on 08/01/2023 at 3:54 PM, she stated she would expect HD to be set up prior to a resident being admitted to the facility. She stated she expected the facility to set up transportation for HD treatments. The DON stated she would expect communication to occur between the dialysis center and the facility. She stated the facility's process for if the communication sheet was not completed, was the facility would contact the dialysis center and get the sheet sent over. She stated the staff at the facility were to monitor for fluid overload and shortness of air of residents. The DON stated she expected a nursing assessment to be completed to monitor a resident when he/she missed an HD treatment, and she expected a post-HD nursing assessment to be completed to monitor for complications. According to the DON, intake and output were monitored for dialysis patients for those with fluid restrictions, she expected a weight pre/post treatment, and the facility had orders to monitor for complications of the access site twice a day. In addition, she further stated employees received education regarding HD in their orientation and she realized the importance for residents with renal problems to recieve the routine schedule dialysis to ensure their renal function did not decline. In an interview with the Administrator on 08/01/2023 at 3:40 PM, she stated she expected HD to be set up prior to a resident being admitted to the facility. She stated expected the facility to set up transportation for residents' HD treatments.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 9. Review of Resident #84's medical record revealed the facility admitted the resident on 05/03/32023, with diagnoses of Post-Traumatic Stress Disorder, Chronic Obstructive Pulmonary Disease, Anxiety, and Diabetes Mellitus type 2. Review of the admission MDS assessment dated [DATE] revealed the facility assessed Resident #84 as having a BIMS score of fifteen (15) out of fifteen (15) indicating he/she was cognitively intact. Continued MDS review of section I, revealed Resident #84 triggered for Post Traumatic Disorder (PTSD). Review of Resident #84's Comprehensive Care Plan dated 05/16/2023 revealed no documented evidence of care plan formulated for the resident's PTSD. Continued review of the Comprehensive Care Plan revealed a list of diagnoses under Resident #84's potential nutrition problem dated 05/16/2023, which listed PTSD with the resident's other diagnoses. In interview on 08/06/2023 at 9:42 AM, the DON stated she was not aware Resident #84 had a diagnosis of PTSD. The DON stated a care plan should have been developed and implemented for Resident #84's PTSD. In interview on 08/06/2023 at 10:08 AM, the Administrator stated a care plan should have been developed for Resident #84 concerning his/her PTSD. In interview on 08/07/2023 at 11:11 AM, the MDS Coordinator stated a comprehensive care plan should have been formulated for Resident #84's PTSD. 5. Review of Resident #15's medical record revealed the facility admitted the resident on 06/16/2023, with diagnoses which included Respiratory Failure, Liver Transplant, Seizures, Dependence on Renal Dialysis, Anemia, Muscle Weakness, and Cognitive Communication Deficit. Review of the admission MDS assessment dated [DATE], revealed the facility assessed the resident to have a BIMS score of fourteen (14) out of fifteen (15) which indicated the resident was cognitively intact. Continued review of the MDS under section G revealed the facility assessed Resident #15 required two (2) person assist for bed mobility and one (1) person physical assist with transfers. Review of Resident #15's Comprehensive Care Plan dated 06/19/2023, revealed the resident was at risk for falls related to impaired balance and mobility, poor safety awareness due to cognitive decline, use of psychotropic medications, and visual impairment. Continued review revealed interventions which included bed in low position, call light within reach, and keep frequently used items close to the resident. Further review revealed an intervention, initiated on 06/29/2023, not to leave the resident up in the chair in the room alone. However, observation on 07/13/2023 at 2:55 PM, revealed Resident #15 sitting in a reclining chair in his/her room alone, with his/her feet raised. Continued observation revealed Resident #15 was attempting to climb out of chair, and no staff were present near the resident's room. The State Survey Agency (SSA) Surveyor notified staff who went to Resident #15's room. Review of Resident #15's Progress Notes revealed the resident slipped out of the wheelchair on 06/28/2023, when he/she was left alone in his/her room. Continued review of the Progress Notes revealed Resident #15 complained of right hip pain on 07/04/2023, at which time an x-ray of his/her right hip was ordered by the Physician. Review of the Progress Notes revealed an x-ray was obtained on 07/07/2023 (nine [9] days after the resident's fall), with a final x-ray report received on 07/08/2023, which revealed Resident #15 had a right hip fracture. Further review of the Progress Notes revealed no documented evidence of entries noted from 07/08/2023 until 07/10/2023, when Resident #15 was admitted to the hospital for the right hip fracture. During an interview with CNA #21 on 07/16/2023 at 7:20 PM, she stated Resident #15 required total assist with transfers and was currently out to the hospital. During an interview with the MDS Nurse on 08/07/2023 at 11:15 AM, she stated the nurse should implement an immediate intervention following a resident's fall and the Interdisciplinary Team (IDT) met at the next scheduled IDT meeting, which was usually held Monday through Friday, to discuss if the intervention was appropriate. She further stated she then placed the intervention on the resident's Comprehensive Care Plan. 6. Review of Resident #72's medical record revealed the facility admitted the resident on 05/01/2023, with diagnoses which included Major Depression, Anxiety, End Stage Renal Disease, and Altered Mental Status. Review of the admission MDS assessment dated [DATE], revealed the facility assessed the resident to have a BIMS score of thirteen (13) out of fifteen (15) indicating he/she was cognitively intact. Continued review of the MDS, section G, revealed the facility assessed Resident #72 as a one (1) person physical assist for bed mobility and review of section J revealed the resident had a history of falls prior to admission. Review of the facility's baseline care plan for Resident #72 dated 05/01/2023, revealed the facility identified and care