Based on observation of the facility's video footage, interviews, record review, and review of facility policy, it was determined the facility failed to ensure one (1) of thirty-seven (37) residents' (Resident #63) right to formulate an Advance Directive and have the Advance Directive carried out per the resident's wishes. Upon admission to the facility, Resident #63 made his/her wishes known and had a signed Kentucky Emergency Medical Services (EMS) Do Not Resuscitate (DNR) order (A standardized form that was developed and approved by the Kentucky Board of Medical Licensure which authorized EMS providers to honor Advanced Directives to withhold or terminate care. The EMS DNR order applies only to resuscitation attempts by health care providers in the Prehospital settings, including long term care facilities and during transport to or from a health care facility.) dated 12/15/17, in place and in the resident's medical record. However, on 01/09/18, when the resident was determined to be critically ill with impending respiratory failure/arrest, the facility failed to provide the form to EMS. Subsequently, EMS provided CPR to Resident #63, and the resident was transferred to the hospital, where the resident was placed on a ventilator, and the resident expired on 01/12/18 (Refer to F656 and F770). The facility's failure to ensure residents' rights were protected has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 01/26/18, and determined to exist on 01/09/18 at 42 CFR 483.10 Resident Rights (F578 and F580), 42 CFR 483.21 Comprehensive Person-Centered Care Planning (F656 and F658), 42 CFR 483.24 Quality of Life (F678), and 42 CFR 483.70 Administration (F842). The facility was notified of the Immediate Jeopardy on 01/26/18. After supervisory review, Immediate Jeopardy was identified on 03/01/18 and determined to exist on 12/12/17 at 42 CFR 483.25 Quality of Care (F692) and 42 CFR 483.70 Administration (F835, F837). The facility was notified of the Immediate Jeopardy on 03/01/18 at 42 CFR 483.25 Quality of Care (F692), and 42 CFR 483.70 Administration (F835 and F837). An acceptable Allegation of Compliance was received on 03/05/18, which alleged removal of the Immediate Jeopardy on 03/05/18. The State Survey Agency determined the Immediate Jeopardy was removed on 03/05/18, prior to exit, which lowered the scope and severity to D at at 42 CFR 483.10 Resident Rights (F578 and F580), 42 CFR 483.21 Comprehensive Person-Centered Care Planning (F658), 42 CFR 483.24 Quality of Life (F678), 42 CFR 483.25 Quality of Care (F692 ) and 42 CFR 483.70 Administration (F835, F837, and 842), and to an E at 42 CFR 483.21 Comprehensive Person-Centered Care Planning (F656), while the facility monitors the effectiveness of systemic changes and quality assurance activities. The findings include: Review of the facility's policy, Advance Directives revised 2008 revealed the Nurse Supervisor was required to inform emergency medical personnel of a resident's advance directive regarding treatment options and provide such personnel with a copy of such directive when transfer from the facility via ambulance or other means was made. Interview with the Director of Nursing (DON), on 02/02/18 at 07:32 PM, revealed documentation, including the resident's face sheet, medication sheet, a report of the situation, and the Kentucky EMS DNR form should be provided to EMS upon transfer. She also stated the facility should provide report to EMS and the receiving facility. Review of Resident #63's medical record revealed the facility admitted the resident on 12/15/17, from an acute care hospital, with diagnoses of Urinary Tract Infection, Chronic Respiratory Failure, Type 2 Diabetes Mellitus, Diabetic Nephropathy, Chronic Kidney Disease Stage IV, Arteriosclerotic Heart Disease, Hypertension and Pressure Ulcer to the left heel. Review of Resident #63's admission Minimum Data Set (MDS) assessment, dated 12/22/17, revealed the resident had a Brief Interview Mental Status (BIMS) score of fourteen (14), which indicated the resident was cognitively intact. Review of a Kentucky Emergency Medical Services Do Not Resuscitate order dated 12/15/17, revealed the resident wished to have no resuscitation should the need arise. Review of a facility Do Not Resuscitate Form dated 12/15/17, revealed the resident's daughter signed the form stating the resident was not to receive Cardiopulmonary Resuscitation in the event of cardiac or respiratory arrest. Review of a Nursing Note dated 01/09/18 at 6:40 PM, revealed Licensed Practical Nurse (LPN) #14 was summoned to the resident's room. The nurse assessed the resident to be nonresponsive, pale, with cyanotic (blue) nail beds, a blood pressure of 68/32 (normal 120/80), pulse of 87, respirations of 10 (normal 18), and a temperature of 96.1 degrees. According to the Nursing Note, the resident's physician was notified and an order was received to send the resident to the Emergency Department (ED). Further review of the Nursing Notes dated 01/09/18 at 6:54 PM, revealed EMS was in the facility. Review of the EMS Prehospital report dated 01/09/18, revealed upon arrival to the facility, the EMS crew was directed to Resident #63's room, and no report was given. Upon entering the resident's room, the resident was found to be unresponsive with shallow, labored, and choppy breaths; and the resident's pupils were dilated and fixed. The report stated the resident appeared critical with impending respiratory failure/arrest. The EMS Report stated the resident's daughter was in the room and provided an immediate history of events. The Report further stated as the crew approached the nurses' station with resident, they requested an ambu bag (provides ventilation to a patient who is not breathing or who is breathing inadequately), which was provided by the staff, and artificial respirations were initiated. The report stated the resident suffered cardiac arrest while on the elevator and chest compressions (CPR) were initiated and continued until transport to the Emergency Department. The report stated the resident was intubated (tube inserted to provide artificial respirations to the lungs). In addition, the EMS report revealed facility staff never provided a report on the resident's condition, and staff were never present in the resident's room while aide was being rendered by EMS. In addition, the Report revealed the facility did not provide any transfer paperwork to EMS. Interview with LPN #14, on 02/02/18 at 12:20 PM, revealed on the evening of 01/09/18, she was assigned to provide care for Resident #63. LPN #14 stated the resident became pale and unresponsive. She stated she obtained vital signs, then checked the resident's medical record and noted the resident had a signed Do Not Resuscitate order. LPN #14 stated she called the resident's physician and EMS. The LPN stated when EMS arrived, she reported the resident's condition and reported the resident had a DNR order. LPN #14 further stated as EMS was coming toward the elevator to leave with Resident #63, they asked for an ambu bag. The LPN stated she provided an ambu bag and did not question when EMS provided artificial resuscitation. Interview with Resident #63's Daughter on 02/05/18 at 5:00 PM, revealed on 01/09/18, the resident's blood pressure and oxygen level dropped and the nurse told the daughter that she was going to send the resident back to hospital. The Daughter stated the nurse also told her that the resident was a DNR, but she did not think the resident was dying at that point. Resident #63's Daughter stated she never saw the nurse again. The interview revealed when EMS arrived, they increased the resident's oxygen and told her that the resident's pupils were dilated. She stated she did not tell EMS to perform CPR and they did not ask about the resident's code status. The Daughter further stated no staff were present in the room while EMS was there and she saw no staff provide report or provide any paper work to EMS. The resident's Daughter stated the paramedic later told her the resident's heart quit in the elevator at the facility and EMS had to do CPR. However, review of facility's video footage from 01/09/18, at 6:56 PM until EMS left the facility with Resident #63 at 7:04 PM, there was no evidence LPN #14 provided report or any paper work to EMS. Review of video surveillance revealed at 6:56 PM, EMS exited the elevator. LPN #14, was seated inside the nurses' station in front of a computer. One of the two EMS crew members looked toward the nurses' station, and LPN #14 point down the hallway. EMS proceeded down the hallway to the resident's room. At 6:57 PM, the video revealed LPN #14 was still seated at the desk as EMS entered the resident's room. At 7:00 PM, LPN #14 was still seated at the nurses' station. At 7:02 PM, the EMS crew exited the resident's room with Resident #63 on the stretcher. As they approached the nurses' station, LPN #14 was observed to get up from a seated position, reappeared outside of the nurses' station at the resident's stretcher, and provided EMS with an ambu bag. Then, at 7:04 PM, EMS entered the elevator with the resident. The surveillance video revealed no evidence LPN #14 provided a report to EMS staff when they arrived to the floor, and no evidence the facility provided any paperwork to EMS. On 02/02/18 at 1:48 PM, an interview conducted with Paramedic #1 revealed on 01/09/18, he was one of the EMS crew members that responded to a non-emergent call to the facility for Resident #63. He confirmed that when they arrived to the floor where the resident resided, the nurse was sitting at the desk. The nurse told them Resident #63's name, and showed them where the resident's room was from the nurses' station. He further stated they did not receive any report regarding the resident's condition and the facility did not provide the resident's code status. Review of Resident #63's hospital record revealed on 01/09/18, the resident arrived to the ED at 7:21 PM via EMS with CPR in progress. Further review of the hospital record revealed the EMS report was present; however, there was no evidence the facility provided EMS or the hospital with a copy of the resident's EMS DNR order or any other paperwork regarding the resident's Advance Directives. Resident #63 was placed on a ventilator in the ED, and transported to a regional hospital, where the resident passed away on 01/18/18, after having another cardiac arrest. The facility implemented the following for removal of jeopardy: 1. On 01/26/18, the Administrator provided an in-service to the Director of Nursing, Minimum Data Set (MDS) Nurse, and the Quality Assurance (QA) Nurse regarding the development and implementation of a comprehensive care plan that included the wishes of each resident related to code status. 2. The policies and procedures were reviewed and updated regarding physician notification and obtaining, documenting, and honoring the wishes of each resident for Advance Directives/Code Status by the PIP Committee on 01/29/18. The resident's wishes for Advance Directives and code status will be obtained upon admission by Social Services and the admission Director. Code status designations will be documented in the physician's orders, in the resident care plan, and on the resident's face sheet. Residents choosing a DNR code status will sign a completed No Code or DNR consent form that will be maintained in the resident's medical record. Residents without an Advance Directive will be considered a Full Code. The Advance Directives and Code Status policies were reviewed, updated, and approved by the QAPI Committee on 01/29/18. 3. On 01/26/18, a comprehensive audit was completed by the Administrator, MDS Nurse, Assistant Administrator, Director of Nursing (DON), QA Nurse, Unit Manager, Activities Director, Admissions Director, and Social Workers for every resident in the facility. The audit was a review of each resident's Advance Directive and code status that included physician orders, Advance Directive designation forms, consent forms, paper record, electronic record, and face sheets with no variances noted. The residents' comprehensive care plans were also reviewed and updated as needed to assure residents' Advance Directives and wishes for code status were included on the plan of care. These audits were conducted at the direction of the Quality Assurance and Performance Improvement (QAPI) Committee and completed on 01/26/18. Members of the QAPI committee included: The Administrator, Director of Nursing, Unit Managers, Medical Director, MDS Coordinator, Staff Development Coordinator, Pharmacy Representative, Social Services Director, and Activity Director. Completed audits were submitted to the QAPI Committee for additional review. 4. The Director of Nursing, Quality Assurance Nurse, Unit Manager, and MDS Nurse completed a focus review to ensure proper notification occurred for changes in resident condition. The audit included review of residents transferred to the hospital within the prior week, all Nurse's Notes documented between 01/22/18 through 01/30/18, and any new Physician's Orders received 01/22/18 through 01/30/18. 5. Licensed staff that were involved with the care of Resident #26 (6) and Resident #63 received additional training related to identification and communication of a resident's wishes regarding Advance Directives and code status, as well as including and honoring those wishes through implementation of the resident's care plan. The training included timely notification of a resident's physician and responsible party, as well as documentation of the notification. The training also included development and implementation of the comprehensive care plan which included the wishes of each resident related to their code status. Post-tests and staff interviews were completed to ensure comprehension of the training material. The training was completed 01/26/18 through 01/31/18 by the Director of Nursing, Staff Development Director. 6. All licensed and certified nursing staff and the Interdisciplinary Care Plan team (IDT) which consisted of MDS Nurse, Social Worker, Activity Director, and the Director of Dietary Services all received additional training beginning on 01/26/18 thru 01/31/18 related to: - identification and communication of a resident's wishes regarding Advance Directives and code status - honoring resident's code status wishes through the implementation of the resident's care plan -providing the necessary care and services such as emergency care, basic life support, and CPR to those residents in accordance with the resident's Advance Directives and wishes regarding code status -how to determine the code status of each resident according to facility protocols - assessing and responding to a resident in distress - timely notification of the physician - initiating a code - honoring the wishes of each resident with a full-code status - documenting care delivered - development and implementation of the comprehensive care plan which included the wishes of each resident related to their code status The training was completed by the Director of Nursing, Staff Development Director, and the Administrator. Post-tests and staff interviews were completed to ensure comprehension of the training material. Any staff member in the nursing department who was off work for any reason will not be permitted to work until training and post testing are completed. 7. On 01/27/18, the Administrator posted a listing of each resident and their desired code status at each nursing unit. The Administrator completed the list after the Advance Directives and CPR desires of each resident were validated through the audit completed on 01/26/18. Monitoring would include a daily review of this list by the Administrator or Assistant Administrator Monday through Friday. The weekend manager would review and update the listing on Saturday and Sunday. 8. Notification to a resident's physician, resident, and resident representative is monitored daily (Monday - Friday) in the Clinical Meeting. Attendees of the Clinical Meeting include the Director of Nursing, MDS Nurse, Social Workers, QA Nurse, and Unit Manager. The Clinical Meeting conducts a review of the following: 24-hour report, physician's telephone orders, nurse's notes, laboratory reports, resident events, changes in residents' condition, new admissions, and discharges. Any concerns identified are corrected immediately. 9. On 01/29/18, training, direction, and responsibility was assigned to Social Services for listing residents' wishes regarding Advance Directive on the residents' comprehensive care plan. The MDS Nurse will verify that Advance Directives are included on the care plan. This review will occur during Care Plan Conferences following the Resident Assessment Instrument (RAI) schedule. 10. On 01/29/18, a focus Performance Improvement Plan (PIP) Committee was formed by the QAPI Committee to review and monitor the facility's processes for obtaining and honoring residents' Advance Directives, code status, development and implementation of a care plan that meets the code status wishes of the resident, procedures for calling a code, and the conditions for implementing CPR to a full code resident. The PIP committee members included: The Administrator, Director of Nursing, Unit Managers, MDS Coordinator, Staff Development Coordinator, Social Services and Activity Director. The PIP Committee meets daily to focus on implementing the plan outlined herein, monitor results of audits and reviews, and provides additional direction as needed. The daily (Monday through Friday) PIP Committee meetings will continue until removal of the immediate jeopardy has been verified. Weekly QAPI meetings would continue to occur until sustained compliance was achieved. 11. The QAPI Committee will monitor and ensure sustained compliance is maintained through a weekly meeting. The members of this meeting will review all audits, training, and corrective actions generated by the focus PIP Committee. QAPI meetings will occur until sustained compliance is achieved. Information reviewed in this meeting will include: - Verbal report and a current Code Status List is reviewed and updated daily with any changes in the resident's Advance Directives and CPR status and is submitted by the Administrator or Assistant Administrator - The MDS Nurse will submit a verbal report and audit tool(s) related to the validation of the resident's code status during resident care plan conferences - The DON or QA Nurse will review the findings of the 24-hour report, physician's telephone orders, nurse's notes, laboratory tests, resident events, and changes in residents' condition identified in the morning clinical meetings and through routine clinical assessments, evaluations, and nurse management rounds, as well as a review of new admissions and discharges. The Daily Audit Tool will also be used to validate proper notification to physicians and the resident representative. - The DON or SDC will submit a verbal report, in-service logs and training agenda(s) regarding training or post testing completed. - The Social Worker will submit a verbal report and census list regarding any changes in Advance Directives or code status, including new admissions and re-admissions. - The DON or QA Nurse will give a verbal report and submit an audit tool related to any resident transfers to the hospital for urgent or critical care. The reports will include verification of proper notification, communication regarding resident's Advance Directives/code status prior to transfer, the Center's response to the resident's wishes, and the outcome of the transfer. - The committee will also discuss any new concerns identified through audits and reviews and applicable corrective action or changes. 12. On 03/02/18, a Long Term Care (LTC) consultant who is licensed as a Long Term Care Health Administrator in the state of Kentucky provided training to the Administrator of the facility for compliance with the federal and state regulations, quality assurance and performance improvement, efficient and effective use of resources, human resource development, and responsibilities of the Governing Body. Additionally, education was provided that according to §483.70 the facility must be administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. 13. On 03/02/18, the Administrator developed a Performance Improvement Team (PIT) to develop a Performance Improvement Plan (PIP) for the purposes of maintaining an effective nutrition/hydration status program. The PIT had the first meeting on 03/02/18 to develop, review, and monitor the resident nutrition/hydration status program. The PIT committee members include: the Administrator, Director of Nursing (DON), Unit Managers, Minimum Data Set (MDS) Coordinator, Staff Development Coordinator, and the internal auditors of nutrition/hydration status. 14. Effective 03/01/18, the Administrator and Director of Nursing have developed audit forms with the assistance of long term care consultants for all recently cited care and service areas. Auditors were appointed by the Administrator with the assistance of long term care consultants on 03/01/18. Education regarding the use of the audit forms was provided to the auditors on 03/01/18, by the Administrator and the long term care consultants. Effective 03/02/18, the audits will identify residents at risk for the cited deficiencies in the areas of assisted nutrition and hydration. The Administrator and Director of Nursing are involved with all compliance and corrective actions taken to correct any alleged deficiency and have assured that the following corrective actions have identified any resident who may be affected. 15. On 03/02/18, the Administrator reviewed the members of the Quality Assurance Committee. These members conform with the requirements of the current regulations and include the Administrator, Medical Director, Director of Nursing, Unit Managers, MDS Coordinator, Staff Development Coordinator, Pharmacy Representative, Social Services Director and Activities Director. 16. Residents #1, #85 (5), #48, #53 (12), and #147 (H) were assessed by the RD from 01/19/18 through 03/02/18. The residents' physicians were notified with any new recommendations. From 01/13/18 through 03/02/18, a licensed nurse conducted a dehydration risk assessment and no additional interventions were recommended. In addition, on 03/03/18, a fluid intake audit was completed for Residents #48, #53, and #147, and the residents were meeting or exceeding their fluid needs. Resident #1 was discharged from the facility on 01/29/18, and is no longer a resident. Resident #85 (5) was discharged from the facility on 02/01/18, and is no longer a resident at the facility. 17. On 02/08/18, a representative from Medline Industries (Medline is the facility provider for feeding tube pumps), completed a Quality Assurance audit of all feeding pumps to ensure function and accuracy. All pumps were found to be in working order. Beginning on 02/08/18 and completed on 02/13/18, the representative and the Director of Nursing (DON) provided education regarding operation and use of the pumps to all licensed nurses and nurses completed a return demonstration. 18. On 03/01/18, implementation began to convert electronic documentation of Food and Fluid Consumption to paper documentation. Education began on 03/02/18 and continued through 03/04/18. Employees not having been in-serviced by 03/04/18 will not be allowed to work until education is completed. Food and fluids consumed daily with resident meals, snacks, and medication administration will be recorded on the Food and Fluid Consumption Sheet. The night shift Charge Nurse will calculate the fluids consumed and compare to the recommended fluid needs calculated by the RD. Residents not meeting the estimated daily fluid needs will be noted on the 24-hour report log for increased monitoring. The resident/resident representative and the resident's physician will be notified if a resident does not consume a daily average of 50% of routine meals without substitutes and supplements for three (3)consecutive days. Food and fluid intake documentation will be monitored daily Monday through Friday by the Unit Managers and the Weekend Manager will monitor on Saturday and Sunday. 19. Licensed Nurses completed Dehydration Risk Assessments for all residents on 03/02/18 and 03/03/18. Any concerns identified during this evaluation were addressed immediately with physician notification, care plan review, and care plan updates as indicated. From 03/02/18 to 03/04/18, a fluid intake audit was completed by comparing the individual fluid needs of all residents to each residents' average fluid consumption from 02/21/18 through 02/27/18. This audit was completed by the Director of Nursing, Unit Manager, MDS Nurse, Administrator, and Assistant Administrator. Any resident not meeting their estimated fluid need was evaluated, notifications were made if indicated to the physician and resident/resident representative, and care plans were reviewed and updated as needed. 20. On 03/03/18, the Tube Feeding Intake Worksheet was implemented to monitor and track formula and fluids administered to residents with tube feeding. This worksheet will be completed at the end of each shift by the licensed nurse. The Unit Manager, Weekend Manager, or designated Nurse Manager will review the Tube Feeding Intake Worksheet daily to ensure residents receiving tube feeding formula and/or fluids receive the amount prescribed by the physician. If reviews indicate that the intake administered is below the prescribed amount, a quality assurance check will be performed on the feeding pump, a dehydration risk assessment will be completed by a licensed nurse, and the physician and resident/resident representative will be notified. An additional review of the Tube Feeding Intake Worksheet will occur daily Monday through Friday by the Quality Assurance Nurse (QA Nurse). 21. On 03/02/18, the DON reviewed all resident weights for significant/severe weight loss. Any resident identified as having new weight loss was evaluated, the resident/responsible representative and the resident's physician were notified, and the resident's comprehensive care plan was reviewed and updated, if indicated. 22. Routine and weekly weights will be obtained by the Restorative Aides, recorded on a resident weight worksheet, and submitted to the Unit Manager for review. Weights will be logged into the medical record after review by the Unit Manager. Once weights are logged, the Director of Nursing will review the computer-generated weight change report weekly on Tuesday prior to the Nutrition at Risk Committee (NAR) meeting. Residents identified to be at risk for nutrition and hydration decline are monitored by the Interdisciplinary NAR Committee. Members of the NAR Committee include the Director of Nursing, the Unit Managers, the Registered Dietitian, the Dietary Manager, the MDS Nurse, and the QA Nurse. The NAR Committee reviews at risk residents' intake, weight, and hydration status. The NAR Committee will review the daily Food and Fluid Consumption Sheets, the daily Tube Feeding Intake Worksheets, and the computer generated weight variance report that are completed each Tuesday by the DON. 23. The Dietary Manager will conduct an additional nutrition and hydration audit daily (Monday through Friday) to ensure any resident not meeting minimal nutrition and hydration requirements have been addressed as needed. 24. The Governing Body is providing oversight through a contract with a Management Company. On 03/02/18, the Long Term Care Consultants with the Management Company (a Registered Nurse and a Licensed Health Care Administrator) provided education to the Governing Body related to the responsibilities of the Governing Body as promulgated in §483.70. The education included the responsibilities of the Governing Body to include the establishment and implementation of policies regarding the management and operation of the facility. The Governing Body has directed that all resources and administration abate deficient practice at nutrition/hydration to include corrective actions for those residents affected. The Management Company oversees the daily operations of the facility and utilizes contracted consultants as necessary for the operation. The consultants have extensive experience and education in the area of operating long term care facilities and are not employees of the facility, but rather act as an outside resource in providing advice and consultation to the management staff of the facility. The Administrator, who was appointed by the Governing Body on 03/07/14, is responsible for the daily management of the facility, and reports and is accountable to the Governing Body. The Governing Board meets with the Management Company each month. 25. The PIP Committee meets daily to focus on implementing the plan outlined herein, monitor results of audits and reviews, and provides additional direction as needed. The daily (Monday through Friday) PIP Committee meetings will continue until removal of the immediate jeopardy has been verified. 26. The Quality Assurance and Performance Improvement (QAPI) policies were reviewed on 03/02/18 by the Long Term Care Consultant and the Administrator with no changes noted. The QAPI policies are in conformance with the current regulatory standards and no changes were necessary. The QAPI Committee reviewed the QAPI policies on 03/22/18 with acceptance. On 03/02/18, the Administrator provided education to the Quality Assurance and Assessment (QAA) Committee related to the policies and the structure of the Quality Assurance and Assessment (QAA) program. The Administrator with the assistance of the long term care consultant developed new tools that are to be used for the Performance Improvement Team (PIT) that includes a new tool for a Performance Improvement Plan (PIP). These new tools are used for the PIP for the abatement of Immediate Jeopardy. Weekly QAPI meetings will be held and will continue to occur until sustained compliance is achieved. The completed PIP will be submitted to the weekly meetings of the QAPI Committee for approval and suggestions. 27. The Administration of the facility to include the Administrator and Director of Nursing are conferring daily with long term care consultants to monitor administration's role with the abatement of jeopardy beginning 03/02/18. The SSA verified the removal of immediate jeopardy by the following: 1. Review of the in-service roster dated 01/26/18, revealed the DON, MDS Nurse, and the QA Nurse had attended an in-service by the Administrator related to the development and implementation of a comprehensive care plan to ensure the wishes of each resident and their code status was included on the care plan. Interviews conducted with the MDS Nurse on 02/16/18 at 1:04 PM; the QA Nurse on 02/16/18 at 1:22 PM; and, the DON on 02/16/18 at 2:00 PM, revealed they attended the in-service provided by the Administrator and began providing in-services for other staff on 01/29/18. 2. Review of the facility's policies and in-service rosters regarding Advance Directives and Code Status revealed the facility reviewed and updated the policies on 01/29/18. The policies revealed the facility's new process to ensure Advance Directives/Wishes were honored was as follows: the physician would be notified after obtaining the resident's/ responsible party's consent, documenting the consent, and honoring the resident's wishes for Advance Directi[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and review of facility policy, it was determined the facility failed to notify the physician of a change of condition and need to alter treatment for five (5) of thirty-seven (37) sampled residents (Residents #26 (6), #147 (H), #85 (5), #53 (12), and #48). On [DATE], Resident #26 (6) sustained a fall which resulted in a laceration above the left eye and a subdural hematoma. However, the facility failed to notify Resident #26's (6) physician of the fall or injury. Further, on [DATE], Resident #26 (6) was assessed by staff to have a low blood pressure, pale skin, and labored breathing at approximately 3:45 PM. Subsequently, Resident #26 (6) expired at the hospital on [DATE] at 5:11 PM. Interview with the resident's physician on [DATE] revealed the facility failed to notify him that Resident #26 (6) had fallen, had a change in condition on [DATE], and the physician was never notified of the resident's death (Refer to F656, F658, F678, and F842). Resident #147 (H) was admitted to the facility on [DATE], and weighed 191 pounds on [DATE]. The dietitian recommended supplements/snacks to prevent weight loss on [DATE] and on [DATE]; however, the facility failed to notify the resident's physician of the need to alter treatment and the resident continued to loose weight. On [DATE], Resident #147 (H) weighed 174 pounds and had lost 8.9 percent of his/her body weight in eighteen (18) days; however, there was no evidence the facility notified the resident's physician of the weight loss and possible need to alter the resident's treatment (Refer to F656 and F692). Further, Resident #85 (5) was readmitted to the facility on [DATE], and was documented to weigh 155 pounds on [DATE] and on [DATE]. The facility failed to administer the resident's tube feeding as ordered from [DATE] through [DATE], and the resident sustained an eight percent weight loss during this time. However, the facility failed to identify that the resident had sustained severe weight loss; subsequently, the resident's physician was not notified of the change in the resident's condition (severe weight loss) and possible need to alter treatment (Refer to F656, F692, F725, and F842). The facility's failure to ensure residents' physicians were notified timely of changes in condition has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on [DATE], and determined to exist on [DATE] at 42 CFR 483.10 Resident Rights (F578 and F580), 42 CFR 483.21 Comprehensive Person-Centered Care Planning (F656 and F658), 42 CFR 483.24 Quality of Life (F678), and 42 CFR 483.70 Administration (F842). The facility was notified of the Immediate Jeopardy on [DATE]. After supervisory review, Immediate Jeopardy was identified on [DATE] and determined to exist on [DATE] at 42 CFR 483.25 Quality of Care (F692 ) and 42 CFR 483.70 Administration (F835, F837). The facility was notified of the Immediate Jeopardy on [DATE] at 42 CFR 483.25 Quality of Care (F692), and 42 CFR 483.70 Administration (F835 and F837). An acceptable Allegation of Compliance was received on [DATE], which alleged removal of the Immediate Jeopardy on [DATE]. The State Survey Agency determined the Immediate Jeopardy was removed on [DATE], prior to exit, which lowered the scope and severity to D at at 42 CFR 483.10 Resident Rights (F578 and F580), 42 CFR 483.21 Comprehensive Person-Centered Care Planning (F658), 42 CFR 483.24 Quality of Life (F678), 42 CFR 483.25 Quality of Care (F692 ) and 42 CFR 483.70 Administration (F835, F837, and 842), and to an E at 42 CFR 483.21 Comprehensive Person-Centered Care Planning (F656), while the facility monitors the effectiveness of systemic changes and quality assurance activities. In addition, the facility failed to notify Resident #85 (5), #53 (12), and #48's physician when the residents did not meet their required fluid needs for three or more consecutive days as required by the facility's policy (Refer to F656, F692, F725, and F842). The findings include: Review of the facility's policy for physician notification dated [DATE], revealed the facility would promptly notify the resident's physician of a change in the resident's medical condition including a change in the resident's vital signs, a need to alter treatment significantly, or a need to transfer a resident to the hospital. 