**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to ensure residents received care to prevent pressure ulcers from developing and promote healing consistent with professional standards of practice for two of 37 sampled residents Resident (R) 26 and R110. Immediate Jeopardy (IJ) was identified on 05/16/2025 and was determined to exist on 10/04/2024 in the areas of 42 CFR §483.25(b)(1) Pressure ulcers (F686) at the scope and severity (S/S) of a K. Substandard Quality of Care (SQC) was identified at 42 CFR §483.25(b)(1) Pressure ulcers (F686). The IJ is ongoing. The facility was notified of the Immediate Jeopardy on 05/16/2025. The findings include: Review of the facility's policy, Comprehensive Care Plans Standard of Practice, dated, 10/2020 revealed that each resident's comprehensive care plan was designed to: identify problem areas, incorporate risk factors associated with identified problems, identify the professional services that are responsible for each element of care, and aid in preventing or reducing declines in the resident's functional status or functional levels. Further review revealed that residents' assessments were ongoing, and care plans were required to be revised as information about the residents and their conditions changed Review of the facility's policy, Skin Care Standard of Practice, dated 07/2020, revealed the facility was required to assess the resident on admission, readmission, and with each change of condition that may compromise the skin. The nurse was required to perform staging and measuring to maintain continuity in documenting the progression of wound healing. Staff were also required to perform weekly documentation of the wound status and response to healing, including the potential need to alter treatment. Wound documentation was to include location of the wound, staging of the wound, size of the wound (length x width x depth), exudate (if present), wound bed description, description of wound edges and surrounding tissue, and pain (if present). Further review revealed that all assessments/evaluations relating to skin/wound care would be documented in the EMR (Electronic Medical Record) System. 1. Review of R26's admission Face Sheet revealed the facility admitted the resident on 12/17/2024 with diagnoses that included Alzheimer's Disease, chronic kidney disease, chronic obstructive pulmonary disease with (acute) exacerbation, delusional disorders, dementia, diffuse large B-cell lymphoma, unspecified site, and malignant neoplasm of brain, unspecified. Review of R26's current Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/09/2025, revealed the facility assessed the resident with a Brief Interview for Mental Status (BIMS) score of 0/15, indicating the resident had severe cognitive impairment. Further review revealed R26 required total assistance with turning side to side in the bed, showering/bathing, and personal hygiene. Review of R26's care plan, related to Impaired Skin Integrity, dated 02/10/2025 revealed the goal was for R26 to be free from additional skin breakdown. Further review revealed that a weekly skin assessment was one of the interventions of the care plan. Review of the Bath/Shower Sheet completed from 02/27/2025 until 05/08/2025 revealed that each time R26 received a shower or bed bath from the State Registered Nurse Aide (SRNA), no new skin areas were identified. Review of R26's progress note, dated 03/04/2025 revealed an order for preventative measures for bilateral heels by painting heels with betadine and apply dry dressing daily, and as needed due to the resident scooting his heels on the bed. Review of R26's Progress Note, dated 03/17/2025 revealed R26's skin assessment was completed with no new areas noted. Review of R26's Progress Note dated 03/17/2025 revealed that the Wound Care Physician Assistant (PA) saw R26 for a pressure wound to the head. However, there was no documented evidence the PA assessed any other areas. Interview with the PA on 05/16/2025 at 12:34 PM revealed that the PA assessed the wound to the resident's head; however, did not assess any other wounds. According to the PA, the DON provided instructions to the PA on which residents were to be evaluated. The PA stated that when evaluating residents for skin breakdown she assessed the high-pressure areas, such as the heels, elbows and bottom, for wounds. The PA stated R26 did not have any other wounds but the wound to the head when she assessed the resident on 03/17/2025. During an interview on 05/14/2025 at 12:10 PM with License Practical Nurse (LPN) 3, she stated her skin assessment was when she looked at a resident's skin that was exposed during her medication pass. LPN3 stated she did not conduct a head-to-toe skin assessment. Interview with Registered Nurse (RN)1 on 05/24/2025 at 12:23 PM revealed that she had never conducted skin assessments during her shift. According to RN1, the DON had instructed facility staff that the wound care staff were responsible to conduct all skin assessments, wound assessments to include surgical wounds and provide any physician ordered wound care. During an interview on 05/14/2025 at 9:38 PM with Registered Nurse (RN) 2, she stated that she did not complete resident head -to-toe assessments weekly. RN2 stated this was a task delegated to the wound nurse by the Director of Nursing (DON). According to RN2, the DON had instructed all the nursing staff that wound care and skin assessment were to be conducted by the wound care staff. Review of R26's Treatment Administration Record (TAR) dated 03/2025 revealed no documentation that the preventive treatment to bilateral heels was provided on 03/19/2025 or 03/20/2025. Record review revealed, on 03/20/2025, R26 was admitted to a local hospital with the following diagnosis: sepsis, acute kidney injury, UTI, and pneumonia. The hospital physician documented multiple areas of skin breakdown that the nursing facility had failed to identify including eschar to bilateral heels, a stage III to the left buttock, a stage III to the right buttock, non-pressure chronic ulcer of the heel and midfoot, and unstageable pressure ulcer of the sacral area. R26 required surgical debridement of his bilateral heels on 03/21/2025 at the hospital. R26 was discharged back to the nursing facility on 03/26/2025. During an interview on 05/15/2025 at 8:40 AM with the Director of Nursing (DON), she stated that the staff had failed to identify the wounds on R26 heels, and that the facility was currently working on improving their skin program after results from a mock survey in 04/2025. The DON stated that she expected a weekly head-to-toe assessment to be completed on residents to identify and prevent pressure ulcers. During an interview on 05/16/2025, the Administrator stated he expected skin assessments to be done weekly and all physician orders to be followed to keep residents safe and healthy. 2. Review of R110's admission Face Sheet revealed the facility admitted the resident on 02/18/2025 with diagnoses that included unspecified dementia, Parkinson's Disease, neurocognitive disorder with Lewy bodies, anxiety, depression, bowel incontinence, generalized weakness, anemia, urinary retention, hypertension, history of dehydration, and a history of malignant neoplasm of large intestine. The resident was also admitted with a Stage II pressure ulcer to the right buttock. Review of R110's current Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/20/2025, revealed the facility assessed the resident with a Brief Interview for Mental Status (BIMS) score of 3/15, indicating the resident had severe cognitive impairment. Further review revealed R110 required total assistance with turning side to side in the bed, showering/bathing, transfers, and personal hygiene. Review of R110's care plan, related to Impaired Skin Integrity, dated 02/20/2025 revealed the resident was identified as high risk for impaired skin integrity due to incontinence, immobility, and multiple comorbidities including dementia, Parkinsonism, and a history of skin breakdown. The interventions included repositioning every two hours, a weekly skin assessment, and to promote adequate nutrition. Review of R110's Turn and Repositioning Log, dated May 2025 revealed the facility had multiple missed repositioning intervals, particularly during critical overnight hours (May 2-5 had missing entries at 3 AM and 5 AM; May 7-10 had missing entries at 1 AM and 3 AM; May 13-15 had missing entries from 3 PM- 9PM; and May 17-18 had missing entries from 1 AM until 7 AM). The facility failed to ensure consistent implementation of repositioning interventions for R110 as outlined in the care plan to prevent skin breakdown. Review of the Skin Committee Progress Notes dated 02/18/2025 through 05/18/2025, revealed the facility did not complete weekly skin assessments as required per the facility policy Skin Care Standards of Practice. The note lacked documentation of the resident's wound status and healing progress, including the need to modify treatment as appropriate. The required documentation such as wound location, stage, size (length x width x depth), presence of exudate, wound bed description, condition of surrounding tissue and, and pain was not consistently recorded. Further review revealed the facility's policy required all skin and wound assessments to be documented in the EMR (Electronic Medical Record) System. Review of R110's Progress Note, dated 02/21/2025 revealed R110's skin assessment was completed and identified one stage two pressure ulcer on the right buttock. Further review revealed the facility initiated a treatment to cleanse the right buttock wound with NS (normal saline) or wound cleanser, dry, and apply zinc, leaving open to air daily and as needed. This treatment remained in place through early March. Review of a Progress Note, dated 04/11/2025, revealed the wound was described as unstageable, measuring 4.0 x 3.4 x 0.3 cm. The wound continued to drain moderate amounts of exudate and eventually required enzymatic debridement and sharp debridement by a wound care provider on 04/21/2025 at the facility. Review of Physician's Orders and the Skin Committee Progress notes revealed no change in the resident's pressure treatments. Continued review revealed the facility failed to conduct weekly skin assessments. Review of Progress Note dated 04/24/2025, revealed the unstageable wound to the right buttock remained open and draining, with only 5% granulation tissue and 95% necrotic tissue. A sharp debridement was performed at the facility. Review of Progress notes from 05/04/2025 and 05/09/2025 revealed continued orders for Santyl, calcium alginate, and super absorbent adhesive dressings with daily application and PRN (as needed). The skin committee noted no changes to the treatment plan despite documented wound deterioration. Review of the Progress Notes revealed a deep tissue injury (DTI) to the right heel was identified on the Progress Note dated, 03/14/2025. Treatment was initiated with Betadine, ABD pads (abdominal pads used to collect drainage), and a tubular bandage. Review of the Skin Committee Progress Notes revealed over time, this DTI progressed to dried necrotic tissue, requiring ongoing management through March and April. Review of the body map dated 05/16/2025 identified extensive breakdown, including multiple wounds on the sacrum, buttocks, heels, and upper back, indicating R110 had widespread deterioration. Review of progress notes, skin assessments, and interviews revealed a lack of shift-to-shift monitoring, failure to reassess and escalate care when wounds worsened, and delays in response following the wound care nurse's departure. Review of the Hospital Discharge summary, dated [DATE], revealed the facility transferred R110 to the hospital due to altered mental status on 05/18/2025. R110 expired at the hospital on [DATE] due to Anemia. During an interview with the Unit Manager on 05/28/2025 at 10:58 AM, she stated that she completed the skin assessment on the Body Map dated 05/16/2025 that identified new areas of skin breakdown. However, the physician was not notified until 05/18/2025 due to miscommunication with the Director of Nursing (DON). During interview with the Interim Director of Nursing (IDON) on 05/29/2025 at 10:04 AM, she stated that upon arrival, she was informed the wound care nurse was on FMLA (Family and Medical Leave Act) leave. The IDON stated the facility had not designated another nurse to monitor, assess, or treat residents' wounds during the wound care nurse's absence for the last few weeks. Review of the resident's nutritional care plan, initiated 02/17/2025, revealed the facility identified the resident was at risk for weight loss with increased protein needs due to wound presence. Interventions included fortified foods, protein supplements, multivitamins, and a dysphagia-pureed diet. Review of a dietary progress note dated 05/01/2025, revealed the resident was generally accepting of oral supplements with an average meal intake of 77%. However, review of the daily meal and fluid intake records from May 11-17, 2025, revealed multiple days of refused or poor intake (0-25%), and fluid intake below 500 mL on at least two days. There was no documented evidence of staff reassessment, physician notification, or additional dietary interventions related to the low intake trends. During an interview conducted on 05/29/2025 at 2:33 PM, State Registered Nurse Aide 7 (SRNA7) stated that R110 had experienced a significant decline the last week at the facility before going to the hospital on [DATE]. SRNA 7 stated R110 just slept all the time and had become difficult to awake for meals. The SRNA stated that R110 just stopped eating and drinking and had very limited fluid output that was dark orange in color. She stated she reported the changes to LPN 2 but did not recall any formal change in dietary interventions or additional monitoring being implemented at that time. During an interview with Licensed Practical Nurse (LPN) 2 on 05/28/2025 at 10 AM, she stated that approximately one week prior to the resident's decline, she noticed the resident was not eating very much. LPN 2 stated the SRNAs mentioned that the resident had reduced intake, and she had gone into R110's room to try and encourage the resident to eat. She stated she notified the unit manager of R110's decline. However, she was unsure if she followed up on her concern. LPN 2 stated she assumed the Unit Manager would notify the physician and did not initiate or observe any changes to the nutritional care plan, or increased monitoring during this period. During an interview with the Unit Manager on 05/28/2025 at 10:58 AM, she stated that staff had reported R110's decline in eating, drinking, and output. However, she acknowledged that she did not notify the physician, stating she believed it was the DON's responsibility to do so. During an interview conducted on 5/29/2025 at 9:55 AM, the Interim Administrator stated there had been a lack of appropriate assessments and absence of a consistent Quality Assurance process. He stated that wound care concerns were not routinely discussed in the morning meetings and were only added to the meeting agenda after the most recent issues were identified. The Intern Administrator stated that failures in the turning, repositioning and wound care processes and lack of rounds had contributed to the problem. He stated, When you have an issue with wounds, it's because of processes mostly. He further explained that it was evident there had been a breakdown in systems and oversight, and that wounds were not included in daily discussions until he intervened. The Intern Administrator stated the failure ultimately rested, in the administrator's chair. He stated that strong morning meetings and clinical leadership could have prevented the breakdown in skin, nutrition, and care coordination systems. During an interview on 05/28/2025 at 7:15 PM the newly appointed Wound Care Physician (WCP) stated after her review of the previous resident wound/skin documentation on 05/28/2025, the WCP felt there were multiple discrepancies and inaccuracies in comparison to her assessment. For example, the WCP explained that every wound had been documented and treated as unstageable; however, there were no weekly skin assessment sheets, minimal to no documentation regarding the wounds and no measurements and/or appropriate treatments in place to support healing of the wounds. The WCP stated that due to the lack of documentation, she became very concerned for the overall health and safety of the residents. The WCP stated after she arrived at the facility, she immediately realized the lack of preventative