planned the resident for his/her risk for falls; however, the facility did not initiate the comprehensive fall care plan until 06/20/2023. Review of the baseline care plan dated 05/02/2023 for Resident #72 revealed the facility identified the resident's risk for falls; however, did not initiate a comprehensive fall care plan for him/her until 06/20/2023. Review of base line care plan dated 05/02/2023, the section H safety risks Resident #72 was identified fell at home, had a history of falls prior to admission, and within the last two (2) to six (6) months. Continued review revealed bed in lowest position was listed under specify other safety devices. Further review revealed under the comments documentation noting: Resident #72 was only oriented to self; could not comprehend where he/she was; his/her gait was weak and unsteady; he/she attempted unassisted transfers; and he/she used the call light. Review of Resident #72's Comprehensive Care Plan dated 06/20/2023 revealed a focus for the resident as at risk for falls related to decreased safety awareness, incontinence of bowel, and incontinence of bladder. Review of the goal dated 06/20/203, revealed Resident #72 was to have a safe environment maintained through the next review target date of 11/07/2023. Further review revealed interventions dated 06/23/2023 for a reacher (grabber) for safety with frequently used items within reach, and on 07/07/2023 for bilateral (enabler) side bars added to bed to assist resident to lay in center of bed. Review of Nurse Progress Note dated 07/06/2023 at 10:00 AM, revealed LPN #2 was notified Resident #72 had been found lying on the floor. Continued review revealed Resident #72 was assessed and found to be bleeding from a gash on his/her left leg below the knee. Further review revealed the medical doctor was notified and gave an order to send to Resident #72 to the emergency room (ER). In addition, the resident's family and management were notified. In interview on 08/06/2023 at 10:10 AM, the Director of Nursing (DON) stated the baseline care plan was in place and was in place for the twenty-one (21) days until the comprehensive care plan. In interview on 08/06/2023 at 10:08 AM, the Administrator stated Resident #72 was a high risk for falls and had interventions on his/her baseline care plan. In interview on 08/07/2023 at 11:14 AM the MDS Coordinator stated the comprehensive care plan took twenty-one (21) days to be developed. The MDS Coordinator stated the fall comprehensive care plan should have been formulated for Resident #72 within the twenty-one (21) day period. 7. Review of Resident #6's medical record revealed the facility admitted the resident on 06/20/2023, with diagnoses including Hypertension, Parkinson's Disease, Anxiety, and Depression. Review of Resident #6's admission MDS assessment dated [DATE], revealed the facility assessed the resident as having a BIMS score of fifteen (15) out of fifteen (15) indicating the resident had intact cognition. Continued MDS review, Section G functional status, revealed the facility assessed the resident to require assistance of two (2) persons for transfers. Review of Resident #6's Comprehensive Care Plan dated 06/21/2023, revealed the facility care planned the resident to require assistance with Activities of Daily Living (ADLs) related to Disease Process and Limited Mobility. Continued review revealed interventions which included extensive assistance by two (2) staff to move between surfaces. Observation on 07/23/2023 at 9:20 AM, revealed Resident #6 suspended in a lift sling from a mechanical lift and being transferred from the bed to the chair by CNA #21. Per observation, CNA #21 had no other staff member present in the room to assist her. Continued observation revealed Registered Nurse (RN) #3 was standing in the hallway outside Resident #6's room at a medication cart. CNA #21 was observed to go to the doorway of the Resident #6's room to ask RN #3 to assist her with the mechanical lift transfer, leaving the resident suspended in the lift sling alone. Observation further revealed RN #3 told the CNA she would help her after she gave the resident's medication. In interview on 07/23/2023 at 9:24 AM, CNA #21 stated that day there were only four (4) CNAs for the whole building, in addition to the CNA sitting 1:1 with a resident. She stated there were two (2) CNA call ins, and no other CNAs were available to assist her at the time of Resident #6's transfer. The CNA stated she knew she should have two (2) staff for all lift transfers and as per the resident's care plan. She stated that day however, she had twenty-four (24) residents to care for by herself on the hall and Resident #6 needed to be gotten up and into his/her wheelchair to attend church services. CNA #21 stated the DON told her before Resident #6 was to be gotten up for church services if he/she wanted to go to church. The CNA further stated Resident #6 could have fallen from the lift, or the lift could have tipped over or the straps have broken, which could have caused the resident injury. In interview on 07/23/2023 9:27 AM, RN #3 stated she was passing medications for the entire hall and was attempting to give the medication she had already prepared for a resident before she assisted CNA #21. She stated two (2) staff should always perform lift transfers so one (1) person could move the lift while the second person assisted the resident so the lift did not move, the sling did not break, or the resident fall out of the sling and cause injury to the resident. In interview on 08/05/2023 at 10:50 AM, Resident #6 stated he/she was very afraid when being in the lift with only the one (1) staff person using it on 07/23/2023. Resident #6 stated he/she had hurt his/her left shoulder and hip after experiencing a fall from a lift at another facility. The resident further stated he/she had been a nurse and knew there should always be two (2) staff with all lift transfers for resident safety. 