1. a. Review of Resident #26's (6) medical record revealed the facility re-admitted the resident on [DATE], with diagnoses including Dementia with Behavioral Disturbance, Osteoarthritis, Difficulty Walking and Lack of Coordination. Review of Resident #26's (6) Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIM) score of two (2), indicating the resident was cognitively impaired. Review of a facility Allegation Report and Investigation initiated on [DATE], and finalized on [DATE], and video surveillance footage recorded on [DATE], revealed on [DATE], at approximately 5:50 PM, Resident #26 (6) attempted to get up unassisted out of a wheelchair and fell head first sustaining a laceration above the left eye. Resident #26 (6) was transported to the Emergency Department (ED) for evaluation and treatment, and was subsequently transferred to another hospital and diagnosed with a subdural hematoma. Further review of the Allegation Report and Investigation initiated on [DATE], and finalized on [DATE], and a facility Incident Investigation dated [DATE], revealed that although the facility notified Emergency Medical Services to transport the resident to the hospital, there was no documented evidence that the facility notified Resident #26's (6) attending physician of the resident's fall and injury. In addition, review of physician orders for Resident #26 (6) conducted on [DATE], revealed a physician's order was written on [DATE] by facility staff to transfer the resident to the hospital; however, the order was not signed by a physician. Interview with Resident #26's (6) Physician on [DATE], at 11:04 AM, revealed he was never notified that Resident #26 (6) had sustained a fall at the facility on [DATE], or that the resident had been transported to the hospital and diagnosed with a subdural hematoma. Interview with Licensed Practical Nurse (LPN) #8 on [DATE] at 2:57 PM, revealed he had notified Resident #26's (6) physician of the fall when the order was written on [DATE]. He stated he did not know why the order had not been signed by the physician or documented in the facility's investigation reports. 1. b. Continued review of Resident #26's (6) medical record revealed the facility re-admitted the resident on [DATE], after treatment of the fall and a subdural hematoma the resident sustained on [DATE]. Review of the Nursing Notes for Resident #26 (6) dated [DATE] at 11:52 AM, revealed the resident's blood pressure was 130/80 (normal is 120/80), pulse was 78 (normal is 80), and respirations were 18 (normal is 18). Review of Resident #26's (6) Medication Administration Record (MAR) for [DATE] at 6:00 PM, and [DATE] at 12:00 AM, revealed the resident's pulse was 74-76 and respirations were 18. Further review of Nursing Notes dated [DATE] at 6:30 AM revealed the resident's blood pressure was 118/68, pulse was 76, and respirations were 18. Further, on [DATE] at 12:00 PM, Resident #26's (6) pulse was 76, respirations were 18. Review of Resident #26's (6) Nursing Notes dated [DATE] at 3:45 PM, and an interview with Licensed Practical Nurse (LPN) #12 on [DATE] at 4:58 PM, revealed on [DATE], Resident #26's (6) skin became pale, breathing was labored, blood pressure was 90/60 (normal is 120/80), and respirations were 24. LPN #12 stated she called the first floor Unit Manager (UM) to request assistance because the resident was actively dying. Further review of Resident #26's (6) Nursing Notes, revealed the resident's physician was notified of the change in the resident's condition on [DATE] at 5:09 PM. Continued interview with LPN #12 on [DATE] at 4:58 PM, revealed she contacted Resident #26's (6) Physician approximately 15-20 minutes after she contacted the UM, and the physician ordered the resident be transferred to the hospital. However, review of the resident's medical record revealed there was no documentation that a physician's order was written to transfer the resident to the hospital. In addition, interview with Resident #26's (6) physician on [DATE] at 11:04 AM, revealed he was never notified that the resident had a change in condition and was transferred to the hospital. Review of the Emergency Medical Services (EMS) Prehospital Care Report dated [DATE], revealed when EMS arrived to Resident #26's (6) room at 4:50 PM, the resident had no pulse and was not breathing. EMS initiated CPR, and the resident was transferred to the hospital, where the resident was pronounced dead at 5:11 PM, three (3) minutes after arrival. Continued interview with Resident #26's (6) Physician on [DATE] at 11:04 AM, revealed in addition to not being notified that the resident had a change in condition, the facility did not notify him that Resident #26 (6) had expired. 2. Review of the facility's policy titled, Weight Program dated [DATE], revealed nursing staff would notify the resident's physician of any significant unplanned weight loss and the interventions strategies to prevent further loss. Interview with the Director of Nursing (DON) on [DATE], at 12:05 PM and [DATE] at 11:43 AM, revealed the Unit Manager was responsible for notifying the resident's physician of any significant or severe weight loss and documenting that the physician was notified. In addition, since [DATE], the Nutritionally at Risk (NAR) Committee was initiated to ensure the resident's physician was notified of weight loss and documented the notification on the resident's NAR Progress Note. 2. a. Review of the medical record revealed the facility admitted Resident #147 (H) on [DATE], with diagnoses that included Dysphagia, Diabetes with Hyperglycemia, Chronic Obstructive Pulmonary Disease, and Alcoholic Hepatitis with Ascities. Review of the resident's weight roster revealed the resident weighed 191 pounds on [DATE]. Review of the Dietary Notes dated [DATE], revealed the resident was a new admission to the facility and weighed 189 pounds on [DATE]. The Registered Dietitian (RD) documented the resident was only eating 42 percent of meals and recommended the resident receive health shake supplements twice daily. However, there was no documented evidence the facility notified the resident's physician to obtain an order for health shakes and there was no evidence the facility provided health shake supplements to the resident. Review of Dietary Notes dated [DATE], revealed the resident had sustained a thirteen-pound (13) weight loss since admission (weight was 178 pounds). The RD recommended the resident receive a multivitamin with minerals and snacks three (3) times per day. However, there was no documented evidence the facility notified the resident's physician of the weight loss or of the RD's recommendations. Further, review of Resident #147's (H) weight record revealed the resident lost four additional pounds and weighed 174 pounds on [DATE], an 8.9 percent weight loss in eighteen (18) days. Review of the resident's record revealed no documentation the resident's physician was notified of the resident's weight loss. Interview with the Registered Dietitian on [DATE] at 2:30 PM, revealed she reviewed residents' weights and made recommendations when needed. She stated she assumed the Unit Managers notified the residents' physicians of the recommendations and necessary action was taken. Interview with Physician #1 on [DATE] at 11:16 AM, revealed he did not recall whether the facility notified him of Resident #147's (H) weight loss. However, he expected the facility to notify him when a resident lost that much weight in just two (2) weeks. 2. b. Review of the medical record revealed the facility readmitted Resident #85 (5) on [DATE], with diagnoses that included Alzheimer's Disease, Gastro-Esophageal Reflux, and Type 2 Diabetes. Review of Resident #85's (5) weekly weights revealed on [DATE], the resident weighed 155 pounds. Review of Resident #85's (5) Intake and Output Record for [DATE], revealed the resident did not meet his/her estimated calorie needs for thirteen of eighteen days from [DATE] through [DATE]. During the time period, the resident received an average of approximately 710 ml per day, approximately 500 ml less than the resident was assessed to require. Further review of Resident #85's (5) weekly weights revealed on [DATE], the resident's weight was down to 144 pounds, an 11 pound weight loss. On [DATE], the resident weighed 142 pounds, an eight (8) percent weight loss in fourteen (14) days. However, there was no evidence the resident's physician was notified that the resident had sustained severe weight loss. Further review of the Nutritionally at Risk (NAR) Progress Notes revealed the facility placed Resident #85 (5) in the NAR program on [DATE]. However, review of the NAR Progress Notes for [DATE] and [DATE], revealed the NAR Committee did not identify that the resident had sustained severe weight loss. Subsequently, there was no evidence the facility notified the resident's physician that the resident had sustained severe weight loss. Interview with Physician #1 on [DATE] at 11:16 AM, revealed he did not recall whether the facility notified him of Resident #85's (5) weight loss from [DATE] to [DATE]. The Physician stated he expected the facility to notify him when a resident lost that much weight, in just two (2) weeks. Interview with the Director of Nursing (DON) on [DATE], at 12:05 PM, on [DATE], at 12:05 PM and on [DATE] at 11:43 AM revealed in [DATE], the facility initiated a Nutritionally at Risk (NAR) Committee that met weekly to review residents who had sustained weight loss. The DON stated the Unit Managers had always been responsible for notifying the resident's physician of any significant or severe weight loss. The DON was unable to explain why Resident #147 (H) and #85's (5) physicians were not notified when the residents sustained severe weight loss. The facility terminated the Unit Manager on [DATE], and an interview was unable to be conducted. 3. Review of the facility's Hydration Policy revised on [DATE], revealed each resident would be provided with sufficient fluid intake to maintain hydration. Further review of the policy revealed if a resident failed to receive 1500 ml of fluids for three (3) consecutive days, the resident would be evaluated for signs and symptoms of dehydration and the physician would be notified. 3. a. Continued review of Resident #85's (5) medical record revealed the resident had an order for a 200 ml water flush via the resident's feeding tube every four hours (1200 ml per day). However, review of Resident #85's (5) [DATE], Medication Administration Record (MAR) revealed the resident did not meet his/her fluid needs on eleven of eighteen days, including three consecutive days on two different occasions, [DATE], [DATE], and [DATE]; and, [DATE], [DATE], and [DATE]. There was no documented evidence the facility evaluated the resident for signs and symptoms of dehydration until [DATE]. There was no evidence the facility notified the resident's physician of the resident's decreased fluid intake as required by the facility's policy. Review of a Dehydration Risk assessment dated [DATE], revealed the facility assessed Resident #85 (5) to have no signs or symptoms of dehydration; the resident's skin turgor was good and the resident's mucous membranes, tongue, and lips were moist. However, review of Resident #85's (5) laboratory values dated [DATE] and [DATE] revealed the resident's Blood Urea Nitrogen (BUN) and creatinine (BUN and creatinine levels test kidney function may temporarily increase if you are dehydrated, have a low blood volume, eat a large amount of meat, or take certain medications) increased from 18 (normal BUN is 6-20) and 0.6 (normal creatinine is 0.4-1.0) on [DATE] to 41 and 0.9 on [DATE]. Interview with Physician #1 on [DATE] at 11:16 AM, revealed he did not recall whether the facility notified him of Resident #85's (5) decreased fluid intake from [DATE] through [DATE], but expected the facility to notify him when a resident did not receive the required fluid needs. 3. b. Review of the medical record revealed the facility admitted Resident #53 (12) on [DATE], and readmitted the resident on [DATE], after receiving a feeding tube on [DATE]. The resident had diagnoses that included Dysphagia, Pneumonia, Hypertension, Alzheimer's Disease, and Dementia. Review of Resident #53's (12) Physician's Orders dated [DATE], revealed an order to flush the resident's feeding tube with 200 ml of water every four hours (1200 ml per day). Review of Resident #53's (12) Intake and Output record for [DATE] through [DATE] revealed the resident did not meet his/her fluid intake for three (3) consecutive days on [DATE] through [DATE]; [DATE] through [DATE]; [DATE] through [DATE]; and [DATE] through [DATE]. Further review revealed Resident #53's (12) average fluid intake for [DATE] through [DATE] was approximately 703 ml, approximately 500 ml less than the resident required. However, there was no documented evidence the resident's physician was notified that the resident had not met his/her fluid needs. Review of Resident #53's (12) laboratory results dated [DATE] and [DATE] revealed the resident's Blood Urea Nitrogen (BUN) and creatinine levels increased from January to February 2018. On [DATE], the resident's BUN was 34 (normal is 6-20) and the resident's creatinine was 0.7 (normal is 0.6 to 1.2). However, on [DATE], Resident #53's (12) BUN had increased to 44, and the creatinine was 0.6. Interview with Physician #1 on [DATE] at 11:16 AM, revealed he did not recall whether the facility notified him of Resident #53's (12) decreased fluid intake in [DATE], but expected the facility to notify him when a resident did not receive their required fluid needs. 3. c. Review of Resident #48's medical record revealed the facility admitted the resident on [DATE], with diagnoses that included Alzheimer's, Chronic Kidney Disease, Muscle Weakness, Dysphasia, and Moderate Protein-Calorie Malnutrition. Review of Resident #48's Physician's Orders dated [DATE], revealed the resident had an order for 200 ml water flushes every six (6) hours per feeding tube (800 ml per day). Review of Resident #48's Intake and Output record for [DATE], revealed the resident did not meet his/her assessed fluid needs [DATE] through [DATE]. The resident only received an average of approximately 363 ml of fluid per day, approximately 437 ml less than the resident required per day. However, there was no evidence the facility completed a dehydration risk assessment until [DATE], twenty-three days later, and no documented evidence the resident's physician was notified that the resident had not met his/her fluid needs. Review of the [DATE] Dehydration Risk Evaluation for Resident #48 revealed the facility assessed the resident to have no signs or symptoms of dehydration, including no skin turgor concerns and the resident's mucous membranes, lips, and tongue were moist. Interview with Physician #1 on [DATE] at 11:16 AM, revealed he did not recall whether the facility notified him of Resident #48's decreased fluid intake in [DATE], but expected the facility to notify him when a resident did not receive their required fluid needs. Interview with the Director of Nursing (DON) on [DATE], at 12:05 PM, on [DATE], at 12:05 PM and on [DATE] at 11:43 AM, revealed in [DATE], the DON began running an Intake and Output report every morning, and staff reviewed the report in the morning meeting to identify anyone who did not have an intake of at least 1500 ml per day. The DON stated if a resident did not receive 1500 ml per day, the Unit Manager was required to notify the resident's physician. However, further interview revealed when totaling residents' daily fluid intake, the DON inaccurately added the amount that was initialed by the nurse on the MAR to the total on the Intake record to determine the resident's total fluid intake and failed to recognize that residents were not meeting their assessed fluid needs. Subsequently, Residents # 85 (5), #53 (12) and #48's physicians were not notified when the residents did not meet their fluid needs for three (3) consecutive days as required by the facility's policy. The facility implemented the following for removal of jeopardy: 1. On [DATE], the Administrator provided an in-service to the Director of Nursing, Minimum Data Set (MDS) Nurse, and the Quality Assurance (QA) Nurse regarding the development and implementation of a comprehensive care plan that included the wishes of each resident related to code status. 2. The policies and procedures were reviewed and updated regarding physician notification and obtaining, documenting, and honoring the wishes of each resident for Advance Directives/Code Status by the PIP Committee on [DATE]. The resident's wishes for Advance Directives and code status will be obtained upon admission by Social Services and the admission Director. Code status designations will be documented in the physician's orders, in the resident care plan, and on the resident's face sheet. Residents choosing a DNR code status will sign a completed No Code or DNR consent form that will be maintained in the resident's medical record. Residents without an Advance Directive will be considered a Full Code. The Advance Directives and Code Status policies were reviewed, updated, and approved by the QAPI Committee on [DATE]. 3. On [DATE], a comprehensive audit was completed by the Administrator, MDS Nurse, Assistant Administrator, Director of Nursing (DON), QA Nurse, Unit Manager, Activities Director, Admissions Director, and Social Workers for every resident in the facility. The audit was a review of each resident's Advance Directive and code status that included physician orders, Advance Directive designation forms, consent forms, paper record, electronic record, and face sheets with no variances noted. The residents' comprehensive care plans were also reviewed and updated as needed to assure residents' Advance Directives and wishes for code status were included on the plan of care. These audits were conducted at the direction of the Quality Assurance and Performance Improvement (QAPI) Committee and completed on [DATE]. Members of the QAPI committee included: The Administrator, Director of Nursing, Unit Managers, Medical Director, MDS Coordinator, Staff Development Coordinator, Pharmacy Representative, Social Services Director, and Activity Director. Completed audits were submitted to the QAPI Committee for additional review. 4. The Director of Nursing, Quality Assurance Nurse, Unit Manager, and MDS Nurse completed a focus review to ensure proper notification occurred for changes in resident condition. The audit included review of residents transferred to the hospital within the prior week, all Nurse's Notes documented between [DATE] through [DATE], and any new Physician's Orders received [DATE] through [DATE]. 5. Licensed staff that were involved with the care of Resident #26 (6) and Resident #63 received additional training related to identification and communication of a resident's wishes regarding Advance Directives and code status, as well as including and honoring those wishes through implementation of the resident's care plan. The training included timely notification of a resident's physician and responsible party, as well as documentation of the notification. The training also included development and implementation of the comprehensive care plan which included the wishes of each resident related to their code status. Post-tests and staff interviews were completed to ensure comprehension of the training material. The training was completed [DATE] through [DATE] by the Director of Nursing, Staff Development Director. 6. All licensed and certified nursing staff and the Interdisciplinary Care Plan team (IDT) which consisted of MDS Nurse, Social Worker, Activity Director, and the Director of Dietary Services all received additional training beginning on [DATE] thru [DATE] related to: - identification and communication of a resident's wishes regarding Advance Directives and code status - honoring resident's code status wishes through the implementation of the resident's care plan -providing the necessary care and services such as emergency care, basic life support, and CPR to those residents in accordance with the resident's Advance Directives and wishes regarding code status -how to determine the code status of each resident according to facility protocols - assessing and responding to a resident in distress - timely notification of the physician - initiating a code - honoring the wishes of each resident with a full-code status - documenting care delivered - development and implementation of the comprehensive care plan which included the wishes of each resident related to their code status The training was completed by the Director of Nursing, Staff Development Director, and the Administrator. Post-tests and staff interviews were completed to ensure comprehension of the training material. Any staff member in the nursing department who was off work for any reason will not be permitted to work until training and post testing are completed. 7. On [DATE], the Administrator posted a listing of each resident and their desired code status at each nursing unit. The Administrator completed the list after the Advance Directives and CPR desires of each resident were validated through the audit completed on [DATE]. Monitoring would include a daily review of this list by the Administrator or Assistant Administrator Monday through Friday. The weekend manager would review and update the listing on Saturday and Sunday. 8. Notification to a resident's physician, resident, and resident representative is monitored daily (Monday - Friday) in the Clinical Meeting. Attendees of the Clinical Meeting include the Director of Nursing, MDS Nurse, Social Workers, QA Nurse, and Unit Manager. The Clinical Meeting conducts a review of the following: 24-hour report, physician's telephone orders, nurse's notes, laboratory reports, resident events, changes in residents' condition, new admissions, and discharges. Any concerns identified are corrected immediately. 9. On [DATE], training, direction, and responsibility was assigned to Social Services for listing residents' wishes regarding Advance Directive on the residents' comprehensive care plan. The MDS Nurse will verify that Advance Directives are included on the care plan. This review will occur during Care Plan Conferences following the Resident Assessment Instrument (RAI) schedule. 10. On [DATE], a focus Performance Improvement Plan (PIP) Committee was formed by the QAPI Committee to review and monitor the facility's processes for obtaining and honoring residents' Advance Directives, code status, development and implementation of a care plan that meets the code status wishes of the resident, procedures for calling a code, and the conditions for implementing CPR to a full code resident. The PIP committee members included: The Administrator, Director of Nursing, Unit Managers, MDS Coordinator, Staff Development Coordinator, Social Services and Activity Director. The PIP Committee meets daily to focus on implementing the plan outlined herein, monitor results of audits and reviews, and provides additional direction as needed. The daily (Monday through Friday) PIP Committee meetings will continue until removal of the immediate jeopardy has been verified. Weekly QAPI meetings would continue to occur until sustained compliance was achieved. 11. The QAPI Committee will monitor and ensure sustained compliance is maintained through a weekly meeting. The members of this meeting will review all audits, training, and corrective actions generated by the focus PIP Committee. QAPI meetings will occur until sustained compliance is achieved. Information reviewed in this meeting will include: - Verbal report and a current Code Status List is reviewed and updated daily with any changes in the resident's Advance Directives and CPR status and is submitted by the Administrator or Assistant Administrator - The MDS Nurse will submit a verbal report and audit tool(s) related to the validation of the resident's code status during resident care plan conferences - The DON or QA Nurse will review the findings of the 24-hour report, physician's telephone orders, nurse's notes, laboratory tests, resident events, and changes in residents' condition identified in the morning clinical meetings and through routine clinical assessments, evaluations, and nurse management rounds, as well as a review of new admissions and discharges. The Daily Audit Tool will also be used to validate proper notification to physicians and the resident representative. - The DON or SDC will submit a verbal report, in-service logs and training agenda(s) regarding training or post testing completed. - The Social Worker will submit a verbal report and census list regarding any changes in Advance Directives or code status, including new admissions and re-admissions. - The DON or QA Nurse will give a verbal report and submit an audit tool related to any resident transfers to the hospital for urgent or critical care. The reports will include verification of proper notification, communication regarding resident's Advance Directives/code status prior to transfer, the Center's response to the resident's wishes, and the outcome of the transfer. - The committee will also discuss any new concerns identified through audits and reviews and applicable corrective action or changes. 12. On [DATE], a Long Term Care (LTC) consultant who is licensed as a Long Term Care Health Administrator in the state of Kentucky provided training to the Administrator of the facility for compliance with the federal and state regulations, quality assurance and performance improvement, efficient and effective use of resources, human resource development, and responsibilities of the Governing Body. Additionally, education was provided that according to §483.70 the facility must be administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. 13. On [DATE], the Administrator developed a Performance Improvement Team (PIT) to develop a Performance Improvement Plan (PIP) for the purposes of maintaining an effective nutrition/hydration status program. The PIT had the first meeting on [DATE] to develop, review, and monitor the resident nutrition/hydration status program. The PIT committee members include: the Administrator, Director of Nursing (DON), Unit Managers, Minimum Data Set (MDS) Coordinator, Staff Development Coordinator, and the internal auditors of nutrition/hydration status. 14. Effective [DATE], the Administrator and Director of Nursing have developed audit forms with the assistance of long term care consultants for all recently cited care and service areas. Auditors we[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Review of the facility's policy titled Administering Medications dated December 2009, revealed medications must be administered in accordance with the orders, including any required time frame. 3. a. Review of the medical record revealed the facility admitted Resident #94 on 05/19/14, with diagnoses that included Diabetes with Diabetic Neuropathy. Review of Resident #94's Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of fifteen (15), which indicated Resident #94 was cognitively intact. Review of Resident #94's Physician's Orders dated 10/31/17, revealed the resident had an order to check his/her blood glucose (blood sugar) four (4) times a day, and to administer Novolin R (regular human Insulin) subcutaneous per sliding scale (the insulin dosage is based on the blood sugar result). Review of Resident #94's Medication Administration Record (MAR) dated 01/16/18, revealed the resident did not receive a blood glucose check and/or administered sliding scale insulin at 11:00 AM. Further review of the MAR, revealed in January 2018, at 11:00 AM, Resident #94's blood glucose averaged 312, which required eight (8) units of Novolin R based on the sliding scale. Interview with Resident #94 on 01/23/18 at 5:00 PM revealed the facility did not have enough staff to provide medications that day and medications were late. 3. b. Review of Resident #70's medical record revealed the facility admitted the resident on 08/28/14, and the resident had diagnoses that included Diabetes, Hypertension, and Personality Disorder. Review of Resident #70's Quarterly Minimum Data Set (MDS) dated [DATE], revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of fourteen (14), which indicated Resident #70 was cognitively intact. Review of Resident #70 Physician's Orders, dated 04/22/16, revealed the resident had an order to check the resident's blood glucose four (4) times per day and to administer Novolog (Fast Acting Insulin) per sliding scale (the insulin dosage is based on the blood sugar result). Review of Resident #70's Medication Administration Record (MAR) dated 01/16/18, revealed no documented evidence the facility checked the resident's blood sugar and/or administered sliding scale insulin at 11:00 AM on 01/16/18. Further review of the MAR, revealed Resident #70's blood sugar at 11:00 AM in January 2018 averaged 280, which required six (6) units of Novolog Insulin. Interview with Resident #70 on 01/23/18 at 5:05 PM revealed he/she believed that staff checked his/her blood sugar when they were supposed to. The resident stated that he/she depended on staff to ensure his/her blood sugar was checked as ordered by the physician. 3. c. Review of Resident #40's medical record revealed the facility admitted the resident on 03/17/15, and the resident had diagnoses that included Type 2 Diabetes, Hypertension, and Alzheimer's Disease. Review of the resident's Quarterly Minimum Data Set (MDS) dated [DATE], revealed Resident #40's cognition was unable to be assessed. Review of Resident #40's Physician's Orders dated 12/07/17, revealed the resident had an order to check his/her blood glucose four (4) times daily, and to administer Novolog Insulin per sliding scale (the insulin dosage is based on the blood sugar result). However, review of Resident #40's Medication Administration Record (MAR) dated 01/16/18, at 11:00 AM revealed no documented evidence the facility checked the resident's blood glucose and/or administered insulin. Further review of Resident #40's January 2018 MAR, revealed the resident's blood sugar averaged 154 at 11:00 AM, in January 2018, which required two (2) units of Novolog Insulin. 3. d. Review of Resident #30's medical record revealed the facility admitted the resident on 08/24/14, with diagnoses that included Type 2 Diabetes. Review of the resident's Quarterly Minimum Data Set (MDS) dated [DATE], revealed the facility assessed Resident #30 to have a Brief Interview for Mental Status (BIMS) score of eight (8), which indicated Resident #30 was moderately cognitively impaired. Review of Resident #30's Physician's Orders, dated 08/15/17, revealed the resident had an order to check his/her blood sugar four (4) times daily, and to administer Humulin R insulin per sliding scale (the insulin dosage is based on the blood glucose result). However, review of Resident #30's Medication Administration Record (MAR) dated 01/16/18 at 11:30 AM, revealed the facility did not check the resident's blood glucose/administer Humulin R Insulin. Further review of the MAR, revealed Resident #30's blood glucose routinely averaged 263 at 11:30 AM in January 2018, which required six (6) units of Humulin R Insulin. 3. e. Review of the medical record revealed the facility admitted Resident #14 on 07/12/13, with diagnoses that included Type 2 Diabetes with Hyperglycemia, Osteomyelitis of the Ankle and Foot, and a Pressure Ulcer of Right Heel. Review of Resident #14's Quarterly Minimum Data Set (MDS) dated [DATE], revealed Resident #14's cognitive status could not be assessed. Review of Resident #14's Physician's Orders dated 11/25/17, revealed the resident had an order to check his/her blood glucose four (4) times daily, and to administer Novolog Insulin per sliding scale (the insulin dosage is based on the blood sugar result). However, review of Resident #14's Medication Administration Record (MAR) dated 01/16/18 at 11:00 AM, revealed no documented evidence the facility checked the resident's blood glucose level and/or administered sliding scale insulin. Further review of the MAR, revealed Resident #14's blood glucose averaged 281 in January 2018, which required six (6) units of Novolog Insulin. 