measures such as off-loading and special support devices for at-risk residents with apparent high-risk areas along with the lack of staff knowledge, education, communication and in-sufficient staffing. Therefore, according to the WCP most of the wounds she assessed were facility acquired and a facility wide failure was identified. During an interview on 05/29/2025 at 9:58 PM with the newly appointed Wound Care Nurse (WCN), the WCN stated during her initial skin sweep assessment of all residents she identified staff were not following up or taking appropriate measures to identify new areas such to include implementing skin assessment sheets, as they were non-existent. In addition, the WCN stated the documentation was not supportive and/or accurate due to a lack of leadership, communication, education and training. The WCN stated wounds were never discussed or part of the clinical meetings. On 05/20/2025 the WCN stated she attended the morning clinical meeting with all other departmental leadership to discuss concerns; however, nothing was discussed about the wounds and/or resident conditions. The WCN stated from her continued observation of resident wrinkles, redness on pressure areas, uncleanliness of digits and poor condition of resident's heels, it was apparent that skin assessments were not being performed nor was the appropriate repositioning or offloading being implemented. In interview, with the Regional Quality Manager (RQM) on 05/29/2025 at 10: 50 AM, she stated she was part of the Governing body and was present during the quarterly calls, as well as onsite at the facility, on a regular basis to audit and monitor any concerns the facility had identified. She stated for example, in March 2025 they performed and assisted with a MOCK survey at the facility. The RQM stated they treated and performed the MOCK survey just as the State performed their surveys. She stated all care areas were reviewed and investigated. During the interview, she stated their survey also identified deficiencies with wounds and that the wound nurse was not assessing and documenting correctly. The RQM stated a plan of correction was provided; however, we were not getting results. She stated she felt the lack of communication, notification and education was the root cause of the problem. In addition, she stated the facility failed to replace the wound care nurse when she went on medical leave and unfortunately residents were not being assessed and/or provided treatment appropriately. Attempts were made to contact the Medical Director on 05/28/2025 at 1:54 PM,1:56 PM and 4:00 PM. There was no response from the Medical Director.

Based on observation, interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for 1 of thirty-seven sampled residents (R) R26. Review of R26's Care Plan for Impaired Skin Integrity, dated 02/10/2025, indicated that R26 would have a weekly skin assessment performed. However, the facility failed to provide evidence of weekly skin assessments. The findings include: Review of the facility's policy, Comprehensive Care Plans Standard of Practice, dated, 10/2020 revealed that each resident's comprehensive care plan was designed to: identify problem areas, incorporate risk factors associated with identified problems, identify the professional services that were responsible for each element of care, and aid in preventing or reducing declines in the resident's functional status or functional levels. Further review revealed that residents' assessments were to be ongoing, and care plans were required to be revised as information about the residents and their conditions changed. Review of R26's admission Face Sheet revealed the facility admitted the resident on 12/17/2024 with diagnoses that included Alzheimer's disease, chronic kidney disease, chronic obstructive pulmonary disease (COPD) with (acute) exacerbation, delusional disorders, dementia, diffuse large B-cell lymphoma, unspecified site, and malignant neoplasm of the brain, unspecified. Review of R26's Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/09/2025, revealed the facility assessed the resident with a Brief Interview for Mental Status (BIMS) score of 0/15. This score indicated the resident had severe cognitive impairment. Further review revealed R26 required total assistance with turning side to side in the bed, showering/bathing, and personal hygiene. Review of R26's care plan, related to Impaired Skin Integrity, dated 02/10/2025 revealed the goal was for R26 to be free from additional skin breakdown. Further review revealed that a weekly skin assessment was one of the interventions of the care plan. Review of the Bath/Shower Sheet completed from 02/27/2025 through 05/08/2025 revealed that each time R26 received a shower or bed bath from the State Registered Nurse Aide (SRNA), no new skin areas were identified. Review of R26's progress note, dated 03/04/2025 revealed an order for preventative measures for bilateral heels by painting the heels with Betadine and applying a dry dressing daily, and as needed due to the resident scooting his heels on the bed. Review of R26's Progress Note, dated 03/17/2025 revealed R26's skin assessment was completed with no new areas noted. Review of R26's Progress Note dated 03/17/2025 revealed that the Wound Care Physician Assistant (PA) saw R26 for a pressure wound to the head. However, there was no documented evidence the PA assessed any other areas. Interview with the PA on 05/16/2025 at 12:34 PM revealed she assessed the wound to the resident's head. However, she did not assess any other wounds. According to the PA, the Director of Nursing (DON) provided her with instructions on which residents were to be evaluated. The PA stated that when evaluating residents for skin breakdown she assessed the high-pressure areas, such as the heels, elbows and bottom, for wounds. The PA stated R26 did not have any other wounds but the wound to the head when she assessed the resident on 03/17/2025. During an interview on 05/14/2025 at 12:10 PM with License Practical Nurse (LPN) 3, she stated she conducted a skin assessment when she looked at a resident's skin that was exposed during the medication pass. LPN3 stated she did not conduct a head-to-toe skin assessment of R26's skin. Interview with Registered Nurse (RN)1 on 05/14/2025 at 12:23 PM revealed that she had never conducted skin assessments during her shift. According to RN1, the Director of Nursing (DON) had instructed facility staff that the wound care staff were responsible to conduct all skin assessments, wound assessments to include surgical wounds and provide any physician ordered wound care. During an interview on 05/14/2025 at 9:38 PM with RN 2, she stated that she did not complete resident head -to-toe assessments weekly. RN2 stated this was a task delegated to the wound nurse by the DON. According to RN2, the DON had instructed all of the nursing staff that wound care and skin assessments were to be conducted by the wound care staff. Review of R26's Treatment Administration Record (TAR) dated 03/2025 revealed no documentation that the preventive treatment to bilateral heels was provided on 03/19/2025 or 03/20/2025. Record review revealed, on 03/20/2025, R26 was admitted to a local hospital with the following diagnoses: sepsis, acute kidney injury, UTI (Urinary Tract Infection), and pneumonia. The hospital physician documented multiple areas of skin breakdown that the nursing facility had failed to identify including eschar to bilateral heels, a stage III to the left buttock, a stage III to the right buttock, a non-pressure chronic ulcer of the heel and midfoot, and an unstageable pressure ulcer of the sacral area. R26 required surgical debridement of his bilateral heels on 03/21/2025 at the hospital. R26 was discharged back to the nursing facility on 03/26/2025. During an interview on 05/15/2025 at 8:40 AM with the DON, she stated that the staff had failed to identify the wounds on R26 heels, and that the facility was currently working on improving their skin program after results from a mock survey in 04/2025. The DON stated that she expected a weekly head-to-toe assessment to be completed on residents to identify and prevent pressure ulcers. During an interview on 05/16/2025, the Administrator stated he expected skin assessments to be done weekly and all physician orders to be followed to keep residents safe and healthy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and review of the facility's policy, it was determined the facility failed to ensure prompt efforts were made to resolve grievances for one (1) of forty-seven (47) sampled residents (Resident #117). On 01/09/19, Resident #117's family member voiced concerns to the Administrator and Director of Nursing (DON) that staff were not adequately suctioning secretions from Resident #117's tracheostomy (an opening in the neck to the windpipe). Resident #117 had been treated in the Emergency Department (ED) on 01/08/19 and diagnosed with Respiratory secretion[s] in [the] tracheostomy tube. According to the family member, the ED Physician who treated the resident on 01/08/19 stated the resident was not receiving appropriate tracheal suctioning. However, the facility failed to take any action to investigate the concerns regarding Resident #117's respiratory care to ensure the resident was receiving appropriate respiratory care. Staff failed to provide tracheostomy care/suctioning on 01/09/19 at 7:00 PM, and at 11:00 PM. On 01/10/19 at 6:40 AM, staff found Resident #117 unresponsive and not breathing. The resident was transferred to a hospital where he/she was pronounced dead due to Cardiopulmonary Arrest due to Upper Airway Obstruction. The facility's failure to ensure a resident's right for prompt resolution of grievances has caused or is likely to cause injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 01/23/19, and determined to exist on 01/09/19 at 42 CFR 483.10 Resident Rights (F585), 42 CFR 483.21 Comprehensive Person-Centered Care Plans (F656), 42 CFR 483.25 Quality of Care (F689 and F695), 42 CFR 483.45 Pharmacy Services (F760), and 42 CFR 483.70 Administration (F835). The facility was notified of the Immediate Jeopardy on 01/23/19. An acceptable Allegation of Compliance was received on 02/04/19, which alleged removal of the Immediate Jeopardy on 02/02/19. The State Survey Agency determined the Immediate Jeopardy was removed on 02/02/19, prior to exit on 02/06/19, which lowered the scope and severity to D level at 42 CFR 483.10 Resident Rights (F585), 42 CFR 483.21 Comprehensive Person-Centered Care Plans (F656), 42 CFR 483.25 Quality of Care (F689 and F695), 42 CFR 483.45 Pharmacy Services (F760), and 42 CFR 483.70 Administration (F835), while the facility monitors the effectiveness of systemic changes and quality assurance activities. The findings include: Review of the facility's Resident and Family Grievances policy, undated, revealed prompt efforts will be made by the facility to resolve grievances. The policy also revealed the grievance would be recorded on a Grievance Form, which would serve as communication to other staff members. Further review of the policy revealed the Administrator or designee would conduct an investigation if warranted. Review of Resident #117's closed medical record revealed the facility admitted the resident on 12/29/18 with diagnoses that included Cerebral Infarction (Stroke), Chronic Obstructive Pulmonary Disease, Chronic Kidney Disease, Tracheostomy status, Gastrostomy status (feeding tube), Dysphagia (trouble swallowing), Hypertension, Heart Failure, Atrial Fibrillation, Anxiety Disorder, and Type II Diabetes. Review of Resident #117's admission Minimum Data Set (MDS) dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) score of five (5), which indicated the resident was severely cognitively impaired. Review of Resident #117's Physician Orders revealed orders to provide tracheostomy care (care includes suctioning) every shift and to suction the resident's tracheostomy, as needed. Review of Resident #117's January 2018, Respiratory Medication Administration Record (MAR) revealed tracheostomy care, was provided on 01/08/19 at 7:00 PM. Review of Resident #117's Nursing Notes dated 01/08/19 revealed at 10:45 PM, the resident was very short of air, with an oxygen saturation of 83 percent (%) (normal is 95-100%) while receiving oxygen via the tracheostomy. According to the Nursing Note, staff suctioned thick, yellow sputum from the resident's tracheostomy and changed the inner cannula. The Note stated the resident's oxygen saturation improved to 87%, but decreased to 83% within five (5) minutes. Further review of the Nursing Note revealed the resident was transferred to the hospital at 10:45 PM on 01/08/19, and returned to the facility on [DATE] at 4:23 AM with a diagnosis of Respiratory secretion in tracheostomy tube. Interview with Resident #117's family member on 01/16/19 at 2:35 PM revealed the hospital physician told him that staff at the facility were not suctioning Resident #117 adequately. He stated he reported what the hospital staff told him to the Director of Nursing (DON) and the facility's Administrator on 01/09/19. According to the family member, the Administrator and DON only wanted to know who gave him the information, but nothing else was offered. Interview with the facility's Social Worker on 01/23/19 at 9:50 AM, revealed she was responsible for ensuring prompt resolution of grievances at the facility. She stated when a grievance was voiced, she completed a grievance form, and forwarded the form to the appropriate department (e.g., nursing, dietary, maintenance) for investigation. After the investigation was completed, the grievance form was returned to the Social Worker so she could inform the resident/family regarding the status/resolution of the grievance. The Social Worker stated she was not aware that Resident #117's family member had voiced a grievance on 01/09/19. Interview with the Director of Nursing (DON) on 01/23/19 at 9:50 AM, revealed that she and the Administrator met with Resident #117's family member on 01/09/19 sometime after lunch. The resident's family member reported that hospital staff stated that the resident had not been suctioned properly. She stated she was aware that Resident #117 had been transferred to the emergency room on [DATE], but was not sure of the reason for the transfer and did not review the resident's hospital medical record. She stated she made some notes regarding the family member's concerns on a piece of paper, but did not complete a grievance form. The DON stated that on 01/09/19, after the family member reported the grievance, she looked into the issues by reviewing the resident's Medication Administration Record (MAR) to ensure breathing treatments were documented. According to the DON, she also reviewed Resident #117's Physician's Orders and noted that the resident only had an order for suctioning ordered prn (as needed). During further interview, the DON stated once she reviewed the documentation, no further action was taken to determine whether staff were properly suctioning Resident #117 or any other resident who had a tracheostomy. Interview with the Administrator on 01/23/19 at 9:55 AM, revealed she was present when Resident #117's family member voiced a grievance regarding not suctioning the resident adequately. She stated she was aware the DON reviewed documentation that the resident only required to be suctioned as needed and no concerns were identified. Further interview with the Administrator revealed that no further action/investigation was taken and that the family member's grievance was not handled per the facility's policy. Review of Resident #117's Medication Administration record revealed no documented evidence that staff completed tracheostomy care/suctioning for Resident #117 on 01/09/19 at 7:00 PM. In addition, interview with Registered Nurse (RN) #3 on 01/17/19 at 12:50 PM, revealed she did not provide tracheostomy care for the resident at 7:00 PM on 01/09/19. RN #3 stated she failed to suction the resident's tracheostomy on 01/09/19 at approximately 11:00 PM, when the resident indicated he/she needed to be suctioned. Continued review of Nursing Notes revealed on 01/10/19 at 6:40 AM, staff found Resident #117 on the floor, not breathing, and the resident was transferred to the hospital. Review of Resident #117's hospital record revealed the resident was pronounced dead on 01/10/19 at 7:32 AM. According to the resident's Death Certificate, the cause of death was Cardiopulmonary Arrest due to Upper Airway Obstruction. **The facility alleged the following actions removed the Immediate Jeopardy on 02/02/19: 1. Resident #117 was transported to the hospital on [DATE] and no longer resides in the facility. 