8. Review of Resident #51's medical record revealed the facility admitted the resident on 04/07/2023, with diagnoses including Hypertension, Malnutrition, Depression and Anxiety. Review of Resident #51's admission MDS assessment dated [DATE], revealed the facility assessed the resident as having a BIMS score of ninety-nine (99), which indicated the resident chose not to participate, or four (4) or more items were coded as zero (0). Further review of the MDS, Section G, functional status revealed the facility assessed the resident as requiring two (2) person assist for bed mobility and transfers, and review of the MDS, section J revealed Resident #51 had a history of falls. Review of Resident #51's Comprehensive Care Plan, dated 04/23/2023, revealed the resident was care planned for a risk for falls with interventions including: two (2) staff for ADL care for safety; bolsters to left side of bed; one-to-one (1:1) supervision for safety due to frequent falls; call light within reach at all times, therapy to assess for locking tray table for geri chair; low bed related to decreased safety awareness; full size mattress to right side of bed; and the resident to be taken to activities to help keep him/her engaged in other forms of stimulation. Review of Resident #51's medical record revealed Resident #51 sustained ten (10) falls after admission to the facility on [DATE], which were as follows: a). On 04/13/2023, Resident #51 was found lying on the floor in his/her room and the facility determined the resident sustained a fall which resulted in a laceration and hematoma over the resident's right eye and a laceration over his/her left eye. Resident #51 was sent to the hospital and underwent a left frontotemporoparietal craniotomy (brain surgery) for evacuation of a right-sided acute on chronic subdural hematoma (brain surgery) for evacuation of a right-sided acute on chronic subdural hematoma (bleed between the covering of the brain {dura}and the surface of the brain). Review revealed Resident #51 was hospitalized from [DATE] to 04/20/2023. b). On 04/22/2023, Resident #51 was found lying on the floor beside the bed with blood noted from the head beside him/her and he/she was transported to the hospital emergency room (ER). On 04/25/2023, the IDT implemented an intervention for Resident #51 to have his/her bed in the low position with a fall mat on the floor. However, review of the resident's care plan revealed the facility implemented a full size mattress beside the bed on 04/23/2023. c). On 04/26/2023, Resident #51 was found lying on the floor with feces on him/her, on the bed, mat, and floor. The IDT implemented an intervention on 04/27/2023, to toilet the resident every two (2) hours. d). On 05/11/2023, Resident #51 was found lying on the floor and was sent to the ER. On 05/12/2023, the IDT implemented an intervention for therapy to do wheelchair modifications. However, care plan review revealed the facility failed to develop the falls care plan further with this intervention. e). On 05/20/2023, Resident #51 was found lying face down on the floor with blood on his/her face and gown, and the resident stated he/she tripped on the mattress beside the bed. Resident #51 was transferred to the ER, and returned on 05/21/2023, with sutures in place to the right eyelid. On 05/23/2023, the IDT placed the resident on 1:1 supervision while in bed. The facility continued the mattress beside the bed as an intervention, even though Resident #51 tripped over it. f). On 05/29/2023, Resident #51 was found sitting on the floor mat beside his/her bed and the facility placed him/her on 1:1 supervision at all times. g). On 06/11/2023, Resident #51 was found lying on the floor with a laceration to his/her head and was sent to the ER for treatment with admission overnight. Review revealed no documented evidence of an IDT note or of an intervention implemented and added to his/her care plan. h). On 06/21/2023, a staff member witnessed Resident #51 fall to the floor and hit his/her head. Resident #51 was sent to the ER and admitted overnight. Review revealed no documented evidence of an IDT note or of an intervention implemented and added to his/her care plan. i). On 07/01/2023, Resident #51 sustained a fall from his/her chair to the floor, and was sent to the ER. The resident returned to the facility on [DATE]. On 07/03/2023, the IDT implemented an intervention to take the resident to activities to be engaged in other forms of stimulation. j). On 07/08/2023, Resident #51 fell and hit his/her nose on the table while staff were providing 1:1 care. On 07/10/2023, the IDT implemented an intervention for two (2) staff members to assist with the resident's ADLs. Observation, on 07/12/2023 at 6:20 PM, revealed Resident #51 sitting at the nurse's station in his/her chair with a lap tray across the tray physically restraining the resident. CNA #11 was assigned to be sitting 1:1 with Resident #51; however, the CNA was observed walking around the nurse's station and chatting with other staff. Based on interview, record review, and review of the facility's policy, it was determined the facility failed to ensure residents' comprehensive person-centered care plans were developed and implemented that included measurable objectives and timeframe's to meet a resident's medical, nursing, and mental and psychosocial needs for nine (9) of sixty-one (61) sampled residents, Residents #6, #15, #11, #51, #72, #84, #242, #243, and #244. 1. The facility failed to thoroughly develop and implement a comprehensive care plan for dialysis for Residents #242, #243, #244 and #11. (a) The facility failed to ensure Resident #242 received his/her dialysis treatment on 04/23/2022 and on 04/26/2022, as per the resident's care plan. Therefore, upon arrival at the dialysis clinic on 04/28/2022, Resident #242 presented slumped over, unresponsive, with his/her body twitching, and required transport to the emergency room (ER). (b) The Physician ordered in-house dialysis treatments for Resident #243 three (3) times a week on Monday-Wednesday-Friday at the in-house clinic. However, the facility failed to develop Resident #243's care plan to include the in-house dialysis clinic's schedule for the resident's dialysis on Mondays, Wednesdays, and Fridays. Therefore, review of Resident #243's Nurse Progress Note dated 07/14/2023 at 3:55 PM, revealed the resident had received no dialysis since Monday, 07/10/2023, prior to his/her admission to the facility. (c) The facility admitted Resident #244 on 02/23/2022, without an outpatient dialysis clinic order for him/her to receive his/her dialysis treatments. The facility failed to develop and implement Resident #244's care plan to include his/her dialysis orders, days of dialysis, his/her access site location; the dialysis center where he/she was to go with the dialysis time and transport company listed. Therefore, Resident #244 was sent back to the acute care hospital on [DATE] to receive his/her dialysis treatment and did not return to the facility. (d) The facility failed to develop Resident #11's care plan to include the dialysis center, the time, frequency, days of the week for treatment, and transport method. Additionally, the facility failed to implement Resident #11's care plan to ensure it communicated with the dialysis center regarding the resident's treatment. 