3. f. Review of Resident #3's medical record revealed the facility admitted the resident on 01/20/15, with diagnoses that included Type 2 Diabetes, Emphysema, and Chronic Obstructive Pulmonary Disease. Review of Resident #3's Quarterly Minimum Data Set (MDS) dated [DATE], revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of fourteen (14), which indicated Resident #3 was cognitively intact. Review of Resident #3's Physicians Orders dated January 2018, revealed the resident had an order for a blood glucose check four times daily, and an order to administer Novolog Insulin per sliding scale. Review of Resident #3's Medication Administration Record (MAR) dated 01/16/18, revealed the resident did not receive a blood glucose check or receive Novolog Insulin at 11:00 AM. Further review of the MAR, revealed Resident #3's blood glucose averaged 249 in January 2018, which required four (4) units of Novolog Insulin. Interview with Resident #3 on 01/18/18 at 6:00 PM revealed the resident could not recall whether staff checked his/her blood sugar on 01/16/18. On 01/19/18 at 6:30 PM, an interview conducted with the second floor Unit Manager (UM) revealed she checked the residents' blood glucose levels and administered insulin as needed on 01/16/18, but she forgot to document that they were completed. However, on 01/19/18 at 5:45 PM observation of the facility's video footage, recorded on 01/16/18 from 10:30 AM to 12:47 PM, revealed a nurse did not enter Resident #14's or Resident #30's room. Further observation of video footage on 01/19/18 at 7:00 PM, with the Administrator and Nurse Consultant, revealed on 01/16/18, a nurse did not enter Resident #3 or Resident #70's room from 10:30 AM to 1:06 PM. In addition, interviews with SRNA #12 on 01/18/18 at 5:45 PM, and SRNA #3 on 01/18/18 at 4:20 PM, direct care staff who worked on the second floor on 01/16/18, revealed there was not a nurse on the floor where the residents resided from 10:30 AM until 2:30 PM. The staff stated the nurse who was assigned to the floor called in sick and another nurse provided care to the residents until 10:30 AM, when she had to leave. The staff stated there was a medication aide on the unit to administer oral medications to residents, but there was not a nurse to check residents' blood sugars or administer insulin injections. Interview with the Director of Nursing (DON) on 01/24/18 at 12:05 PM, revealed she was not aware staff did not provide blood glucose testing or administer insulin to insulin dependent residents on 01/16/18. The DON stated she was aware the nurse who covered the second floor had to leave at 10:30, but she believed the nurse checked all residents' blood sugars and administered insulin before she left. 4. Review of the facility's Laboratory, Policy and Procedure, dated November 2017, revealed upon receipt of a physician's order for a laboratory test, the nurse who received the order was required to document the resident's name, the laboratory test, and the date the test was to be obtained in a laboratory binder. The policy stated the nurse was also required to complete and submit an electronic or a hard copy laboratory requisition to the laboratory with the date the laboratory was due. The requisition was then to be filed in the appropriate month in the laboratory binder or filed at the nurses' station. Further review of the policy revealed the Unit Manager would monitor and verify that all physician orders for laboratory services were processed according to the facility's procedures. In addition, the policy stated a routine quality assurance review of laboratory tests would occur as outlined in the facility's Quality Assurance and Performance Improvement (QAPI) program. Review of Resident #63's closed medical record revealed the facility admitted the resident on 12/15/17 from an acute care hospital, with diagnoses that included Urinary Tract Infection, Chronic Respiratory Failure, Type 2 Diabetes Mellitus, Diabetic Nephropathy, Chronic Kidney Disease Stage IV, Arteriosclerotic Heart Disease, Hypertension, and a Stage 4 Pressure Ulcer to the left heel. Review of Resident #63's admission Minimum Data Set (MDS) assessment dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) score of fourteen (14), which indicated the resident was cognitively intact. Review of Resident #63's Bowel Roster revealed the resident had an extra-large watery liquid stool on 12/27/17 and 12/28/17. Review of a Nurse's Note for Resident #63 dated 12/28/17, revealed the note stated, New order obtained to obtain stool for C-Diff and hemoccult stool. Review of Resident #63's Physician's Orders revealed an order dated 12/28/17, to obtain a stool specimen to test for Clostridium Difficile (C-Diff) and blood (hemoccult), and to place the resident in contact precautions. According to the order, the tests were being conducted because the resident had foul odor, loose stool. Further review revealed another Physician's Order dated 12/29/17, to place the resident in Contact Precautions due to possibly C-Diff. Observation of the laboratory binder on 02/15/18 at 1:30 PM, revealed Resident #63's order for a C. Diff and Hemoccult were not in the binder. Review of Resident #63's medical record revealed stool culture results dated 12/29/17. However, there was no documented evidence the facility obtained a C. Diff or hemoccult stool test for the resident as ordered by the resident's physician on 12/28/17. On 02/02/18 at 6:25 PM, an interview conducted with a Laboratory Supervisor at the contracted laboratory service utilized by facility, revealed the facility did not order a C. Diff or Hemoccult stool test for Resident #63 on 12/28/17. The Laboratory Supervisor stated the facility ordered a stool culture only, which did not include testing for Clostridium Difficile and was not a hemoccult test; subsequently the C. Diff and hemoccult tests were not obtained. Interview with Licensed Practical Nurse (LPN) #7, on 02/02/18 at 05:08 PM, revealed she was the nurse who received the laboratory result for the stool culture for Resident #63, and communicated the results to the physician on 12/31/17. LPN #7 stated she did not recognize that the wrong test was ordered and obtained for Resident #63. Interview with the DON on 02/15/18 at 1:30 PM revealed that the C. Diff order could only be entered into the computer system as an order for a stool culture. However, observation of the facility's computerized system for entering laboratory orders conducted with the DON on 02/15/18, revealed the DON was able to order a C. Diff test. Additional interview with the DON on 02/02/18 at 07:28 PM, revealed Unit Managers were responsible for monitoring laboratory tests to ensure they were completed accurately. She stated the Unit Manager was responsible for checking each physician's order to ensure the correct laboratory order was placed on the laboratory book. The facility implemented the following for removal of jeopardy: 1. On 01/26/18, the Administrator provided an in-service to the Director of Nursing, Minimum Data Set (MDS) Nurse, and the Quality Assurance (QA) Nurse regarding the development and implementation of a comprehensive care plan that included the wishes of each resident related to code status. 2. The policies and procedures were reviewed and updated regarding physician notification and obtaining, documenting, and honoring the wishes of each resident for Advance Directives/Code Status by the PIP Committee on 01/29/18. The resident's wishes for Advance Directives and code status will be obtained upon admission by Social Services and the admission Director. Code status designations will be documented in the physician's orders, in the resident care plan, and on the resident's face sheet. Residents choosing a DNR code status will sign a completed No Code or DNR consent form that will be maintained in the resident's medical record. Residents without an Advance Directive will be considered a Full Code. The Advance Directives and Code Status policies were reviewed, updated, and approved by the QAPI Committee on 01/29/18. 3. On 01/26/18, a comprehensive audit was completed by the Administrator, MDS Nurse, Assistant Administrator, Director of Nursing (DON), QA Nurse, Unit Manager, Activities Director, Admissions Director, and Social Workers for every resident in the facility. The audit was a review of each resident's Advance Directive and code status that included physician orders, Advance Directive designation forms, consent forms, paper record, electronic record, and face sheets with no variances noted. The residents' comprehensive care plans were also reviewed and updated as needed to assure residents' Advance Directives and wishes for code status were included on the plan of care. These audits were conducted at the direction of the Quality Assurance and Performance Improvement (QAPI) Committee and completed on 01/26/18. Members of the QAPI committee included: The Administrator, Director of Nursing, Unit Managers, Medical Director, MDS Coordinator, Staff Development Coordinator, Pharmacy Representative, Social Services Director, and Activity Director. Completed audits were submitted to the QAPI Committee for additional review. 4. The Director of Nursing, Quality Assurance Nurse, Unit Manager, and MDS Nurse completed a focus review to ensure proper notification occurred for changes in resident condition. The audit included review of residents transferred to the hospital within the prior week, all Nurse's Notes documented between 01/22/18 through 01/30/18, and any new Physician's Orders received 01/22/18 through 01/30/18. 5. Licensed staff that were involved with the care of Resident #26 (6) and Resident #63 received additional training related to identification and communication of a resident's wishes regarding Advance Directives and code status, as well as including and honoring those wishes through implementation of the resident's care plan. The training included timely notification of a resident's physician and responsible party, as well as documentation of the notification. The training also included development and implementation of the comprehensive care plan which included the wishes of each resident related to their code status. Post-tests and staff interviews were completed to ensure comprehension of the training material. The training was completed 01/26/18 through 01/31/18 by the Director of Nursing, Staff Development Director. 6. All licensed and certified nursing staff and the Interdisciplinary Care Plan team (IDT) which consisted of MDS Nurse, Social Worker, Activity Director, and the Director of Dietary Services all received additional training beginning on 01/26/18 thru 01/31/18 related to: - identification and communication of a resident's wishes regarding Advance Directives and code status - honoring resident's code status wishes through the implementation of the resident's care plan -providing the necessary care and services such as emergency care, basic life support, and CPR to those residents in accordance with the resident's Advance Directives and wishes regarding code status -how to determine the code status of each resident according to facility protocols - assessing and responding to a resident in distress - timely notification of the physician - initiating a code - honoring the wishes of each resident with a full-code status - documenting care delivered - development and implementation of the comprehensive care plan which included the wishes of each resident related to their code status The training was completed by the Director of Nursing, Staff Development Director, and the Administrator. Post-tests and staff interviews were completed to ensure comprehension of the training material. Any staff member in the nursing department who was off work for any reason will not be permitted to work until training and post testing are completed. 7. On 01/27/18, the Administrator posted a listing of each resident and their desired code status at each nursing unit. The Administrator completed the list after the Advance Directives and CPR desires of each resident were validated through the audit completed on 01/26/18. Monitoring would include a daily review of this list by the Administrator or Assistant Administrator Monday through Friday. The weekend manager would review and update the listing on Saturday and Sunday. 8. Notification to a resident's physician, resident, and resident representative is monitored daily (Monday - Friday) in the Clinical Meeting. Attendees of the Clinical Meeting include the Director of Nursing, MDS Nurse, Social Workers, QA Nurse, and Unit Manager. The Clinical Meeting conducts a review of the following: 24-hour report, physician's telephone orders, nurse's notes, laboratory reports, resident events, changes in residents' condition, new admissions, and discharges. Any concerns identified are corrected immediately. 9. On 01/29/18, training, direction, and responsibility was assigned to Social Services for listing residents' wishes regarding Advance Directive on the residents' comprehensive care plan. The MDS Nurse will verify that Advance Directives are included on the care plan. This review will occur during Care Plan Conferences following the Resident Assessment Instrument (RAI) schedule. 10. On 01/29/18, a focus Performance Improvement Plan (PIP) Committee was formed by the QAPI Committee to review and monitor the facility's processes for obtaining and honoring residents' Advance Directives, code status, development and implementation of a care plan that meets the code status wishes of the resident, procedures for calling a code, and the conditions for implementing CPR to a full code resident. The PIP committee members included: The Administrator, Director of Nursing, Unit Managers, MDS Coordinator, Staff Development Coordinator, Social Services and Activity Director. The PIP Committee meets daily to focus on implementing the plan outlined herein, monitor results of audits and reviews, and provides additional direction as needed. The daily (Monday through Friday) PIP Committee meetings will continue until removal of the immediate jeopardy has been verified. Weekly QAPI meetings would continue to occur until sustained compliance was achieved. 11. The QAPI Committee will monitor and ensure sustained compliance is maintained through a weekly meeting. The members of this meeting will review all audits, training, and corrective actions generated by the focus PIP Committee. QAPI meetings will occur until sustained compliance is achieved. Information reviewed in this meeting will include: - Verbal report and a current Code Status List is reviewed and updated daily with any changes in the resident's Advance Directives and CPR status and is submitted by the Administrator or Assistant Administrator - The MDS Nurse will submit a verbal report and audit tool(s) related to the validation of the resident's code status during resident care plan conferences - The DON or QA Nurse will review the findings of the 24-hour report, physician's telephone orders, nurse's notes, laboratory tests, resident events, and changes in residents' condition identified in the morning clinical meetings and through routine clinical assessments, evaluations, and nurse management rounds, as well as a review of new admissions and discharges. The Daily Audit Tool will also be used to validate proper notification to physicians and the resident representative. - The DON or SDC will submit a verbal report, in-service logs and training agenda(s) regarding training or post testing completed. - The Social Worker will submit a verbal report and census list regarding any changes in Advance Directives or code status, including new admissions and re-admissions. - The DON or QA Nurse will give a verbal report and submit an audit tool related to any resident transfers to the hospital for urgent or critical care. The reports will include verification of proper notification, communication regarding resident's Advance Directives/code status prior to transfer, the Center's response to the resident's wishes, and the outcome of the transfer. - The committee will also discuss any new concerns identified through audits and reviews and applicable corrective action or changes. 12. On 03/02/18, a Long Term Care (LTC) consultant who is licensed as a Long Term Care Health Administrator in the state of Kentucky provided training to the Administrator of the facility for compliance with the federal and state regulations, quality assurance and performance improvement, efficient and effective use of resources, human resource development, and responsibilities of the Governing Body. Additionally, education was provided that according to §483.70 the facility must be administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. 13. On 03/02/18, the Administrator developed a Performance Improvement Team (PIT) to develop a Performance Improvement Plan (PIP) for the purposes of maintaining an effective nutrition/hydration status program. The PIT had the first meeting on 03/02/18 to develop, review, and monitor the resident nutrition/hydration status program. The PIT committee members include: the Administrator, Director of Nursing (DON), Unit Managers, Minimum Data Set (MDS) Coordinator, Staff Development Coordinator, and the internal auditors of nutrition/hydration status. 14. Effective 03/01/18, the Administrator and Director of Nursing have developed audit forms with the assistance of long term care consultants for all recently cited care and service areas. Auditors were appointed by the Administrator with the assistance of long term care consultants on 03/01/18. Education regarding the use of the audit forms was provided to the auditors on 03/01/18, by the Administrator and the long term care consultants. Effective 03/02/18, the audits will identify residents at risk for the cited deficiencies in the areas of assisted nutrition and hydration. The Administrator and Director of Nursing are involved with all compliance and corrective actions taken to correct any alleged deficiency and have assured that the following corrective actions have identified any resident who may be affected. 15. On 03/02/18, the Administrator reviewed the members of the Quality Assurance Committee. These members conform with the requirements of the current regulations and include the Administrator, Medical Director, Director of Nursing, Unit Managers, MDS Coordinator, Staff Development Coordinator, Pharmacy Representative, Social Services Director and Activities Director. 16. Residents #1, #85 (5), #48, #53 (12), and #147 (H) were assessed by the RD from 01/19/18 through 03/02/18. The residents' physicians were notified with any new recommendations. From 01/13/18 through 03/02/18, a licensed nurse conducted a dehydration risk assessment and no additional interventions were recommended. In addition, on 03/03/18, a fluid intake audit was completed for Residents #48, #53, and #147, and the residents were meeting or exceeding their fluid needs. Resident #1 was discharged from the facility on 01/29/18, and is no longer a resident. Resident #85 (5) was discharged from the facility on 02/01/18, and is no longer a resident at the facility. 17. On 02/08/18, a representative from Medline Industries (Medline is the facility provider for feeding tube pumps), completed a Quality Assurance audit of all feeding pumps to ensure function and accuracy. All pumps were found to be in working order. Beginning on 02/08/18 and completed on 02/13/18, the representative and the Director of Nursing (DON) provided education regarding operation and use of the pumps to all licensed nurses and nurses completed a return demonstration. 18. On 03/01/18, implementation began to convert electronic documentation of Food and Fluid Consumption to paper documentation. Education began on 03/02/18 and continued through 03/04/18. Employees not having been in-serviced by 03/04/18 will not be allowed to work until education is completed. Food and fluids consumed daily with resident meals, snacks, and medication administration will be recorded on the Food and Fluid Consumption Sheet. The night shift Charge Nurse will calculate the fluids consumed and compare to the recommended fluid needs calculated by the RD. Residents not meeting the estimated daily fluid needs will be noted on the 24-hour report log for increased monitoring. The resident/resident representative and the resident's physician will be notified if a resident does not consume a daily average of 50% of routine meals without substitutes and supplements for three (3)consecutive days. Food and fluid intake documentation will be monitored daily Monday through Friday by the Unit Managers and the Weekend Manager will monitor on Saturday and Sunday. 19. Licensed Nurses completed Dehydration Risk Assessments for all residents on 03/02/18 and 03/03/18. Any concerns identified during this evaluation were addressed immediately with physician notification, care plan review, and care plan updates as indicated. From 03/02/18 to 03/04/18, a fluid intake audit was completed by comparing the individual fluid needs of all residents to each residents' average fluid consumption from 02/21/18 through 02/27/18. This audit was completed by the Director of Nursing, Unit Manager, MDS Nurse, Administrator, and Assistant Administrator. Any resident not meeting their estimated fluid need was evaluated, notifications were made if indicated to the physician and resident/resident representative, and care plans were reviewed and updated as needed. 20. On 03/03/18, the Tube Feeding Intake Worksheet was implemented to monitor and track formula and fluids administered to residents with tube feeding. This worksheet will be completed at the end of each shift by the licensed nurse. The Unit Manager, Weekend Manager, or designated Nurse Manager will review the Tube Feeding Intake Worksheet daily to ensure residents receiving tube feeding formula and/or fluids receive the amount prescribed by the physician. If reviews indicate that the intake administered is below the prescribed amount, a quality assurance check will be performed on the feeding pump, a dehydration risk assessment will be completed by a licensed nurse, and the physician and resident/resident representative will be notified. An additional review of the Tube Feeding Intake Worksheet will occur daily Monday through Friday by the Quality Assurance Nurse (QA Nurse). 21. On 03/02/18, the DON reviewed all resident weights for significant/severe weight loss. Any resident identified as having new weight loss was evaluated, the resident/responsible representative and the resident's physician were notified, and the resident's comprehensive care plan was reviewed and updated, if indicated. 22. Routine and weekly weights will be obtained by the Restorative Aides, recorded on a resident weight worksheet, and submitted to the Unit Manager for review. Weights will be logged into the medical record after review by the Unit Manager. Once weights are logged, the Director of Nursing will review the computer-generated weight change report weekly on Tuesday prior to the Nutrition at Risk Committee (NAR) meeting. Residents identified to be at risk for nutrition and hydration decline are monitored by the Interdisciplinary NAR Committee. Members of the NAR Committee include the Director of Nursing, the Unit Managers, the Registered Dietitian, the Dietary Manager, the MDS Nurse, and the QA Nurse. The NAR Committee reviews at risk residents' intake, weight, and hydration status. The NAR Committee will review the daily Food and Fluid Consumption Sheets, the daily Tube Feeding Intake Worksheets, and the computer generated weight variance report that are completed each Tuesday by the DON. 23. The Dietary Manager will conduct an additional nutrition and hydration audit daily (Monday through Friday) to ensure any resident not meeting minimal nutrition and hydration requirements have been addressed as needed. 24. The Governing Body is providing oversight through a contract with a Management Company. On 03/02/18, the Long Term Care Consultants with the Management Company (a Registered Nurse and a Licensed Health Care Administrator) provided education to the Governing Body related to the responsibilities of the Governing Body as promulgated in §483.70. The education included the responsibilities of the Governing Body to include the establishment and implementation of policies regarding the management and operation of the facility. The Governing Body has directed that all resources and administration abate deficient practice at nutrition/hydration to include corrective actions for those residents affected. The Management Company oversees the daily operations of the facility and utilizes contracted consultants as necessary for the operation. The consultants have extensive experience and education in the area of operating long term care facilities and are not employees of the facility, but rather act as an outside resource in providing advice and consultation to the management staff of the facility. The Administrator, who was appointed by the Governing Body on 03/07/14, is responsible for the daily management of the facility, and reports and is accountable to the Governing Body. The Governing Board meets with the Management Company each month. 25. The PIP Committee meets daily to focus on implementing the plan outlined herein, monitor results of audits and reviews, and provides additional direction as needed. The daily (Monday through Friday) PIP Committee meetings will continue until removal of the[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and review of facility policy, it was determined the facility failed to provide basic life support to a resident requiring emergency care prior to the arrival of emergency medical personnel for one (1) of thirty-seven (37) sampled residents (Resident #26 (6)). On 01/12/18, at 3:45 PM, staff assessed Resident #26 (6) to have a low blood pressure, pale skin, and labored breathing. However, the facility failed to continue to assess the resident and provide basic life support and Cardiopulmonary Resuscitation (CPR) if needed. Further, the facility failed to activate EMS until fifty-three minutes after the resident's decline. When EMS arrived, Resident #26 (6) had no pulse and was not breathing, and expired at the hospital on [DATE] at 5:11 PM (Refer to F580, F656, F658, and F842). The facility's failure to ensure residents received basic life support has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 01/26/18, and determined to exist on 01/09/18 at 42 CFR 483.10 Resident Rights (F578 and F580), 42 CFR 483.21 Comprehensive Person-Centered Care Planning (F656 and F658), 42 CFR 483.24 Quality of Life (F678), and 42 CFR 483.70 Administration (F842). The facility was notified of the Immediate Jeopardy on 01/26/18. After supervisory review, Immediate Jeopardy was identified on 03/01/18 and determined to exist on 12/12/17 at 42 CFR 483.25 Quality of Care (F692 ) and 42 CFR 483.70 Administration (F835, F837). The facility was notified of the Immediate Jeopardy on 03/01/18 at 42 CFR 483.25 Quality of Care (F692), and 42 CFR 483.70 Administration (F835 and F837). An acceptable Allegation of Compliance was received on 03/05/18, which alleged removal of the Immediate Jeopardy on 03/05/18. The State Survey Agency determined the Immediate Jeopardy was removed on 03/05/18, prior to exit, which lowered the scope and severity to D at at 42 CFR 483.10 Resident Rights (F578 and F580), 42 CFR 483.21 Comprehensive Person-Centered Care Planning (F658), 42 CFR 483.24 Quality of Life (F678), 42 CFR 483.25 Quality of Care (F692 ) and 42 CFR 483.70 Administration (F835, F837, and 842), and to an E at 42 CFR 483.21 Comprehensive Person-Centered Care Planning (F656), while the facility monitors the effectiveness of systemic changes and quality assurance activities. The findings include: Review of the facility's Emergency Procedure-Cardiopulmonary Resuscitation policy revised August 2011, revealed cardiac arrest may initially result in gasping respirations or appear to be seizure activity. Training for basic life support should include recognizing these atypical presentations. The chances of surviving sudden cardiac arrest may be increased if Cardiopulmonary Resuscitation (CPR) is initiated immediately. The policy further stated facility staff had completed training on the initiation of Cardiopulmonary Resuscitation (CPR)/Basic Life Support (BLS) in victims of sudden cardiac arrest. Review of Resident #26's (6) closed medical record revealed the facility admitted the resident on 06/14/16, with a readmission date of 01/09/18, with diagnoses of Alzheimer's Disease, Dysphagia, Gastrostomy tube, Trauma related to a Subdural Hematoma, and Multiple Rib Fractures. Review of the resident's Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of two (2), which indicated the resident had severe cognitive impairment. Review of Resident 26's (6) Emergency Medical Services Do Not Resuscitate Order, not dated, and review of a facility CPR form (untitled) dated 06/14/16, revealed the resident wished to have CPR performed and was designated as a full code. Review of Resident #26's (6) Physician's Orders for January 2018 revealed the resident's code status was full code. Interview with Licensed Practical Nurse (LPN) #12 on 01/21/18 at 2:45 PM; on 01/24/18 at 4:58 PM; and on 01/25/18 at 11:13 AM and 1:30 PM, and review of the Nursing Notes dated 01/12/18 at 3:45 PM, revealed Resident #26's (6) skin was pale, breathing was labored, respirations were 24 (normal is 18), and blood pressure was 90/60 (normal is 120/80). LPN #12 stated she reviewed Resident #26's (6) medical record, determined the resident was a full code, and called the first floor Unit Manager (UM) to request assistance because the resident was actively dying. LPN #12 stated Resident #26 (6) continued to decline and was going downhill. LPN #12 stated the resident's breathing got worse, and his/her blood pressure and pulse continued to drop. Continued interview with LPN #12 revealed she contacted EMS to transport the resident to the hospital and did not call a code because she . thought EMS would get there in time. However, LPN #12 stated she did not notify EMS immediately when the resident was assessed to have a change in condition because she was trying to get the paper work ready for the resident's transfer. Interview with Unit Manager (UM) #2 on 01/25/18 at 10:55 AM revealed on 01/12/18, LPN #12 notified her that Resident #26 (6) was sick and dying and asked about moving the resident's roommate. However, the UM stated she did not check on Resident #26 (6) until after EMS arrived and was transporting the resident out of the facility. Review of facility video footage for 01/12/18 confirmed Licensed Practical Nurse (LPN) #12 was in Resident #26's (6) room at 3:40 PM, and exited the room less than one minute later. Further review of the video footage from 3:42 PM to 4:37 PM revealed LPN #12 entered and exited Resident #26's (6) room five (5) times, staying approximately one minute or less each time, and was observed to have no medical equipment when entering or exiting the room. Observation revealed Resident #26 (6) was alone in his/her room, with no staff present for nine (9) minutes. At 4:46 PM, LPN #12 was observed to enter Resident #26's (6) room with EMS. Review of the Fire-EMS Prehospital Care Report dated 01/12/18, and interview with Emergency Medical Services Provider #1 on 01/24/18 at 8:30 PM, revealed they did not receive a call from the facility requesting emergency services for Resident #26 (6) until 4:38 PM on 01/12/18, approximately fifty-three (53) minutes after the resident was assessed to have a change in condition. According to the EMS report, facility staff reported that Resident #26 (6) had a low blood pressure and staff advised Patient had been congested. Further review of the report revealed when EMS arrived to Resident #26's (6) room at 4:50 PM, accompanied by staff [LPN #12], the resident had no pulse and was not breathing, and the staff member [LPN #12] stated, Well I believe (he/she) is already gone. Continued review of the EMS report revealed facility staff advised EMS that the resident was a full code, and Cardiopulmonary Resuscitation (CPR) was initiated by EMS staff. EMS continued CPR during transport to the hospital. Interview with Kentucky Medication Assistant (KMA) #1 on 01/24/18 at 5:56 PM revealed she was working on 01/12/18 when Resident #26 (6) passed away. She stated LPN #12 called UM #2 and told her that Resident #26 (6) was actively dying. She stated she went into Resident #26's (6) room with LPN #12 when EMS arrived, and LPN #12 yelled (He/She) is already dead, get the crash cart. Review of Resident #26's (6) Emergency Department (ED) record revealed the resident presented to the ED with CPR in progress by EMS at 5:09 PM, on 01/12/18, and was pronounced dead at 5:11 PM, three (3) minutes after arrival. The facility implemented the following for removal of jeopardy: 1. On 01/26/18, the Administrator provided an in-service to the Director of Nursing, Minimum Data Set (MDS) Nurse, and the Quality Assurance (QA) Nurse regarding the development and implementation of a comprehensive care plan that included the wishes of each resident related to code status. 2. The policies and procedures were reviewed and updated regarding physician notification and obtaining, documenting, and honoring the wishes of each resident for Advance Directives/Code Status by the PIP Committee on 01/29/18. The resident's wishes for Advance Directives and code status will be obtained upon admission by Social Services and the admission Director. Code status designations will be documented in the physician's orders, in the resident care plan, and on the resident's face sheet. Residents choosing a DNR code status will sign a completed No Code or DNR consent form that will be maintained in the resident's medical record. Residents without an Advance Directive will be considered a Full Code. The Advance Directives and Code Status policies were reviewed, updated, and approved by the QAPI Committee on 01/29/18. 3. On 01/26/18, a comprehensive audit was completed by the Administrator, MDS Nurse, Assistant Administrator, Director of Nursing (DON), QA Nurse, Unit Manager, Activities Director, Admissions Director, and Social Workers for every resident in the facility. The audit was a review of each resident's Advance Directive and code status that included physician orders, Advance Directive designation forms, consent forms, paper record, electronic record, and face sheets with no variances noted. The residents' comprehensive care plans were also reviewed and updated as needed to assure residents' Advance Directives and wishes for code status were included on the plan of care. These audits were conducted at the direction of the Quality Assurance and Performance Improvement (QAPI) Committee and completed on 01/26/18. Members of the QAPI committee included: The Administrator, Director of Nursing, Unit Managers, Medical Director, MDS Coordinator, Staff Development Coordinator, Pharmacy Representative, Social Services Director, and Activity Director. Completed audits were submitted to the QAPI Committee for additional review. 4. The Director of Nursing, Quality Assurance Nurse, Unit Manager, and MDS Nurse completed a focus review to ensure proper notification occurred for changes in resident condition. The audit included review of residents transferred to the hospital within the prior week, all Nurse's Notes documented between 01/22/18 through 01/30/18, and any new Physician's Orders received 01/22/18 through 01/30/18. 5. Licensed staff that were involved with the care of Resident #26 (6) and Resident #63 received additional training related to identification and communication of a resident's wishes regarding Advance Directives and code status, as well as including and honoring those wishes through implementation of the resident's care plan. The training included timely notification of a resident's physician and responsible party, as well as documentation of the notification. The training also included development and implementation of the comprehensive care plan which included the wishes of each resident related to their code status. Post-tests and staff interviews were completed to ensure comprehension of the training material. The training was completed 01/26/18 through 01/31/18 by the Director of Nursing, Staff Development Director. 6. All licensed and certified nursing staff and the Interdisciplinary Care Plan team (IDT) which consisted of MDS Nurse, Social Worker, Activity Director, and the Director of Dietary Services all received additional training beginning on 01/26/18 thru 01/31/18 related to: - identification and communication of a resident's wishes regarding Advance Directives and code status - honoring resident's code status wishes through the implementation of the resident's care plan -providing the necessary care and services such as emergency care, basic life support, and CPR to those residents in accordance with the resident's Advance Directives and wishes regarding code status -how to determine the code status of each resident according to facility protocols - assessing and responding to a resident in distress - timely notification of the physician - initiating a code - honoring the wishes of each resident with a full-code status - documenting care delivered - development and implementation of the comprehensive care plan which included the wishes of each resident related to their code status The training was completed by the Director of Nursing, Staff Development Director, and the Administrator. Post-tests and staff interviews were completed to ensure comprehension of the training material. Any staff member in the nursing department who was off work for any reason will not be permitted to work until training and post testing are completed. 