2. A) On 01/24/19, the Activities Director conducted a resident council meeting to review with the residents the Grievance Process and guidelines. By 01/28/19 the Activities Director, Social Services Director, or facility Administrator will provide education on the Grievance Standard of Practice and Compliance guideline for those resident(s) with a Brief Interview for Mental Status (BIMS) score of nine (9) or higher, who did not attend the resident council meeting. By 01/29/19 the Social Services Director (Grievance Officer) or Social Services Assistant will interview current in-house residents with a BIMS of nine (9) or higher to identify if there are any current grievances. By 01/29/19 the Social Services Director (Grievance Officer) or Social Services Assistant will contact the respective responsible party or guardian, for those residents with a BIMS of eight (8) or less, to identify if they have any concerns and address the concern(s) following the Grievance Standard of Practice and Compliance guideline. Any concerns/grievance(s) voiced will be addressed following the Grievance Standard of Practice and Compliance guideline. B) Grievances identified Monday through Friday will be addressed by the Social Services Director, who is the Grievance Official, and/or the Social Services staff. All grievances will be addressed per the Grievance Standard of Practice and Compliance Guidelines and submitted to the Administrator for review. The Administrator will log the grievance for review and recommendations in Quality Assurance/Performance Improvement (QAPI). The Social Services Director will send a letter to the resident's representative and/or resident with resolution per guidelines. C) By 01/26/19, the Administrator will post a copy of the Grievance Process summary along with the facility's administration contacts throughout the facility. Copies of blank grievance forms will accompany the posting. D) By 01/28/19, the Admissions Director will add a copy of the Grievance Standards of Practice and Compliance in the admission packets to provide information to any new residents/families. 3. On 01/23/19, the Regional Quality Manager (RQM) provided education to the Director of Nursing (DON) and the Administrator regarding the facility's Grievance Standards of Practice and Compliance Guidelines, which included, but was not limited to, ensuring investigation and resolution of a grievance per regulation. Beginning 01/23/19, the facility's Administrator educated the Education Training Director (ETD) regarding the facility's Grievance Process. Education was provided to the Department Heads (Business Office Manager, Social Services, DON, Activities Director, MDS, Unit Manager, Dietary Manager, Housekeeping Supervisor, Maintenance, Marketing, and Payroll) on the Grievance Process by the Administrator on 01/28/19. 4. A) On or before 01/31/19, education was provided by the Administrator and Education Training Director on Grievance Standards of Practice and Compliance Guidelines to all facility staff. A post test accompanied the education to validate understanding of the materials. Newly hired staff will receive education during orientation regarding Grievance Standards of Practice and Compliance Guidelines, including a post test. Any employee who has not received the education and passed the post test will not be allowed to return to work after 01/31/19. The facility does not use agency staff. B) Beginning 01/30/19, the Administrator, DON, Unit Manager (UM), or Grievance Officer will interview three (3) residents with a BIMS score of nine (9) or greater, three (3) random employees, and three (3) representatives of residents with a BIMS score of eight (8) or less weekly for four (4) weeks to ensure staff and residents understand the grievance process. Results of the audits will be reported to the Quality Assurance Committee for its review and recommendations. The Administrator will assign follow-up as needed. C) Beginning 01/30/19, the facility's Administrator will submit the grievance log, with completed concern/grievance investigation, and follow up daily with a member of the Regional Team for review. Any discrepancy noted during the review will be immediately addressed with the Administrator by the Regional Team Member. 5. A) On or before 01/26/19, the Nurse Management team, consisting of the Director of Nursing, RN Education Training Director, Unit Manager, MDS Coordinator(s), and/or Respiratory Therapist, completed a one hundred (100) percent (%) audit of respiratory care needs for each in-house resident having a tracheostomy, which included a review of their care plans. On or before 01/28/19, the respiratory care plans will be revised by the DON, if indicated, to include individualized care and services to be furnished related to their tracheostomy/respiratory needs. This will include, but not be limited to, tracheostomy care, suctioning, and specialized services related to respiratory care for their tracheostomy and in line with the resident's goals and desired outcomes. B) Any new admissions, or readmissions, with tracheostomy needs for care and services, will be reviewed by the Nursing Administrative Team, Respiratory Therapist, and/or MDS Coordinator(s) within twenty-four (24) hours. This review will include individualized care approaches and services to be implemented related to their ongoing tracheostomy/respiratory needs. This will include, but not be limited to, tracheostomy care, suctioning, and specialized services related to respiratory care and in line with the resident's goals and desired outcomes. C) On or before 01/29/19, each resident will have their ADL (Activities of Daily Living) status reviewed for the level of assistance required, including toileting. The ADL comprehensive baseline and State Registered Nurse Aide (SRNA) care plan were audited to ensure ADL interventions described the appropriate level of assistance and/or supervision needed. This will be completed by the Nurse Management Team (Director of Nursing, Education Training Director, RN, and Unit Manager), MDS Coordinator(s), and nursing staff (nurses and SRNAs) and, if applicable, the resident by 01/29/19. These will be resident-centered to reflect the amount of assistance and or supervision necessary to complete ADL tasks to attain or maintain his/her highest practicable physical, mental, and psychosocial well-being. 6. A) On or before 01/25/19, the Regional Quality Manager completed education for the Nurse Management Team (Director of Nursing, Education Training Director, RN, MDS Coordinator(s), and Unit Manager) regarding completion and review of resident-centered respiratory care plans for tracheostomy care. The Respiratory Care plan will be initiated by the Interdisciplinary Team (IDT) Team, in conjunction with Respiratory Therapy, consisting of, but not limited to, Administrator, DON, Unit Managers, Social Services, MDS Coordinator(s), Activities, and Dietary Manager. B) On or before 01/31/19, the Regional Quality Manager completed education to the Nurse Management Team (Director of Nursing, Education Training Director, RN, MDS Coordinator(s), and Unit Manager) on completing a tracheostomy patient admission questionnaire. The questionnaire consists of the name of the resident, resident specific tracheostomy orders, including care and suctioning, other services needed and who will provide any specialty services. On Saturday and Sunday, the clinical manager will initiate the respiratory care plan completing a tracheostomy patient admission questionnaire. The MDS Coordinator(s) will review the plan to ensure it is appropriate and implemented within forty-eight (48) hours. This education includes referencing the respiratory care plan for specific interventions regarding trach care, revision of care plans, if indicated, to include individualized care and services furnished related to their tracheostomy/respiratory needs and what, at a minimum, will be provided on the respiratory care plan. The care plan will include, but may not be limited to, tracheostomy care, suctioning, and specialized services. Education includes communication of the respiratory care plan to licensed nurses and Respiratory Therapist (RT)s and changes in interventions by the IDT (Admin, DON, Unit Managers, Social Services, MDS Coordinator, Activities, and Dietary Manager) if indicated. The Regional Quality Manager will educate the outside Vendor Respiratory Therapy by 01/31/19. C) A post test will be given to the Director of Nursing by the Regional Quality Manager on 01/31/19, to ensure understanding of the tracheostomy care plans and expectations of care. The Director of Nursing will provide education to the Education Training Director, MDS Coordinators, Unit Manager, and Respiratory Therapist to ensure understanding of the material related to respiratory care plans. Education will be completed and post test passed prior to working by 02/01/19. D) On or before 01/25/19, the Regional Reimbursement Nurse (RRN) provided an in-service for the Interdisciplinary Team (IDT) consisting of the Director of Nursing, Social Services, Assistant Dietary Manager, Activities Director, and Registered Nurse (RN) Education Training Director regarding person-centered care plan development related to ADLs for transferring and toileting. E) On or before 01/31/19, the Education Training Director will provide education to the nursing staff, to include SRNAs, regarding the comprehensive care plan, or baseline care plan, to include respiratory/tracheostomy care. Education was provided regarding the SRNA care plan to include ADL interventions for the level of assistance and/or supervision needed. This education will include the expectation that the nursing staff (Nurses and SRNAs) use the SRNA care plan to determine the ADL status and level of assistance or supervision required for their assignment. A post test will be given to the nurses and SRNAs on the education provided to ensure understanding of the material by 02/01/19. After 02/01/19, licensed nurses and SRNAs will not be allowed to work without receiving the required education. This same education will be added to the new hire orientation packet for training during orientation. The facility does not use agency staff. 7. Beginning 01/30/19, direct observation audits will be conducted five (5) times weekly times four (4) weeks, of twenty (20) different residents each week to ensure that the comprehensive care plan, baseline care plan, and SRNA care plan is being followed while care is being provided. Observation audits will be completed by Nursing Administration (Director of Nursing, Education Training Director, RN Unit Manager, or MDS Coordinators) and will encompass observations of at least ten (10) SRNAs, on varying shifts a week. The auditor will address any discrepancy noted during the audit at that time and re-educate staff as needed. 8. On or before 01/31/19, the Education Training Director, Unit Manager, Director of Nursing, and the MDS Nurses completed education for all the nursing staff regarding comprehensive, baseline, and SRNA care plan. The education provided included following the care plan to provide adequate supervision and assistance to prevent accidents. It also included educating staff that each resident's ADL care plan is located in the kiosk and a printed version will be available in a book at the nurses' station. This same education will be added to the new hire orientation packets. After 01/31/19, licensed nurses and SRNAs will not be allowed to work without receiving the required education and passing a post test. The facility does not use agency staff. 9. The Nurse working the 7PM-7AM shift on 01/09/19 was in-serviced by the DON regarding performing tracheostomy care as per physician order per plan of care. The nurse was in-serviced on the responsibility of the nurse of the 7PM-7AM shift. The nurse was provided with verbal instruction, by the DON, regarding following physician orders related to medication administration and appropriate medication documentation. This verbal education was provided on 01/23/19 by the DON. 10. A) On or before 01/25/19, a one-time assessment was completed by the Education Training Director (RN), which consisted of a head to toe clinical assessment of four (4) in-house tracheostomy residents. Residents were in no distress and no issues were identified. B) On or before 1/31/19, a one-time audit was completed by the RN Unit Manager on all residents with tracheostomies to validate orders. Any discrepancies noted were immediately corrected by notifying the MD. On or before 01/29/19, the Director of Nursing reviewed the MARs, for dates of service from 01/24/19 to 01/31/19, consisting of two (2) in-house tracheostomy residents. The audits included verified documentation of tracheostomy care in the medical record. No issues were identified. Any readmission will have documentation reviewed within 24 hours of return. On or before 01/28/19, a one-time audit was completed by the Respiratory Therapist to ensure all tracheostomy residents with oxygen had valid orders. Any discrepancies noted were immediately corrected by notifying the MD by a licensed nurse. 11. A) On 01/25/19, the Contracted Respiratory Therapist (RT) completed education and skills competency for the Director of Nursing, Education Training Director, RN Unit Manager, and a Staff Respiratory Therapist to validate they were competent in tracheostomy care and the suctioning process. B) On or before 01/31/19, the Respiratory Vendor (RT) and/or Nursing Management team, consisting of the DON, Education Training Director, and/or UM, began education for the licensed nurses on following the physician orders regarding tracheostomy care/suctioning and on the respiratory policies provided by the respiratory therapy vendor regarding tracheostomy care and suctioning. This education will be completed by 01/31/19. This education has been added to the new hire-licensed nurse orientation packet. Facility staff will be in-serviced by 01/31/19. The facility does not use agency staff. C) On or before 01/31/19, the Nurse Management Team (Director of Nursing, Education Training Director, RN, and Unit Manager) will complete return demonstration competencies for each licensed nurse on tracheostomy care and suctioning. In addition, nursing administration (the Nurse Management Team (Director of Nursing, Education Training Director, RN, and Unit Manager)) will provide in-servicing regarding the facility Respiratory Therapist (RT) services availability for tracheostomy care and suctioning. The in-service also educated regarding nursing responsibility to provide tracheostomy care and suctioning if and/or when a RT is not available or on the schedule to provide such treatments. This education material will be added to the new hire-licensed nurse orientation packet. The facility does not use agency staff. No employees will work after 01/31/19 until educated and passing post test. 12. A) Beginning 01/31/19, the Nurse Management Team (Director of Nursing, Education Training Director, RN, and Unit Manager) MDS Nurses, or Contract Respiratory Therapy and/or facility Respiratory Therapist, will conduct audits of five (5) nurses and/or RTs each week, on varying shifts, using the tracheostomy competency validation tool. 13. On or before 01/31/19, the Nursing Management Team, consisting of the DON, Unit Manager(s), and licensed nurses from sister facilities, completed a one-time audit on all residents with insulin orders starting 01/24/19 to identify if any insulin was not given per physician orders and/or not signed timely. Any issues/concerns identified during the audit were discussed with the attending physician including a clinical assessment/observation to ensure there were no adverse reactions by the Director of Nursing and/or Nursing Management. It is the practice of the facility for insulin to be administered correctly, according to physician orders, and per the expected timeframe to prevent significant insulin medication errors. 14. On or before 01/31/19, the DON or Education Director will provide education to all licensed nurses regarding physician orders for administration/time parameters of medication, following physician orders for insulin administration and documenting doses administered at the time of administration. The education also included the notification of the physician if the administration fell outside the time parameters, incorrect dose given/omitted, and an assessment of the resident to ensure no adverse effects. A post education quiz for licensed nurses included education regarding the five (5) Rights of Medication administration, following physician's orders for medication administration, and insulin administration. Documentation will be completed by the nursing management team by each licensed nurse by 01/29/19. Licensed nurses must pass the quiz with 100% score or be re-educated by nursing administration and retake the quiz with a 100% score before returning to work on their next shift. No licensed staff will be permitted to work until test is passed as of 01/31/19. 