2. The facility failed to thoroughly develop and implement the comprehensive care plan with necessary fall interventions for Residents #6, #15, #51, and #72. (a) The facility failed to implement Resident #6's care plan on 07/23/2023, when Certified Nursing Assistant (CNA) #21 transferred the resident via mechanical lift alone, and left the resident suspended in the lift sling to try to get assistance from Registered Nurse (RN) #3. Resident #6 stated he/she was afraid when left alone in the lift sling. (b) On 06/28/2023, Resident #15 sustained a fall which resulted in a hip fracture, and on 06/29/2023, the facility implemented an intervention not to leave the resident sitting in a chair alone in his/her room. However, observation on 07/13/2023 at 2:55 PM, revealed Resident #15 sitting in a reclining chair with his/her feet elevated in his/her room alone, and attempting to climb out of chair with no staff near the resident's room. (c) The facility failed to develop and implement Resident #51's fall risk care plan as necessary. Resident #51 therefore sustained ten (10) falls after admission to the facility on [DATE] through 07/08/2023, seven (7) of which resulted in injury and the resident being transferred to the emergency room (ER). (d) The facility failed to develop and implement Resident #72's care plan related to his/her history of falls. Resident #72 sustained a fall from his/her bed on 07/06/2023 at 10:00 AM, resulting in a gash to his/her leg requiring transport to the ER where the resident's gash was closed with sutures. 3. The facility admitted Resident #84 with a diagnosis of Post Traumatic Stress Disorder (PTSD); however, failed to develop and implement a care plan for the resident's PTSD diagnosis and ensure staff were knowledgeable of his/her diagnosis. The facility's failure to ensure residents' comprehensive person-centered care plans were developed and implemented to include measurable objectives and timeframe's to meet a resident's medical, nursing, and mental and psychosocial needs is likely to cause serious injury, serious harm, serious impairment, or death to residents. Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) were identified on 07/21/2023 and determined to exist on 02/25/2022 in the area of 42 CFR 483.21(b)(1) Quality of Care F656 at a Scope and Severity (S/S) of a K. The facility was notified of the Immediate Jeopardy on 07/21/2023, and the IJ is ongoing. The findings include: Review of the facility's policy titled, Care Plan Policy, revised 11/24/2022, revealed it was the facility's policy to ensure every resident had a Baseline Care Plan completed and implemented within forty-eight (48) hours of admission to promote continuity of care and communication among nursing home staff, increase resident safety, and safeguard against adverse events most likely to occur right after admission. Continued review revealed the Baseline Care Plan was to be updated with changes in risk factors, goals and interventions until the Comprehensive Care Plan was completed, then discontinued. Review revealed the Comprehensive Care Plan further expanded on the resident's risks, goals, and interventions using the Person-Centered Plan of Care approach for each resident that included measurable objectives and timetables to meet the resident's medical, nursing, physical functioning, mental, and psychosocial needs. Further review revealed the resident's needs were to be defined from observation, interviews, clinical medical record review and thorough assessments and Care Area Assessments (CAAs). Review further revealed the facility's Interdisciplinary Team (IDT), in conjunction with the resident, resident's family, or representative as appropriate along with a hands on caregiver, such as a Certified Nursing Assistant were to discuss and develop quantifiable objectives along with appropriate interventions in an effort to achieve the highest level of functioning and the greatest degree of comfort/safety and overall well-being attainable for the resident. 1. Review of Resident #242's medical record revealed the facility admitted the resident on 04/21/2022, with diagnoses which included: Hypotension, End Stage Renal Disease (ESRD), and Pain in Leg. Review of the resident's admission Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed Resident #242 to have a Brief Interview for Mental Status score of eleven (11) out of fifteen (15), indicating he/she was moderately cognitively impaired. Review of Resident #242's baseline care plan initiated on 04/22/2022, revealed a potential for complications related to ESRD and dialysis treatment three (3) times a week on Tuesday, Thursday, Saturday, resident to be picked up at 2:00 PM; however, the facility listed no dialysis company on the baseline care plan. Continued review revealed the care plan interventions included: protect the resident's shunt (dialysis access) site from injury; avoid constriction on affected arm, such as a blood pressure (BP) cuff, carrying purse, constrictive clothing; however, the facility did not list the site of the dialysis access on the care plan. Further review of the care plan revealed additional interventions: to monitor/record/report to Physician/Medical Director (MD) as needed (PRN) for signs and symptoms related to renal disease, including fluid overload, itching, BP changes, confusion, altered mental status, fatigue, hair/skin/nail texture changes, nausea/vomiting, and restless leg syndrome. In addition, the further interventions included to make transportation arrangements for dialysis; however, the facility listed no transport company on the care plan. Review of Resident #242's records from the outpatient dialysis center revealed he/she did not receive a dialysis treatment on Saturday, 04/23/2022 or on Tuesday, 04/26/2022, as per the resident's care plan. Continued review revealed on Thursday, 04/28/2022, Resident #242 was transported from the facility to the dialysis clinic's lobby; however, was sent to the local hospital Emergency Department (ED) from the lobby. Further review revealed Resident #242 had presented to the dialysis clinic lobby slumped over and unresponsive, with his/her body twitching. Review of Resident #242's facility medical record revealed no documented evidence of the resident's missed dialysis treatments on 04/23/2022 and 04/26/2022. Continued review revealed manual BPs were taken with the BP cuff on 04/23/2022 at 12:56 AM, 04/23/2022 at 10:40 AM, 04/26/2022 at 1:39 AM, 04/27/2022 at 8:08 AM, and 04/28/2022 at 2:02 AM on Resident #242's affected arm with the shunt site, even though the resident's care plan interventions specified this was not to be done. In an interview with the former Assistant Director of Nursing (ADON) on 07/13/2023 at 12:11 PM, she stated when Resident #242 was accepted by the facility the transport for dialysis should have already been set up by the facility prior to the resident being admitted , and this was stated in his/her care plan. She stated Resident #242's missed treatment on 04/23/2022 was on a weekend (Saturday), and the facility could not get transport because it was not set up prior to the resident coming to the facility. 