7. On 01/27/18, the Administrator posted a listing of each resident and their desired code status at each nursing unit. The Administrator completed the list after the Advance Directives and CPR desires of each resident were validated through the audit completed on 01/26/18. Monitoring would include a daily review of this list by the Administrator or Assistant Administrator Monday through Friday. The weekend manager would review and update the listing on Saturday and Sunday. 8. Notification to a resident's physician, resident, and resident representative is monitored daily (Monday - Friday) in the Clinical Meeting. Attendees of the Clinical Meeting include the Director of Nursing, MDS Nurse, Social Workers, QA Nurse, and Unit Manager. The Clinical Meeting conducts a review of the following: 24-hour report, physician's telephone orders, nurse's notes, laboratory reports, resident events, changes in residents' condition, new admissions, and discharges. Any concerns identified are corrected immediately. 9. On 01/29/18, training, direction, and responsibility was assigned to Social Services for listing residents' wishes regarding Advance Directive on the residents' comprehensive care plan. The MDS Nurse will verify that Advance Directives are included on the care plan. This review will occur during Care Plan Conferences following the Resident Assessment Instrument (RAI) schedule. 10. On 01/29/18, a focus Performance Improvement Plan (PIP) Committee was formed by the QAPI Committee to review and monitor the facility's processes for obtaining and honoring residents' Advance Directives, code status, development and implementation of a care plan that meets the code status wishes of the resident, procedures for calling a code, and the conditions for implementing CPR to a full code resident. The PIP committee members included: The Administrator, Director of Nursing, Unit Managers, MDS Coordinator, Staff Development Coordinator, Social Services and Activity Director. The PIP Committee meets daily to focus on implementing the plan outlined herein, monitor results of audits and reviews, and provides additional direction as needed. The daily (Monday through Friday) PIP Committee meetings will continue until removal of the immediate jeopardy has been verified. Weekly QAPI meetings would continue to occur until sustained compliance was achieved. 11. The QAPI Committee will monitor and ensure sustained compliance is maintained through a weekly meeting. The members of this meeting will review all audits, training, and corrective actions generated by the focus PIP Committee. QAPI meetings will occur until sustained compliance is achieved. Information reviewed in this meeting will include: - Verbal report and a current Code Status List is reviewed and updated daily with any changes in the resident's Advance Directives and CPR status and is submitted by the Administrator or Assistant Administrator - The MDS Nurse will submit a verbal report and audit tool(s) related to the validation of the resident's code status during resident care plan conferences - The DON or QA Nurse will review the findings of the 24-hour report, physician's telephone orders, nurse's notes, laboratory tests, resident events, and changes in residents' condition identified in the morning clinical meetings and through routine clinical assessments, evaluations, and nurse management rounds, as well as a review of new admissions and discharges. The Daily Audit Tool will also be used to validate proper notification to physicians and the resident representative. - The DON or SDC will submit a verbal report, in-service logs and training agenda(s) regarding training or post testing completed. - The Social Worker will submit a verbal report and census list regarding any changes in Advance Directives or code status, including new admissions and re-admissions. - The DON or QA Nurse will give a verbal report and submit an audit tool related to any resident transfers to the hospital for urgent or critical care. The reports will include verification of proper notification, communication regarding resident's Advance Directives/code status prior to transfer, the Center's response to the resident's wishes, and the outcome of the transfer. - The committee will also discuss any new concerns identified through audits and reviews and applicable corrective action or changes. 12. On 03/02/18, a Long Term Care (LTC) consultant who is licensed as a Long Term Care Health Administrator in the state of Kentucky provided training to the Administrator of the facility for compliance with the federal and state regulations, quality assurance and performance improvement, efficient and effective use of resources, human resource development, and responsibilities of the Governing Body. Additionally, education was provided that according to §483.70 the facility must be administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. 13. On 03/02/18, the Administrator developed a Performance Improvement Team (PIT) to develop a Performance Improvement Plan (PIP) for the purposes of maintaining an effective nutrition/hydration status program. The PIT had the first meeting on 03/02/18 to develop, review, and monitor the resident nutrition/hydration status program. The PIT committee members include: the Administrator, Director of Nursing (DON), Unit Managers, Minimum Data Set (MDS) Coordinator, Staff Development Coordinator, and the internal auditors of nutrition/hydration status. 14. Effective 03/01/18, the Administrator and Director of Nursing have developed audit forms with the assistance of long term care consultants for all recently cited care and service areas. Auditors were appointed by the Administrator with the assistance of long term care consultants on 03/01/18. Education regarding the use of the audit forms was provided to the auditors on 03/01/18, by the Administrator and the long term care consultants. Effective 03/02/18, the audits will identify residents at risk for the cited deficiencies in the areas of assisted nutrition and hydration. The Administrator and Director of Nursing are involved with all compliance and corrective actions taken to correct any alleged deficiency and have assured that the following corrective actions have identified any resident who may be affected. 15. On 03/02/18, the Administrator reviewed the members of the Quality Assurance Committee. These members conform with the requirements of the current regulations and include the Administrator, Medical Director, Director of Nursing, Unit Managers, MDS Coordinator, Staff Development Coordinator, Pharmacy Representative, Social Services Director and Activities Director. 16. Residents #1, #85 (5), #48, #53 (12), and #147 (H) were assessed by the RD from 01/19/18 through 03/02/18. The residents' physicians were notified with any new recommendations. From 01/13/18 through 03/02/18, a licensed nurse conducted a dehydration risk assessment and no additional interventions were recommended. In addition, on 03/03/18, a fluid intake audit was completed for Residents #48, #53, and #147, and the residents were meeting or exceeding their fluid needs. Resident #1 was discharged from the facility on 01/29/18, and is no longer a resident. Resident #85 (5) was discharged from the facility on 02/01/18, and is no longer a resident at the facility. 17. On 02/08/18, a representative from Medline Industries (Medline is the facility provider for feeding tube pumps), completed a Quality Assurance audit of all feeding pumps to ensure function and accuracy. All pumps were found to be in working order. Beginning on 02/08/18 and completed on 02/13/18, the representative and the Director of Nursing (DON) provided education regarding operation and use of the pumps to all licensed nurses and nurses completed a return demonstration. 18. On 03/01/18, implementation began to convert electronic documentation of Food and Fluid Consumption to paper documentation. Education began on 03/02/18 and continued through 03/04/18. Employees not having been in-serviced by 03/04/18 will not be allowed to work until education is completed. Food and fluids consumed daily with resident meals, snacks, and medication administration will be recorded on the Food and Fluid Consumption Sheet. The night shift Charge Nurse will calculate the fluids consumed and compare to the recommended fluid needs calculated by the RD. Residents not meeting the estimated daily fluid needs will be noted on the 24-hour report log for increased monitoring. The resident/resident representative and the resident's physician will be notified if a resident does not consume a daily average of 50% of routine meals without substitutes and supplements for three (3)consecutive days. Food and fluid intake documentation will be monitored daily Monday through Friday by the Unit Managers and the Weekend Manager will monitor on Saturday and Sunday. 19. Licensed Nurses completed Dehydration Risk Assessments for all residents on 03/02/18 and 03/03/18. Any concerns identified during this evaluation were addressed immediately with physician notification, care plan review, and care plan updates as indicated. From 03/02/18 to 03/04/18, a fluid intake audit was completed by comparing the individual fluid needs of all residents to each residents' average fluid consumption from 02/21/18 through 02/27/18. This audit was completed by the Director of Nursing, Unit Manager, MDS Nurse, Administrator, and Assistant Administrator. Any resident not meeting their estimated fluid need was evaluated, notifications were made if indicated to the physician and resident/resident representative, and care plans were reviewed and updated as needed. 20. On 03/03/18, the Tube Feeding Intake Worksheet was implemented to monitor and track formula and fluids administered to residents with tube feeding. This worksheet will be completed at the end of each shift by the licensed nurse. The Unit Manager, Weekend Manager, or designated Nurse Manager will review the Tube Feeding Intake Worksheet daily to ensure residents receiving tube feeding formula and/or fluids receive the amount prescribed by the physician. If reviews indicate that the intake administered is below the prescribed amount, a quality assurance check will be performed on the feeding pump, a dehydration risk assessment will be completed by a licensed nurse, and the physician and resident/resident representative will be notified. An additional review of the Tube Feeding Intake Worksheet will occur daily Monday through Friday by the Quality Assurance Nurse (QA Nurse). 21. On 03/02/18, the DON reviewed all resident weights for significant/severe weight loss. Any resident identified as having new weight loss was evaluated, the resident/responsible representative and the resident's physician were notified, and the resident's comprehensive care plan was reviewed and updated, if indicated. 22. Routine and weekly weights will be obtained by the Restorative Aides, recorded on a resident weight worksheet, and submitted to the Unit Manager for review. Weights will be logged into the medical record after review by the Unit Manager. Once weights are logged, the Director of Nursing will review the computer-generated weight change report weekly on Tuesday prior to the Nutrition at Risk Committee (NAR) meeting. Residents identified to be at risk for nutrition and hydration decline are monitored by the Interdisciplinary NAR Committee. Members of the NAR Committee include the Director of Nursing, the Unit Managers, the Registered Dietitian, the Dietary Manager, the MDS Nurse, and the QA Nurse. The NAR Committee reviews at risk residents' intake, weight, and hydration status. The NAR Committee will review the daily Food and Fluid Consumption Sheets, the daily Tube Feeding Intake Worksheets, and the computer generated weight variance report that are completed each Tuesday by the DON. 23. The Dietary Manager will conduct an additional nutrition and hydration audit daily (Monday through Friday) to ensure any resident not meeting minimal nutrition and hydration requirements have been addressed as needed. 24. The Governing Body is providing oversight through a contract with a Management Company. On 03/02/18, the Long Term Care Consultants with the Management Company (a Registered Nurse and a Licensed Health Care Administrator) provided education to the Governing Body related to the responsibilities of the Governing Body as promulgated in §483.70. The education included the responsibilities of the Governing Body to include the establishment and implementation of policies regarding the management and operation of the facility. The Governing Body has directed that all resources and administration abate deficient practice at nutrition/hydration to include corrective actions for those residents affected. The Management Company oversees the daily operations of the facility and utilizes contracted consultants as necessary for the operation. The consultants have extensive experience and education in the area of operating long term care facilities and are not employees of the facility, but rather act as an outside resource in providing advice and consultation to the management staff of the facility. The Administrator, who was appointed by the Governing Body on 03/07/14, is responsible for the daily management of the facility, and reports and is accountable to the Governing Body. The Governing Board meets with the Management Company each month. 25. The PIP Committee meets daily to focus on implementing the plan outlined herein, monitor results of audits and reviews, and provides additional direction as needed. The daily (Monday through Friday) PIP Committee meetings will continue until removal of the immediate jeopardy has been verified. 26. The Quality Assurance and Performance Improvement (QAPI) policies were reviewed on 03/02/18 by the Long Term Care Consultant and the Administrator with no changes noted. The QAPI policies are in conformance with the current regulatory standards and no changes were necessary. The QAPI Committee reviewed the QAPI policies on 03/22/18 with acceptance. On 03/02/18, the Administrator provided education to the Quality Assurance and Assessment (QAA) Committee related to the policies and the structure of the Quality Assurance and Assessment (QAA) program. The Administrator with the assistance of the long term care consultant developed new tools that are to be used for the Performance Improvement Team (PIT) that includes a new tool for a Performance Improvement Plan (PIP). These new tools are used for the PIP for the abatement of Immediate Jeopardy. Weekly QAPI meetings will be held and will continue to occur until sustained compliance is achieved. The completed PIP will be submitted to the weekly meetings of the QAPI Committee for approval and suggestions. 27. The Administration of the facility to include the Administrator and Director of Nursing are conferring daily with long term care consultants to monitor administration's role with the abatement of jeopardy beginning 03/02/18. The SSA verified the removal of immediate jeopardy by the following: 1. Review of the in-service roster dated 01/26/18, revealed the DON, MDS Nurse, and the QA Nurse had attended an in-service by the Administrator related to the development and implementation of a comprehensive care plan to ensure the wishes of each resident and their code status was included on the care plan. Interviews conducted with the MDS Nurse on 02/16/18 at 1:04 PM; the QA Nurse on 02/16/18 at 1:22 PM; and, the DON on 02/16/18 at 2:00 PM, revealed they attended the in-service provided by the Administrator and began providing in-services for other staff on 01/29/18. 2. Review of the facility's policies and in-service rosters regarding Advance Directives and Code Status revealed the facility reviewed and updated the policies on 01/29/18. The policies revealed the facility's new process to ensure Advance Directives/Wishes were honored was as follows: the physician would be notified after obtaining the resident's/ responsible party's consent, documenting the consent, and honoring the resident's wishes for Advance Directives and Code Status. The policy revealed the resident's wishes for Advance Directives and code status would be obtained upon admission by Social Services and the admission Director. This would be documented in the physician's orders, resident care plan, and on the resident's face sheet. Interviews conducted with the Unit Manager on 02/16/18 at 11:04 AM, SSD on 02/16/18 at 11:25 AM, Activities Director on 02/16/18 at 12:59 PM, MDS Nurse on 02/16/18 at 1:04 PM, QA Nurse on 02/16/18 at 1:22 PM, Assistant Administrator on 02/16/18 at 1:40 PM, DON on 02/16/18 at 2:00 PM, and the Administrator on 02/16/18 at 2:10 PM, revealed they had reviewed/updated the facility's policies regarding Advance Directives and Code Status. 3. Review of audit sheets completed by the Administrator, MDS Nurse, Assistant Administrator, DON, QA Nurse, Unit Manager, Activities Director, Admissions Director, and Social Worker revealed an audit was conducted for all residents to ensure the resident's code status/Advance Directive was accurately documented on the physician's orders, designation forms, and consent forms. Interviews conducted with the Admissions Director on 02/16/18 at 11:00 AM, Unit Manager on 02/16/18 at 11:04 AM, SSD on 02/16/18 at 11:25 AM, Activities Director on 02/16/18 at 12:59 PM, MDS Nurse on 02/16/18 at 1:04 PM, QA Nurse on 02/16/18 at 1:22 PM, Assistant Administrator on 02/16/18 at 1:40 PM, DON on 02/16/18 at 2:00 PM, and the Administrator on 02/16/18 at 2:10 PM, revealed they had conducted audits on every resident to ensure the resident's code status/Advance Directive was accurate on the physician's orders, designation forms, and consent forms. They also revealed the audits were then reviewed in the facility's QAPI meeting. 4. Review of audits completed by the DON, QA Nurse, Unit Manager, and MDS Nurse, revealed all residents had been reviewed for any change in their condition, Nurses' Notes reviewed, any new Physician's Orders and transfers from 01/22/18 through 01/30/18. Interviews conducted with the Unit Manager on 02/16/18 at 11:04 AM, the MDS Nurse on 02/16/18 at 1:04 PM, QA Nurse on 02/16/18 at 1:22 PM, and the DON on 02/16/18 at 2:00 PM, revealed they completed the reviews regarding any residents who were transferred to the hospital, including their nurses notes and any new physician's orders 01/22/18 through 01/30/18. 5. Review of staff in-service rosters, posttests, and interviews dated 01/26/18, revealed LPN #12, LPN #14, and SRNA #4 attended in-services by the DON and SDC regarding: - Advance Directives - Code Status - Implementation of the care plan which included wishes of the resident related to their code status - Timely notification of the physician and responsible party - Documentation of the notification of the physician and responsible party

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and review of facility policies, it was determined the facility failed to ensure six (6) of thirty-seven (37) sampled residents maintained acceptable parameters of nutritional/hydration status. Residents #53 (12), #147 (H), and #85 (5) sustained severe weight loss while in the facility. Although the facility recognized Residents #53 (12) lost weight, the facility failed to recognize that the 14 percent severe weight loss (21 pounds) in 15 days possibly resulted from not meeting his/her tube feeding needs, and implemented no interventions to prevent further loss. In addition, the resident's physician recommended the resident's tube feeding be increased on 01/30/18; however, the facility failed to increase the feeding for two days (Refer F580 and F656). Four days after admission to the facility, the Dietitian recommended Resident #147 (H) receive a health shake because the resident's food intake was low. However, the facility failed to provide the health shakes as recommended. Resident #147 (H) sustained further weight loss that the facility failed to identify for seven days. When the Dietitian eventually identified the resident had sustained weight loss, she recommended a multivitamin and snacks for the resident; however, the facility again failed to implement the recommendations and the resident lost four (4) additional pounds for a total of 8.9 percent weight loss (17 pounds) in eighteen (18) days (severe weight loss) (F580 and F656). In addition, the facility failed to recognize Resident #85 (5) was not receiving tube feeding as ordered and had sustained an 8% weight loss in fifteen days; subsequently, the facility failed to implement interventions to prevent further weight loss (Refer to F580, F656, F725, and F842). The facility's failure to ensure residents maintained acceptable parameters of nutrition and received sufficient fluid intake has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 01/26/18, and determined to exist on 01/09/18 at 42 CFR 483.10 Resident Rights (F578 and F580), 42 CFR 483.21 Comprehensive Person-Centered Care Planning (F656 and F658), 42 CFR 483.24 Quality of Life (F678), and 42 CFR 483.70 Administration (F842). The facility was notified of the Immediate Jeopardy on 01/26/18. After supervisory review, Immediate Jeopardy was identified on 03/01/18 and determined to exist on 12/12/17 at 42 CFR 483.25 Quality of Care (F692 ) and 42 CFR 483.70 Administration (F835, F837). The facility was notified of the Immediate Jeopardy on 03/01/18 at 42 CFR 483.25 Quality of Care (F692), and 42 CFR 483.70 Administration (F835 and F837). An acceptable Allegation of Compliance was received on 03/05/18, which alleged removal of the Immediate Jeopardy on 03/05/18. The State Survey Agency determined the Immediate Jeopardy was removed on 03/05/18, prior to exit, which lowered the scope and severity to D at at 42 CFR 483.10 Resident Rights (F578 and F580), 42 CFR 483.21 Comprehensive Person-Centered Care Planning (F658), 42 CFR 483.24 Quality of Life (F678), 42 CFR 483.25 Quality of Care (F692 ) and 42 CFR 483.70 Administration (F835, F837, and 842), and to an E at 42 CFR 483.21 Comprehensive Person-Centered Care Planning (F656), while the facility monitors the effectiveness of systemic changes and quality assurance activities. In addition, the facility failed to provide Residents #48 and #53 the physician's ordered tube feeding to meet the resident's caloric needs and failed to ensure Residents #1, #85 (5), #147 (H), #53 (12), and #48 received sufficient fluid intake to maintain proper hydration. Interviews with staff revealed the facility failed to have an effective system to ensure physician ordered water flushes were provided to residents. Although interviews with the Director of Nursing revealed the facility had a system in place for monitoring resident intake to ensure residents were receiving appropriate hydration, the facility failed to identify that the system was not effective. The findings include: 1. Review of the facility's policy titled Weight Program dated 12/16/16, revealed the Registered Dietitian (RD) and licensed nurses were responsible for reviewing each resident with identified weight loss and recommending appropriate interventions. Review of the facility's policy titled Nutritionally at Risk (NAR) dated 12/16/16, revealed the NAR Committee would monitor and intervene in the care of residents related to weight loss. Review of the facility's Enteral Nutrition policy dated December 2008, revealed a dietitian would assess residents to ensure they were receiving enteral feedings to ensure nutritional adequacy. The policy further stated enteral feeding orders would be written to ensure consistent volume infusion. 1. a. Review of the medical record revealed the facility admitted Resident #53 (12) on 11/30/17, and readmitted the resident on 12/30/17, with diagnoses that included Pneumonia, Hypertension, Alzheimer's Disease, and Dementia. Review of the admission Minimum Data Set (MDS) dated [DATE], revealed Resident #53 (12) was cognitively impaired, received a mechanically altered diet, and weighed 143 pounds. Further review of Resident #53's (12) record revealed the resident was readmitted to the facility on [DATE], after receiving a feeding tube. A review of the resident's progress notes dated 12/31/17, revealed the resident's readmission weight was 143 pounds. Review of Resident #53's (12) Physician's Orders dated 12/30/17, revealed an order to administer Jevity (type of tube feeding) 1.5 at 60 milliliters (ml) per hour (1440 ml per day). Review of a Dietary Note dated 01/05/18, completed after Resident #53 (12) received a feeding tube, revealed the resident's weight was 143 pounds, and would receive all nutrition via tube feeding. The dietitian estimated the resident's nutritional needs were 1950-2275 calories per day, and Jevity 1.5 at 60 ml per hour provided 1980 calories. Review of the resident's Intake and Output record for 01/01/18 through 01/22/18, revealed the resident did not meet his/her nutritional needs on eighteen of twenty-two days. The resident's tube feeding intake ranged from 0-1440 ml per day, with an average of approximately 840 ml of tube feeding per day, approximately 600 ml less per day than the resident required. Review of Resident #53's (12) weight record dated 01/08/18, revealed Resident #53 (12) weighed 135 pounds, an eight-pound weight loss. Review of a NAR Note dated 01/08/18, revealed the Committee recognized the resident had sustained an eight-pound weight loss, but failed to identify the resident was not receiving his/her tube feeding as ordered and failed to implement interventions to prevent further weight loss. Further review of Resident #53's (12) weight record revealed the resident continued to sustain weight loss and on 01/15/18 weighed 122 pounds, a total weight loss of 21 pounds (14 percent body weight) in fifteen days. Review of a NAR Note dated 01/15/18, revealed the Committee again recognized that the resident had sustained additional weight loss, but again failed to recognize that the resident was not meeting his/her nutritional needs and only recommended the resident be weighed daily for seven (7) days and to obtain a prealbumin and total protein laboratory tests (when these levels are low it may be a sign of malnutrition). A review of the laboratory test results dated 01/17/18 revealed the resident's prealbumin level was low at 8 (normal is 18-38) and the resident's protein level was 5.9 (normal is 6.7-8.2). Continued review of Resident #53's (12) dietary notes dated 01/30/18, revealed the residents weight was 136 pounds, and had sustained significant weight loss. The Dietitian recommended increasing the resident's tube feeding from Jevity 1.5 at 60 ml per hour to 65 ml per hour to promote a stable weight. Continued review of Resident #53's Physician's Orders dated 01/30/18 at 5:35 PM, revealed the resident's physician ordered to increase the resident's tube feeding to 65 ml per hour. However, observations of Resident #53's tube feeding pump on 01/31/18 at 10:25 AM and 11:00 AM, 02/01/18 at 10:15 AM, and 02/01/18 at 4:30 PM, revealed the facility had not increased the resident's tube feeding, and continued to administer the Jevity 1.5 at 60 ml per hour. Interview on 02/02/18 at 2:25 PM with LPN #4, revealed she was the nurse assigned to Resident #53 on 01/30/18 and 01/31/08. Even though documentation revealed the nurse signed off on the order to increase the resident's tube feeding, LPN #4 stated she was not aware that the resident's tube feeding rate had changed. Interview with LPN #9 on 02/01/18 at 5:35 PM, revealed she was not aware Resident #53's physician had written an order for the resident's tube feeding rate to be increased. She stated she made walking rounds with the nurse on the previous shift and the resident's tube feeding was infusing at 60 ml per hour. LPN #9 stated the nurse from the previous shift did not report that the resident's tube feeding rate had changed, and the rate change was not listed on the shift report. Interview on 01/24/18, at 12:05 PM, and on 02/02/18 at 5:30 PM, with the Director of Nursing (DON), revealed Resident #53's tube feeding rate should have been changed and communicated to the oncoming staff. The DON stated staff were also required to note any changes on the report sheet. She stated that every morning Monday through Friday, she was responsible for monitoring caloric intake for residents receiving tube feeding. The DON further stated the facility had a Nutritionally at Risk Committee that met every Tuesday to review residents' weights and recommend nutritional interventions to be implemented. However, the DON was unable to explain why Residents #53 (12) did not have interventions implemented related to his/her severe weight loss. 1. b. Review of the medical record revealed the facility admitted Resident #147 (H) on 12/08/17, with diagnoses that included Diabetes with Hyperglycemia, Chronic Obstructive Pulmonary Disease, and Alcoholic Hepatitis with Ascities. A review of the resident's weight roster revealed the resident weighed 191 pounds on 12/10/17. Review of Resident #147's (H) admission Minimum Data Set (MDS) dated [DATE], revealed the resident's Brief Interview for Mental Status (BIMS) score was nine (9), which indicated the resident was moderately cognitively impaired. Review of the Dietary Notes dated 12/12/17, revealed Resident #147 (H) was a new admission and weighed 189 pounds on 12/11/17. The Note stated the resident received a pureed diet with thin liquids and was eating approximately 42 percent of meals. The Registered Dietitian (RD) recommended the resident receive health shake supplements twice daily; however, there was no documented evidence the facility provided health shake supplements to the resident. A review of Resident #147' (H) Weight Roster dated 12/19/17, the resident's weight was 175 pounds, a 16 pound weight loss in nine (9) days. However, there was no evidence the facility identified the weight loss or implemented interventions to prevent further loss. Further review of a Dietary Notes revealed the Dietitian assessed Resident #147 (H) on 12/26/17, seven days after the resident sustained a 16 pound weight loss. The RD documented the resident's weight was recorded at 178 pounds and recommended initiating a multivitamin with minerals and snacks three (3) times per day; however, there was no documented evidence the facility notified the resident's physician of the RD's recommendations and no evidence the facility implemented the Dietitian's recommendations. Further review of Resident #147's (H) weight record revealed the resident lost four (4) additional pounds and weighed 174 on 12/28/17, an 8.9 percent weight loss in eighteen (18) days (severe weight loss). Further review of Resident #147's (H) nursing notes dated 12/29/17 at 3:36 AM revealed the facility transferred the resident to the hospital due to lethargy, slurred speech, diaphoresis, low blood pressure, and low oxygen saturation. Resident #147 (H) was readmitted to the facility on [DATE] with a feeding tube that was placed during the resident's hospital admission because the resident was aspirating (going into the lungs) food/fluids. Interview with the Director of Nursing (DON) on on 01/24/18, at 12:05 PM, on 01/24/18, at 12:05 PM and on 01/25/18 at 11:43 AM revealed in the facility did not initiate a Nutritionally at Risk (NAR) Committee until January 2018, after Resident #147 (H) lost weight. The DON stated the Unit Manager had always been responsible for recognizing weight loss and notifying the resident's physician of any significant or severe weight loss. The DON stated the Unit Manager was responsible for communicating RD recommendations to the resident's physician. Interview with the RD on 02/15/18 at 2:30 PM, revealed she reviewed residents' weights weekly and made recommendations when needed. She stated she assumed the Unit Managers notified the residents' physicians of her recommendations and necessary action was taken. The RD was unable to explain why she did not identify the resident's weight loss prior to 12/26/18. Review of a Termination Form dated 01/24/18 revealed the Unit Manager was terminated due to unsatisfactory performance and was unable to be interviewed. 1. c. Review of the medical record revealed the facility readmitted Resident #85 (5) on 12/27/17, after an acute hospital stay from 12/14/17 through 12/27/17 for treatment of Sepsis, Pneumonia, and Dehydration. The Resident had diagnoses that included Dysphagia, Aphasia, Alzheimer's Disease, Gastro-Esophageal Reflux, and Type 2 Diabetes. Review of Resident #85's (5) Dietary assessment dated [DATE] revealed the resident weighed 142 pounds and required 1613-1935 calories per day. According to the Registered Dietitian (RD), the resident was receiving Glucerna 1.5 tube feeding at 50 ml per hour, which provided 1650 calories. The RD stated the resident had no significant weight changes. A review of the resident's weight roster revealed on 12/28/17, after readmission from the hospital, and on 01/01/18, the resident weighed 155 pounds. Review of the Dietary Notes dated 01/05/18, revealed the resident's weight was 155 pounds, which was a significant weight gain after the resident returned from a hospital stay. Further review revealed the resident required 1505-1806 calories of tube feeding to maintain his/her weight, and continued to receive Glucerna tube feeding at 50 milliliters (ml) per hour (1200 ml per day), which provided 1650 calories per day. However, review of Resident #85's (5) Intake and Output Record for January 2018, revealed the resident did not meet his/her estimated calorie needs for thirteen of eighteen days from 01/01/18 through 01/18/18. During the time period, the resident received an average of approximately 710 ml per day, approximately 500 ml less than the resident was assessed to require. Further review of Resident #85's (5) weight roster revealed on 01/08/18, the resident's weight was down to 144 pounds, an 11 pound weight loss since admission. A review of the Nutritionally at Risk (NAR) Progress Notes revealed the facility placed Resident #85 (5) in the NAR program on 01/08/18; however, they did not recognize that the resident had sustained weight loss and implemented no interventions to prevent further loss. Further review of the resident's weight roster revealed the resident lost two more pounds and weighed 142 pounds on 01/15/18, an eight percent weight loss in fourteen (14) days A review of the NAR progress notes for 01/15/18, revealed the NAR Committee documented the resident had lost 1.3 pounds and did not identify that the resident had sustained severe weight loss or implement interventions to address the resident's weight loss. Further review of the RD's notes revealed she assessed the resident again on 01/18/18, and documented the resident's weight was 142; however, no recommendations were made and there was no evidence the RD recognized the resident's weight loss. Interview with the Registered Dietitian (RD) on 01/23/18 at 5:20 PM revealed she monitored residents' weights weekly; however, there was no documented evidence the RD recognized the resident had lost weight. Further interview with the RD on 01/25/18 at 2:30 PM, revealed she had overlooked Resident #85's (5) weight loss. Interview with Physician #1 on 01/25/18 at 11:16 AM, revealed he did not recall whether the facility notified him of Resident #85's (5) weight loss from 01/01/18 to 01/15/18; however, he expected the facility to notify him when a resident lost that much weight, in just two (2) weeks. 