15. Beginning 01/30/19, the Nursing Management Team (Director of Nursing, Education Training Director, RN, and Unit Manager) and MDS Coordinator(s) will complete audits, related to insulin administration, to include if any insulin was not given per physician orders and/or not signed timely. All residents with insulin orders will have Medication Administration documentation checked to ensure the insulin is documented given in accordance with physician orders and following professional standards of practice within time restrictions. The audit will be conducted five (5) days per week for four (4) weeks, then weekly times four (4) weeks, and then monthly. Any discrepancy identified during the audit, which consists of any insulin not given per physician orders and/or not signed timely, will be corrected immediately with MD and family notification and an assessment of the resident to ensure no adverse effects at the time the discrepancy is identified. 16. Beginning 01/31/19, the Nursing management team (DON, Education Training Director, Unit Manager, and MDS Nurses) will observe medication pass opportunities for 5 residents with insulin, to validate that licensed nurses are giving insulin per physician orders and within the timeframe. Any discrepancy identified will be corrected at the time of discrepancy by notifying the MD and Family by the Director of Nursing and/or Unit Manager. 17. On or before 01/25/19, the Specialized Medical Services (SMS) tracheostomy care and suctioning policy was adopted for use, by the facility, to ensure residents with a tracheostomy receive care per physician order and plan of care. The Director of Nursing developed an ancillary tracheostomy care and suctioning order for licensed nurses to utilize when admitting a resident to ensure that all appropriate physician orders are written for a resident who has a tracheostomy and/or requires oxygen. 18. On or before 01/31/19, the Regional Director of Operations educated facility management (DON and Administrator) on their responsibilities as it relates to using resources effectively and efficiently to attain or maintain the highest practicable physical well-being for residents in the facility. On or before 01/31/19, the Regional Director of Operations gave a post test to the Administrator and Director of Nursing on their job duties and what is required daily to ensure the facility is operating in a manner that prompts quality of life for the residents. 19. An ADHOC/Quality Assurance and Performance Improvement (QAPI) meeting was conducted on 01/24/19 to discuss the alleged deficient practices and corrective actions. The QAPI team met again on 01/30/19, with at least one Regional team member in attendance (either in person or by phone), and will continue weekly times four (4) weeks and then the facility will continue monthly thereafter. A QAPI meeting was held 02/01/19, for review of data from ongoing audits and staff education. This data will be reviewed weekly and continue times four (4) weeks and then monthly thereafter ongoing. Members of the facility's Quality Assurance Committee consist of the Administrator, Director of Nursing, Assistant Directors of Nursing, Dietary Manager, Business Office Manager, Activities Director, Director of Rehab, Maintenance Director, Social Services Manager, and Medical Director, who participates at least quarterly and as needed. The plan will be updated, as indicated, by the QAPI Committee. For all audits submitted to the QAPI Committee, the Administrator will assign follow-up as needed. ***The State Survey Agency determined the following removed Immediate Jeopardy on 02/02/19, as alleged by the facility: 1. Review of the medical records for Resident #117 revealed the resident was discharged from the facility on 01/10/19. 2. A) Review of the Resident Council Meeting Minutes, dated 01/24/19, revealed fourteen (14) residents attended the meeting and education was provided on the grievance process. Interview with Resident #59 on 02/06/19 at 2:20 PM, revealed the facility staff met with the resident council and reviewed the grievance process, and forms were located throughout the facility for the residents. Review of medical records for Residents #171, #322, and #323 revealed documentation of a social services interview with residents or residents' representatives regarding the grievance process. B) Interview with the Social Services Director on 02/06/19 at 1:56 PM, revealed she was the Grievance Officer for the facility. She stated grievance forms have been placed in several locations in the facility with a locked grievance box located on the Peach Wing. She further stated she would initiate the grievance process and would assign the grievance to the appropriate department. She added the Administrator was to be informed immediately of all grievances. The Grievance Officer also stated the initial response to the grievance must be within seventy-two (72) hours. Review of the Allegation of Compliance binder revealed the grievance log was up to date and maintained by the Administrator. C) Observations of the Blue, Peach, and [NAME] Units on 02/05/19, revealed the Grievance Process Summary was posted with grievance forms available to staff and residents. D) Review of the facility's admission packet on 02/06/19, revealed presence of the Grievance Standards of Practice and Compliance forms. 3. Review of the facility's documentation on 02/06/19, revealed education on the grievance process was provided to the Director of Nursing (DON) and the Administrator on 01/23/19, per the sign-in sheet. The facility's documentation also revealed evidence that this education was provided to department heads on 01/28/19 and to all facility staff on or before 01/31/19 by the sign-in sheets. Interviews on 02/06/19, with State Registered Nurse Aide (SRNA) #15 at 1:00 PM, SRNA #16 at 3:44 PM, SRNA #2 at 1:13 PM, SRNA #4 at 1:30 PM, Licensed Practical Nurse (LPN) #7 at 1:25 PM, LPN #1 at 1:00 PM, LPN #3 at 1:15 PM, with Dietary Staff at 1:40 PM, Maintenance Staff at 1:51 PM, the Respiratory Director at 2:33 PM, and the MDS Coordinator at 1:50 PM revealed knowledge of the Grievance Standard of Practice and Compliance process. 4. A) Review of the facility's New Hire Orientation binder on 02/06/19, revealed presence of the Grievance Standard of Practice and Compliance policy. Review of the binder also revealed evidence of post tests administered to the staff. B) Review of the facility's documentation on 02/06//19, revealed [TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to develop/implement comprehensive, person-centered care plans for four (4) of forty-seven (47) sampled residents (Resident #117, #21, #98, and #106). The facility failed to implement Resident #117's care plan, which stated staff were required to provide tracheostomy (an opening in the neck to the windpipe) care and administer insulin as ordered. On [DATE], at 7:00 PM staff failed to provide tracheostomy care (which includes suctioning) and at 11:00 PM, when the resident indicated he/she needed to be suctioned, staff only suctioned the resident's oral cavity but did not suction the resident's tracheostomy. Further, the facility failed to follow Resident #117's Physician's Orders for administration of Humulin R Insulin (regular, fast acting). On [DATE], staff did not administer the resident's insulin that was due at 12:00 AM, until 2:00 AM, two hours late. In addition, staff documented another dose of insulin was administered four (4) hours later at 6:00 AM, when the resident's blood sugar was 111 milligrams per deciliter (mg/dl). However, according to Resident #117's Physician's Orders, staff were required to hold the resident's insulin if the resident's blood sugar was below 140 mg/dl. In addition, the facility failed to develop a care plan for Resident #117, with individualized interventions to address the resident's need for assistance with transferring from the bed to a chair, ambulation, and toilet use. According to the resident's admission assessment, Resident #117 required extensive to total assistance; however, on [DATE] at approximately 5:30 AM, staff did not assist the resident and left the resident on a bedside commode. At 6:40 PM, staff found Resident #117 on the floor beside the bedside commode, not breathing. Resident #117 was transferred to the hospital, where he/she was pronounced dead at 7:32 AM. The cause of the resident's death was Cardiopulmonary Arrest due to Upper Airway Obstruction. The facility also failed to follow Resident #21 and #98's care plan and provide tracheostomy care/suctioning of the residents' tracheostomies on [DATE]. In addition, the facility failed to develop a care plan for Resident #106 with interventions to address the resident's refusal to take medications and to utilize oxygen. The facility's failure to develop care plans with interventions 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 (F585), 42 CFR 483.21 Comprehensive Person-Centered Care Plans (F656), 42 CFR 483.25 Quality of Care (F689 and F695), 42 CFR 483.45 Pharmacy Services (F760), and 42 CFR 483.70 Administration (F835). The facility was notified of the Immediate Jeopardy on [DATE]. 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 on [DATE], which lowered the scope and severity to D level at 42 CFR 483.10 Resident Rights (F585), 42 CFR 483.21 Comprehensive Person-Centered Care Plans (F656), 42 CFR 483.25 Quality of Care (F689 and F695), 42 CFR 483.45 Pharmacy Services (F760), and 42 CFR 483.70 Administration (F835), while the facility monitors the effectiveness of systemic changes and quality assurance activities. The findings include: Review of the facility's policy, Care Plans-Comprehensive, not dated, revealed care plan interventions were designed after careful consideration of the relationship between the resident's problem areas and their causes. The policy stated an individualized comprehensive care plan should include measurable objectives and timetables to meet the resident's needs. 1. Interview with the facility's Administrator on [DATE] at 12:00 PM, the Respiratory Therapy Director on [DATE] at 9:30 AM, and the Director of Nursing (DON) on [DATE] at 9:12 AM, revealed the facility did not have policies regarding respiratory care, tracheostomy care, suctioning, or oxygen. Review of Resident #117's closed medical record revealed that the facility admitted the resident on [DATE] with diagnoses that included Cerebral Infarction (Stroke), Chronic Obstructive Pulmonary Disease (COPD), Chronic Kidney Disease, Tracheostomy status, Gastrostomy status (feeding tube), Dysphagia (trouble swallowing), Hypertension, Heart Failure, Atrial Fibrillation, Anxiety Disorder, and Type II Diabetes. Review of Resident #117's admission Minimum Data Set (MDS) assessment dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) score of five (5), which indicated the resident was severely cognitively impaired. Further review of the MDS revealed the resident required oxygen therapy, suctioning, and tracheostomy care. 1. a. Review of Resident #117's care plan dated [DATE], revealed the facility identified the resident had a skin care problem and developed an intervention for Trach Care as ordered. According to the care plan, nursing and respiratory technicians (respiratory therapists) were responsible for implementing the care plan. Review of Resident #117's Physician's Orders for [DATE] revealed orders to suction the resident as needed and to provide tracheostomy care every shift. The order stated the care should include changing the inner cannula, cleaning around the stoma with sterile saline and Hydrogen Peroxide followed by cleaning with sterile saline, and then applying a dry dressing (However, tracheostomy care also includes suctioning the resident's tracheostomy to clear any secretions. Excess secretions are due to the reduced ability to swallow and cough.). Review of Resident #117's Respiratory Medication Administration Record (MAR) for [DATE] revealed tracheostomy care was required at 7:00 AM and 7:00 PM each day and suctioning was required as needed. However, there was no documented evidence that staff provided tracheostomy care or suctioning at 7:00 PM as ordered by the resident's physician. Interview with Registered Nurse (RN) #3, the Unit Manager, on [DATE] at 12:50 PM revealed she was responsible for Resident #117's care on [DATE] from 7:00 PM until [DATE] at 7:00 AM. She stated she did not provide tracheostomy care or suction the resident's tracheostomy that night because she assumed that respiratory therapy staff provided the care. The Unit Manager stated she was in Resident #117's room at approximately 11:00 PM on [DATE], and the resident motioned to his/her mouth, indicating he/she needed to be suctioned. According to the Unit Manager, she suctioned the resident's oral cavity, but did not suction the resident's tracheostomy. Review of Resident #117's Nursing Note dated [DATE] at 6:40 AM revealed staff found the resident face down on the floor, not breathing. Cardiopulmonary Resuscitation (CPR) was initiated, and the resident was transferred to the hospital. Interview with the DON on [DATE] at 10:30 AM revealed the Unit Supervisor (RN #3) should have been aware that nursing staff was responsible for providing respiratory care during the night shift, and should have provided tracheostomy care/suctioning for Resident #117. 1. b. Further review of the care plan for Resident #117, dated [DATE], revealed the facility identified that the resident had Diabetes and developed an intervention to administer insulin as ordered. Review of Resident #117's [DATE] Physician's Orders revealed an order to administer eight (8) units of Humulin R insulin (100 units per milliliter) every (6) six hours and to provide an additional amount of Humulin R per sliding scale (amount of insulin to be administered based on the blood sugar result). Further review of Resident #117's Physician's Orders revealed an order to hold the resident's insulin if the resident's blood sugar was less than 140 mg/dl. Review of Resident #117's Nurse Medication Administration Record (MAR) revealed on [DATE] at 12:00 AM, the resident's blood sugar was 222 mg/dl and RN #3 documented that Humulin R insulin was administered. On [DATE], at 6:00 AM, RN #3 documented that Resident #117's blood sugar was 111. Further review revealed RN #3 documented that Humulin R insulin was administered, even though the Physician's Order was to hold the resident's insulin for a blood sugar less than 140. Interview on [DATE] at 2:04 PM with Registered Nurse (RN) #3 revealed she administered Resident #117's 12:00 AM dose of Humulin R, two (2) hours late. She stated she did not administer the medication until 2:00 AM, because she was busy. According to the RN, she did not remember administering insulin to Resident #117 at 6:00 AM on [DATE]; however, the nurse documented that the medication was administered. Review of Resident #117's Nursing Notes revealed staff found the resident on the floor at 6:40 AM on [DATE]. The resident was unresponsive and not breathing. 