2. Review of Resident #243's admission Record revealed the facility admitted the resident, on 07/11/2023, with diagnoses of ESRD, Diabetes, and Abnormal Findings of Blood Chemistry. Record review revealed the facility discharged Resident #243 on 07/14/2023, therefore, the resident's BIMS score was not assessed due to his/her short stay in the facility. Review of Resident #243's baseline care plan initiated on 07/11/2023, revealed care plan interventions to monitor/document/report PRN (as needed) the following signs and/or symptoms: edema, weight gain of over two (2) pounds a day, neck vein distension, difficulty breathing (dyspnea), increased heart rate (tachycardia), elevated blood pressure (hypertension), peripheral pulses, level of consciousness, and breath sounds for crackles. Continued review revealed additional interventions included: to check and change dressing daily at the dialysis access site and document; and do not draw blood or take BP in arm with graft (dialysis access, however, no site was listed). Further review revealed the interventions also included monitor/document/report PRN for signs and/or symptoms of renal insufficiency: changes in level of consciousness; changes in skin turgor; oral mucosa; and changes in heart and lung sounds. Review further revealed however, the facility documented no dialysis clinic, frequency of dialysis treatments, or days of dialysis treatment on Resident #243's care plan. Continued review of Resident 243's medical record revealed the facility ordered in-house dialysis treatments for the resident on 07/12/2023, a Wednesday. Review further revealed the order was for Resident #243 to have dialysis treatments three (3) times a week on Monday-Wednesday-Friday at the in-house clinic. However, the facility failed to develop Resident #243's care plan to include the in-house dialysis clinic's schedule of dialyzing the resident on Monday-Wednesday-Friday. Review of Resident #243's Nurse Progress Note dated 07/14/2023 at 3:55 PM, revealed the resident had received no dialysis since Monday, 07/10/2023, prior to his/her admission to the facility. In an interview on 07/25/2023 at 9:30 AM, with Licensed Practical Nurse (LPN) #2, she stated it was not communicated to her that Resident #243 had a dialysis order in place. She stated if Resident #243 had an order for dialysis on 07/12/2023 and she had known, she would have taken the resident to dialysis. She stated she relied on the resident's care plan to inform her on how to care for the resident. 3. Review of Resident #244's admission Record revealed the facility admitted the resident on 02/23/2022, with diagnoses of Chronic Kidney Disease Stage 4, Diabetes, and Hypertension. Continued review revealed Resident #244 had a tunnel catheter in the right upper chest for dialysis access. Further review revealed Resident #244 was discharged on 02/25/2022, and therefore, a BIMS score was not assessed to determine the resident's cognition. Continued review of Resident #244's medical record revealed the facility admitted the resident on 02/23/2022, without an outpatient dialysis clinic order for him/her to receive his/her dialysis treatments. Review of Resident #244's baseline care plan initiated on 02/25/2022, revealed a potential for complications related to end stage renal disease and dialysis treatments three (3) times a week; however, there was no documented evidence of the resident's dialysis orders or days listed. Continued review revealed other interventions included: to make transport arrangements for dialysis; protect shunt site from injury; and avoid constriction on affected arm, such as with BP cuff, carrying purse, constrictive clothing. Further review revealed however, no documented evidence of Resident #244's access site listed. In addition, review further revealed no documented evidence of a dialysis center listed, the time listed, or a transport company listed. Further review of Resident #244's medical record revealed the resident was sent back to the acute care hospital on [DATE] to receive his/her dialysis treatment and did not return to the facility. Review of Resident #244's Nurse Progress Note dated 02/25/2022 at 11:11 AM, documented by the former ADON, revealed the resident was being transported to a local ED because the resident needed to have dialysis. Further review of the Note revealed upon Resident #244's return to the facility, a dialysis center needed to be assigned to establish a regular dialysis schedule; however, the resident did not return to the facility. In interview on 07/23/2023 at 8:05 AM, LPN 11 stated for HD residents nurses got their vital signs and made sure their medications were given. She stated they checked the resident's access site for infection and swelling, and monitored the residents for swelling. LPN #11 stated for fluid overload the nurse would talk to the doctor and send the resident out if their dialysis was missed. She stated they used a monitoring form and filled it out on residents' HD days, monitoring the access site and weights prior HD. The LPN further stated nurses used residents' care plans and orders for dialysis information about their access site and how to care for the resident. 