1. d. Review of the medical record revealed the facility admitted Resident #48 on 08/18/15, with diagnoses that included Alzheimer's, Chronic Kidney Disease, Muscle Weakness, and Dysphasia. Review of the resident's Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #48 was cognitively impaired and had a feeding tube. Review of Resident #48's Physician's Orders dated 11/14/17, revealed an order for the resident to receive a continuous tube feeding of Jevity 1.5 at 40 milliliters (ml) per hour (960 ml per day). Review of the Registered Dietitian's Monthly Tube Feeding Review dated 12/08/17, revealed Resident #48 was receiving Jevity 1.5 at 40 ml per hour, which provided 1,320 calories. The RD documented the resident was meeting his/her nutritional needs and weighed 151 on 12/03/17. However, review of Resident #48's intake and output record revealed the resident did not meet his/her tube feeding needs from 01/04/18 through 01/08/18. On 01/04/18, the facility documented the resident received 600 ml of tube feeding; on 01/05/18, the resident received 480 ml; on 01/06/18, the resident received 480 ml; on 01/07/18, the facility documented the resident had no tube feeding; and, on 01/08/18, the resident received 540 of tube feeding. Although the resident was ordered to received 4,800 ml of tube feeding from 01/04/18 through 01/08/18, the resident only received 2,100 ml's of tube feeding during this time period. Review of the resident's Weight Change History dated 12/31/17, 01/07/18, and 01/21/18 revealed the resident weighed 150, and had sustained no weight loss. Review of the Dietitian Monthly Review Note dated 01/09/18, revealed Resident #48 was assessed to require 1243-1491 calories per day. The dietitian documented the resident received 1320 calories per day and was meeting his/her nutritional needs, even though the resident had not met his tube feeding needs for the previous five (5) days. Interview with Kentucky Medication Aide (KMA) #2 on 01/23/18 at 2:46 PM, Registered Nurse (RN) #2 on 01/24/18 at 5:12 PM and 7:16 PM, Licensed Practical Nurse (LPN) #14 on 01/24/18 at 11:47 AM, LPN #13 on 01/19/18 at 9:10 AM, and LPN #9 on 01/24/18 at 11:30 AM and with LPN #15 on 01/24/18 at 5:12 PM, revealed they could not specifically say why no tube feeding was documented for some residents on the intake and output records. The staff stated that they documented the amount of tube feeding that infused on their shift, but did not monitor the total amount administered to the residents. The staff stated the Director of Nursing (DON) was responsible for monitoring residents' daily tube feeding intake. Continued interviews with KMA #2 on 01/23/18 at 2:46 PM, RN #2 on 01/24/18 at 7:16 PM, and with KMA #3 01/23/18 at 1:16 PM, Certified Nursing Assistant (CNA) #10 on 01/24/18 at 7:09 PM revealed frequently there was not a nurse available on the floor to provide care for residents, such as tube feeding administration, medications, and treatments. Interview with the Registered Dietitian (RD) on 01/23/18 at 5:20 PM revealed she monitored residents' weights weekly, discussed the resident's weekly during the Nutritionally at Risk (NAR) meeting, and watch them closely. Interview with the Director of Nursing (DON) on 01/24/18, at 12:05 PM and 01/25/18 at 11:43 AM, revealed she prints an Intake and Output (I and O) report every morning for each resident for the previous 24 hours. She stated she reviewed the report, and if a resident did not meet their tube feeding needs, Then I look at the MAR and add what the MAR says. However, interviews with Licensed Practical Nurse (LPN) #14 on 01/24/18 at 11:47 AM, LPN #13 on 01/19/18 at 9:10 AM, Registered Nurse (RN) #2 on 01/24/18 at 5:12 PM, LPN #9 on 01/24/18 at 11:30 AM and with LPN #15 on 01/24/18 at 5:12 PM, revealed they initialed the MAR to indicate they were aware of the amount of tube feeding that was ordered to be infused, not to indicate that was the actual amount the resident received. 2. Review of the facility's Hydration policy revised on 07/25/12, revealed each resident would be provided with sufficient fluid intake to maintain hydration. Further review of the policy, revealed if a resident failed to receive 1500 ml of fluids for three (3) consecutive days, the resident would be evaluated for signs and symptoms of dehydration. 2. a. Review of the medical record revealed the facility admitted Resident #1 on 01/10/18, with diagnoses that included Partial Intestinal Obstruction, Hypertension, Osteoporosis, and Arthritis. Review of the resident's medical record revealed the resident was discharged and readmitted multiple times; therefore, a Minimum Data Set (MDS) assessment had not been required prior to the resident's discharge on [DATE]. Review of Resident #1's Physician Orders dated 01/12/18, revealed the resident had an order for 150 ml of water flush every four hours (900 ml per day). Review of Resident #1's admission Nutritional assessment dated [DATE], revealed to meet the resident's fluid needs, the resident would require the ordered tube feeding and water flushes of 150 ml every four hours. Review of Resident #1's Intake and Output record revealed the resident did not meet his/her fluid needs on four of seven days (4 of 7) from 01/12/18 through 01/18/18. On 01/12/18, the resident received 120 ml; on 01/13/18, the resident received 600 ml; on 0/16/18, the resident received 500 ml; and, on 01/17/18, the resident received 750 ml of water via the feeding tube. 2. b. Review of the medical record revealed the facility admitted Resident #85 (5) on 06/27/17, with diagnoses that included Alzheimer's Disease, Hypertension, Gastro-Esophageal Reflux, and Type 2 Diabetes without complications. Review of the Quarterly Minimum Data Set (MDS) dated [DATE], revealed Resident #85 (5) was not interviewable. Review of Resident #85's (5) Physician Orders dated 12/27/17, revealed the resident had an order for 200 ml water flush via the resident's feeding tube every four hours (1200 ml per day). Review of Resident #85's (5) Dietary assessment dated [DATE], revealed the resident required 1505-1806 cc's of water to maintain hydration. The Assessment stated the resident received Glucerna 1.5 at 50 ml per hour with 200 ml water flush every 4 hours, which provided 2035 cc of total fluid per day. Observation of Resident #85's (5) feeding tube pump 01/24/18 at 4:32 PM, revealed only 163 ml's of water had been administered to the resident in approximately eight (8) hours, approximately 237 ml less than was required for the resident. Further, review of Resident #85's (5) Medication Administration Record (MAR) revealed the resident did not meet his/her fluid needs on eleven of eighteen days from 01/01/18 through 01/16/18, and no fluid intake was documented on 01/22/18 or 01/23/18. Review of a Dehydration Risk assessment dated [DATE] revealed the facility assessed Resident #85 (5) to have no signs or symptoms of dehydration; the resident's skin turgor was good and the resident's mucous membranes, tongue, and lips were moist. However, review of Resident #85's (5) laboratory values dated 12/29/17 and 01/27/18 revealed the resident's Blood Urea Nitrogen (BUN) and creatinine (BUN and creatinine levels test kidney function and may temporarily increase if you are dehydrated, have a low blood volume, eat a large amount of meat, or take certain medications) increased from 18 (normal BUN is 6-20) and 0.6 (normal creatinine is 0.4-1.0) on 12/29/17 to 41 and 0.9, respectively on 01/27/18. A post survey interview was attemepted with Resident #85's (5) Physician on 04/06/18, but the Physician was not available. 2. c. Review of the medical record revealed the facility admitted Resident #147 (H) on 12/08/17, with diagnoses that included Diabetes with Hyperglycemia, Chronic Obstructive Pulmonary Disease, and Alcoholic Hepatitis with Ascities. Review of Resident #147's (H) admission Minimum Data Set (MDS) dated [DATE], revealed the resident's Brief Interview for Mental Status (BIMS) score was nine (9), which indicated the resident was moderately cognitively impaired. Review of Resident #147's (H) Physician's Orders dated 01/23/18, revealed the resident had an order for a 100 ml water flush via the resident's feeding tube four times a day (600 ml per day). However, observation on 01/24/18 at 7:08 PM, of Resident #147's (H) feeding tube pump revealed the resident had only received 32 ml of water in the previous 8.5 hours, approximately 168 ml less than the resident's required amount. 2. d. Review of the medical record revealed the facility admitted Resident #53 (12) on 11/30/17, and readmitted the resident on 12/30/17, with diagnoses that included Pneumonia, Hypertension, Alzheimer's Disease, and Dementia. Review of the admission MDS dated [DATE], revealed Resident #53 (12) was cognitively impaired. Review of Resident #53's (12) Physician's Orders revealed an order to flush the resident's feeding tube with 200 ml of water every four (4) hours (1200 ml per day). Review of a Dietary Note for Resident #53 (12) dated 01/05/18, revealed the resident's estimated fluid needs were 1950-2275 ml of fluid per day. According to the Dietitian's Note, the resident received Jevity 1.5 at 60 ml per hour with a 200 ml water flush every four hours to provide 2203 ml of fluid per day. However, review of Resident #53's (12) Intake and Output record for January 2018, for 01/01/18 through 01/22/18 revealed the resident's average daily fluid intake was approximately 703 ml, approximately 500 ml less than the resident required. A review of Resident #53's (12) laboratory results dated [DATE] and 02/05/18 revealed the resident's Blood Urea Nitrogen (BUN) and creatinine levels increased from January to February 2018 (BUN and creatinine levels test kidney function may temporarily increase if you are dehydrated, have a low blood volume, eat a large amount of meat, or take certain medications). On 01/02/18, the resident's BUN was 34 (normal is 6-20). However, on 02/06/18, Resident #53's (12) BUN had increased to 44. A post survey interview was attemepted with Resident #53's (12) Physician on 04/06/18, but the Physician was not available. 2. e. Review of Resident #48's medical record revealed the facility admitted the resident on 08/18/15, with diagnoses that included Alzheimer's, Chronic Kidney Disease, Muscle Weakness, Dysphasia, and Moderate Protein-Calorie Malnutrition. Review of the Quarterly Minimum Data Set (MDS) dated [DATE], revealed Resident #48 was cognitively impaired and had a feeding tube. Review of Resident #48's Physician's Orders dated 11/14/17, revealed the resident had an order for 200 ml water flushes every six (6) hours per feeding tube (800 ml per day). A review of the Monthly Tube Feeding Review dated 12/08/17, revealed Resident #48 required 1245-1494 ml of fluid to provide proper hydration. However, observation of Resident #48's tube feeding pump on 01/24/18 at 7:10 PM, revealed the resident had only received 57 ml of water in the previous 8.5 hours, approximately 143 ml less than the resident required in 6 hours. Further, review of Resident #48's Intake and Output Record for January 2018, revealed the resident did not meet his/her assessed fluid 01/04/18 through 01/08/18, and only received an average of 363 ml of fluid per day, approximately 437 ml less than the resident required per day. Review of the Dietitian's Monthly Review Note dated 01/09/18, revealed Resident #48 was assessed to require 1243-1491 ml of water per day. The Dietitian documented the resident was receiving 1469 ml of fluid per day and was meeting his/her nutritional needs, even though the resident had not met his/her fluid needs for the previous five (5) days. Review of Resident #48's medical record revealed no evidence the facility assessed the resident's hydration status until 01/31/18, twenty-three days later. Review of the 01/31/18 Dehydration Risk Evaluation for Resident #48 revealed the facility assessed the resident to have no signs or symptoms of dehydration, including no skin turgor concerns and the resident's mucous membranes, lips, and tongue were moist. Interview with the Registered Dietitian (RD) on 01/23/18 at 5:20 PM revealed she monitored residents' intake weekly to obtain an average of the resident's daily fluid intake. However, the RD stated she did not take action if the resident failed to meet their needs. She stated she guessed the unit manager was responsible for notifying the resident's physician if they did not meet their fluid needs. Interviews with Licensed Practical Nurse (LPN) #14 on 01/24/18 at 11:47 AM, LPN #13 on 01/19/18 t 9:10 AM, and Registered Nurse (RN) #2 on 01/24/18 at 5:12 PM revealed they were aware that tube feeding pumps did not function correctly and did not consistently deliver the correct amount of water flushes to residents. The LPNs stated they checked the residents' feeding pump at the times indicated on the residents' Medication Administration Record (MAR). Continued interview revealed they often had to supplement the amount of water delivered to the resident with manual water flushes to ensure the resident received the amount of water ordered by the physician. Further, the LPNs stated they totaled the amount of water delivered by the pump and the amount of water manually infused and documented the total amount on each residents' I and O record. However, interviews with LPN #9 on 01/24/18 at 11:30 AM and with LPN #15 on 01/24/18 at 5:12 PM, revealed physician ordered water flushes were automatically infused by the feeding tube pump and they did not check the pump and supplement the amount of water the resident had received. The LPNs stated they initialed the MAR to indicate they were aware of the amount ordered to be infused, not to indicate that was the amount the resident received. The LPNs stated that at the end of each shift, the amount of water infused by the pump was documented on the Intake and Output Record, and the resident did not receive any additional fluids. Interview with the Director of Nursing (DON) on 01/24/18, at 12:05 PM,on 01/24/18, at 12:05 PM and on 01/25/18 at 11:43 AM, revealed prior to January 2018, the facility did not have a system to monitor resident's fluid intake. However, in January 2018, the DON began running an Intake and Output (I and O) report every morning for the previous 24 hours. She stated the I and O Report was reviewed in the morning meeting to identify anyone who did not have an intake of at least 1500 ml per day. If a resident did not meet 1500 ml, a nurse was required to do a hydration assessment and the Unit Manager was required to notify the resident's physician. The DON stated when totaling the daily fluid intake for residents, she added the amount that was initialed by the nurse on the MAR to the total on the Intake record to determine the resident's total fluid intake. However, the DON was not aware that not all nursing staff were ensuring the feeding tube pump delivered an adequate amount of water to the resident. The DON had not identified that staff had conflicting knowledge regarding whether they were to provide [TRUNCATE

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, review of facility policies, and review of the Administrator's Job Description, it was determined the facility failed to be administered in a manner that enabled its resources to be used effectively to maintain the highest practicable physical, mental, and psychosocial well-being of each resident. The facility submitted a Plan of Correction (POC) in response to Immediate Jeopardy level deficiencies cited on 11/17/17, and alleged compliance effective 12/25/17. In addition, the facility submitted a Plan of Correction for deficiencies cited on 12/21/17, alleging compliance 01/11/18. However, during a noncompliance revisit conducted on 02/16/18, it was determined the facility's Administrator failed to ensure the deficiencies were corrected as alleged in the facility's POC, and failed to ensure regulatory compliance as required by the Administrator's job description. Immediate Jeopardy was identified to exist again at the facility on 01/09/18. The facility's failure to be administered effectively has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 01/26/18, and determined to exist on 01/09/18 at 42 CFR 483.10 Resident Rights (F578 and F580), 42 CFR 483.21 Comprehensive Person-Centered Care Planning (F656 and F658), 42 CFR 483.24 Quality of Life (F678), and 42 CFR 483.70 Administration (F842). The facility was notified of the Immediate Jeopardy on 01/26/18. After supervisory review, Immediate Jeopardy was identified on 03/01/18 and determined to exist on 12/12/17 at 42 CFR 483.25 Quality of Care (F692 ) and 42 CFR 483.70 Administration (F835, F837). The facility was notified of the Immediate Jeopardy on 03/01/18 at 42 CFR 483.25 Quality of Care (F692), and 42 CFR 483.70 Administration (F835 and F837). An acceptable Allegation of Compliance was received on 03/05/18, which alleged removal of the Immediate Jeopardy on 03/05/18. The State Survey Agency determined the Immediate Jeopardy was removed on 03/05/18, prior to exit, which lowered the scope and severity to D at at 42 CFR 483.10 Resident Rights (F578 and F580), 42 CFR 483.21 Comprehensive Person-Centered Care Planning (F658), 42 CFR 483.24 Quality of Life (F678), 42 CFR 483.25 Quality of Care (F692 ) and 42 CFR 483.70 Administration (F835, F837, and 842), and to an E at 42 CFR 483.21 Comprehensive Person-Centered Care Planning (F656), while the facility monitors the effectiveness of systemic changes and quality assurance activities. The findings include: Review of the Administrator's Job Description dated September 2013, revealed the primary responsibility of the Administrator was to oversee the overall observation, leadership, and management of the facility. The Administrator would ensure appropriate resident care, quality assurance, and regulatory management. 1. An abbreviated survey was conducted at the facility on 11/17/17, and Immediate Jeopardy was determined to exist at 42 CFR 483.21 Comprehensive Person-Centered Care Plans; 42 CFR 483.25 Quality of Care; and 42 CFR 483.50 Laboratory, Radiology, and Other Diagnostic Services. Substandard Quality of Care was identified at 42 CFR 483.25 Quality of Care due to the facility's failure to ensure an effective system was in place to conduct laboratory testing as ordered by the resident's physician and in accordance with standards of practice. The facility submitted a Plan of Correction (POC) on 12/20/17, and alleged compliance effective 12/25/17. Another abbreviated survey was conducted on 12/21/17, and deficient practice was identified at 483.45 Pharmacy Services due to the facility's failure to ensure medications were available to administer to residents. The facility submitted a POC on 01/20/18, and alleged compliance effective 01/11/18. However, review of Resident #146's medical record revealed no documented evidence the facility administered the resident's physician ordered Levaquin (Intravenous (IV) antibiotic to treat infection) on 01/24/18, at 6:30 AM, to treat the resident's Urinary Tract Infection. The resident was transferred and readmitted to the hospital on [DATE] at 7:25 PM, approximately thirteen (13) hours later, with diagnoses of Urinary Tract Infection and Pneumonia. Review of the facility's Post admission Quality Assurance Reviews, completed on 01/23/18 and on 01/24/18 after Resident #146's readmission to the facility from the acute care hospital stay, revealed the facility documented that the resident's medications were ordered from the pharmacy and no concerns were identified. However, interview with the QA Nurse on 02/16/18 at 1:30 PM, revealed she did not confirm the resident's physician orders were sent to the pharmacy as required by the facility's POC, when the resident was readmitted on [DATE]. She stated she discovered on 01/24/18, after the resident's medication was past due, that the resident's physician orders had not sent to the pharmacy as required on 01/23/18. She stated Resident #146's medication was not available when it was due to be administered on 01/24/18. Further, review of Resident #63's closed medical record revealed the resident had a physician's order on 12/28/17, to obtain a stool specimen to test for Clostridium Difficile (C-Diff) and blood (hemoccult), due to foul odor, loose stool. However, record review revealed the facility entered the physician's order as a stool culture. There was no documented evidence the facility obtained the test for C. Diff or hemoccult as ordered by the physician. Observation of a laboratory binder on 02/15/18 at 1:30 PM, revealed the facility failed to track the resident's ordered laboratory tests for C. Diff and Hemoccult in the binder maintained at the nurses' station as required by the facility's plan of correction. Interview with the Director of Nursing on 01/24/18 at 12:05 PM, revealed the facility was tracking lab orders on a white board and had no documented evidence that the facility implemented their plan of correction and monitored to ensure Resident #63's laboratory tests were completed as ordered. 2. Based on the findings of a non-compliance revisit and annual recertification survey, Immediate Jeopardy was identified again on 01/26/18, and determined to exist on 01/09/18 at 42 CFR 483.10 Resident Rights (F578 and F580), 42 CFR 483.21 Comprehensive Person-Centered Care Planning (F656 and F658), 42 CFR 483.24 Quality of Life (F678), and 42 CFR 483.70 Medical Records (F842). The facility was notified of the Immediate Jeopardy on 01/26/18. Resident #63 had a signed Kentucky Emergency Medical Services (EMS) Do Not Resuscitate (DNR) order dated 12/15/17. However, on 01/09/18, when the resident was determined to be critically ill with impending respiratory failure/arrest, the facility failed to provide the form to EMS. EMS provided CPR to Resident #63 and transferred the resident to the hospital, where the resident was placed on a ventilator and expired on 01/12/18 (Refer to F578, F656, and F770). The Administrator failed to identify that the KY EMS form was not provided and the resident's end of life wishes were not honored, and no action was taken to ensure residents' wishes were honored. Subsequently, three days later, the facility failed to provide basic life to Resident #26 (6) and honor the resident's wishes when the resident experienced a change in condition. On 01/12/18, Resident #26 (6) was assessed by staff to have a low blood pressure, pale skin, and labored breathing at approximately 3:45 PM. The facility failed to notify the resident's physician of the change in the resident's condition, failed to provide basic life support, and failed to immediately notify Emergency Medical Services (EMS) when Resident #26 (6) experienced a change in condition. When EMS arrived on 01/12/18 at 4:50 PM, Resident #26 (6) was not breathing and had no pulse. EMS initiated Cardiopulmonary Resuscitation (CPR) and transferred the resident to the hospital. However, Resident #26 (6) expired at 5:11 PM on 01/12/18, when resuscitation efforts were unsuccessful (Refer to F580, F656, F658, F678, and 842). Interview with the Administrator on 03/06/18 at 2:30 PM, revealed she assisted in developing the plans of correction. The Administrator stated her role in implementing the plans of correction consisted of reviewing the audits, determining education needs of staff, completing disciplinary action if needed, and monitoring weekly to ensure the plans of correction were implemented. Further interview with the Administrator revealed the facility's Plans of Correction were not effective in identifying that Resident #146 did not receive physician ordered medication or that Resident #63 did not receive a physician ordered laboratory test. Further interview revealed the Administrator had not identified any concerns regarding Resident #63 or #26's (6) end of life wishes. The facility implemented the following for removal of jeopardy: 1. On 01/26/18, the Administrator provided an in-service to the Director of Nursing, Minimum Data Set (MDS) Nurse, and the Quality Assurance (QA) Nurse regarding the development and implementation of a comprehensive care plan that included the wishes of each resident related to code status. 2. The policies and procedures were reviewed and updated regarding physician notification and obtaining, documenting, and honoring the wishes of each resident for Advance Directives/Code Status by the PIP Committee on 01/29/18. The resident's wishes for Advance Directives and code status will be obtained upon admission by Social Services and the admission Director. Code status designations will be documented in the physician's orders, in the resident care plan, and on the resident's face sheet. Residents choosing a DNR code status will sign a completed No Code or DNR consent form that will be maintained in the resident's medical record. Residents without an Advance Directive will be considered a Full Code. The Advance Directives and Code Status policies were reviewed, updated, and approved by the QAPI Committee on 01/29/18. 3. On 01/26/18, a comprehensive audit was completed by the Administrator, MDS Nurse, Assistant Administrator, Director of Nursing (DON), QA Nurse, Unit Manager, Activities Director, Admissions Director, and Social Workers for every resident in the facility. The audit was a review of each resident's Advance Directive and code status that included physician orders, Advance Directive designation forms, consent forms, paper record, electronic record, and face sheets with no variances noted. The residents' comprehensive care plans were also reviewed and updated as needed to assure residents' Advance Directives and wishes for code status were included on the plan of care. These audits were conducted at the direction of the Quality Assurance and Performance Improvement (QAPI) Committee and completed on 01/26/18. Members of the QAPI committee included: The Administrator, Director of Nursing, Unit Managers, Medical Director, MDS Coordinator, Staff Development Coordinator, Pharmacy Representative, Social Services Director, and Activity Director. Completed audits were submitted to the QAPI Committee for additional review. 4. The Director of Nursing, Quality Assurance Nurse, Unit Manager, and MDS Nurse completed a focus review to ensure proper notification occurred for changes in resident condition. The audit included review of residents transferred to the hospital within the prior week, all Nurse's Notes documented between 01/22/18 through 01/30/18, and any new Physician's Orders received 01/22/18 through 01/30/18. 5. Licensed staff that were involved with the care of Resident #26 (6) and Resident #63 received additional training related to identification and communication of a resident's wishes regarding Advance Directives and code status, as well as including and honoring those wishes through implementation of the resident's care plan. The training included timely notification of a resident's physician and responsible party, as well as documentation of the notification. The training also included development and implementation of the comprehensive care plan which included the wishes of each resident related to their code status. Post-tests and staff interviews were completed to ensure comprehension of the training material. The training was completed 01/26/18 through 01/31/18 by the Director of Nursing, Staff Development Director. 6. All licensed and certified nursing staff and the Interdisciplinary Care Plan team (IDT) which consisted of MDS Nurse, Social Worker, Activity Director, and the Director of Dietary Services all received additional training beginning on 01/26/18 thru 01/31/18 related to: - identification and communication of a resident's wishes regarding Advance Directives and code status - honoring resident's code status wishes through the implementation of the resident's care plan -providing the necessary care and services such as emergency care, basic life support, and CPR to those residents in accordance with the resident's Advance Directives and wishes regarding code status -how to determine the code status of each resident according to facility protocols - assessing and responding to a resident in distress - timely notification of the physician - initiating a code - honoring the wishes of each resident with a full-code status - documenting care delivered - development and implementation of the comprehensive care plan which included the wishes of each resident related to their code status The training was completed by the Director of Nursing, Staff Development Director, and the Administrator. Post-tests and staff interviews were completed to ensure comprehension of the training material. Any staff member in the nursing department who was off work for any reason will not be permitted to work until training and post testing are completed. 7. On 01/27/18, the Administrator posted a listing of each resident and their desired code status at each nursing unit. The Administrator completed the list after the Advance Directives and CPR desires of each resident were validated through the audit completed on 01/26/18. Monitoring would include a daily review of this list by the Administrator or Assistant Administrator Monday through Friday. The weekend manager would review and update the listing on Saturday and Sunday. 8. Notification to a resident's physician, resident, and resident representative is monitored daily (Monday - Friday) in the Clinical Meeting. Attendees of the Clinical Meeting include the Director of Nursing, MDS Nurse, Social Workers, QA Nurse, and Unit Manager. The Clinical Meeting conducts a review of the following: 24-hour report, physician's telephone orders, nurse's notes, laboratory reports, resident events, changes in residents' condition, new admissions, and discharges. Any concerns identified are corrected immediately. 9. On 01/29/18, training, direction, and responsibility was assigned to Social Services for listing residents' wishes regarding Advance Directive on the residents' comprehensive care plan. The MDS Nurse will verify that Advance Directives are included on the care plan. This review will occur during Care Plan Conferences following the Resident Assessment Instrument (RAI) schedule. 10. On 01/29/18, a focus Performance Improvement Plan (PIP) Committee was formed by the QAPI Committee to review and monitor the facility's processes for obtaining and honoring residents' Advance Directives, code status, development and implementation of a care plan that meets the code status wishes of the resident, procedures for calling a code, and the conditions for implementing CPR to a full code resident. The PIP committee members included: The Administrator, Director of Nursing, Unit Managers, MDS Coordinator, Staff Development Coordinator, Social Services and Activity Director. The PIP Committee meets daily to focus on implementing the plan outlined herein, monitor results of audits and reviews, and provides additional direction as needed. The daily (Monday through Friday) PIP Committee meetings will continue until removal of the immediate jeopardy has been verified. Weekly QAPI meetings would continue to occur until sustained compliance was achieved. 11. The QAPI Committee will monitor and ensure sustained compliance is maintained through a weekly meeting. The members of this meeting will review all audits, training, and corrective actions generated by the focus PIP Committee. QAPI meetings will occur until sustained compliance is achieved. Information reviewed in this meeting will include: - Verbal report and a current Code Status List is reviewed and updated daily with any changes in the resident's Advance Directives and CPR status and is submitted by the Administrator or Assistant Administrator - The MDS Nurse will submit a verbal report and audit tool(s) related to the validation of the resident's code status during resident care plan conferences - The DON or QA Nurse will review the findings of the 24-hour report, physician's telephone orders, nurse's notes, laboratory tests, resident events, and changes in residents' condition identified in the morning clinical meetings and through routine clinical assessments, evaluations, and nurse management rounds, as well as a review of new admissions and discharges. The Daily Audit Tool will also be used to validate proper notification to physicians and the resident representative. - The DON or SDC will submit a verbal report, in-service logs and training agenda(s) regarding training or post testing completed. - The Social Worker will submit a verbal report and census list regarding any changes in Advance Directives or code status, including new admissions and re-admissions. - The DON or QA Nurse will give a verbal report and submit an audit tool related to any resident transfers to the hospital for urgent or critical care. The reports will include verification of proper notification, communication regarding resident's Advance Directives/code status prior to transfer, the Center's response to the resident's wishes, and the outcome of the transfer. - The committee will also discuss any new concerns identified through audits and reviews and applicable corrective action or changes. 12. On 03/02/18, a Long Term Care (LTC) consultant who is licensed as a Long Term Care Health Administrator in the state of Kentucky provided training to the Administrator of the facility for compliance with the federal and state regulations, quality assurance and performance improvement, efficient and effective use of resources, human resource development, and responsibilities of the Governing Body. Additionally, education was provided that according to §483.70 the facility must be administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. 13. On 03/02/18, the Administrator developed a Performance Improvement Team (PIT) to develop a Performance Improvement Plan (PIP) for the purposes of maintaining an effective nutrition/hydration status program. The PIT had the first meeting on 03/02/18 to develop, review, and monitor the resident nutrition/hydration status program. The PIT committee members include: the Administrator, Director of Nursing (DON), Unit Managers, Minimum Data Set (MDS) Coordinator, Staff Development Coordinator, and the internal auditors of nutrition/hydration status. 14. Effective 03/01/18, the Administrator and Director of Nursing have developed audit forms with the assistance of long term care consultants for all recently cited care and service areas. Auditors were appointed by the Administrator with the assistance of long term care consultants on 03/01/18. Education regarding the use of the audit forms was provided to the auditors on 03/01/18, by the Administrator and the long term care consultants. Effective 03/02/18, the audits will identify residents at risk for the cited deficiencies in the areas of assisted nutrition and hydration. The Administrator and Director of Nursing are involved with all compliance and corrective actions taken to correct any alleged deficiency and have assured that the following corrective actions have identified any resident who may be affected. 