1. c. Review of Resident #117's admission Minimum Data Set (MDS) assessment dated [DATE], revealed the resident required extensive assistance of two (2) or more persons for bed mobility, toilet use, and personal hygiene; limited assistance of one staff person for ambulation (utilized a wheelchair for ambulation); and limited assistance of two (2) or more persons for transfers. Review of Resident #117's care plan dated [DATE] and the Daily Care Guide (guide that State Registered Nurse Aides utilize to provide care) revealed the facility identified that the resident required assistance with Activities of Daily Living (ADL). However, the interventions the facility developed were not individualized. The interventions for bed mobility and toileting stated the resident required limited assistance of one person, extensive assistance of two persons, and total assistance of one to two persons, as needed. Further review of Resident #117's care plan revealed the resident required limited assistance of two (2) or more persons for transfers and utilized a wheelchair for mobility. Interview with State Registered Nurse Aide (SRNA) #4 on [DATE] at 10:15 AM, revealed she had been assigned to care for Resident #117 in the past. SRNA #4 stated the Daily Care Guides were confusing as to what level of assistance the resident required, but she provided limited assistance of one (1) staff member when transferring the resident from the bed or a chair. Interview with SRNA #10 on [DATE] at 10:30 AM, revealed she looked at a resident and decided how much assistance she thinks the resident needs. SRNA #10 further stated if she was not sure about how much assistance a resident required, she would ask a nurse. Interview with SRNA #11 on [DATE] at 6:20 PM, revealed on the morning of [DATE], she was assigned to provide care for Resident #117. She stated at approximately 5:30 AM, she observed the resident transfer from bed to the bedside commode. SRNA #11 stated she did not enter the resident's room and assist the resident, but watched from the hallway until the resident was on the bedside commode. According to SRNA #11, Resident #117 was independent with ADLs and did not require any assistance. The SRNA stated she then continued down the hallway to provide care for another resident and left the resident on the bedside commode. According to SRNA #11, at approximately 6:00 AM, Registered Nurse (RN) #3 notified her that the resident had fallen and asked her to help get Resident #117 up from the floor. Interview with RN #3 on [DATE] at 12:50 PM, revealed on [DATE] at approximately 6:30 AM, she found the resident lying face down on the floor. She stated it appeared the resident had been on the bedside commode because the resident's incontinence brief was down and there was feces in the bedside commode. RN #3 stated she could not get the resident to respond, but was able to feel a faint pulse. According to the RN, Cardiopulmonary Resuscitation (CPR) was initiated and the resident was transferred to the hospital. Review of Resident #117's hospital record revealed the resident was pronounced dead on [DATE] at 7:32 AM on [DATE], as a result of Cardiopulmonary Arrest. A review of Resident #117's Death Certificate revealed the cause of death was Cardiopulmonary Arrest due to upper airway obstruction. Interview with the Staff Development Nurse on [DATE] at 10:30 AM, revealed residents' care plans were somewhat confusing because they were standardized. She stated the Interdisciplinary Team (IDT) tried to individualize them, but stated the SRNAs could decide what level of assistance a resident needed when the care plan was not individualized. Interview with MDS Coordinator #2 on [DATE] at 11:15 AM, revealed she did not complete the MDS assessment or care plan for Resident #117. After reviewing the resident's MDS, she stated the resident's care plan should have stated that the resident required two (2) staff persons for assistance with ADLs. Interview on [DATE] at 10:50 AM with MDS Coordinator #1 revealed she considered Resident #117's care plan to be an individualized care plan, even though tracheostomy care was listed under skin care and the care plan listed options for the level of assistance the resident required, that were not in accordance with the resident's assessed level of need. 2. Observation of Resident #21 on [DATE] at 10:15 AM revealed the resident had a tracheostomy and was receiving oxygen via the tracheostomy. Further observation revealed Registered Nurse (RN) #9 suctioned clear secretions from the resident's tracheostomy. Review of Resident #21's medical record revealed the facility admitted the resident on [DATE] with diagnoses that included Traumatic Brain Injury, Acute Respiratory Failure with Hypoxia, Tracheostomy, and Feeding Tube. Review of Resident #21's Minimum Data Set (MDS) dated [DATE], revealed the resident was in a persistent vegetative state with no discernible consciousness. The MDS also revealed the resident required respiratory treatments that included tracheostomy care, suctioning, and oxygen. Review of Resident #21's care plan dated [DATE], revealed the facility developed an intervention to provide tracheostomy care and suction as needed as ordered by the resident's physician. Review of Resident #21's Physician's Orders dated [DATE] revealed orders to provide tracheostomy care every shift and to suction the tracheostomy as needed. However, interview with the Unit Manager, RN #3, on [DATE] at 11:10 AM revealed she did not provide any tracheostomy care for Patient #21 on [DATE] at 7:00 PM. She stated she was not aware nursing staff was required to provide any type of respiratory care during the night shift. 3. Review of Resident #98's medical record revealed the facility admitted the resident on [DATE] with diagnoses that included Hemiplegia following Cerebral Infarction (Stroke), Tracheostomy, Acute Respiratory Failure, Gastrostomy, Dysphagia, Muscle Weakness, Neuromuscular Dysfunction of the Bladder, Chronic Kidney Disease, and Heart Failure. Review of Resident #98's Minimum Data Set (MDS) dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) score of ten (10), which indicated moderately impaired cognition. Further review of the MDS revealed the resident required respiratory treatments that included tracheostomy care, suctioning, and oxygen. Review of Resident #98's care plan dated [DATE], revealed the facility developed an intervention to provide tracheostomy care and to suction as needed, as ordered by the resident's physician. Review of Resident #98's Physician's Orders dated [DATE] revealed orders to provide tracheostomy care every shift and suctioning of the tracheostomy as needed. Interview with the Unit Manager, RN #3, on [DATE] at 11:10 AM revealed she was assigned to provide care for Resident #98 on [DATE] from 7:00 PM until [DATE] at 7:00 AM. She stated she did not suction the resident's tracheostomy or provide any type of tracheostomy care during that time. She stated she was not aware nursing staff was required to provide any type of respiratory care during the night shift. 4. Review of the facility's Med-Pass policy dated [DATE] revealed each resident's comprehensive care plan was designed to incorporate identified problem areas and the risk factors associated with identified problems. The policy also revealed identified problem areas and their causes, and developed interventions that should be targeted and meaningful to the resident. Observation of Resident #106 on [DATE] at 8:48 AM, revealed the resident's oxygen concentrator was set on two (2) liters per minute (lpm). However, the oxygen tubing was hanging on the left side rail and the resident was not utilizing the oxygen. Interview with the resident on [DATE] at 8:49 AM, revealed he/she did not use the oxygen because It hurts my nose. The resident stated staff told him/her to utilize the oxygen or they (staff) would put it on the resident; however, the resident stated he/she would just remove it. Review of Resident #106's medical record revealed the facility admitted the resident on [DATE], and the resident had diagnoses that included Unspecified Dementia without behaviors, Cardiac Arrhythmia, and Acute Respiratory Failure with Hypoxia (low oxygen). Review of Resident #106's Physician's Order summary for [DATE] (original order [DATE]) revealed an order for the resident to utilize oxygen at 2 lpm via a nasal cannula. Review of Resident #106's Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) score of seven (7), which indicated the resident had moderately impaired cognition. Further review of the MDS revealed the resident had rejected care during the seven (7) days prior to the assessment. Review of Resident #106's Medication Administration Records (MARs) for [DATE] revealed the resident refused medications on [DATE], and 21, which were within the seven (7) day look-back period for the [DATE] MDS assessment. Review of Resident #106's care plan dated [DATE] revealed the facility developed an intervention for the resident to utilize oxygen as ordered. Further review of the care plan revealed the resident was at risk for psychosocial well-being related to Dementia and Depression and on [DATE], the facility revised the resident's care plan to state the resident had refused laboratory testing. However, there was no documented evidence the facility identified that the resident refused to utilize oxygen and take medications, nor implemented interventions to address the resident's refusal (e.g., oxygen hurt the resident's nose). Interview with Registered Nurse (RN) #1 on [DATE] at 10:50 AM and RN #4 on [DATE] at 10:13 AM, revealed Resident #106 was noncompliant with oxygen and frequently refused medication, but was not aware of any interventions to address the behavior. RN #4 stated that Social Worker #1 was responsible for developing care plans for residents who refused care. Interview with Social Worker #1 on [DATE] at 3:50 PM, revealed she was responsible for developing care plans for residents who refused care. She stated she reviewed residents' medical records to identify behaviors. According to the Social Worker, staff had not documented that Resident #106 refused oxygen; subsequently, the Social Worker had not developed a care plan with interventions to address the resident's refusal. **The facility alleged the following actions removed the Immediate Jeopardy on [DATE]: 1. Resident #117 was transported to the hospital on [DATE] and no longer resides in the facility. 2. A) On [DATE], the Activities Director conducted a resident council meeting to review with the residents the Grievance Process and guidelines. By [DATE] the Activities Director, Social Services Director, or facility Administrator will provide education on the Grievance Standard of Practice and Compliance guideline for those resident(s) with a Brief Interview for Mental Status (BIMS) score of nine (9) or higher, who did not attend the resident council meeting. By [DATE] the Social Services Director (Grievance Officer) or Social Services Assistant will interview current in-house residents with a BIMS of nine (9) or higher to identify if there are any current grievances. By [DATE] the Social Services Director (Grievance Officer) or Social Services Assistant will contact the respective responsible party or guardian, for those residents with a BIMS of eight (8) or less, to identify if they have any concerns and address the concern(s) following the Grievance Standard of Practice and Compliance guideline. Any concerns/grievance(s) voiced will be addressed following the Grievance Standard of Practice and Compliance guideline. B) Grievances identified Monday through Friday will be addressed by the Social Services Director, who is the Grievance Official, and/or the Social Services staff. All grievances will be addressed per the Grievance Standard of Practice and Compliance Guidelines and submitted to the Administrator for review. The Administrator will log the grievance for review and recommendations in Quality Assurance/Performance Improvement (QAPI). The Social Services Director will send a letter to the resident's representative and/or resident with resolution per guidelines. C) By [DATE], the Administrator will post a copy of the Grievance Process summary along with the facility's administration contacts throughout the facility. Copies of blank grievance forms will accompany the posting. D) By [DATE], the Admissions Director will add a copy of the Grievance Standards of Practice and Compliance in the admission packets to provide information to any new residents/families. 3. On [DATE], the Regional Quality Manager (RQM) provided education to the Director of Nursing (DON) and the Administrator regarding the facility's Grievance Standards of Practice and Compliance Guidelines, which included, but was not limited to, ensuring investigation and resolution of a grievance per regulation. Beginning [DATE], the facility's Administrator educated the Education Training Director (ETD) regarding the facility's Grievance Process. Education was provided to the Department Heads (Business Office Manager, Social Services, DON, Activities Director, MDS, Unit Manager, Dietary Manager, Housekeeping Supervisor, Maintenance, Marketing, and Payroll) on the Grievance Process by the Administrator on [DATE]. 4. A) On or before [DATE], education was provided by the Administrator and Education Training Director on Grievance Standards of Practice and Compliance Guidelines to all facility staff. A post test accompanied the education to validate understanding of the materials. Newly hired staff will receive education during orientation regarding Grievance Standards of Practice and Compliance Guidelines, including a post test. Any employee who has not received the education and passed the post test will not be allowed to return to work after [DATE]. The facility does not use agency staff. B) Beginning [DATE], the Administrator, DON, Unit Manager (UM), or Grievance Officer will interview three (3) residents with a BIMS score of nine (9) or greater, three (3) random employees, and three (3) representatives of residents with a BIMS score of eight (8) or less weekly for four (4) weeks to ensure staff and residents understand the grievance process. Results of the audits will be reported to the Quality Assurance Committee for its review and recommendations. The Administrator will assign follow-up as needed. C) Beginning [DATE], the facility's Administrator will submit the grievance log, with completed concern/grievance investigation, and follow up daily with a member of the Regional Team for review. Any discrepancy noted during the review will be immediately addressed with the Administrator by the Regional Team Member. 5. A) On or before [DATE], the Nurse Management team, consisting of the Director of Nursing, RN Education Training Director, Unit Manager, MDS Coordinator(s), and/or Respiratory Therapist, completed a one hundred (100) percent (%) audit of respiratory care needs for each in-house resident having a tracheostomy, which included a review of their care plans. On or before [DATE], the respiratory care plans will be revised by the DON, if indicated, to include individualized care and services to be furnished related to their tracheostomy/respiratory needs. This will include, but not be limited to, tracheostomy care, suctioning, and specialized services related to respiratory care for their tracheostomy and in line with the resident's goals and desired outcomes. B) Any new admissions, or readmissions, with tracheostomy needs for care and services, will be reviewed by the Nursing Administrative Team, Respiratory Therapist, and/or MDS Coordinator(s) within twenty-four (24) hours. This review will include individualized care approaches and services to be implemented related to their ongoing tracheostomy/respiratory needs. This will include, but not be limited to, tracheostomy care, suctioning, and specialized services related to respiratory care and in line with the resident's goals and desired outcomes. C) On or before [DATE], each resident will have their ADL (Activities of Daily Living) status reviewed for the level of assistance required, including toileting. The ADL comprehensive baseline and State Registered Nurse Aide (SRNA) care plan were audited to ensure ADL interventions described the appropriate level of assistance and/or supervision needed. This will be completed by the Nurse Management Team (Director of Nursing, Education Training Director, RN, and Unit Manager), MDS Coordinator(s), and nursing staff (nurses and SRNAs) and, if applicable, the resident by [DATE]. These will be resident-centered to reflect the amount of assistance and or supervision necessary to complete ADL tasks to attain or maintain his/her highest practicable physical, mental, and psychosocial well-being. 