4. Review of the facility's policy titled, Community Hemodialysis (HD), effective and last revised date 07/25/2019, revealed a dialysis communication sheet was to return with the resident after the dialysis session to communicate to the facility information regarding the dialysis session. Review of Resident #11's medical record revealed the facility admitted the resident on 10/26/2022, with diagnoses of ESRD, Diabetes, and Hypertension. Review of Resident #11's Quarterly MDS assessment dated [DATE], revealed the facility assessed the resident to have a BIMS score of fifteen (15) out of fifteen (15), indicating he/she was cognitively intact. Review of Resident #11's Comprehensive Care Plan revealed care plan interventions initiated on 10/27/2022 to: communicate with dialysis center regarding medication, diet, and lab results; protect shunt (dialysis access) site from injury; avoid constrictio [TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Review of Resident #72's medical record revealed the facility admitted the resident on 05/01/2023, with diagnoses including Major Depression, Anxiety, End Stage Renal Disease, and Altered Mental Status. Review of the admission MDS assessment dated [DATE], revealed the facility assessed the resident as having a BIMS score of thirteen (13) out of fifteen (15) indicating he/she was cognitively intact. Continued MDS review of section G, revealed the facility assessed Resident #72 as a one (1) person physical assist for bed mobility. Further MDS review of section J revealed the resident had a history of falls prior to admission. Review of the facility's fall risk assessments dated 05/01/2023 and 07/06/2023, revealed the facility assessed Resident #72 with a score of thirteen (13) which indicated he/she was a high fall risk. Review of the baseline care plan dated 05/02/2023 for Resident #72 revealed the facility identified the resident's risk for falls; however, did not initiate a comprehensive fall care plan for him/her until 06/20/2023. Review of Resident #72's base line care plan dated 05/02/2023, was a safety risk, was identified fell at home, had a history of falls prior to admission, and within the last two (2) to six (6) months. Continued review revealed listed under specify other safety devices-bed in lowest position was noted. Further review revealed under comments it was noted Resident #72 was only oriented to self, could not comprehend where he/she was and could not use a call light. In addition, it was noted Resident #72 attempted unassisted transfers, and his/her gait was weak and unsteady. Review of Nurse Progress Note dated 07/06/2023 at 10:00 AM, revealed LPN #2 was notified Resident #72 had been found lying on the floor. Continued review revealed Resident #72 was assessed and found to be bleeding from a gash on his/her left leg below the knee. Further review revealed the medical doctor was notified and gave an order to send to Resident #72 to the emergency room (ER). In addition, the resident's family and management were notified. Interviews with LPN #2 were attempted on 08/01/2023, 08/02/2023, and 08/03/2023; however, were unsuccessful. Review of the Emergency Department history and physical dated 07/06/2023 revealed Resident #72 presented to the ER after a fall out of bed that morning. Continued review revealed Resident #72 had an open laceration to the left proximal tibia (upper part of the shinbone next to the knee). Review revealed the bone was exposed, and the description of the repair noted as a laceration eight (8) centimeters (CM) in length on the left lower extremity, anterior, lateral, lower leg. Further review revealed the repair included skin closure with eleven (11) sutures in a single layer. In addition, review revealed Resident #72 tolerated the procedure well. Review of the Nurse Progress Note dated 07/07/2023 at 10:34 AM, documented by the DON, revealed Resident #72's fall was reviewed in the facility's Interdisciplinary Team (IDT) meeting. Continued review revealed the Note stated Resident #72 was lying to close to the edge of the bed and rolled out of bed while sleeping. Further review revealed Resident #72 needed assistance with moving to the center of the bed, and side rails were to be added to his/her bed for bed positioning. In interview with Resident #72's spouse and family member on 08/03/2023 at 2:38 PM, they stated Resident #72 had rolled out of bed and hit his/her leg on the floor. Resident #72's sister-in-law stated she had requested bed rails ever since the resident's admission because he/she had a history of falls from the bed at home. In interview on 08/04/2023 at 2:05 PM, Resident #72 stated he/she rolled out of bed and had a hard fall to the floor. Resident #72 stated there had been nothing in the way of the side on the side of the bed and the floor. The resident further stated he/she had not rolled out of bed since the side rails were added. In interview on 08/06/2023 at 9:42 AM, the DON stated Resident #72 had been independent in his/her room and since admission he/she had lain too close to the edge of the bed. The DON stated Resident #72 was assessed as a high fall risk. She further stated Resident #72 appeared as less of a risk for falls after receiving dialysis and therapy; however, the resident had not been reassessed for falls. In interview on 08/06/2023 at 10:08 AM, the Administrator stated Resident #72 was a high risk for falls and had interventions on his/her baseline care plan which covered his/her fall risk. Based on observation, interview, record review and review of facility policy, it was determined the facility failed to have an effective system in place to ensure adequate supervision and monitoring to prevent falls and accident hazards for four (4) of sixty-one (61) sampled residents, Residents #6, #15, #51, and #72. Observation on 07/23/2023, revealed Resident #6 being transferred by a mechanical lift with the assistance of one (1) staff member. The facility assessed Resident #6 to require extensive assistance of two (2) staff to move between surfaces on 06/21/2023. Record review revealed Resident #15 had a fall on 06/28/2023 and was diagnosed with a right hip fracture on 07/07/2023. Review revealed Resident #15 was noted to be rolling to the edge of the bed on 07/28/2023. Further record review revealed Resident #15 fell from his/her bed on 07/28/2023. Record review revealed Resident #51 sustained ten (10) falls after his/her admission to the facility on [DATE] through 07/08/2023. Review of medical record Resident #72 revealed the facility assessed the resident as a high risk for falls. On 07/06/2023, Resident #72 rolled out of bed and fell to the floor sustaining an injury which required eleven (11) sutures to his/her leg. The facility's failure to to have an effective system in place to ensure adequate supervision and monitoring to prevent falls and accident hazards 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 07/21/2023 and determined to exist on 02/25/2022 in the area of 42 CFR 483.25(d)(1)(2) Quality of Care F689 at a Scope and Severity (S/S) of a K. The facility was notified of the Immediate Jeopardy on 07/21/2023, and the IJ is ongoing. The findings include: Review of the facility policy titled, Incident, Accidents and Falls revised 01/30/2022, last reviewed 02/01/2023, dated revealed it was the facility's policy to ensure any incident/accident to include falls was reported immediately to the nurse or appropriate person designated to be in charge. Continued review revealed after the resident had received immediate attention and their safety was established, a written report was to be entered into Risk Management. Further review revealed the facility was to ensure incidents and accidents involving residents were identified, reported, investigated, and resolved. 