15. On 03/02/18, the Administrator reviewed the members of the Quality Assurance Committee. These members conform with the requirements of the current regulations and include the Administrator, Medical Director, Director of Nursing, Unit Managers, MDS Coordinator, Staff Development Coordinator, Pharmacy Representative, Social Services Director and Activities Director. 16. Residents #1, #85 (5), #48, #53 (12), and #147 (H) were assessed by the RD from 01/19/18 through 03/02/18. The residents' physicians were notified with any new recommendations. From 01/13/18 through 03/02/18, a licensed nurse conducted a dehydration risk assessment and no additional interventions were recommended. In addition, on 03/03/18, a fluid intake audit was completed for Residents #48, #53, and #147, and the residents were meeting or exceeding their fluid needs. Resident #1 was discharged from the facility on 01/29/18, and is no longer a resident. Resident #85 (5) was discharged from the facility on 02/01/18, and is no longer a resident at the facility. 17. On 02/08/18, a representative from Medline Industries (Medline is the facility provider for feeding tube pumps), completed a Quality Assurance audit of all feeding pumps to ensure function and accuracy. All pumps were found to be in working order. Beginning on 02/08/18 and completed on 02/13/18, the representative and the Director of Nursing (DON) provided education regarding operation and use of the pumps to all licensed nurses and nurses completed a return demonstration. 18. On 03/01/18, implementation began to convert electronic documentation of Food and Fluid Consumption to paper documentation. Education began on 03/02/18 and continued through 03/04/18. Employees not having been in-serviced by 03/04/18 will not be allowed to work until education is completed. Food and fluids consumed daily with resident meals, snacks, and medication administration will be recorded on the Food and Fluid Consumption Sheet. The night shift Charge Nurse will calculate the fluids consumed and compare to the recommended fluid needs calculated by the RD. Residents not meeting the estimated daily fluid needs will be noted on the 24-hour report log for increased monitoring. The resident/resident representative and the resident's physician will be notified if a resident does not consume a daily average of 50% of routine meals without substitutes and supplements for three (3)consecutive days. Food and fluid intake documentation will be monitored daily Monday through Friday by the Unit Managers and the Weekend Manager will monitor on Saturday and Sunday. 19. Licensed Nurses completed Dehydration Risk Assessments for all residents on 03/02/18 and 03/03/18. Any concerns identified during this evaluation were addressed immediately with physician notification, care plan review, and care plan updates as indicated. From 03/02/18 to 03/04/18, a fluid intake audit was completed by comparing the individual fluid needs of all residents to each residents' average fluid consumption from 02/21/18 through 02/27/18. This audit was completed by the Director of Nursing, Unit Manager, MDS Nurse, Administrator, and Assistant Administrator. Any resident not meeting their estimated fluid need was evaluated, notifications were made if indicated to the physician and resident/resident representative, and care plans were reviewed and updated as needed. 20. On 03/03/18, the Tube Feeding Intake Worksheet was implemented to monitor and track formula and fluids administered to residents with tube feeding. This worksheet will be completed at the end of each shift by the licensed nurse. The Unit Manager, Weekend Manager, or designated Nurse Manager will review the Tube Feeding Intake Worksheet daily to ensure residents receiving tube feeding formula and/or fluids receive the amount prescribed by the physician. If reviews indicate that the intake administered is below the prescribed amount, a quality assurance check will be performed on the feeding pump, a dehydration risk assessment will be completed by a licensed nurse, and the physician and resident/resident representative will be notified. An additional review of the Tube Feeding Intake Worksheet will occur daily Monday through Friday by the Quality Assurance Nurse (QA Nurse). 21. On 03/02/18, the DON reviewed all resident weights for significant/severe weight loss. Any resident identified as having new weight loss was evaluated, the resident/responsible representative and the resident's physician were notified, and the resident's comprehensive care plan was reviewed and updated, if indicated. 22. Routine and weekly weights will be obtained by the Restorative Aides, recorded on a resident weight worksheet, and submitted to the Unit Manager for review. Weights will be logged into the medical record after review by the Unit Manager. Once weights are logged, the Director of Nursing will review the computer-generated weight change report weekly on Tuesday prior to the Nutrition at Risk Committee (NAR) meeting. Residents identified to be at risk for nutrition and hydration decline are monitored by the Interdisciplinary NAR Committee. Members of the NAR Committee include the Director of Nursing, the Unit Managers, the Registered Dietitian, the Dietary Manager, the MDS Nurse, and the QA Nurse. The NAR Committee reviews at risk residents' intake, weight, and hydration status. The NAR Committee will review the daily Food and Fluid Consumption Sheets, the daily Tube Feeding Intake Worksheets, and the computer generated weight variance report that are completed each Tuesday by the DON. 23. The Dietary Manager will conduct an additional nutrition and hydration audit daily (Monday through Friday) to ensure any resident not meeting minimal nutrition and hydration requirements have been addressed as needed. 24. The Governing Body is providing oversight through a contract with a Management Company. On 03/02/18, the Long Term Care Consultants with the Management Company (a Registered Nurse and a Licensed Health Care Administrator) provided education to the Governing Body related to the responsibilities of the Governing Body as promulgated in §483.70. The education included the responsibilities of the Governing Body to include the establishment and implementation of policies regarding the management and operation of the facility. The Governing Body has directed that all resources and administration abate deficient practice at nutrition/hydration to include corrective actions for those residents affected. The Management Company oversees the daily operations of the facility and utilizes contracted consultants as necessary for the operation. The consultants have extensive experience and education in the area of operating long term care facilities and are not employees of the facility, but rather act as an outside resource in providing advice and consultation to the management staff of the facility. The Administrator, who was appointed by the Governing Body on 03/07/14, is responsible for the daily management of the facility, and reports and is accountable to the Governing Body. The Governing Board meets with the Management Company each month. 25. The PIP Committee meets daily to focus on implementing the plan outlined herein, monitor results of audits and reviews, and provides additional direction as needed. The daily (Monday through Friday) PIP Committee meetings will continue until removal of the immediate jeopardy has been verified. 26. The Quality Assurance and Performance Improvement (QAPI) policies were reviewed on 03/02/18 by the Long Term Care Consultant and the Administrator with no changes noted. The QAPI policies are in conformance with the current regulatory standards and no changes were necessary. The QAPI Committee reviewed the QAPI policies on 03/22/18 with acceptance. On 03/02/18, the Administrator provided education to the Quality Assurance and Assessment (QAA) Committee related to the policies and the structure of the Quality Assurance and Assessment (QAA) program. The Administrator with the assistance of the long term care consultant developed new tools that are to be used for the Performance Improvement Team (PIT) that includes a new tool for a Performance Improvement Plan (PIP). These new tools are used for the PIP for the abatement of Immediate Jeopardy. Weekly QAPI meetings will be held and will continue to occur until sustained compliance is achieved. The completed PIP will be submitted to the weekly meetings of the QAPI Committee for approval and suggestions. 27. The Administration of the facility to include the Administrator and Director of Nursing are conferring daily with long term care consultants to monitor administration's role with the abatement of jeopardy beginning 03/02/18. The SSA verified the removal of immediate jeopardy by the following: 1. Review of the in-service roster dated 01/26/18, revealed the DON, MDS Nurse, and the QA Nurse had attended an in-service by the Administrator related to the development and implementation of a comprehensive care plan to ensure the wishes of each resident and their code status was included on the care plan. Interviews conducted with the MDS Nurse on 02/16/18 at 1:04 PM; the QA Nurse on 02/16/18 at 1:22 PM; and, the DON on 02/16/18 at 2:00 PM, revealed they attended the in-service provided by the Administrator and began providing in-services for other staff on 01/29/18. 2. Review of the facility's policies and in-service rosters regarding Advance Directives and Code Status revealed the facility reviewed and updated the policies on 01/29/18. The policies revealed the facility's new process to ensure Advance Directives/Wishes were honored was as follows: the physician would be notified after obtaining the resident's/ responsible party's consent, documenting the consent, and honoring the resident's wishes for Advance Directives and Code Status. The policy revealed the resident's wishes for Advance Directives and code status would be obtained upon admission by Social Services and the admission Director. This would be documented in the physician's orders, resident care plan, and on the resident's face sheet. Interviews conducted with the Unit Manager on 02/16/18 at 11:04 AM, SSD on 02/16/18 at 11:25 AM, Activities Director on 02/16/18 at 12:59 PM, MDS Nurse on 02/16/18 at 1:04 PM, QA Nurse on 02/16/18 at 1:22 PM, Assistant Administrator on 02/16/18 at 1:40 PM, DON on 02/16/18 at 2:00 PM, and the Administrator on 02/16/18 at 2:10 PM, revealed they had reviewed/updated the facility's policies regarding Advance Directives and Code Status. 3. Review of audit sheets completed by the Administrator, MDS Nurse, Assistant Administrator, DON, QA Nurse, Unit Manager, Activities Director, Admissions Director, and Social Worker revealed an audit was conducted for all residents to ensure the resident's code status/Advance Directive was accurately documented on the physician's orders, designation forms, and consent forms. Interviews conducted with the Admissions Director on 02/16/18 at 11:00 AM, Unit Manager on 02/16/18 at 11:04 AM, SSD on 02/16/18 at 11:25 AM, Activities Director on 02/16/18 at 12:59 PM, MDS Nurse on 02/16/18 at 1:04 PM, QA Nurse on 02/16/18 at 1:22 PM, Assistant Administrator on 02/16/18 at 1:40 PM, DON on 02/16/18 at 2:00 PM, and the Administrator on 02/16/18 at 2:10 PM, revealed they had conducted audits on every resident to ensure the resident's code status/Advance Directive was accurate on the physician's orders, designation forms, and conse[TRUNCATED]

Based on interview, record review, and review of facility policies, it was determined the governing body failed to ensure policies were implemented regarding the management and operation of the facility. The facility submitted a Plan of Correction in response to Immediate Jeopardy deficiencies cited on 11/17/17, and alleged compliance effective 12/25/17. In addition, the facility submitted a Plan of Correction for deficiencies cited on 12/21/17, alleging compliance 01/11/18. However, during a noncompliance revisit conducted on 02/16/18, it was determined the facility failed to implement their plans of correction as described in the documents issued to the State Survey Agency, and Immediate Jeopardy was again identified to exist. The Governing Body's failure to ensure the facility's policies were implemented has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 01/26/18, and determined to exist on 01/09/18 at 42 CFR 483.10 Resident Rights (F578 and F580), 42 CFR 483.21 Comprehensive Person-Centered Care Planning (F656 and F658), 42 CFR 483.24 Quality of Life (F678), and 42 CFR 483.70 Administration (F842). The facility was notified of the Immediate Jeopardy on 01/26/18. After supervisory review, Immediate Jeopardy was identified on 03/01/18 and determined to exist on 12/12/17 at 42 CFR 483.25 Quality of Care (F692 ) and 42 CFR 483.70 Administration (F835, F837). The facility was notified of the Immediate Jeopardy on 03/01/18 at 42 CFR 483.25 Quality of Care (F692), and 42 CFR 483.70 Administration (F835 and F837). An acceptable Allegation of Compliance was received on 03/05/18, which alleged removal of the Immediate Jeopardy on 03/05/18. The State Survey Agency determined the Immediate Jeopardy was removed on 03/05/18, prior to exit, which lowered the scope and severity to D at at 42 CFR 483.10 Resident Rights (F578 and F580), 42 CFR 483.21 Comprehensive Person-Centered Care Planning (F658), 42 CFR 483.24 Quality of Life (F678), 42 CFR 483.25 Quality of Care (F692 ) and 42 CFR 483.70 Administration (F835, F837, and 842), and to an E at 42 CFR 483.21 Comprehensive Person-Centered Care Planning (F656), while the facility monitors the effectiveness of systemic changes and quality assurance activities. The findings include: Review of the Governing Body policy, undated, revealed the Governing Body was responsible for establishing and implementing policies regarding the management and operation of the facility. The policy revealed the Governing Body employeed a management company to direct the overall management of the facility. The Governing Body also appointed an Administrator who was responsible for the daily operation of the facility. On 11/17/17, an abbreviated survey was conducted at the facility and Immediate Jeopardy was determined to exist at 42 CFR 483.21 Comprehensive Person-Centered Care Plans; 42 CFR 483.25 Quality of Care; and 42 CFR 483.50 Laboratory, Radiology, and Other Diagnostic Services. Substandard Quality of Care was identified at 42 CFR 483.25 Quality of Care due to the facility's failure to ensure an effective system was in place to conduct laboratory testing as ordered by the resident's physician and in accordance with standards of practice. The facility submitted a Plan of Correction (POC) on 12/20/17, and alleged compliance effective 12/25/17. On 12/21/17, another abbreviated survey was conducted and deficient practice was identified at 483.45 Pharmacy Services due to the facility's failure to ensure medications were available to administer to residents. The facility submitted a POC on 01/20/18, and alleged compliance effective 01/11/18. However, based on the findings of a non-compliance revisit and an annual recertification survey, Immediate Jeopardy was again identified on 01/26/18 (fifteen (15) days after the facility alleged compliance) and determined to exist on 01/09/18 at 42 CFR 483.10 Resident Rights (F578 and F580), 42 CFR 483.21 Comprehensive Person-Centered Care Planning (F656 and F658), 42 CFR 483.24 Quality of Life (F678), and 42 CFR 483.70 Medical Records (F842). Interview with a Governing Body Member on 03/06/18 at 2:00 PM via telephone and a post survey interview conducted on 04/03/18, at 6:10 PM, via telephone revealed the Governing Body consisted of herself and the Co-owner of the facility. The Member stated that neither she nor the Co-owner had a medical background and therefore the facility had entered into a management agreement with a consultant company to manage the day to day operations of the facility. The Board Member stated that a Governing Body meeting was conducted monthly at the facility which consisted of the Administrator, the Management Company Team, and the Governing Body Members. The Member stated that the Governing Body Members were not provided with written reports, but were advised of general problems such as staffing issues or personnel action that needed their approval such as termination of employees. The Board Member stated that she was aware that deficient practice had been identified during the previous surveys, but was not aware of specific details of the deficient practice or resident specific information. The Board member stated the Governing Body was dependent upon the Management Company to ensure policies and procedures were implemented. Review of a Management Agreement entered into by the facility and the Management Company on 11/01/15, revealed the facility had retained the Management Company to supervise and manage the operation of the facility. The Agreement states that the Management Company will manage all aspects of the facility's operation in an efficient manner and periodically consult with the owners authorized represenatives and keep them advised as to all fisical and operational matters relating to the facility. The agreement also states that all general policy decisions would be made by the owner. (Refer to F578, 580, F656, F658, F678, and F692, F835, F842 and F868.) The facility implemented the following for removal of jeopardy: 1. On 01/26/18, the Administrator provided an in-service to the Director of Nursing, Minimum Data Set (MDS) Nurse, and the Quality Assurance (QA) Nurse regarding the development and implementation of a comprehensive care plan that included the wishes of each resident related to code status. 2. The policies and procedures were reviewed and updated regarding physician notification and obtaining, documenting, and honoring the wishes of each resident for Advance Directives/Code Status by the PIP Committee on 01/29/18. The resident's wishes for Advance Directives and code status will be obtained upon admission by Social Services and the admission Director. Code status designations will be documented in the physician's orders, in the resident care plan, and on the resident's face sheet. Residents choosing a DNR code status will sign a completed No Code or DNR consent form that will be maintained in the resident's medical record. Residents without an Advance Directive will be considered a Full Code. The Advance Directives and Code Status policies were reviewed, updated, and approved by the QAPI Committee on 01/29/18. 3. On 01/26/18, a comprehensive audit was completed by the Administrator, MDS Nurse, Assistant Administrator, Director of Nursing (DON), QA Nurse, Unit Manager, Activities Director, Admissions Director, and Social Workers for every resident in the facility. The audit was a review of each resident's Advance Directive and code status that included physician orders, Advance Directive designation forms, consent forms, paper record, electronic record, and face sheets with no variances noted. The residents' comprehensive care plans were also reviewed and updated as needed to assure residents' Advance Directives and wishes for code status were included on the plan of care. These audits were conducted at the direction of the Quality Assurance and Performance Improvement (QAPI) Committee and completed on 01/26/18. Members of the QAPI committee included: The Administrator, Director of Nursing, Unit Managers, Medical Director, MDS Coordinator, Staff Development Coordinator, Pharmacy Representative, Social Services Director, and Activity Director. Completed audits were submitted to the QAPI Committee for additional review. 4. The Director of Nursing, Quality Assurance Nurse, Unit Manager, and MDS Nurse completed a focus review to ensure proper notification occurred for changes in resident condition. The audit included review of residents transferred to the hospital within the prior week, all Nurse's Notes documented between 01/22/18 through 01/30/18, and any new Physician's Orders received 01/22/18 through 01/30/18. 5. Licensed staff that were involved with the care of Resident #26 (6) and Resident #63 received additional training related to identification and communication of a resident's wishes regarding Advance Directives and code status, as well as including and honoring those wishes through implementation of the resident's care plan. The training included timely notification of a resident's physician and responsible party, as well as documentation of the notification. The training also included development and implementation of the comprehensive care plan which included the wishes of each resident related to their code status. Post-tests and staff interviews were completed to ensure comprehension of the training material. The training was completed 01/26/18 through 01/31/18 by the Director of Nursing, Staff Development Director. 6. All licensed and certified nursing staff and the Interdisciplinary Care Plan team (IDT) which consisted of MDS Nurse, Social Worker, Activity Director, and the Director of Dietary Services all received additional training beginning on 01/26/18 thru 01/31/18 related to: - identification and communication of a resident's wishes regarding Advance Directives and code status - honoring resident's code status wishes through the implementation of the resident's care plan -providing the necessary care and services such as emergency care, basic life support, and CPR to those residents in accordance with the resident's Advance Directives and wishes regarding code status -how to determine the code status of each resident according to facility protocols - assessing and responding to a resident in distress - timely notification of the physician - initiating a code - honoring the wishes of each resident with a full-code status - documenting care delivered - development and implementation of the comprehensive care plan which included the wishes of each resident related to their code status The training was completed by the Director of Nursing, Staff Development Director, and the Administrator. Post-tests and staff interviews were completed to ensure comprehension of the training material. Any staff member in the nursing department who was off work for any reason will not be permitted to work until training and post testing are completed. 7. On 01/27/18, the Administrator posted a listing of each resident and their desired code status at each nursing unit. The Administrator completed the list after the Advance Directives and CPR desires of each resident were validated through the audit completed on 01/26/18. Monitoring would include a daily review of this list by the Administrator or Assistant Administrator Monday through Friday. The weekend manager would review and update the listing on Saturday and Sunday. 8. Notification to a resident's physician, resident, and resident representative is monitored daily (Monday - Friday) in the Clinical Meeting. Attendees of the Clinical Meeting include the Director of Nursing, MDS Nurse, Social Workers, QA Nurse, and Unit Manager. The Clinical Meeting conducts a review of the following: 24-hour report, physician's telephone orders, nurse's notes, laboratory reports, resident events, changes in residents' condition, new admissions, and discharges. Any concerns identified are corrected immediately. 9. On 01/29/18, training, direction, and responsibility was assigned to Social Services for listing residents' wishes regarding Advance Directive on the residents' comprehensive care plan. The MDS Nurse will verify that Advance Directives are included on the care plan. This review will occur during Care Plan Conferences following the Resident Assessment Instrument (RAI) schedule. 10. On 01/29/18, a focus Performance Improvement Plan (PIP) Committee was formed by the QAPI Committee to review and monitor the facility's processes for obtaining and honoring residents' Advance Directives, code status, development and implementation of a care plan that meets the code status wishes of the resident, procedures for calling a code, and the conditions for implementing CPR to a full code resident. The PIP committee members included: The Administrator, Director of Nursing, Unit Managers, MDS Coordinator, Staff Development Coordinator, Social Services and Activity Director. The PIP Committee meets daily to focus on implementing the plan outlined herein, monitor results of audits and reviews, and provides additional direction as needed. The daily (Monday through Friday) PIP Committee meetings will continue until removal of the immediate jeopardy has been verified. Weekly QAPI meetings would continue to occur until sustained compliance was achieved. 11. The QAPI Committee will monitor and ensure sustained compliance is maintained through a weekly meeting. The members of this meeting will review all audits, training, and corrective actions generated by the focus PIP Committee. QAPI meetings will occur until sustained compliance is achieved. Information reviewed in this meeting will include: - Verbal report and a current Code Status List is reviewed and updated daily with any changes in the resident's Advance Directives and CPR status and is submitted by the Administrator or Assistant Administrator - The MDS Nurse will submit a verbal report and audit tool(s) related to the validation of the resident's code status during resident care plan conferences - The DON or QA Nurse will review the findings of the 24-hour report, physician's telephone orders, nurse's notes, laboratory tests, resident events, and changes in residents' condition identified in the morning clinical meetings and through routine clinical assessments, evaluations, and nurse management rounds, as well as a review of new admissions and discharges. The Daily Audit Tool will also be used to validate proper notification to physicians and the resident representative. - The DON or SDC will submit a verbal report, in-service logs and training agenda(s) regarding training or post testing completed. - The Social Worker will submit a verbal report and census list regarding any changes in Advance Directives or code status, including new admissions and re-admissions. - The DON or QA Nurse will give a verbal report and submit an audit tool related to any resident transfers to the hospital for urgent or critical care. The reports will include verification of proper notification, communication regarding resident's Advance Directives/code status prior to transfer, the Center's response to the resident's wishes, and the outcome of the transfer. - The committee will also discuss any new concerns identified through audits and reviews and applicable corrective action or changes. 12. On 03/02/18, a Long Term Care (LTC) consultant who is licensed as a Long Term Care Health Administrator in the state of Kentucky provided training to the Administrator of the facility for compliance with the federal and state regulations, quality assurance and performance improvement, efficient and effective use of resources, human resource development, and responsibilities of the Governing Body. Additionally, education was provided that according to §483.70 the facility must be administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. 13. On 03/02/18, the Administrator developed a Performance Improvement Team (PIT) to develop a Performance Improvement Plan (PIP) for the purposes of maintaining an effective nutrition/hydration status program. The PIT had the first meeting on 03/02/18 to develop, review, and monitor the resident nutrition/hydration status program. The PIT committee members include: the Administrator, Director of Nursing (DON), Unit Managers, Minimum Data Set (MDS) Coordinator, Staff Development Coordinator, and the internal auditors of nutrition/hydration status. 14. Effective 03/01/18, the Administrator and Director of Nursing have developed audit forms with the assistance of long term care consultants for all recently cited care and service areas. Auditors were appointed by the Administrator with the assistance of long term care consultants on 03/01/18. Education regarding the use of the audit forms was provided to the auditors on 03/01/18, by the Administrator and the long term care consultants. Effective 03/02/18, the audits will identify residents at risk for the cited deficiencies in the areas of assisted nutrition and hydration. The Administrator and Director of Nursing are involved with all compliance and corrective actions taken to correct any alleged deficiency and have assured that the following corrective actions have identified any resident who may be affected. 15. On 03/02/18, the Administrator reviewed the members of the Quality Assurance Committee. These members conform with the requirements of the current regulations and include the Administrator, Medical Director, Director of Nursing, Unit Managers, MDS Coordinator, Staff Development Coordinator, Pharmacy Representative, Social Services Director and Activities Director. 16. Residents #1, #85 (5), #48, #53 (12), and #147 (H) were assessed by the RD from 01/19/18 through 03/02/18. The residents' physicians were notified with any new recommendations. From 01/13/18 through 03/02/18, a licensed nurse conducted a dehydration risk assessment and no additional interventions were recommended. In addition, on 03/03/18, a fluid intake audit was completed for Residents #48, #53, and #147, and the residents were meeting or exceeding their fluid needs. Resident #1 was discharged from the facility on 01/29/18, and is no longer a resident. Resident #85 (5) was discharged from the facility on 02/01/18, and is no longer a resident at the facility. 17. On 02/08/18, a representative from Medline Industries (Medline is the facility provider for feeding tube pumps), completed a Quality Assurance audit of all feeding pumps to ensure function and accuracy. All pumps were found to be in working order. Beginning on 02/08/18 and completed on 02/13/18, the representative and the Director of Nursing (DON) provided education regarding operation and use of the pumps to all licensed nurses and nurses completed a return demonstration. 18. On 03/01/18, implementation began to convert electronic documentation of Food and Fluid Consumption to paper documentation. Education began on 03/02/18 and continued through 03/04/18. Employees not having been in-serviced by 03/04/18 will not be allowed to work until education is completed. Food and fluids consumed daily with resident meals, snacks, and medication administration will be recorded on the Food and Fluid Consumption Sheet. The night shift Charge Nurse will calculate the fluids consumed and compare to the recommended fluid needs calculated by the RD. Residents not meeting the estimated daily fluid needs will be noted on the 24-hour report log for increased monitoring. The resident/resident representative and the resident's physician will be notified if a resident does not consume a daily average of 50% of routine meals without substitutes and supplements for three (3)consecutive days. Food and fluid intake documentation will be monitored daily Monday through Friday by the Unit Managers and the Weekend Manager will monitor on Saturday and Sunday. 19. Licensed Nurses completed Dehydration Risk Assessments for all residents on 03/02/18 and 03/03/18. Any concerns identified during this evaluation were addressed immediately with physician notification, care plan review, and care plan updates as indicated. From 03/02/18 to 03/04/18, a fluid intake audit was completed by comparing the individual fluid needs of all residents to each residents' average fluid consumption from 02/21/18 through 02/27/18. This audit was completed by the Director of Nursing, Unit Manager, MDS Nurse, Administrator, and Assistant Administrator. Any resident not meeting their estimated fluid need was evaluated, notifications were made if indicated to the physician and resident/resident representative, and care plans were reviewed and updated as needed. 20. On 03/03/18, the Tube Feeding Intake Worksheet was implemented to monitor and track formula and fluids administered to residents with tube feeding. This worksheet will be completed at the end of each shift by the licensed nurse. The Unit Manager, Weekend Manager, or designated Nurse Manager will review the Tube Feeding Intake Worksheet daily to ensure residents receiving tube feeding formula and/or fluids receive the amount prescribed by the physician. If reviews indicate that the intake administered is below the prescribed amount, a quality assurance check will be performed on the feeding pump, a dehydration risk assessment will be completed by a licensed nurse, and the physician and resident/resident representative will be notified. An additional review of the Tube Feeding Intake Worksheet will occur daily Monday through Friday by the Quality Assurance Nurse (QA Nurse). 21. On 03/02/18, the DON reviewed all resident weights for significant/severe weight loss. Any resident identified as having new weight loss was evaluated, the resident/responsible representative and the resident's physician were notified, and the resident's comprehensive care plan was reviewed and updated, if indicated. 22. Routine and weekly weights will be obtained by the Restorative Aides, recorded on a resident weight worksheet, and submitted to the Unit Manager for review. Weights will be logged into the medical record after review by the Unit Manager. Once weights are logged, the Director of Nursing will review the computer-generated weight change report weekly on Tuesday prior to the Nutrition at Risk Committee (NAR) meeting. Residents identified to be at risk for nutrition and hydration decline are monitored by the Interdisciplinary NAR Committee. Members of the NAR Committee include the Director of Nursing, the Unit Managers, the Registered Dietitian, the Dietary Manager, the MDS Nurse, and the QA Nurse. The NAR Committee reviews at risk residents' intake, weight, and hydration status. The NAR Committee will review the daily Food and Fluid Consumption Sheets, the daily Tube Feeding Intake Worksheets, and the computer generated weight variance report that are completed each Tuesday by the DON. 23. The Dietary Manager will conduct an additional nutrition and hydration audit daily (Monday through Friday) to ensure any resident not meeting minimal nutrition and hydration requirements have been addressed as needed. 