6. A) On or before [DATE], the Regional Quality Manager completed education for the Nurse Management Team (Director of Nursing, Education Training Director, RN, MDS Coordinator(s), and Unit Manager) regarding completion and review of resident-centered respiratory care plans for tracheostomy care. The Respiratory Care plan will be initiated by the Interdisciplinary Team (IDT) Team, in conjunction with Respiratory Therapy, consisting of, but not limited to, Administrator, DON, Unit Managers, Social Services, MDS Coordinator(s), Activities, and Dietary Manager. B) On or before [DATE], the Regional Quality Manager completed education to the Nurse Management Team (Director of Nursing, Education Training Director, RN, MDS Coordinator(s), and Unit Manager) on completing a tracheostomy patient admission questionnaire. The questionnaire consists of the name of the resident, resident specific tracheostomy orders, including care and suctioning, other services needed and who will provide any specialty services. On Saturday and Sunday, the clinical manager will initiate the respiratory care plan completing a tracheostomy patient admission questionnaire. The MDS Coordinator(s) will review the plan to ensure it is appropriate and implemented within forty-eight (48) hours. This education includes referencing the respiratory care plan for specific interventions regarding trach care, revision of care plans, if indicated, to include individualized care and services furnished related to their tracheostomy/respiratory needs and what, at a minimum, will be provided on the respiratory care plan. The care plan will include, but may not be limited to, tracheostomy care, suctioning, and specialized services. Education includes communication of the respiratory care plan to licensed nurses and Respiratory Therapist (RT)s and changes in interventions by the IDT (Admin, DON, Unit Managers, Social Services, MDS Coordinator, Activities, and Dietary Manager) if indicated. The Regional Quality Manager will educate the outside Vendor Respiratory Therapy by [DATE]. C) A post test will be given to the Director of Nursing by the Regional Quality Manager on [DATE], to ensure understanding of the tracheostomy care plans and expectations of care. The Director of Nursing will provide education to the Education Training Director, MDS Coordinators, Unit Manager, and Respiratory Therapist to ensure understanding of the material related to respiratory care plans. Education will be completed and post test passed prior to working by [DATE]. D) On or before [DATE], the Regional Reimbursement Nurse (RRN) provided an in-service for the Interdisciplinary Team (IDT) consisting of the Director of Nursing, Social Services, Assistant Dietary Manager, Activities Director, and Registered Nurse (RN) Education Training Director regarding person-centered care plan development related to ADLs for transferring and toileting. E) On or before [DATE], the Education Training Director will provide education to the nursing staff, to include SRNAs, regarding the comprehensive care plan, or baseline care plan, to include respiratory/tracheostomy care. Education was provided regarding the SRNA care plan to include ADL interventions for the level of assistance and/or supervision needed. This education will include the expectation that the nursing staff (Nurses and SRNAs) use the SRNA care plan to determine the ADL status and level of assistance or supervision required for their assignment. A post test will be given to the nurses and SRNAs on the education provided to ensure understanding of the material by [DATE]. After [DATE], licensed nurses and SRNAs will not be allowed to work without receiving the required education. This same education will be added to the new hire orientation packet for training during orientation. The facility does not use agency staff. 7. Beginning [DATE], direct observation audits will be conducted five (5) times weekly times four (4) weeks, of twenty (20) different residents each week to ensure that the comprehensive care plan, baseline care plan, and SRNA care plan is being followed while care is being provided. Observation audits will be completed by Nursing Administration (Director of Nursing, Education Training Director, RN Unit Manager, or MDS Coordinators) and will encompass observations of at least ten (10) SRNAs, on varying shifts a week. The auditor will address any discrepancy noted during the audit at that time and re-educate staff as needed. 8. On or before [DATE], the Education Training Director, Unit Manager, Director of Nursing, and the MDS Nurses completed education for all the nursing staff regarding comprehensive, baseline, and SRNA care plan. The education provided included following the care plan to provide adequate supervision and assistance to prevent accidents. It also included educating staff that each resident's ADL care plan is located in the kiosk and a printed version will be available in a book at the nurses' station. This same education will be added to the new hire orientation packets. After [DATE], licensed nurses and SRNAs will not be allowed to work without receiving the required education and passing a post test. The facility does not use agency staff. 9. The Nurse working the 7PM-7AM shift on [DATE] was in-serviced by the DON regarding performing tracheostomy care as per physician order per plan of care. The nurse was in-serviced on the responsibility of the nurse of the 7PM-7AM shift. The nurse was provided with verbal instruction, by the DON, regarding following physician orders related to medication administration and appropriate medication documentation. This verbal education was provided on [DATE] by the D[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, closed record review, and review of facility policy, it was determined that the facility failed to ensure one (1) of forty-seven (47) sampled residents (Resident #117) received adequate supervision to prevent accidents. A review of Resident #117's admission assessment and a Physical Therapy Note dated [DATE], revealed the resident required assistance with transfers to/from bed/chair. The admission assessment revealed the resident also required extensive assistance with ambulation and toileting. However, on [DATE], at approximately 5:30 AM, staff observed Resident #117 transfer from bed to the bedside commode alone without offering to assist the resident. In addition, staff left the resident on the bedside commode unassisted. At approximately 6:30 AM, one hour later, staff found the resident on the floor, face down, unresponsive and not breathing. The facility initiated Cardiopulmonary Resuscitation (CPR) and transferred the resident to the hospital where the resident was pronounced dead at 7:32 AM on [DATE]. The facility's failure to ensure residents were supervised to prevent accidents has caused or is likely to cause serious injury, harm, impairment, or death to a resident. The facility's failure to ensure tracheostomy care and tracheal suctioning was provided to residents has caused or 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 (F585), 42 CFR 483.21 Comprehensive Person-Centered Care Plans (F656), 42 CFR 483.25 Quality of Care (F689 and F695), 42 CFR 483.45 Pharmacy Services (F760), and 42 CFR 483.70 Administration (F835). The facility was notified of the Immediate Jeopardy on [DATE]. 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 42 CFR 483.10 Resident Rights (F585), 42 CFR 483.21 Comprehensive Person-Centered Care Plans (F656), 42 CFR 483.25 Quality of Care (F689 and F695), 42 CFR 483.45 Pharmacy Services (F760), and 42 CFR 483.70 Administration (F835), while the facility monitors the effectiveness of systemic changes and quality assurance activities. The findings include Review of the facility's Incident and Accident Process policy, dated [DATE], revealed the purpose of the process was to ensure each resident received adequate supervision and assistive devices to prevent avoidable accidents. Review of Resident #117's closed medical record revealed that the facility admitted the resident on [DATE] with diagnoses that included Cerebral Infarction (Stroke), Chronic Obstructive Pulmonary Disease, Chronic Kidney Disease, Tracheostomy status, Gastrostomy status (feeding tube), Dysphagia (trouble swallowing), Hypertension, Heart Failure, Atrial Fibrillation, Anxiety Disorder, and Type II Diabetes. Review of Resident #117's admission Minimum Data Set (MDS) assessment dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) score of five (5), which indicated the resident was severely cognitively impaired. The MDS further revealed the resident required extensive assistance of two (2) or more persons for bed mobility, toilet use, and personal hygiene. Further review revealed the resident required limited assistance of one person for ambulation (via a wheelchair) and two (2) or more persons for transfers. Review of an Occupational Therapy (OT) Treatment Encounter Note dated [DATE], revealed OT evaluated Resident #117, and a plan of care was developed. The plan of care revealed the OT was treating the patient for gross motor coordination; and transfer training, range of motion techniques, and strengthening activities to increase functional task performance training with mobility. Review of the Physical Therapy (PT) Treatment Encounter Note dated [DATE], revealed an evaluation was completed on Resident #117 and a plan of care was developed. The plan of care revealed PT was treating the patient for bed mobility activities to increase functional skills, training in rolling, scooting, and bridging to facilitate independent bed mobility, and transfer training to increase functional task performance. According to a Physical Therapy Note dated [DATE], Resident #117 transferred with assistance of one (1) person. Review of Resident #117's comprehensive plan of care, dated [DATE], revealed the facility identified the resident needed assistance with activities of daily living (ADL) related to Chronic Obstructive Pulmonary Disease, Respiratory Failure, Weakness, Chronic Kidney Disease, and Congestive Heart Failure. However, review of the resident's care plan revealed the facility developed interventions that were not individualized to the resident's assessed level of need. According to the care plan and the Daily Care Guide, Resident #117 required limited assistance of one person, extensive assistance of two (2) persons, and total assistance of one to two persons as needed for bed mobility and toileting; required limited assistance of two (2) or more persons for transfers; and required a wheelchair for mobility. Review of Resident #117's Nursing Notes revealed on [DATE], at 6:40 AM, Registered Nurse (RN) #3 found the resident lying face down on the floor beside the bedside commode. The Note stated the resident had a faint pulse, but was not breathing, and the resident's fingers were blue. Interview with SRNA #11 on [DATE] at 6:20 PM, revealed on the morning of [DATE], she was assigned to provide care for Resident #117. According to SRNA #11, the resident did not need assistance with ADLs. She stated that at approximately 5:30 AM, she observed the resident transfer from the bed to the bedside commode. SRNA #11 stated she did not enter the resident's room and assist the resident, but watched from the hallway until the resident was on the bedside commode. The SRNA stated she then continued down the hallway to provide care for another resident. According to SRNA #11, at approximately 6:00 AM, Registered Nurse (RN) #3 notified her that Resident #117 had fallen and asked her to help get Resident #117 up from the floor. Interview with RN #3 on [DATE] at 12:50 PM, revealed she was assigned to the care of Resident #117 during the night of 01/09-10/19. She stated that at approximately 6:30 AM, she found the resident lying face down on the floor. She stated it appeared the resident had been on the bedside commode because the resident's clothes were down and the resident had feces on his/her bottom. RN #3 stated the resident was not breathing, and initially had a faint pulse. Further review of Resident #117's Nursing Notes revealed the facility transferred the resident to a hospital on [DATE], where the resident was pronounced dead at 7:32 AM due to Cardiopulmonary Arrest due to Upper Airway Obstruction. Interview with MDS Coordinator #2 on [DATE] at 11:15 AM revealed she did not complete Resident #117's care plan. However, after reviewing the resident's MDS assessment, she stated the resident's care plan should have stated that the resident required two (2) staff persons for transferring and should have utilized a wheelchair for mobility. **The facility alleged the following actions removed the Immediate Jeopardy on [DATE]: 1. Resident #117 was transported to the hospital on [DATE] and no longer resides in the facility. 2. A) On [DATE], the Activities Director conducted a resident council meeting to review with the residents the Grievance Process and guidelines. By [DATE] the Activities Director, Social Services Director, or facility Administrator will provide education on the Grievance Standard of Practice and Compliance guideline for those resident(s) with a Brief Interview for Mental Status (BIMS) score of nine (9) or higher, who did not attend the resident council meeting. By [DATE] the Social Services Director (Grievance Officer) or Social Services Assistant will interview current in-house residents with a BIMS of nine (9) or higher to identify if there are any current grievances. By [DATE] the Social Services Director (Grievance Officer) or Social Services Assistant will contact the respective responsible party or guardian, for those residents with a BIMS of eight (8) or less, to identify if they have any concerns and address the concern(s) following the Grievance Standard of Practice and Compliance guideline. Any concerns/grievance(s) voiced will be addressed following the Grievance Standard of Practice and Compliance guideline. B) Grievances identified Monday through Friday will be addressed by the Social Services Director, who is the Grievance Official, and/or the Social Services staff. All grievances will be addressed per the Grievance Standard of Practice and Compliance Guidelines and submitted to the Administrator for review. The Administrator will log the grievance for review and recommendations in Quality Assurance/Performance Improvement (QAPI). The Social Services Director will send a letter to the resident's representative and/or resident with resolution per guidelines. C) By [DATE], the Administrator will post a copy of the Grievance Process summary along with the facility's administration contacts throughout the facility. Copies of blank grievance forms will accompany the posting. D) By [DATE], the Admissions Director will add a copy of the Grievance Standards of Practice and Compliance in the admission packets to provide information to any new residents/families. 3. On [DATE], the Regional Quality Manager (RQM) provided education to the Director of Nursing (DON) and the Administrator regarding the facility's Grievance Standards of Practice and Compliance Guidelines, which included, but was not limited to, ensuring investigation and resolution of a grievance per regulation. Beginning [DATE], the facility's Administrator educated the Education Training Director (ETD) regarding the facility's Grievance Process. Education was provided to the Department Heads (Business Office Manager, Social Services, DON, Activities Director, MDS, Unit Manager, Dietary Manager, Housekeeping Supervisor, Maintenance, Marketing, and Payroll) on the Grievance Process by the Administrator on [DATE]. 4. A) On or before [DATE], education was provided by the Administrator and Education Training Director on Grievance Standards of Practice and Compliance Guidelines to all facility staff. A post test accompanied the education to validate understanding of the materials. Newly hired staff will receive education during orientation regarding Grievance Standards of Practice and Compliance Guidelines, including a post test. Any employee who has not received the education and passed the post test will not be allowed to return to work after [DATE]. The facility does not use agency staff. B) Beginning [DATE], the Administrator, DON, Unit Manager (UM), or Grievance Officer will interview three (3) residents with a BIMS score of nine (9) or greater, three (3) random employees, and three (3) representatives of residents with a BIMS score of eight (8) or less weekly for four (4) weeks to ensure staff and residents understand the grievance process. Results of the audits will be reported to the Quality Assurance Committee for its review and recommendations. The Administrator will assign follow-up as needed. C) Beginning [DATE], the facility's Administrator will submit the grievance log, with completed concern/grievance investigation, and follow up daily with a member of the Regional Team for review. Any discrepancy noted during the review will be immediately addressed with the Administrator by the Regional Team Member. 