1. Review of the facility policy titled, Mechanical Lift Transfer Usage Guideline dated 01/09/2023, revealed to avoid slinging the resident lift only high enough to clear the bed or chair to facilitate a transfer. Continued review revealed one (1) person was to always maintain control of the resident in the sling while the second person did not move once the mechanical lift was in the correct position. Review of Resident #6's medical record revealed the facility admitted the resident on 06/20/2023, with diagnoses including Hypertension, Parkinson's Disease, Anxiety, and Depression. Review of Resident #6's admission Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of fifteen (15) out of fifteen (15) indicating he/she was cognitively intact. Further MDS review, Section G functional status, revealed the facility assessed Resident #6 as a two (2) person assist for transfers. Observation on 07/23/2023 at 9:20 AM, revealed Resident #6 suspended in a lift sling from a mechanical lift being transferred from the bed to the chair by Certified Nurse Assistant (CNA) #21. Continued observation revealed no other staff member present in the room; however, Registered Nurse #3 was standing in the hallway outside Resident #6's room at the medication cart. Observation revealed CNA #21 went to the doorway of the resident's room to ask RN #3 to assist with the mechanical lift transfer, leaving Resident #6 suspended in the lift sling. Further observation revealed RN #3 informed CNA #21 she would assist after she passed the resident's medication. In interview with Resident #6 on 08/05/2023 at 10:50 AM, the resident stated he/she was very afraid while in the lift with only the one (1) person using it on 07/23/2023. The resident stated he/she had fallen from a lift at another facility and hurt his/her left shoulder and hip. Resident #6 stated he/she had been a nurse and was aware there should always be two (2) staff with all lift transfers for resident safety. In interview with CNA #21 on 07/23/2023 at 9:24 AM, she stated there were only four (4) CNAs for the building in addition to the CNA sitting one-to-one (1:1) with another resident. The CNA stated there had been two (2) call ins, and there were no other CNAs available to assist her at the time of Resident #6's transfer. She stated she was aware she should have two (2) staff for all lift transfers; however, she had twenty-four (24) residents to care for by herself on the hall and Resident #6 needed to be assisted into his/her wheelchair to attend church services. CNA #21 stated the Director of Nursing (DON) had previously told her Resident #6 was to get up for church services if he/she desired to go to church. She further stated Resident #6 could have fallen from the lift, the lift could have tipped over or the straps could have broken, causing the resident injury. In interview RN #3 she stated she had to pass medications for the entire hall and was attempting to give the medication she had already got ready for a resident before assisting the CNA. She further stated two (2) staff should always perform lift transfers so one person could move the lift while the second person assisted the resident so the lift doesn't move, the sling break, or the resident fall out of the sling and cause injury to the resident. 2. Review of Resident #51's medical record revealed the facility admitted the resident on 04/07/2023, with diagnoses including Hypertension, Malnutrition, Depression and Anxiety. Review of the admission MDS assessment dated [DATE], revealed the facility assessed Resident #51 as having a BIMS score of ninety-nine (99), which indicated the resident chose not to participate, or four (4) or more items were coded zero (0). Continued MDS review, Section G functional status revealed the facility assessed Resident #51 to require two (2) person assist for bed mobility and transfers and review of section J revealed the resident had a history of falls. Review of Resident #51's Comprehensive Care Plan revealed the facility care planned the resident for his/her risk for falls. Continued review revealed interventions which included one-to-one (1:1) supervision for safety due to frequent falls; two (2) staff for Activities of Daily Living (ADL) care for safety; and call light within reach at all times. Further review revealed additional intervention included: bolsters to left side of bed; full size mattress to right side of bed; low bed related to decreased safety awareness; and the resident to be taken to activities to help keep him/her engaged in other forms of stimulation. Review of Resident #51's medical record revealed the resident experienced a history of ten (10) falls since admission to the facility on [DATE] which included: a) On 04/13/2023, Resident #51 was found in room with a laceration and hematoma over his/her right eye and laceration over his/her left eye and the facility determined he/she had fallen. Resident #51 was sent to the hospital and underwent a left frontotemporoparietal craniotomy (brain surgery) for evacuation of a right-sided acute on chronic subdural hematoma (bleed between the covering of the brain [dura] and the surface of the brain). The resident was admitted to the hospital from [DATE] to 04/20/2023. b) On 04/22/2023, Resident #51 was found lying on the floor beside the bed with blood noted coming from his/her head beside him/her and around the room. Resident #51 required transport to the hospital emergency room (ER) due to his/her sutures pulling loose from his/her head trauma on 04/14/2023. On 04/25/2023, the Interdisciplinary Team (IDT) implemented an intervention for Resident #51 to have his/her bed in the low position with a fall mat to the floor by the bed. c) On 04/26/2023, Resident #51 was found on the floor with feces on his/her bed, mat, floor and the resident. The IDT implemented an intervention on 04/27/2023 to toilet the resident every two (2) hours. However, review of the care plan revealed no documented evidence of the intervention for toileting the resident every two (2) hours. d) On 05/11/2023, Resident #51 was found lying on the floor and was sent to the ER. On 05/12/2023, the IDT determined therapy would make wheelchair modifications to the resident's wheelchair. e) On 05/20/2023, Resident #51 was found lying face down on the floor, behind his/her closed door, with blood noted on his/her face and gown. Resident #51 stated he/she tripped on the mattress beside the bed. Resident #51 required transfer to the ER where he/she required sutures to his/her right eyelid. The resident returned to the facility on [DATE]. The IDT met on 05/23/2023 and implemented 1:1 supervision of Resident #51 while he/she was in bed. f) On 05/29/2023, Resident #51 was found sitting on the floor mat beside the bed and was placed 1:1 supervision at all times. g) On 06/11/2023, Resident #51 was found lying on the floor with a laceration to his/her head and was sent to the ER for treatment and was admitted overnight. Review revealed no documented evidence of an IDT note or intervention noted on the care plan. h) On 06/21/2023, Resident #51 fell to the floor and hit his/her head which was witnessed by a staff member. Resident #51 was sent to the ER and was admitted overnight. Review revealed no documented evidence of an IDT note and the intervention on the Care Plan was to send to the ER. i) On 07/01/2023, Resident #51 fell from his/her chair to the floor and was sent to the ER. The resident returned to the facility on [DATE]. On 07/03/2023, the IDT implemented an intervention to take the resident to activities to be engaged in other forms of stimulation. j) On 07/08/2023, Resident #51 fell on his/her hands and knees and hit his/her nose on the table. On 07/10/2023, the IDT implemented an intervention for two (2) staff members to assist with Resident #51's ADLs. Observation, on 07/12/2023 at 6:20 PM, revealed Resident #51 sitting at the nurse's station in his/her chair with a lap tray physically restraining the resident while CNA #11 walked around the nurse's station and chatted with other staff. In interview with CNA #8 on 07/12/2023 at 10:20 AM, she stated she had been sitting with Resident #51 to provide a break for the CNA taking care of the resident at 2:30 PM yesterday (07/11/2023) and the other CNA left for the day without notifying her. She stated Resident #51 kept trying to reach out of bed and she turned around to turn on the television, and, when she turned back around, the resident was coming up out of the bed like he/she was going to choke her. CNA #8 stated Resident #51 then got fidgety with his/her gastrostomy tube (G-tube) and pulled it out and had to be sent to the hospital. She further stated she had sat with Resident #51 in the past and the resident tried to get out of bed which had not been locked. During interview with LPN #7 on 07/12/2023 at 10:35 AM, she stated Resident #51 had been pretty much 1:1 since he/she had been at the facility. The LPN stated Resident #51 had behaviors since admission, was ambulatory on admission, and continued to be ambulatory; however, needed assistance as he/she was now unsteady on his/her feet. She stated Resident #51 had a psychiatric evaluation and medication changes which worked temporarily, but we can't chemically restrain the resident. During interview with Resident #51's family member on 07/27/2023 at 10:42 AM, she stated the resident had a traumatic brain injury in January 2023 and she felt the facility did not have resources to take care of the resident. She stated Resident #51 was wasting away and had been self ambulatory upon admission but now the resident can't stand and cannot walk now. The family member stated Resident #51 had declined since admission to the facility and had to have a craniotomy related to a fall the very first week he/she was a resident in the facility. She further stated she was unsure how Resident #51 kept falling if he/she was on 1:1 supervision. 3. Review of Resident #15's medical record revealed the facility admitted the resident on 06/16/2023, with diagnoses which included Respiratory Failure, Liver Transplant, Seizures, Dependence on Renal Dialysis, Anemia, Muscle Weakness, and Cognitive Communication Deficit. Review of the admission MDS assessment dated [DATE], revealed the facility assessed Resident #15 to have a BIMS score of fourteen (14) out of fourteen (14) which indicated the resident was cognitively intact. Continued review of the MDS, section G revealed the facility assessed Resident #15 to require two (2) person assist for bed mobility and one (1) person physical assist with transfers. Review of Resident #15's Comprehensive Care Plan dated 06/19/2023, revealed the facility care planned the resident as at risk for falls related to impaired balance and mobility, poor safety awareness due to cognitive decline, use of psychotropic medications, and visual impairment. Continued review revealed interventions which included bed in low position, call light within reach, and keep frequently used items close to the resident. Further review revealed an intervention initiated on 06/29/2023, not to leave Resident #15 up in the chair in the room alone. Observation on 07/13/2023 at 2:55 PM, revealed Resident #15 sitting in a reclining chair with feet raised, attempting to climb out of chair in his/her room alone with no staff present near the resident's room. Staff were notified and went to the resident's room. Review of Resident #15's Progress Notes revealed the resident fell on [DATE], then complained of right hip pain on 07/04/2023 at which time an x-ray of the right hip was ordered by the Physician. Continued review of the Progress Notes revealed an x-ray was obtained on 07/07/2023, with a final x-ray report on 07/08/2023, which revealed a right hip fracture. Review of the Progress Notes revealed no documented evidence of entries noted from 07/08/2023 until 07/10/2023. Further review reveale Resident #15 was transported to the hospital on [DATE] and admitted for a right hip fracture. Additional review of Resident #15's Progress Notes revealed the resident returned from the hospital on [DATE]; however, was readmitted to the hospital on [DATE], for oxygen saturation levels of seventy-eight percent (78%) and facial edema. Review of the Progress Notes revealed Resident #15 continued to be in the hospital until 07/24/2023. Review of the 07/31/2023 Hospital History and Physical Note revealed the diagnosis for Resident #15 had been Sepsis with acute on chronic Encephalopathy due to Pneumonia. Interview with CNA #21, on 07/16/2023 at 7:20 PM, revealed Resident #15 required total assist with transfers and was currently out to the hospital.