24. The Governing Body is providing oversight through a contract with a Management Company. On 03/02/18, the Long Term Care Consultants with the Management Company (a Registered Nurse and a Licensed Health Care Administrator) provided education to the Governing Body related to the responsibilities of the Governing Body as promulgated in §483.70. The education included the responsibilities of the Governing Body to include the establishment and implementation of policies regarding the management and operation of the facility. The Governing Body has directed that all resources and administration abate deficient practice at nutrition/hydration to include corrective actions for those residents affected. The Management Company oversees the daily operations of the facility and utilizes contracted consultants as necessary for the operation. The consultants have extensive experience and education in the area of operating long term care facilities and are not employees of the facility, but rather act as an outside resource in providing advice and consultation to the management staff of the facility. The Administrator, who was appointed by the Governing Body on 03/07/14, is responsible for the daily management of the facility, and reports and is accountable to the Governing Body. The Governing Board meets with the Management Company each month. 25. The PIP Committee meets daily to focus on implementing the plan outlined herein, monitor results of audits and reviews, and provides additional direction as needed. The daily (Monday through Friday) PIP Committee meetings will continue until removal of the immediate jeopardy has been verified. 26. The Quality Assurance and Performance Improvement (QAPI) policies were reviewed on 03/02/18 by the Long Term Care Consultant and the Administrator with no changes noted. The QAPI policies are in conformance with the current regulatory standards and no changes were necessary. The QAPI Committee reviewed the QAPI policies on 03/22/18 with acceptance. On 03/02/18, the Administrator provided education to the Quality Assurance and Assessment (QAA) Committee related to the policies and the structure of the Quality Assurance and Assessment (QAA) program. The Administrator with the assistance of the long term care consultant developed new tools that are to be used for the Performance Improvement Team (PIT) that includes a new tool for a Performance Improvement Plan (PIP). These new tools are used for the PIP for the abatement of Immediate Jeopardy. Weekly QAPI meetings will be held and will continue to occur until sustained compliance is achieved. The completed PIP will be submitted to the weekly meetings of the QAPI Committee for approval and suggestions. 27. The Administration of the facility to include the Administrator and Director of Nursing are conferring daily with long term care consultants to monitor administration's role with the abatement of jeopardy beginning 03/02/18. The SSA verified the removal of immediate jeopardy by the following: 1. Review of the in-service roster dated 01/26/18, revealed the DON, MDS Nurse, and the QA Nurse had attended an in-service by the Administrator related to the development and implementation of a comprehensive care plan to ensure the wishes of each resident and their code status was included on the care plan. Interviews conducted with the MDS Nurse on 02/16/18 at 1:04 PM; the QA Nurse on 02/16/18 at 1:22 PM; and, the DON on 02/16/18 at 2:00 PM, revealed they attended the in-service provided by the Administrator and began providing in-services for other staff on 01/29/18. 2. Review of the facility's policies and in-service rosters regarding Advance Directives and Code Status revealed the facility reviewed and updated the policies on 01/29/18. The policies revealed the facility's new process to ensure Advance Directives/Wishes were honored was as follows: the physician would be notified after obtaining the resident's/ responsible party's consent, documenting the consent, and honoring the resident's wishes for Advance Directives and Code Status. The policy revealed the resident's wishes for Advance Directives and code status would be obtained upon admission by Social Services and the admission Director. This would be documented in the physician's orders, resident care plan, and on the resident's face sheet. Interviews conducted with the Unit Manager on 02/16/18 at 11:04 AM, SSD on 02/16/18 at 11:25 AM, Activities Director on 02/16/18 at 12:59 PM, MDS Nurse on 02/16/18 at 1:04 PM, QA Nurse on 02/16/18 at 1:22 PM, Assistant Administrator on 02/16/18 at 1:40 PM, DON on 02/16/18 at 2:00 PM, and the Administrator on 02/16/18 at 2:10 PM, revealed they had reviewed/updated the facility's policies regarding Advance Directives and Code Status. 3. Review of audit sheets completed by the Administrator, MDS Nurse, Assistant Administrator, DON, QA Nurse, Unit Manager, Activities Director, Admissions Director, and Social Worker revealed an audit was conducted for all residents to ensure the resident's code status/Advance Directive was accurately documented on the physician's orders, designation forms, and consent forms. Interviews conducted with the Admissions Director on 02/16/18 at 11:00 AM, Unit Manager on 02/16/18 at 11:04 AM, SSD on 02/16/18 at 11:25 AM, Activities Director on 02/16/18 at 12:59 PM, MDS Nurse on 02/16/18 at 1:04 PM, QA Nurse on 02/16/18 at 1:22 PM, Assistant Administrator on 02/16/18 at 1:40 PM, DON on 02/16/18 at 2:00 PM, and the Administrator on 02/16/18 at 2:10 PM, revealed they had conducted audits on every resident to ensure the resident's code status/Advance Directive was accurate on the physician's orders, designation forms, and consent forms. They also revealed the audits were then reviewed in the facility's QAPI meeting. 4. Review of audits completed by the DON, QA Nurse, Unit Manager, and MDS Nurse, revealed all residents had been reviewed for any change in their condition, Nurses' Notes reviewed, any new Physician's Orders and transfers from 01/22/18 through 01/30/18. Interviews conducted with the Unit Manager on 02/16/18 at 11:04 AM, the MDS Nurse on 02/16/18 at 1:04 PM, QA Nurse on 02/16/18 at 1:22 PM, and the DON on 02/16/18 at 2:00 PM, revealed they completed the reviews regarding any residents who were transferred to the hospital, including their nurses notes and any new physician's orders 01/22/18 through 01/30/18. 5. Review of staff in-service rosters, posttests, and interviews dated 01/26/18, revealed LPN #12, LPN #14, and SRNA #4 attended in-services by the DON and SDC regarding: - Advance Directives - Code Status - Implementation of the care plan which included wishes of the resident related to their code status - Timely notification of the physician and responsible party - Documentation of the notification of the physician and responsible party Interview with LPN #12 on 02/16/18 at 10:30 AM, LPN #14 on 02/16/18 at 11:00 AM, and SRNA #4 on 02/16/18 at 12:15 PM, revealed they attended the in-services and also completed a posttest as well as an interview to ensure they were knowledgeable of the information provided in the training. 6. Review of staff in-service rosters, posttests, and interviews dated 01/26/18 through 01/31/18, revealed all staff had attended the in-services given by the DON and SDC on: - Advance Directives - Code Status - Development and implementation of the care plan which included wishes of the resident related to their code status - Timely notification of the physician and responsible party - Documentation of the notification of the physician and responsible party - Provision of the necessary care and services such as emergency care, basic life support, and CPR to those residents in accordance with the resident's Advance Directives and wishes -Determination of a resident's code status according to the facility's protocols -Assessing and responding to a resident in distress - Initiation of a code -Communication of a resident's wishes regarding Advance Directives and code status -Honoring a resident's wishes in a full code status - Documentation of care delivered Interviews conducted with LPN #9 on 02/15/18 at 4:05 PM, SRNA #23 on 02/15/18 at 4:10 PM, SRNA #24 on 02/15/18 at 4:15 PM, Dietary Employee #1 on 02/15/18 at 4:25 PM, Dietary Manager on 02/15/18 at 4:30 PM, Dietary Employee #2 on 02/15/18 at 4:35 PM, KMA #3 on 02/15/18 at 4:50 PM, SRNA #5 on 02/16/18 at 9:10 AM, SRNA #12 on 02/16/18 at 9:15 AM, SRNA #14 on 02/16/18 at 9:25 AM, LPN #1 on 02/16/18 at 9:30 AM, and SRNA #25 on 02/16/18[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and review of facility policy, it was determined the facility failed to ensure three (3) of thirty-seven (37) residents (Residents #58, #26 (6), and #85 (5)) medical records were complete and correctly documented. The facility inaccurately documented Resident #26's (6) vital signs, failed to accurately document Resident #58's intravenous antibiotic medication and documented a physician's order for Resident #58, that the physician did not authorize. In addition, staff documented the amount of tube feeding that Resident #85 (5) had received before the resident had actually received the feeding and failed to accurately document Resident #85's (5) transfer to an acute care hospital (Refer to F580, F656, F658, F678). The facility's failure to ensure residents' medical records were complete and accurate has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 01/26/18, and determined to exist on 01/09/18 at 42 CFR 483.10 Resident Rights (F578 and F580), 42 CFR 483.21 Comprehensive Person-Centered Care Planning (F656 and F658), 42 CFR 483.24 Quality of Life (F678), and 42 CFR 483.70 Administration (F842). The facility was notified of the Immediate Jeopardy on 01/26/18. After supervisory review, Immediate Jeopardy was identified on 03/01/18 and determined to exist on 12/12/17 at 42 CFR 483.25 Quality of Care (F692 ) and 42 CFR 483.70 Administration (F835, F837). The facility was notified of the Immediate Jeopardy on 03/01/18 at 42 CFR 483.25 Quality of Care (F692), and 42 CFR 483.70 Administration (F835 and F837). An acceptable Allegation of Compliance was received on 03/05/18, which alleged removal of the Immediate Jeopardy on 03/05/18. The State Survey Agency determined the Immediate Jeopardy was removed on 03/05/18, prior to exit, which lowered the scope and severity to D at at 42 CFR 483.10 Resident Rights (F578 and F580), 42 CFR 483.21 Comprehensive Person-Centered Care Planning (F658), 42 CFR 483.24 Quality of Life (F678), 42 CFR 483.25 Quality of Care (F692 ) and 42 CFR 483.70 Administration (F835, F837, and 842), and to an E at 42 CFR 483.21 Comprehensive Person-Centered Care Planning (F656), while the facility monitors the effectiveness of systemic changes and quality assurance activities. The findings include: 1. A review of the facility's Notification of Changes/Documentation policy, not dated, revealed when a resident had a change in condition, a nursing note had to be charted about the condition, who was contacted, and what interventions were being implemented. Review of Resident #26's (6) closed medical record revealed the facility admitted the resident on 06/14/16, with a readmission date of 01/09/18, with diagnoses of Alzheimer's Disease, Dysphagia, Gastrostomy tube, Trauma related to a Subdural Hematoma, and Multiple Rib Fractures. Review of the Nursing Notes dated 01/12/18 at 3:45 PM, revealed Licensed Practical Nurse (LPN) #12 documented that Resident #26's (6) skin was pale, breathing was labored, and blood pressure was 90/60 (normal is 120/80). Continued review of Resident #26's (6) Nursing Notes revealed on 01/12/18 at 5:09 PM, LPN #12 documented that the physician was notified about the resident's condition and new orders were received to send the resident to the hospital for evaluation, the resident's blood pressure was 80/30, pulse 60, respirations 24, and oxygen saturation was 97%. However, review of the Fire-EMS Prehospital Care Report dated 01/12/18, revealed when EMS arrived to the resident's room at 4:50 PM, nineteen minutes before the Nursing Note was written, the resident had no pulse and was not breathing, and was transferred to the hospital at 5:01 PM with CPR in progress. In addition, interview with Resident #26's (6) physician on 01/15/18 at 11:04 AM revealed the facility never notified him that the resident had a change in condition or was transferred to the hospital. Review of Resident #26's (6) Emergency Department (ED) record revealed the resident presented to the ED with CPR in progress by EMS at 5:09 PM, which was the same time that LPN #12 documented that the resident had vital signs at the facility. Further review revealed Resident #26 (6) was pronounced dead at 5:11 PM, on 01/12/18. Interview with the Director of Nursing on 01/25/18 at 11:41 AM, revealed the facility had no system in place to review nursing documentation to ensure medical records were complete and accurate. 2. a. Review of the facility's policy titled, Documenting in the Medication Administration Record revealed staff who administered a medication was required to record the administration on the resident's MAR immediately after the medication was administered. The policy stated after the completion of each medication pass, staff were required to review the MAR to ensure correct doses were administered and documented. If any dose of medication was refused, with-held, or given at an alternate time, an explanatory note was required to be made on the MAR providing the reason the medication was not given as ordered. Review of Resident #58's medical record revealed the facility admitted the resident on 10/05/09 and was readmitted on [DATE], after an acute hospital stay for treatment of an infection to the left knee after knee surgery. The resident had diagnoses that included Bacteremia and Staphylococcal Arthritis in the Left Knee. Review of a Physician Telephone Order dated 01/09/18, for Resident #58 revealed an order for Vancomycin one (1) gram intravenously. According to the resident's Medication Administration Record (MAR), the medication was administered as ordered. However, review of Resident #58's Medication Administration History from 01/09/18 through 01/18/18, revealed on 01/09/18, the resident's Vancomycin was administered approximately two and one-half hours after it was scheduled to be administered. On 01/10/18 at 10:00 PM, the resident did not receive the physician ordered Vancomycin at 10:00 PM. In addition, on 01/14/18, the resident's medication was administered approximately 15 hours late, and the resident received another dose within approximately two (2) hours. Further review of the MAR revealed no explanatory note indicating why the medication was administered late as required by the facility's policy. Further, review of Resident #58's MAR revealed the resident had a dose of Vancomycin due on 01/18/18 at 4:00 PM. However, review of the Medication Administration History, revealed that the resident's 4:00 PM dose was not administered until 10:42 PM, approximately seven (7) hours late. Review of Resident #58's January 2018 Physician's Orders revealed an order was handwritten on the typed orders to hold the 4:00 PM dose of Levaquin for the resident. However, an interview with Physician #2 on 01/19/18 at 12:18 PM, Resident #58's physician, revealed he did not give an order to hold Resident #58's 4:00 PM dose of Vancomycin on 01/24/18. Physician #2 stated the facility contacted him and asked if the dose of Vancomycin could be held until they received the results of the Vancomycin trough. The Physician stated he instructed the nurse not to hold the medication and to administer the 4:00 PM dose of Vancomycin. Interview with the Infection Control Nurse on 01/19/18 at 12:08 PM, revealed she contacted Resident #58's physician for an order to hold the resident's 4:00 PM dose of Vancomycin medication on 01/24/18, until laboratory results were obtained. The Infection Control Nurse stated the physician instructed her not to hold the dose and to administer the medication as ordered. The Infection Control Nurse stated she was not sure who wrote the order to hold the dose. Interview with the Director of Nursing (DON) on 01/24/18 at 12:05 PM, revealed the facility had no system in place to compare the MAR history to the MAR to ensure medications were actually being administered timely as ordered. The DON stated that the MAR indicated the time the medication was due to be administered, but did not necessarily indicate the actual time the medication was administered. The DON stated if the medication was not given at the time the MAR required, a note should be made indicating the reason, as directed by the facility's policy.3. a. Review of the facility's policy titled Change in a Resident's Condition or Status, dated August 2011, revealed the nurse supervisor/charge nurse should record in the resident's medical record information relative to changes in the resident's medical/mental condition or status. Review of the medical record for Resident #85 (5) revealed the facility readmitted the resident on 12/27/17, with diagnoses which include Alzheimer's Disease, Pneumonia, Hypertension, Acute Respiratory Distress Syndrome, Diabetes Mellitus Type II, Dysphagia, and Aphasia. Review of Resident #85's admission Minimum Data Set (MDS) assessment dated [DATE], revealed the resident's Brief Interview for Mental Status (BIMS) score was zero (0), which indicated the resident was severely cognitively impaired. The MDS also revealed the resident was totally dependent on staff for Activities of Daily Living (ADL). On 02/02/18 at 9:30 AM, an observation of Resident #85 (5) was attempted; however, the resident was not present in his/her room. Interview with Licensed Practical Nurse (LPN) #13 on 02/02/18 at 11:51 AM revealed the resident had been transferred to an acute care hospital on [DATE] at approximately 5:00 PM, for evaluation due to a change in the medical condition, and was admitted to the hospital. However, review of Resident #85's medical record on 02/02/18 at 9:40 AM revealed no documentation that the resident had a change in condition or had been transferred out of the facility. Further review of the medical record revealed no documented evidence that a physician's order was written to transfer the resident to another facility. Interview with LPN #13 on 02/02/18 at 11:51 AM revealed she was the nurse on duty on 02/01/18, when Resident #85 (5) was transferred to the hospital. LPN #13 stated she notified the physician of the change in the resident's condition and obtained an order to transfer the resident to a hospital. The LPN stated the resident's responsible party was present when the change of condition occurred, and accompanied the resident to the hospital. LPN #13 stated she forgot to document the resident's condition and transfer in the resident's Nursing Notes, and forgot to write the physician's order to transfer the resident. Interview with the Director of Nursing (DON) on 02/02/18 at 6:49 PM revealed the nurse taking the physician's order and caring for the resident was responsible for documenting a change of condition and writing the physician's order. The DON further stated she monitored physician's orders from the previous day every morning, but she was not aware that Resident #85 (5) had a change of condition or had been transferred from the facility because there was no documentation of the occurrence. 3. b. Further review of Resident #85's medical record revealed physician orders for January 2018, required the resident to receive Glucerna 1.5 at 50 milliliters (ml) per hour. Review of Resident #85's Medication Administration Record (MAR) on 01/25/18 at approximately 1:00 PM, revealed staff had already documented the resident's 7:00 PM tube feeding had been administered, six (6) hours prior to the time the tube feeding was due to be administered. Interview with LPN #12 on 01/25/18 at 1:30 PM, the nurse providing care for Resident #85, revealed she was unable to state why the tube feeding was documented for the future, when it had not been administered to the resident. The facility implemented the following for removal of jeopardy: 1. On 01/26/18, the Administrator provided an in-service to the Director of Nursing, Minimum Data Set (MDS) Nurse, and the Quality Assurance (QA) Nurse regarding the development and implementation of a comprehensive care plan that included the wishes of each resident related to code status. 2. The policies and procedures were reviewed and updated regarding physician notification and obtaining, documenting, and honoring the wishes of each resident for Advance Directives/Code Status by the PIP Committee on 01/29/18. The resident's wishes for Advance Directives and code status will be obtained upon admission by Social Services and the admission Director. Code status designations will be documented in the physician's orders, in the resident care plan, and on the resident's face sheet. Residents choosing a DNR code status will sign a completed No Code or DNR consent form that will be maintained in the resident's medical record. Residents without an Advance Directive will be considered a Full Code. The Advance Directives and Code Status policies were reviewed, updated, and approved by the QAPI Committee on 01/29/18. 3. On 01/26/18, a comprehensive audit was completed by the Administrator, MDS Nurse, Assistant Administrator, Director of Nursing (DON), QA Nurse, Unit Manager, Activities Director, Admissions Director, and Social Workers for every resident in the facility. The audit was a review of each resident's Advance Directive and code status that included physician orders, Advance Directive designation forms, consent forms, paper record, electronic record, and face sheets with no variances noted. The residents' comprehensive care plans were also reviewed and updated as needed to assure residents' Advance Directives and wishes for code status were included on the plan of care. These audits were conducted at the direction of the Quality Assurance and Performance Improvement (QAPI) Committee and completed on 01/26/18. Members of the QAPI committee included: The Administrator, Director of Nursing, Unit Managers, Medical Director, MDS Coordinator, Staff Development Coordinator, Pharmacy Representative, Social Services Director, and Activity Director. Completed audits were submitted to the QAPI Committee for additional review. 4. The Director of Nursing, Quality Assurance Nurse, Unit Manager, and MDS Nurse completed a focus review to ensure proper notification occurred for changes in resident condition. The audit included review of residents transferred to the hospital within the prior week, all Nurse's Notes documented between 01/22/18 through 01/30/18, and any new Physician's Orders received 01/22/18 through 01/30/18. 5. Licensed staff that were involved with the care of Resident #26 (6) and Resident #63 received additional training related to identification and communication of a resident's wishes regarding Advance Directives and code status, as well as including and honoring those wishes through implementation of the resident's care plan. The training included timely notification of a resident's physician and responsible party, as well as documentation of the notification. The training also included development and implementation of the comprehensive care plan which included the wishes of each resident related to their code status. Post-tests and staff interviews were completed to ensure comprehension of the training material. The training was completed 01/26/18 through 01/31/18 by the Director of Nursing, Staff Development Director. 6. All licensed and certified nursing staff and the Interdisciplinary Care Plan team (IDT) which consisted of MDS Nurse, Social Worker, Activity Director, and the Director of Dietary Services all received additional training beginning on 01/26/18 thru 01/31/18 related to: - identification and communication of a resident's wishes regarding Advance Directives and code status - honoring resident's code status wishes through the implementation of the resident's care plan -providing the necessary care and services such as emergency care, basic life support, and CPR to those residents in accordance with the resident's Advance Directives and wishes regarding code status -how to determine the code status of each resident according to facility protocols - assessing and responding to a resident in distress - timely notification of the physician - initiating a code - honoring the wishes of each resident with a full-code status - documenting care delivered - development and implementation of the comprehensive care plan which included the wishes of each resident related to their code status The training was completed by the Director of Nursing, Staff Development Director, and the Administrator. Post-tests and staff interviews were completed to ensure comprehension of the training material. Any staff member in the nursing department who was off work for any reason will not be permitted to work until training and post testing are completed. 7. On 01/27/18, the Administrator posted a listing of each resident and their desired code status at each nursing unit. The Administrator completed the list after the Advance Directives and CPR desires of each resident were validated through the audit completed on 01/26/18. Monitoring would include a daily review of this list by the Administrator or Assistant Administrator Monday through Friday. The weekend manager would review and update the listing on Saturday and Sunday. 8. Notification to a resident's physician, resident, and resident representative is monitored daily (Monday - Friday) in the Clinical Meeting. Attendees of the Clinical Meeting include the Director of Nursing, MDS Nurse, Social Workers, QA Nurse, and Unit Manager. The Clinical Meeting conducts a review of the following: 24-hour report, physician's telephone orders, nurse's notes, laboratory reports, resident events, changes in residents' condition, new admissions, and discharges. Any concerns identified are corrected immediately. 9. On 01/29/18, training, direction, and responsibility was assigned to Social Services for listing residents' wishes regarding Advance Directive on the residents' comprehensive care plan. The MDS Nurse will verify that Advance Directives are included on the care plan. This review will occur during Care Plan Conferences following the Resident Assessment Instrument (RAI) schedule. 10. On 01/29/18, a focus Performance Improvement Plan (PIP) Committee was formed by the QAPI Committee to review and monitor the facility's processes for obtaining and honoring residents' Advance Directives, code status, development and implementation of a care plan that meets the code status wishes of the resident, procedures for calling a code, and the conditions for implementing CPR to a full code resident. The PIP committee members included: The Administrator, Director of Nursing, Unit Managers, MDS Coordinator, Staff Development Coordinator, Social Services and Activity Director. The PIP Committee meets daily to focus on implementing the plan outlined herein, monitor results of audits and reviews, and provides additional direction as needed. The daily (Monday through Friday) PIP Committee meetings will continue until removal of the immediate jeopardy has been verified. Weekly QAPI meetings would continue to occur until sustained compliance was achieved. 11. The QAPI Committee will monitor and ensure sustained compliance is maintained through a weekly meeting. The members of this meeting will review all audits, training, and corrective actions generated by the focus PIP Committee. QAPI meetings will occur until sustained compliance is achieved. Information reviewed in this meeting will include: - Verbal report and a current Code Status List is reviewed and updated daily with any changes in the resident's Advance Directives and CPR status and is submitted by the Administrator or Assistant Administrator - The MDS Nurse will submit a verbal report and audit tool(s) related to the validation of the resident's code status during resident care plan conferences - The DON or QA Nurse will review the findings of the 24-hour report, physician's telephone orders, nurse's notes, laboratory tests, resident events, and changes in residents' condition identified in the morning clinical meetings and through routine clinical assessments, evaluations, and nurse management rounds, as well as a review of new admissions and discharges. The Daily Audit Tool will also be used to validate proper notification to physicians and the resident representative. - The DON or SDC will submit a verbal report, in-service logs and training agenda(s) regarding training or post testing completed. - The Social Worker will submit a verbal report and census list regarding any changes in Advance Directives or code status, including new admissions and re-admissions. - The DON or QA Nurse will give a verbal report and submit an audit tool related to any resident transfers to the hospital for urgent or critical care. The reports will include verification of proper notification, communication regarding resident's Advance Directives/code status prior to transfer, the Center's response to the resident's wishes, and the outcome of the transfer. - The committee will also discuss any new concerns identified through audits and reviews and applicable corrective action or changes. 12. On 03/02/18, a Long Term Care (LTC) consultant who is licensed as a Long Term Care Health Administrator in the state of Kentucky provided training to the Administrator of the facility for compliance with the federal and state regulations, quality assurance and performance improvement, efficient and effective use of resources, human resource development, and responsibilities of the Governing Body. Additionally, education was provided that according to §483.70 the facility must be administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. 13. On 03/02/18, the Administrator developed a Performance Improvement Team (PIT) to develop a Performance Improvement Plan (PIP) for the purposes of maintaining an effective nutrition/hydration status program. The PIT had the first meeting on 03/02/18 to develop, review, and monitor the resident nutrition/hydration status program. The PIT committee members include: the Administrator, Director of Nursing (DON), Unit Managers, Minimum Data Set (MDS) Coordinator, Staff Development Coordinator, and the internal auditors of nutrition/hydration status. 14. Effective 03/01/18, the Administrator and Director of Nursing have developed audit forms with the assistance of long term care consultants for all recently cited care and service areas. Auditors were appointed by the Administrator with the assistance of long term care consultants on 03/01/18. Education regarding the use of the audit forms was provided to the auditors on 03/01/18, by the Administrator and the long term care consultants. Effective 03/02/18, the audits will identify residents at risk for the cited deficiencies in the areas of assisted nutrition and hydration. The Administrator and Director of Nursing are involved with all compliance and corrective actions taken to correct any alleged deficiency and have assured that the following corrective actions have identified any resident who may be affected. 15. On 03/02/18, the Administrator reviewed the members of the Quality Assurance Committee. These members conform with the requirements of the current regulations and include the Administrator, Medical Director, Director of Nursing, Unit Managers, MDS Coordinator, Staff Development Coordinator, Pharmacy Representative, Social Services Director and Activities Director. 16. Residents #1, #85 (5), #48, #53 (12), and #147 (H) were assessed by the RD from 01/19/18 through 03/02/18. The residents' physicians were notified with any new recommendations. From 01/13/18 through 03/02/18, a licensed nurse conducted a dehydration risk assessment and no additional interventions were recommended. In addition, on 03/03/18, a fluid intake audit was completed for Residents #48, #53, and #147, and the residents were meeting or exceeding their fluid needs. Resident #1 was discharged from the facility on 01/29/18, and is no longer a resident. Resident #85 (5) was discharged from the facility on 02/01/18, and is no longer a resident at the facility. 17. On 02/08/18, a representative from Medline Industries (Medline is the facility provider for feeding tube pumps), completed a Quality Assurance audit of all feeding pumps to ensure function and accuracy. All pumps were found to be in working order. Beginning on 02/08/18 and completed on 02/13/18, the representative and the Director of Nursing (DON) provided education regarding operation and use of the pumps to all licensed nurses and nurses completed a return demonstration. 18. On 03/01/18, implementation began to convert electronic documentation of Food and Fluid Consumption to paper documentation. Education began on 03/02/18 and continued through 03/04/18. Employees not having been in-serviced by 03/04/18 will not be allowed to work until education is completed. Food and fluids consumed daily with resident meals, snacks, and medication administration will be recorded on the Food and Fluid Consumption Sheet. The night shift Charge Nurse will calculate the fluids consumed and compare to the recommended fluid needs calculated by the RD. Residents not meeting the estimated daily fluid needs will be noted on the 24-hour report log for increased monitoring. The resident/resident representative and the resident's physician will be notified if a resident does not consume a daily average of 50% of routine meals without substitutes and supplements for three (3)consecutive days. Food and fluid intake documentation will be monitored daily Monday through Friday by the Unit Managers and the Weekend Manager will monitor on Saturday and Sunday. 19. Licensed Nurses completed Dehydration Risk Assessments for all residents on 03/02/18 and 03/03/18. Any concerns identified during this evaluation were addressed immediately with physician notification, care plan review, and care plan updates as indicated. From 03/02/18 to 03/04/18, a fluid intake audit was completed by comparing the individual fluid needs of all residents to each residents' average fluid consumption from 02/21/18 through 02/27/18. This audit was completed by the Director of Nursing, Unit Manager, MDS Nurse, Administrator, and Assistant Administrator. Any resident not meeting their estimated fluid need was evaluated, notifications were made if indicated to the physician and resident/resident representative, and care plans were reviewed and updated as needed. 20. On 03/03/18, the Tube Feeding Intake Worksheet was implemented to monitor and track formula and fluids administered to residents with tube feeding. This worksheet will be completed at the end of each shift by the licensed nurse. The Unit Manager, Weekend Manager, or designated Nurse Manager will review the Tube Feeding Intake Worksheet daily to ensure residents receiving tube feeding formula and/or fluids receive the amount prescribed by the physician. If reviews indicate that the intake administered is below the prescribed amount, a quality assurance check will be performed on the feeding pump, a dehydration risk assessment will be completed by a licensed nurse, and the physician and resident/resident representative will be notified. An additional review of the Tube Feeding Intake Worksheet will occur daily Monday through Friday by the Quality Assurance Nurse (QA Nurse). 21. On 03/02/18, the DON reviewed all resident weights for significant/severe weight loss. Any resident identified as having new weight loss was evaluated, the resident/responsible representative and the resident's physician were notified, and the resident's comprehensive care plan was reviewed and updated, if indicated. 