5. A) On or before [DATE], the Nurse Management team, consisting of the Director of Nursing, RN Education Training Director, Unit Manager, MDS Coordinator(s), and/or Respiratory Therapist, completed a one hundred (100) percent (%) audit of respiratory care needs for each in-house resident having a tracheostomy, which included a review of their care plans. On or before [DATE], the respiratory care plans will be revised by the DON, if indicated, to include individualized care and services to be furnished related to their tracheostomy/respiratory needs. This will include, but not be limited to, tracheostomy care, suctioning, and specialized services related to respiratory care for their tracheostomy and in line with the resident's goals and desired outcomes. B) Any new admissions, or readmissions, with tracheostomy needs for care and services, will be reviewed by the Nursing Administrative Team, Respiratory Therapist, and/or MDS Coordinator(s) within twenty-four (24) hours. This review will include individualized care approaches and services to be implemented related to their ongoing tracheostomy/respiratory needs. This will include, but not be limited to, tracheostomy care, suctioning, and specialized services related to respiratory care and in line with the resident's goals and desired outcomes. C) On or before [DATE], each resident will have their ADL (Activities of Daily Living) status reviewed for the level of assistance required, including toileting. The ADL comprehensive baseline and State Registered Nurse Aide (SRNA) care plan were audited to ensure ADL interventions described the appropriate level of assistance and/or supervision needed. This will be completed by the Nurse Management Team (Director of Nursing, Education Training Director, RN, and Unit Manager), MDS Coordinator(s), and nursing staff (nurses and SRNAs) and, if applicable, the resident by [DATE]. These will be resident-centered to reflect the amount of assistance and or supervision necessary to complete ADL tasks to attain or maintain his/her highest practicable physical, mental, and psychosocial well-being. 6. A) On or before [DATE], the Regional Quality Manager completed education for the Nurse Management Team (Director of Nursing, Education Training Director, RN, MDS Coordinator(s), and Unit Manager) regarding completion and review of resident-centered respiratory care plans for tracheostomy care. The Respiratory Care plan will be initiated by the Interdisciplinary Team (IDT) Team, in conjunction with Respiratory Therapy, consisting of, but not limited to, Administrator, DON, Unit Managers, Social Services, MDS Coordinator(s), Activities, and Dietary Manager. B) On or before [DATE], the Regional Quality Manager completed education to the Nurse Management Team (Director of Nursing, Education Training Director, RN, MDS Coordinator(s), and Unit Manager) on completing a tracheostomy patient admission questionnaire. The questionnaire consists of the name of the resident, resident specific tracheostomy orders, including care and suctioning, other services needed and who will provide any specialty services. On Saturday and Sunday, the clinical manager will initiate the respiratory care plan completing a tracheostomy patient admission questionnaire. The MDS Coordinator(s) will review the plan to ensure it is appropriate and implemented within forty-eight (48) hours. This education includes referencing the respiratory care plan for specific interventions regarding trach care, revision of care plans, if indicated, to include individualized care and services furnished related to their tracheostomy/respiratory needs and what, at a minimum, will be provided on the respiratory care plan. The care plan will include, but may not be limited to, tracheostomy care, suctioning, and specialized services. Education includes communication of the respiratory care plan to licensed nurses and Respiratory Therapist (RT)s and changes in interventions by the IDT (Admin, DON, Unit Managers, Social Services, MDS Coordinator, Activities, and Dietary Manager) if indicated. The Regional Quality Manager will educate the outside Vendor Respiratory Therapy by [DATE]. C) A post test will be given to the Director of Nursing by the Regional Quality Manager on [DATE], to ensure understanding of the tracheostomy care plans and expectations of care. The Director of Nursing will provide education to the Education Training Director, MDS Coordinators, Unit Manager, and Respiratory Therapist to ensure understanding of the material related to respiratory care plans. Education will be completed and post test passed prior to working by [DATE]. D) On or before [DATE], the Regional Reimbursement Nurse (RRN) provided an in-service for the Interdisciplinary Team (IDT) consisting of the Director of Nursing, Social Services, Assistant Dietary Manager, Activities Director, and Registered Nurse (RN) Education Training Director regarding person-centered care plan development related to ADLs for transferring and toileting. E) On or before [DATE], the Education Training Director will provide education to the nursing staff, to include SRNAs, regarding the comprehensive care plan, or baseline care plan, to include respiratory/tracheostomy care. Education was provided regarding the SRNA care plan to include ADL interventions for the level of assistance and/or supervision needed. This education will include the expectation that the nursing staff (Nurses and SRNAs) use the SRNA care plan to determine the ADL status and level of assistance or supervision required for their assignment. A post test will be given to the nurses and SRNAs on the education provided to ensure understanding of the material by [DATE]. After [DATE], licensed nurses and SRNAs will not be allowed to work without receiving the required education. This same education will be added to the new hire orientation packet for training during orientation. The facility does not use agency staff. 7. Beginning [DATE], direct observation audits will be conducted five (5) times weekly times four (4) weeks, of twenty (20) different residents each week to ensure that the comprehensive care plan, baseline care plan, and SRNA care plan is being followed while care is being provided. Observation audits will be completed by Nursing Administration (Director of Nursing, Education Training Director, RN Unit Manager, or MDS Coordinators) and will encompass observations of at least ten (10) SRNAs, on varying shifts a week. The auditor will address any discrepancy noted during the audit at that time and re-educate staff as needed. 8. On or before [DATE], the Education Training Director, Unit Manager, Director of Nursing, and the MDS Nurses completed education for all the nursing staff regarding comprehensive, baseline, and SRNA care plan. The education provided included following the care plan to provide adequate supervision and assistance to prevent accidents. It also included educating staff that each resident's ADL care plan is located in the kiosk and a printed version will be available in a book at the nurses' station. This same education will be added to the new hire orientation packets. After [DATE], licensed nurses and SRNAs will not be allowed to work without receiving the required education and passing a post test. The facility does not use agency staff. 9. The Nurse working the 7PM-7AM shift on [DATE] was in-serviced by the DON regarding performing tracheostomy care as per physician order per plan of care. The nurse was in-serviced on the responsibility of the nurse of the 7PM-7AM shift. The nurse was provided with verbal instruction, by the DON, regarding following physician orders related to medication administration and appropriate medication documentation. This verbal education was provided on [DATE] by the DON. 10. A) On or before [DATE], a one-time assessment was completed by the Education Training Director (RN), which consisted of a head to toe clinical assessment of four (4) in-house tracheostomy residents. Residents were in no distress and no issues were identified. B) On or before [DATE], a one-time audit was completed by the RN Unit Manager on all residents with tracheostomies to validate orders. Any discrepancies noted were immediately corrected by notifying the MD. On or before [DATE], the Director of Nursing reviewed the MARs, for dates of service from [DATE] to [DATE], consisting of two (2) in-house tracheostomy residents. The audits included verified documentation of tracheostomy care in the medical record. No issues were identified. Any readmission will have documentation reviewed within 24 hours of return. On or before [DATE], a one-time audit was completed by the Respiratory Therapist to ensure all tracheostomy residents with oxygen had valid orders. Any discrepancies noted were immediately corrected by notifying the MD by a licensed nurse. 11. A) On [DATE], the Contracted Respiratory Therapist (RT) completed education and skills competency for the Director of Nursing, Education Training Director, RN Unit Manager, and a Staff Respiratory Therapist to validate they were competent in tracheostomy care and the suctioning process. B) On or before [DATE], the Respiratory Vendor (RT) and/or Nursing Management team, consisting of the DON, Education Training Director, and/or UM, began education for the licensed nurses on following the physician orders regarding tracheostomy care/suctioning and on the respiratory policies provided by the respiratory therapy vendor regarding tracheostomy care and suctioning. This education will be completed by [DATE]. This education has been added to the new hire-licensed nurse orientation packet. Facility staff will be in-serviced by [DATE]. The facility does not use agency staff. C) On or before [DATE], the Nurse Management Team (Director of Nursing, Education Training Director, RN, and Unit Manager) will complete return demonstration competencies for each licensed nurse on tracheostomy care and suctioning. In addition, nursing administration (the Nurse Management Team (Director of Nursing, Education Training Director, RN, and Unit Manager)) will provide in-servicing regarding the facility Respiratory Therapist (RT) services availability for tracheostomy care and suctioning. The in-service also educated regarding nursing responsibility to provide tracheostomy care and suctioning if and/or when a RT is not available or on the schedule to provide such treatments. This education material will be added to the new hire-licensed nurse orientation packet. The facility does not use agency staff. No employees will work after [DATE] until educated and passing post test. 12. A) Beginning [DATE], the Nurse Management Team (Director of Nursing, Education Training Director, RN, and Unit Manager) MDS Nurses, or Contract Respiratory Therapy and/or facility Respiratory Therapist, will conduct audits of five (5) nurses and/or RTs each week, on varying shifts, using the tracheostomy competency validation tool. 13. On or before [DATE], the Nursing Management Team, consisting of the DON, Unit Manager(s), and licensed nurses from sister facilities, completed a one-time audit on all residents with insulin orders starting [DATE] to identify if any insulin was not given per physician orders and/or not signed timely. Any issues/concerns identified during the audit were discussed with the attending physician including a clinical assessment/observation to ensure there were no adverse reactions by the Director of Nursing and/or Nursing Management. It is the practice of the facility for insulin to be administered correctly, according to physician orders, and per the expected timeframe to prevent significant insulin medication errors. 14. On or before [DATE], the DON or Education Director will provide education to all licensed nurses regarding physician orders for administration/time parameters of medication, following physician orders for insulin administration and documenting doses administered at the time of administration. The education also included the notification of the physician if the administration fell outside the time parameters, incorrect dose given/omitted, and an assessment of the resident to ensure no adverse effects. A post education quiz for licensed nurses included education regarding the five (5) Rights of Medication administration, following physician's orders for medication administration, and insulin administration. Documentation will be completed by the nursing management team by each licensed nurse by [DATE]. Licensed nurses must pass the quiz with 100% score or be re-educated by nursing administration and retake the quiz with a 100% score before returning to work on their next shift. No licensed staff will be permitted to work until test is passed as of [DATE]. 15. Beginning [DATE], the Nursing Management Team (Director of Nursing, Education Training Director, RN, and Unit Manager) and MDS Coordinator(s) will complete audits, related to insulin administration, to include if any insulin was not given per physician orders and/or not signed timely. All residents with insulin orders will have Medication Administration documentation checked to ensure the insulin is documented given in accordance with physician orders and following professional standards of practice within time restrictions. The audit will be conducted five (5) days per week for four (4) weeks, then weekly times four (4) weeks, and then monthly. Any discrepancy identified during the audit, which consists of any insulin not given per physician orders and/or not signed timely, will be corrected immediately with MD and family notification and an assessment of the resident to ensure no adverse effects at the time the discrepancy is identified. 16. Beginning [DATE], the Nursing management team (DON, Education Training Director, Unit Manager, and MDS Nurses) will observe medication pass opportunities for 5 residents with insulin, to validate that licensed nurses are giving insulin per physician orders and within the timeframe. Any discrepancy identified will be corrected at the time of discrepancy by notifying the MD and Family by the Director of Nursing and/or Unit Manager. 17. On or before [DATE], the Specialized Medical Services (SMS) tracheostomy care and suctioning policy was adopted for use, by the facility, to ensure residents with a tracheostomy receive care per physician order and plan of care. The Director of Nursing developed an ancillary tracheostomy care and suctioning order for licensed nurses to utilize when admitting a resident to ensure that all appropriate physician orders are written for a resident who has a tracheostomy and/or requires oxygen. 18. On or before [DATE], the Regional Director of Operations educated facility management (DON and Administrator) on their responsibilities as it relates to using resources effectively and efficiently to attain or maintain the highest practicable physical well-being for residents in the facility. On or before [DATE], the Regional Director of Operations gave a post test to the Administrator and Director of Nursing on their job duties and what is required daily to ensure the facility is operating in a manner that prompts quality of life for the residents. 19. An ADHOC/Quality Assurance and Performance Improvement (QAPI) meeting was conducted on [DATE] to discuss the alleged deficient practices and corrective actions. The QAPI team met again on [DATE], with at least one Regional team member in attendance (either in person or by phone), and will continue weekly times four (4) weeks and then the facility will continue monthly thereafter. A QAPI meeting was held [DATE], for review of data from ongoing audits and staff education. This data will be reviewed weekly and continue times four (4) weeks and then monthly thereafter ongoing. Members of the facility's Quality Assurance Committee consist of the Administrator, Director of Nursing, Assistant Directors of Nursing, Dietary Manager, Business Office Manager, Activities Director, Director of Rehab, Maintenance Director, Social Services Manager, and Medical Director, who participates at least quarterly and as needed. The plan will be updated, as indicated, by the QAPI Committee. For all audits submitted to the QAPI Committee, the Administrator will assign follow-up as needed. ***The State Survey Agency determined the following removed Immediate Jeopardy on [DATE], as alleged by the facility: 1. Review of the medical records for Resident #117 revealed the resident was discharged from the facility on [DATE]. 