22. Routine and weekly weights will be obtained by the Restorative Aides, recorded on a resident weight worksheet, and submitted to the Unit Manager for review. Weights will be logged into the medical record after review by the Unit Manager. Once weights are logged, the Director of Nursing will review the computer-generated weight change report weekly on Tuesday prior to the Nutrition at Risk Committee (NAR) meeting. Residents identified to be at risk for nutrition and hydration decline are monitored by the Interdisciplinary NAR Committee. Members of the NAR Committee include the Director of Nursing, the Unit Managers, the Registered Dietitian, the Dietary Manager, the MDS Nurse, and the QA Nurse. The NAR Committee reviews at risk residents' intake, weight, and hydration status. The NAR Committee will review the daily Food and Fluid Consumption Sheets, the daily Tube Feeding Intake Worksheets, and the computer generated weight variance report that are completed each Tuesday by the DON. 23. The Dietary Manager will conduct an additional nutrition and hydration audit daily (Monday through Friday) to ensure any resident not meeting minimal nutrition and hydration requirements have been addressed as needed. 24. The Governing Body is providing oversight through a contract with a Management Company. On 03/02/18, the Long Term Care Consultants with the Management Company (a Registered Nurse and a Licensed Health Care Administrator) provided education to the Governing Body related to the responsibilities of the Governing Body as promulgated in §483.70. The education included the responsibilities of the Governing Body to include the establishment and implementation of policies regarding the management and operation of the facility. The Governing Body has directed that all resources and administration abate deficient practice at nutrition/hydration to include corrective actions for those residents affected. The Management Company oversees the daily operations of the facility and utilizes contracted consultants as necessary for the operation. The consultants have extensive experience and education in the area of operating long term care facilities and are not employees of the facility, but rather act as an outside resource in providing advice and consultation to the management staff of the facility. The Administrator, who was appointed by the Governing Body on 03/07/14, is responsible for the daily management of the facility, and reports and is accountable to the Governing Body. The Governing Board meets with the Management Company each month. 25. The PIP Committee meets daily to focus on implementing the plan outlined herein, monitor results of audits and reviews, and provides additional direction as needed. The daily (Monday through Friday) PIP Committee meetings will continue until removal of the immediate jeopardy has been verified. 26. The Quality Assurance and Performance Improvement (QAPI) policies were reviewed on 03/02/18 by the Long Term Care Consultant and the Administrator with no changes noted. The QAPI policies are in conformance with the current regulatory standards and no changes were necessary. The QAPI Committee reviewed the QAPI policies on 03/22/18 with acceptance. On 03/02/18, the Administrator provided education to the Quality Assurance and Assessment (QAA) Committee related to the policies and the structure of the Quality Assurance and Assessment (QAA) program. The Administrator with the assistance of the long term care consultant developed new tools that are to be used for the Performance Improvement Team (PIT) that includes a new tool for a Performance Improvement Plan (PIP). These new tools are used for the PIP for the abatement of Immediate Jeopardy. Weekly QAPI meetings will be held and will continue to occur until sustained compliance is achieved. The completed PIP will be submitted to the weekly meetings of the QAPI Committee for approval and suggestions. 27. The Administration of the facility to include the Administrator and Director of Nursing are conferring daily with long term care consultants to monitor administratio[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and review of facility policy it was determined the facility failed to develop/implement a care plan for twenty-six (26) of thirty-seven (37) sampled residents (Residents #1, #14, #26 (6), #28, #30, #34, #35, #38, #40, #46, #48, #53 (12), #57, #59, #63, #64, #67, #70, #78, #80, #85 (5), #92, #94, #146, and #147 (H)) and thirty-five (35) Unsampled Residents (Residents #4, #6, #7, #9, #11, #22, #25, #27, #29, #32, #33, #37, #44, #50, #54, #55, #56, #65, #73, #75, #77, #79, #84, #87, #88, #93, #95, #396, #397, #399, #448, #449, B, F, and Z). On 06/14/16, Resident #26 (6) was designated as full code by the resident's representative. However, the facility failed to develop a care plan that addressed the resident's full code status. On 01/12/18, Resident #26 (6) had a decline in health status and the facility failed to provide basic life support prior to Emergency Medical Services' (EMS) arrival. When EMS arrived, Resident #26 (6) had no pulse and was not breathing. The resident was transferred to the hospital. Resident #26 (6) expired at the hospital on [DATE] at 5:11 PM (Refer to F580, F658, F678, and F842). Resident #63 had a signed Kentucky Emergency Medical Services (EMS) Do Not Resuscitate (DNR) order dated 12/15/17, in place and in the resident's medical record. However, the facility failed to develop a care plan related to the resident's wishes. On 01/09/18, when the resident had a change in condition, the facility failed to provide the form to EMS. EMS initiated CPR to Resident #63 at the facility. The resident was transferred to the hospital, where the resident was placed on a ventilator, and expired on 01/12/18 (Refer to F578 and F770). In addition, the facility developed a care plan for Residents #53 (12), #147 (H), and #85 (5) that required the facility to notify the residents' physician of any nutritional changes. However, the facility failed to notify the residents' physician when the residents did not meet their nutritional needs. Subsequently, the residents sustained severe weight loss in the facility (Refer to F580, F692, F725, and F842). The facility's failure to develop/implement residents' care plans has caused or is likely to cause serious injury, harm, impairment, or death to a resident. The facility's failure to ensure residents' rights were protected has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 01/26/18, and determined to exist on 01/09/18 at 42 CFR 483.10 Resident Rights (F578 and F580), 42 CFR 483.21 Comprehensive Person-Centered Care Planning (F656 and F658), 42 CFR 483.24 Quality of Life (F678), and 42 CFR 483.70 Administration (F842). The facility was notified of the Immediate Jeopardy on 01/26/18. After supervisory review, Immediate Jeopardy was identified on 03/01/18 and determined to exist on 12/12/17 at 42 CFR 483.25 Quality of Care (F692 ) and 42 CFR 483.70 Administration (F835, F837). The facility was notified of the Immediate Jeopardy on 03/01/18 at 42 CFR 483.25 Quality of Care (F692), and 42 CFR 483.70 Administration (F835 and F837). An acceptable Allegation of Compliance was received on 03/05/18, which alleged removal of the Immediate Jeopardy on 03/05/18. The State Survey Agency determined the Immediate Jeopardy was removed on 03/05/18, prior to exit, which lowered the scope and severity to D at at 42 CFR 483.10 Resident Rights (F578 and F580), 42 CFR 483.21 Comprehensive Person-Centered Care Planning (F658), 42 CFR 483.24 Quality of Life (F678), 42 CFR 483.25 Quality of Care (F692 ) and 42 CFR 483.70 Administration (F835, F837, and 842), and to an E at 42 CFR 483.21 Comprehensive Person-Centered Care Planning (F656), while the facility monitors the effectiveness of systemic changes and quality assurance activities. Further Sampled Residents #1, #28, #34, #35, #38, #57, #59, #64, #67, #70, #78, #92, #94, #147 and Unsampled Residents #4, #6, #7, #9, #11, #22, #25, #27, #29, #32, #33, #37, #44, #50, #54, #55, #56, #65, #73, #75, #77, #79, #84, #87, #88, #93, #95, #396, #397, #399, #448, #449, B, F, and Z, had a signed consent for Cardiopulmonary Resuscitation (CPR) to be provided should the need arise; however, the facility failed to develop a care plan that addressed the residents' wishes. The facility failed to provide tube feeding and/or water flushes as ordered and as required by the care plans for Residents #48, #53 (12), #85 (5), and #147 (H); and failed to implement the care plans for Residents #94, #70, #40, #30, #14, #3, #85 (5), #48, and #59 related to medication administration/monitoring. In addition, Residents #64's, #146's, and #85's (5) care plans required staff to provide oxygen as ordered; however, observation revealed the facility failed to provide the residents' oxygen as ordered. Further, the facility failed to provide Residents #80's, #85's (5), and #35's splints/hand rolls as required by their care plans; and failed to honor Resident #46's food preferences as required by the resident's care plan. The findings include: Review of the facility's Comprehensive Person-Centered Care Planning Policy and Procedure dated November 2017 revealed the facility would develop, maintain, and follow resident-centered plans for each resident's individualized care needs. The policy stated the comprehensive care plan would be based on the resident's needs, goals, and preferences as identified through comprehensive assessments. According to the policy, the comprehensive care plan would include information that was pertinent to the delivery of care including any resident specific goals, wishes, or advanced directives. 1. a. Review of Resident #26's (6) medical record revealed the facility admitted the resident on 06/14/16, with a readmission date of 01/09/18. The resident had diagnoses that included Alzheimer's Disease, Dysphagia, Gastrostomy tube, Trauma related to a Subdural Hematoma, and Multiple Rib Fractures. Review of Resident #26's (6) Emergency Medical Services Do Not Resuscitate Order, not dated, and a review of a facility CPR form (untitled) dated 06/14/16 revealed the resident's representative signed consent for the resident to have CPR performed. The resident was designated as a full code. Review of Resident #26's (6) Physician orders for January 2018, also revealed the resident's code status was full code. Review of Resident #26's (6) care plan initiated 06/30/16, and last revised on 01/10/18, revealed no documented evidence that the facility developed a care plan with interventions to provide Resident #26's (6) wishes. Review of Resident #26's (6) Nurses' Notes dated 01/12/18 at 3:45 PM, revealed the resident's condition deteriorated; however, interview with the resident's physician on 02/15/18 at 11:04 AM revealed the facility failed to notify the resident's physician of the resident's change in condition. Further, review of the resident's Emergency Medical Services report dated 01/12/18, revealed the Licensed Practical Nurse (LPN) failed to notify EMS until 4:38 PM on 01/12/18, approximately fifty-three minutes (53) after the resident was assessed to have a change in condition. Upon EMS's arrival to the facility on [DATE] at 4:50 PM, Resident #26 (6) was found to be not breathing and had no pulse and CPR was initiated. The resident was transferred to the hospital where the resident was pronounced dead at 5:11 PM on 01/12/18. 1. b. Review of Resident #63's medical record revealed the facility admitted the resident on 12/15/17, from acute care hospital, with diagnoses that included Urinary Tract Infection, Chronic Respiratory Failure, Type 2 Diabetes Mellitus, Diabetic nephropathy, Chronic Kidney Disease Stage IV, Arteriosclerotic Heart Disease, Hypertension and Pressure Ulcer Stage 4 to left heel. Review of Resident #63's admission Minimum Data Set (MDS) assessment, dated 12/22/17, revealed the resident had a Brief Interview Mental Status (BIMS) score of fourteen (14), which indicated the resident was cognitively intact. Review of a Kentucky Emergency Medical Services Do Not Resuscitate (DNR) order (A standardized form that was developed and approved by the Kentucky Board of Medical Licensure which authorized EMS providers to honor Advanced Directives to withhold or terminate care. The EMS DNR order applies only to resuscitation attempts by health care providers in the prehospital settings, including long term care facilities and during transport to or from a health care facility) dated 12/15/17, and review of a facility Do Not Resuscitate Form dated 12/15/17, revealed the resident wished to have no Cardiopulmonary Resuscitation (CPR) should the need arise. Review of Resident #63's care plan dated 12/15/17, revealed no documented evidence the facility developed a care plan related to the resident's wishes to be a DNR and receive no CPR should the need arise. Record review on 01/09/18, at 6:40 PM, revealed a nursing note which stated Resident #63 became nonresponsive, pale, cyanotic (blue) nail beds, with a low blood pressure of 68/32 (normal 120/80) and low respirations of 10 (normal 18). EMS arrived at the facility at 6:54 PM on 01/09/18. Review of the EMS Prehospital Report dated 01/09/18, revealed upon arrival to the facility, the EMS crew was directed to the resident's room; report was given; no facility staff were present in the resident's room while aide was being rendered by EMS; and facility staff provided no paperwork regarding the resident. The EMS report stated the resident's daughter was present and gave EMS a report on the resident. The report stated the resident appeared critical with impending respiratory failure/arrest, and CPR was initiated. The resident was intubated, and CPR continued until transport to the Emergency Department. Review of Resident #63's hospital record revealed on 01/09/18, the resident was placed on a ventilator once at the ED, and transported to a regional hospital, where the resident passed away on 01/18/18, after having another cardiac arrest. 1. c. Review of the medical records for sampled Residents #1, #28, #34, #35, #38, #57, #59, #64, #67, #70, #78, #92, #94, #147 and Unsampled Residents #4, #6, #7, #9, #11, #22, #25, #27, #29, #32, #33, #37, #44, #50, #54, #55, #56, #65, #73, #75, #77, #79, #84, #87, #88, #93, #95, #396, #397, #399, #448, #449, B, F, and Z revealed the residents/responsible party/legal guardian signed consent for the residents to receive Cardiopulmonary Resuscitation (CPR) and the facility designated the residents as a full code. However, review of the residents' comprehensive person-centered care plans revealed the residents did not have a care plan that addressed their wishes for CPR. An interview with the Minimum Data Set (MDS) Coordinator on 01/26/18 at 12:47 PM, revealed she was responsible for initiating resident care plans on admission. The MDS Coordinator stated she only developed care plans if a resident elected to be a DNR, but she was unable to state why Resident #63's care plan did not list the resident's wishes to be a DNR. Further, the MDS Coordinator stated she never developed a care plan related to resident's wishes if the resident requested a full code or had other explicit wishes expressed in an Advanced Directive. 2. a. Review of the medical record revealed the facility admitted Resident #53 (12) on 11/30/17, and readmitted the resident on 12/30/17, with diagnoses that included Pneumonia, Hypertension, Alzheimer's Disease, and Dementia. Review of the admission MDS dated [DATE], revealed Resident #53 (12) was cognitively impaired, received a mechanically altered diet, and weighed 143 pounds. Review of Resident #53's (12) Comprehensive Person-Centered Care Plan dated 01/02/18, revealed the facility identified the resident was at risk for altered nutrition and had a newly placed feeding tube. The facility developed interventions to prevent dehydration and to maintain the resident's current body weight that included receiving tube feeding and water flushes as ordered, and notifying the resident's physician of any nutritional changes as needed. Review of Resident #53's (12) Physician's Orders dated 12/30/17, revealed an order to administer Jevity 1.5 at 60 milliliters (ml) per hour (1440 ml per day), and to receive 200 ml of water every four hours (1200 ml per day) via the feeding tube. However, review of Resident #53's (12) Intake and Output record for 01/01/18 through 01/22/18, revealed the resident did not meet his/her nutritional needs eighteen of twenty-two days. Further review revealed the resident's average daily fluid intake was approximately 703 ml, approximately 500 ml less than the physician ordered for the resident. Review of Resident #53's (12) weight record revealed on 01/08/18, Resident #53 (12) weighed 135 pounds, and had sustained an eight-pound weight loss in one week. Further review of Resident #53's (12) weight record revealed the resident continued to sustain weight loss and on 01/15/18 weighed 122 pounds, a total weight loss of 21 pounds (14 percent body weight) in fifteen days. A review of the resident's nutritionally at risk (NAR) notes revealed the facility documented the resident's physician was notified of the wieght loss; however, there was no documented evidence the facility identified that the resident was not receiving tube feeding as ordered by the resident's physician or that the physician was notified that the resident was not meeting his/her nutritional needs. 2. b. Review of the medical record revealed the facility admitted Resident #147 (H) on 12/08/17, with diagnoses that included Diabetes with Hyperglycemia, Chronic Obstructive Pulmonary Disease, and Alcoholic Hepatitis with Ascities. Review of Resident 147's (H) admission Minimum Data Set (MDS) dated [DATE], revealed the resident's Brief Interview for Mental Status (BIMS) score was nine (9), which indicated the resident was moderately cognitively impaired. Review of Resident #147's (H) care plan dated 12/08/17, revealed the resident was at risk for alteration in nutrition related to dysphagia and diabetes mellitus. The facility developed interventions to prevent dehydration and to maintain the resident's current body weight that included notifying the resident's physician of any nutritional changes, and to receive nutrition and fluids as ordered. Review of Resident #147's (H) Physician's Orders dated 01/23/18, revealed the resident was to receive 100 ml of water four (4) times a day. However, observation on 01/24/18 at 7:08 PM, revealed the resident had only received 32 ml of water in the previous 8.5 hours, approximately 168 ml less than the physician ordered amount. Further review of a Dietary Notes revealed on 12/26/17, the Dietitian identified that Resident #147 (H) had an eleven-pound weight loss (weight 178). Review of Resident #147's (H) weight record revealed the resident lost four (4) additional pounds and weighed 174 on 12/28/17, an eight (8) percent weight loss in seventeen (17) days. There was no documented evidence the facility notified the resident's physician of the nutritional changes as required by the resident's care plan. 2. c. Review of Resident #85's (5) medical record revealed the facility admitted the resident on 06/27/17 and readmitted Resident #85 (5) on 12/27/17, with diagnoses that included Alzheimer's Disease, Gastro-Esophageal Reflux, and Type 2 Diabetes. Review of Resident #85's (5) Quarterly Minimum Data Set (MDS) dated [DATE], revealed the resident's Brief Interview for Mental Status was unable to be assessed and the resident was not interviewable. The assessment further revealed the resident had a feeding tube and had sustained no weight loss. Review of Resident #85's (5) care plan dated 07/17/17, revealed the resident was at nutritional risk due to Diabetes Mellitus and being fed via a feeding tube. The facility developed interventions to prevent dehydration and to maintain the resident's maintain current body weight that included providing nutritional feeding and water flushes as ordered by the physician and notifying the resident's physician of any nutritional changes. Review of Resident #85's (5) Physician's Orders dated 12/27/17, revealed the resident had an order for Glucerna 1.5 tube feeding at 50 ml per hour and 200 ml water flushes every four (4) hours via the resident's feeding tube. However, observation of Resident #85's (5) feeding tube pump on 01/24/18 at 4:32 PM, revealed 163 ml's of water had been administered to the resident in approximately eight (8) hours, approximately 237 ml less than was ordered by the physician. Further, review of Resident #85's (5) Intake and Output Record for 01/01/18 through 01/16/18, revealed the resident did not meet his/her fluid needs on eleven of eighteen days and did not meet his/her estimated calorie needs on thirteen of eighteen days. There was no documented evidence the facility notified the resident's physician. In addition, review of Resident #85's (5) weekly weights revealed on 01/15/18, the resident weighed 142 pounds, an eight (8) percent weight loss in fifteen (15) days. There was no documented evidence the facility notified the resident's physician as required by the resident's care plan. 2. d. Review of the medical record revealed the facility admitted Resident #48 on 08/18/15, with diagnoses that included Alzheimer's disease, Chronic Kidney Disease, Muscle Weakness, Dysphasia, and Moderate Protein-Calorie Malnutrition. Review of the resident's Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #48 was cognitively impaired and had a feeding tube. Review of Resident #48's care plan dated 02/09/17, revealed the resident was at nutritional risk due to dysphagia and being fed via a feeding tube. The facility developed interventions to prevent dehydration and to maintain the resident's current body weight that included providing tube feeding and water flushes as ordered by the physician and notifying the resident's physician of any nutritional changes. Review of Resident #48s' Physician's Orders dated 11/14/17, revealed an order for the resident to receive a continuous tube feeding of Jevity 1.5 at 40 milliliters (ml) per hour and a 200 ml water flushes every six (6) hours. However, observation of Resident #48's feeding tube pump on 01/24/18 at 7:10 PM, revealed the resident had only received 57 ml of water in the previous 8.5 hours, approximately 143 ml less than the physician ordered amount. Further, review of Resident #48's Intake and Output Record for January 2018, revealed the resident did not meet his/her assessed fluid or nutrition needs from 01/04/18 to 01/08/18. There was no documented evidence the physician was notified of the nutritional changes. 3. a. Review of the medical record revealed the facility admitted Resident #94 on 05/19/14, with diagnoses that included Diabetes with Diabetic Neuropathy. Review of Resident #94's Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of fifteen (15), which indicated Resident #94 was cognitively intact. Review of Resident #94's care plan initially dated 06/08/14, revealed the facility would perform blood glucose checks and administer insulin as ordered by the resident's physician. Review of Resident #94 Physician's Orders dated 10/31/17, revealed an order for staff to check the resident's blood glucose, and to administer Novolin R (regular human Insulin) subcutaneous per sliding scale (the insulin dosage is based on the blood sugar result). However, review of Resident #94's Medication Administration Record (MAR) revealed no documented evidence staff checked the resident's blood glucose and/or administered sliding scale insulin on 01/16/18 at 11:00 AM. 3. b. Review of Resident #70's medical record revealed the facility admitted the resident on 08/28/14, with diagnoses that included Diabetes, Hypertension, and Personality Disorder. Review of Resident #70's Quarterly Minimum Data Set (MDS) dated [DATE], revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of fourteen (14), which indicated Resident #70 was cognitively intact. Review of Resident #70's care plan initially dated 09/17/14, revealed the facility would perform blood glucose checks and administer insulin as ordered by the resident's physician. Review of Resident #70's Physician's Orders, dated 04/22/16, revealed an order to check the resident's blood glucose four (4) times daily and to administer Novolog (Fast Acting Insulin) per a sliding scale (the insulin dosage is based on the blood sugar result). However, Review of Resident #70's Medication Administration Record (MAR) revealed no documented evidence the facility checked the resident's blood sugar and/or administered sliding scale insulin at 11:00 AM on 01/16/18. 3. c. Review of Resident #40's medical record revealed the facility admitted the resident on 03/17/15, and the resident had diagnoses that included Type 2 Diabetes, Hypertension, and Alzheimer's Disease. Review of the resident's Quarterly Minimum Data Set (MDS) dated [DATE], revealed Resident #40's cognition was unable to be assessed. Review of Resident #40's care plan initially dated 09/17/14, revealed the facility would administer the resident's medication as ordered by the resident's physician. Review of Resident #40's Physician's Orders dated 12/07/17, revealed the resident had an order to check his/her blood glucose four (4) times daily, and to administer Novolog Insulin per sliding scale (the insulin dosage is based on the blood sugar result). However, a review of Resident #40's Medication Administration Record (MAR) dated 01/16/18, at 11:00 AM revealed no documented evidence the facility checked the resident's blood glucose and/or administered insulin. 3. d. Review of Resident #30's medical record revealed the facility admitted the resident on 08/24/14, with diagnoses that included Type 2 Diabetes. Review of Resident #30's Quarterly Minimum Data Set (MDS) dated [DATE], revealed the facility assessed Resident #30 to have a Brief Interview for Mental Status (BIMS) score of eight (8), which indicated Resident #30 was moderately cognitively impaired. Review of Resident #30's care plan initially dated 04/14/14, revealed the facility would administer the resident's medication as ordered by the resident's physician. Review of Resident #30's Physician's Orders, dated 08/15/17, revealed an order to check the resident's blood sugar four (4) times daily, and to administer Humulin R insulin per sliding scale (the insulin dosage is based on the blood glucose result). However, review of Resident #30's Medication Administration Record (MAR) dated 01/16/18 at 11:30 AM revealed the facility did not check the resident's blood glucose and/or administer Humulin R Insulin. 3. e. Review of the medical record revealed the facility admitted Resident #14 on 07/12/13, with diagnoses that included Type 2 Diabetes with Hyperglycemia, Osteomyelitis of the Ankle and Foot, and a Pressure Ulcer of Right Heel. Review of Resident #14's Quarterly Minimum Data Set (MDS) dated [DATE], revealed Resident #14's cognitive status could not be assessed. Review of Resident #14's care plan initially dated 07/27/13, revealed the facility would administer the resident's medication as ordered by the resident's physician. Review of Resident #14's Physician's Orders dated 11/25/17, revealed the resident had an order to check his/her blood glucose four (4) times daily, and to administer Novolog Insulin per sliding scale (the insulin dosage is based on the blood sugar result). However, review of Resident #14's Medication Administration Record (MAR) dated 01/16/18 at 11:00 AM, revealed no documented evidence the facility checked the resident's blood glucose level and/or administered sliding scale insulin. 3. f. Review of Resident #3's medical record revealed the facility admitted the resident on 01/20/15, with diagnoses that included Type 2 Diabetes, Emphysema, and Chronic Obstructive Pulmonary Disease. Review of Resident #3's Quarterly Minimum Data Set (MDS) dated [DATE], revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of fourteen (14), which indicated Resident #3 was cognitively intact. Review of Resident #3's care plan dated 04/25/16, revealed the facility developed a care plan for the resident with interventions to check the resident's blood sugar before meals and at bedtime as ordered by the resident's physician. Review of Resident #3's Physician's Orders dated January 2018, revealed the resident had an order for a blood glucose check four (4) times daily, and an order to administer Novolog Insulin per sliding scale (insulin dose based on the resident's blood glucose result). However, review of Resident #3's Medication Administration Record (MAR) dated 01/16/18, revealed the resident did not receive a blood glucose check or receive Novolog Insulin at 11:00 AM. 4. a. Review of the medical record revealed the facility admitted Resident #85 (5) on 06/27/17, with diagnoses that included Hypertension. Review of the resident's Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #85 (5) was cognitively impaired. Review of Resident #85's (5) care plan dated 07/17/17, revealed the facility would administer Resident #85's (5) medication as ordered. Review of Resident #85's (5) Physician's Orders dated 12/28/17, revealed an order for the resident to receive Potassium Chloride (KCL- an electrolyte supplement) per feeding tube three (3) times daily. However, review of Resident #85's (5) Medication Administration Record (MAR) dated 01/16/18 at 1:00 PM, revealed no documented evidence staff administered the resident's physician ordered Potassium as required by the resident's care plan. 4. b. Review of Resident #48's medical record revealed the facility admitted the resident on 08/18/15, with diagnoses that included Hyperlipidemia and Presence of Cardiac Pacemaker. Review of the Significant Change MDS assessment dated [DATE], revealed Resident #48's cognition could not be assessed. Review of Resident #48's care plan dated 09/26/17, revealed the facility developed an intervention to administer the resident's medication as ordered. Review of Resident #48's Physician's Orders dated 11/11/17, revealed the resident had an order for Metoprolol Tartrate (treats high blood pressure) 25 mg one twice daily via the resident's feeding tube. However, review of the resident's MAR dated 01/16/18 at 1:00 PM, revealed no documented evidence the facility administered Resident #48's Metoprolol tablet. 4. c. Review of Resident #59's medical record revealed the facility admitted the resident on 02/15/17, with diagnoses that included Hypertension. Review of Resident #59's Quarterly MDS assessment dated [DATE], revealed the facility was unable to assess the resident's cognition. Review of Resident #59's care plan dated 03/07/17, revealed the facility developed a care plan with interventions to administer the resident's medication as ordered. Review of Resident #59's Physician's Orders dated 04/03/17, revealed an order for Calan (to treat blood pressure) three (3) times daily via the resident's feeding tube. However, review of Resident #59's MAR dated 01/16/18 at 2:00 PM revealed no documented evidence staff administered the resident's Calan as ordered by the physician and as required by the resident's care plan. 5. a. Review of Resident #64's medical record, revealed the facility admitted the resident was admitted on [DATE], with diagnoses including Pneumonia and Chronic Obstructive Pulmonary Disease. Review of Resident #64's Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of fourteen (14), indicating the resident was cognitively intact. Review of physician's orders dated 12/27/17, for Resident #64, revealed an order for Oxygen to be administered to the resident at two (2) liters per minute via nasal cannula. Review of Resident #64's Comprehensive Plan of Care dated 12/27/17, revealed the resident was to be administered oxygen as ordered by the physician. Observation of Resident #64 on 01/30/18, at 9:50 AM, 12:50 PM, and 3:30 PM, revealed the resident's oxygen tubing was observed to be on the floor at the head of the resident's bed, and not being administered to the resident. Interview with Resident #64 on 02/01/18 at 2:30 PM, revealed he/she was unable to reach the oxygen tubing that was on the floor. The resident stated he/she was not sure how the oxygen tubing got on the floor. 5.b. Review of the medical record for Resident #146, revealed the facility admitted the resident on 01/10/18, with diagnoses including Parkinson's Disease and Pneumonia. The medical record also revealed a Minimum Data Set assessment had not yet been completed by the facility for Resident #146. Review of physician's orders for Resident #146 dated 01/24/18, revealed the facility was to administer the resident oxygen via nasal cannula at two (2) liters per minute. Review of Resident #146's Comprehensive Plan of Care dated 01/24/18, revealed the resident was to receive oxygen as ordered by the physician. Observation of Resident #146 on 01/30/18 at 4:08 PM, 2:45 PM, 3:15 PM, and 4:00 PM, revealed the resident's oxygen was lying on the floor beside the resident's bed. The resident was not receiving oxygen. 5. c. Review of Resident #85's (5) medical record, revealed the facility readmitted Resident #85 (5) on 12/27/17, with diagnoses including Alzheimer's Disease, Pneumonia and Acute Respiratory Distress Syndrome. Review of Resident #85's (5) Comprehensive Plan of Care dated 12/23/17, revealed an intervention for Resident #85 (5) to be administered oxygen as ordered by the physician. Review of physician orders for Resident #85 (5) dated 12/27/17, revealed an order for the resident to be administered two (2) liters of oxygen per minute via nasal cannula. Observations of Resident #85 (5) on 01/31/18 at 9:27 AM, 10:34 AM, 3:31 PM, and on 02/01/18 at 11:06 AM revealed the resident was being administered oxygen at four (4) liters per minute via nasal cannula. 6. a. Review of the medical record for Resident #80 revealed the facility admitted the resident on 07/27/15, with diagnoses that include Alzheimer's Disease, Cerebrovascular Disease, Atherosclerosis, Muscle Weakness and Osteoarthritis. Review of Resident #80's Quarterly Minimum Data Set (MDS) assessment completed on 12/28/17, revealed the resident had a Brief Interview for Mental Status (BIMS) score of zero, indicating the resident was severely cognitively impaired. Review of Resident #80's Comprehensive Care Plan in effect revealed the facility's restorative nursing program was to apply a left hand splint for two (2) hours in the morning and two (2) hours in evening. Further review revealed a hand roll was to be utilized to the resident's left hand when the hand splint was not in place. Review of Resident #80's Physician Orders for the month of February 2018, revealed an order to apply a left hand splint two (2) hours in the morning and two (2) hours in the evening and to apply a hand roll to the resident's left hand when the splint was not applied. Observations of Resident #80 on 02/02/18 at 9:26 AM and 10:52 AM revealed the resident did not have a splint or hand roll present in his/her left hand. 6. b. Review of the medical record for Resident #85 (5) revealed the facility readmitted the resident on 12/27/17, with diagnoses that include Alzheimer's, Muscle Weakness, and Polyneuropathy. Review of the MDS Quarterly assessment dated [DATE] revealed Resident #85 (5) had a Brief Interview for