2. A) Review of the Resident Council Meeting Minutes, dated [DATE], revealed fourteen (14) residents attended the meeting and education was provided on the grievance process. Interview with Resident #59 on [DATE] at 2:20 PM, revealed the facility staff met with the resident council and reviewed the grievance process, and forms were located throughout the facility for the residents. Review of medical records for Residents #171, #322, and #323 revealed documentation of a social services interview with residents or residents' representatives regarding the grievance process. B) Interview with the Social Services Director on [DATE] at 1:56 PM, revealed she was the Grievance Officer for the facility. She stated grievance forms have been placed in several locations in the facility with a locked grievance box located on the Peach Wing. She further stated she would initiate the grievance process and would assign the grievance to the appropriate department. She added the Administrator was to be informed immediately of all grievances. The Grievance Officer also stated the initial response to the grievance must be within seventy-two (72) hours. Review of the Allegation of Compliance binder revealed the grievance log was up to date and maintained by the Administrator. C) Observations of the Blue, Peach, and [NAME] Units on [DATE], revealed the Grievance Process Summary was posted with grievance forms available to staff and residents. D) Review of the facility's admission packet on [DATE], revealed presence of the Grievance Standards of Practice and Compliance forms. 3. Review of the facility's documentation on [DATE], revealed education on the grievance process was provided to the Director of Nursing (DON) and the Administrator on [DATE], per the sign-in sheet. The facility's documentation also revealed evidence that this education was provided to department heads on [DATE] and to all facility staff on or before [DATE] by the sign-in sheets. Interviews on [DATE], with State Registered Nurse Aide (SRNA) #15 at 1:00 PM, SRNA #16 at 3:44 PM, SRNA #2 at 1:13 PM, SRNA #4 at 1:30 PM, Licensed Practical Nurse (LPN) #7 at 1:25 PM, LPN #1 at 1:00 PM, LPN #3 at 1:15 PM, with Dietary Staff at 1:40 PM, Maintenance Staff at 1:51 PM, the Respiratory Director at 2:33 PM, and the MDS Coordinator at 1:50 PM revealed knowledge of the Grievance Standard of Practice and Compliance process. 4. A) Review of the facility's New Hire Orientation binder on [DATE], revealed presence of the Grievance Standard of Practice and Compliance policy. Review of the binder also revealed evidence of post tests administered to the staff. B) Review of the facility's documentation on 02/06//19, revealed results of the audit interviews, with stated population, related to the knowledge of the grievance process. C) Interview with the Administrator on [DATE] at 3:30 PM, revealed grievance logs and audits are reviewed daily with a Regional team member, who was still on sight. 5. A) Review of the facility's documentation on [DATE], revealed audits completed on 100% of tracheostomy residents' respiratory needs, to include care plans on or before [DATE]. The information also revealed a tracheostomy care plan was initiated on [DATE] on 100% of tracheostomy residents. B) Review of Resident #98's care plan on [DATE], revealed the care plan was updated with tracheostomy and activities of daily living (ADL) assistance on [DATE], upon re-entry from a hospital admission. C) Review of the facility's documentation on [DATE], revealed all facility residents had a review of their ADL assistance needs and were revised as indicated on [DATE]. 6. A) Review of

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, it was determined the facility failed to ensure that three (3) of four (4) residents who required tracheostomy care and tracheal suctioning were provided such care, in accordance with physician's orders. Resident #117 had a tracheostomy (an opening in the neck to the windpipe) and had physician's orders for tracheostomy (trach) care every shift and suctioning as needed. On [DATE], the facility transferred Resident #117 to the hospital due to a low oxygen saturation and the resident returned to the facility on [DATE] at 4:23 AM, with a diagnosis of Respiratory secretion[s] in [the] tracheostomy tube. The resident's family member reported to the facility that the hospital physician stated staff were not suctioning the resident adequately. However, during the night of 01/09-10/19, the facility failed to ensure tracheostomy care/suctioning was provided for the resident. At 6:40 AM on [DATE], staff found the resident on the floor, unresponsive, and not breathing. The facility initiated Cardiopulmonary Resuscitation (CPR) and transferred the resident to the hospital where the resident was pronounced dead at 7:32 AM on [DATE], as a result of Cardiopulmonary Arrest due to Upper Airway Obstruction. The facility also failed to provide tracheostomy care for Resident #21 and Resident #98 during the night shift of [DATE] at 7:00 PM until [DATE] at 7:00 AM. The facility's failure to ensure tracheostomy care and tracheal suctioning was provided to residents 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 (F585), 42 CFR 483.21 Comprehensive Person-Centered Care Plans (F656), 42 CFR 483.25 Quality of Care (F689 and F695), 42 CFR 483.45 Pharmacy Services (F760), and 42 CFR 483.70 Administration (F835). The facility was notified of the Immediate Jeopardy on [DATE]. 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 on [DATE], which lowered the scope and severity to D level at 42 CFR 483.10 Resident Rights (F585), 42 CFR 483.21 Comprehensive Person-Centered Care Plans (F656), 42 CFR 483.25 Quality of Care (F689 and F695), 42 CFR 483.45 Pharmacy Services (F760), and 42 CFR 483.70 Administration (F835), while the facility monitors the effectiveness of systemic changes and quality assurance activities. The findings include: Interview with the facility's Administrator on [DATE] at 12:00 PM, the Respiratory Therapy Director on [DATE] at 9:30 AM, and the Director of Nursing (DON) on [DATE] at 9:12 AM revealed the facility did not have policies regarding respiratory care, tracheostomy care, suctioning, or oxygen. 1. Review of Resident #117's closed medical record revealed that the facility admitted the resident on [DATE] with diagnoses that included Cerebral Infarction (Stroke), Chronic Obstructive Pulmonary Disease, Chronic Kidney Disease, Tracheostomy status, Gastrostomy status (feeding tube), Dysphagia (trouble swallowing), Hypertension, Heart Failure, Atrial Fibrillation, Anxiety Disorder, and Type II Diabetes. Review of Resident #117's admission Minimum Data Set (MDS) assessment dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) score of five (5), which indicated the resident was severely cognitively impaired. Further review of the MDS revealed the resident required oxygen therapy, suctioning, and tracheostomy care. Review of Resident #117's Physician's Orders for [DATE] revealed orders to suction the resident as needed and to provide tracheostomy care every shift. The care included changing the inner cannula, cleaning around the stoma with sterile saline and Hydrogen Peroxide followed by cleaning with sterile saline, and then applying a dry dressing (Tracheostomy care also includes suctioning the resident's tracheostomy to clear any secretions. Excess secretions are due to the reduced ability to swallow and cough.). Review of Resident #117's [DATE] Respiratory Medication Administration Record (MAR) revealed tracheostomy care was required daily at 7:00 AM and 7:00 PM, and suctioning was required as needed. Review of Resident #117's Nursing Notes revealed on [DATE] at 10:45 PM, the resident was transferred to the hospital. The Note stated the resident was very short of air, with an oxygen saturation of 83 percent (%) (normal is 95-100%) while receiving oxygen via the tracheostomy. The Nursing Note also stated rales and rhonchi (crackling and rattling) were heard in the resident's lungs. According to the Nursing Note, staff suctioned thick, yellow sputum from the resident's tracheostomy and changed the inner cannula. Further review revealed the Note stated the resident's oxygen saturation improved to 87%, but decreased to 83% within five (5) minutes. According to the Note, the resident returned to the facility on [DATE] at 4:23 AM, and was diagnosed with Respiratory secretion in tracheostomy tube at the hospital Emergency Department (ED). Interview with Resident #117's family member on [DATE] at 2:35 PM revealed he accompanied the resident to the hospital on [DATE]. The family member stated the hospital physician told him that staff at the facility were not suctioning Resident #117 adequately. Further interview with the family member revealed after hospital staff suctioned the resident's tracheostomy, the resident got better and was able to rest. The family member stated he reported what the hospital physician told him about inadequate suctioning to the facility's administrative staff (the Director of Nursing and Administrator) on [DATE]. Interview on [DATE] at 9:30 AM with the Respiratory Therapy Director revealed she cared for Resident #117 on [DATE] from 7:00 AM until 7:00 PM. The Director stated she provided tracheostomy care and suctioned Resident #117 at 9:00 AM and suctioned the resident's tracheostomy again at approximately 3:00-4:00 PM that evening. The Director stated she did not provide tracheostomy care or suctioning at 7:00 PM. She stated Nursing was responsible for providing respiratory care at 7:00 PM. However, further review of Resident #117's Respiratory MAR for [DATE] revealed no documented evidence that staff provided tracheostomy care or suctioning at 7:00 PM as ordered by the resident's physician. Review of the resident's Nursing Note revealed at 6:40 AM on [DATE], staff found the resident face down on the floor, not breathing. Interview with RN #3, the Unit Manager, on [DATE] at 12:50 PM revealed she was responsible for Resident #117's care from [DATE] at 7:00 PM until [DATE] at 7:00 AM. She stated she did not provide tracheostomy care or suction any resident's tracheostomy that night because she assumed that respiratory therapy staff provided the care. The Unit Manager stated she was aware that the Respiratory Therapist's shift ended at 7:00 PM. RN #3 stated they (Respiratory Therapy) were there late some days and she was not aware that nurses who worked the night shift were required to provide tracheostomy care/suctioning. The Unit Manager stated she was in Resident #117's room at approximately 11:00 PM on [DATE], and the resident had motioned to his/her mouth, indicating he/she needed to be suctioned. According to the Unit Manager, she did not suction the resident's tracheostomy, but suctioned the resident's oral cavity. The Unit Manager stated she was in Resident #117's room again at approximately 2:00 AM to 3:00 AM to provide tube feeding/administer insulin and the resident was in no distress. Further interview revealed when she entered the resident's room at approximately 6:40 AM, the resident was found face down on the floor, unresponsive, and not breathing. She stated Cardiopulmonary Resuscitation (CPR) was initiated and an ambulance arrived approximately fifteen (15) minutes later. The resident was transferred to the hospital where he/she was pronounced dead. Interview on [DATE] at 6:20 AM, with State Registered Nursing Aide (SRNA) #11 revealed on [DATE] at approximately 6:00 AM, the Unit Manager came to her and asked for help with Resident #117. SRNA #11 stated the resident was face down and his/her lips were blue. The SRNA stated two (2) nurses started CPR and she called the ambulance. Review of Resident #117's Emergency Medical Services (EMS) record dated [DATE] revealed EMS arrived at the facility at 7:06 AM. The primary impression was unresponsive, vital signs were recorded as UTO (unable to obtain), and the resident's EKG (Electrocardiography) showed PEA (Pulseless Electrical Activity, the EKG showed some heart activity, but the resident had no pulse). Review of Resident #117's hospital record revealed when the resident arrived at the ED, hospital staff suctioned a large amount of bloody sputum from the resident's tracheostomy. Resident #117 was pronounced dead at 7:32 AM on [DATE], as a result of Cardiopulmonary Arrest. Review of Resident #117's Death Certificate revealed the cause of death was Cardiopulmonary Arrest due to upper airway obstruction. Interview with Physician #1 on [DATE] at 8:00 PM revealed Resident #117 was too far gone when the resident arrived at the Emergency Department. Physician #1 stated the resident's family also voiced concerns about the care the resident was receiving at the nursing facility and he did not think the resident had been suctioned adequately either. According to Physician #1, the cause of the resident's death was an upper airway obstruction, and not being suctioned would be a contributing factor. 2. Observation of Resident #21 on [DATE] at 10:15 AM revealed the resident had a tracheostomy and was receiving oxygen via the tracheostomy. Further observation revealed Registered Nurse (RN) #9 suctioned clear secretions from the resident's tracheostomy. Review of Resident #21's medical record revealed the facility admitted the resident on [DATE] with diagnoses that included Traumatic Brain Injury, Acute Respiratory Failure with Hypoxia, Tracheostomy, and Feeding Tube. Review of Resident # 21's Minimum Data Set (MDS) dated [DATE], revealed the resident was unable to complete the Brief Interview for Mental Status (BIMS). According to the MDS, the resident was in a persistent vegetative state with no discernible consciousness. Further review of the MDS revealed the resident required respiratory treatments that included tracheostomy care, suctioning, and oxygen. Review of Resident #21's Physician's Orders dated [DATE] revealed orders to provide tracheostomy care every shift that included changing the inner cannula; cleaning around the stoma with sterile saline and hydrogen peroxide, then with sterile saline; and applying a dressing. Further review of the Physician's Orders revealed Resident #21 required suctioning of the tracheostomy as needed. Interview with RN #9 on [DATE] at 7:10 PM revealed Resident #21 had a lot of secretions and usually required suctioning three to four times during the night shift. However, interview with the Unit Manager on [DATE] at 11:10 AM revealed she was assigned to provide care for Resident #21 on [DATE] at 7:00 PM until [DATE] at 7:00 AM. Further interview with the Unit Manager revealed she did not suction the resident or provide any type of tracheostomy care during that time. She stated she was not aware nursing staff was required to provide tracheostomy care or suctioning. 3. Review of Resident #98's medical record revealed the facility admitted the resident on [DATE] with diagnoses that included Hemiplegia following Cerebral Infarction (Stroke), Tracheostomy, Acute Respiratory Failure, Gastrostomy, Dysphagia, Muscle Weakness, Neuromuscular Dysfunction of the Bladder, Chronic Kidney Disease, and Heart Failure. Review of Resident #98's Minimum Data Set (MDS) dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) score of ten (10), which indicated moderately impaired cognition. Further review of the MDS revealed the resident required respiratory treatments that included tracheostomy care, suctioning, and oxygen. Review of Resident #98's Physician's Orders dated [DATE] revealed orders to provide tracheostomy care every shift, which included changing the inner cannula; cleaning around the stoma with sterile saline and hydrogen peroxide, then with sterile saline; and applying a dressing. Further review of the Physician's Orders revealed Resident #98 required suctioning of the tracheostomy as needed. Interview with the Unit Manager on [DATE] at 11:10 AM revealed she was assigned to provide care for Resident #98 on [DATE] at 7:00 PM until [DATE] at 7:00 AM. She stated she was not aware nursing staff was required to provide tracheostomy care or suctioning and she did not suction the resident or provide tracheostomy care. Interview on [DATE] at 10:30 AM with the DON revealed Respiratory Therapists were only in the building from 7:00 AM until 7:00 PM daily, and nursing staff were responsible for residents' respiratory care from 7:00 PM until 7:00 AM each day. The DON stated that the Unit Supervisor should have been aware that nursing staff was responsible for providing respiratory care during the night shift. **The facility alleged the following actions removed the Immediate Jeopardy on [DATE]: 1. Resident #117 was transported to the hospital on [DATE] and no longer resides in the facility. 2. A) On [DATE], the Activities Director conducted a resident council meeting to review with the residents the Grievance Process and guidelines. By [DATE] the Activities Director, Social Services Director, or facility Administrator will provide education on the Grievance Standard of Practice and Compliance guideline for those resident(s) with a Brief Interview for Mental Status (BIMS) score of nine (9) or higher, who did not attend the resident council meeting. By [DATE] the Social Services Director (Grievance Officer) or Social Services Assistant will interview current in-house residents with a BIMS of nine (9) or higher to identify if there are any current grievances. By [DATE] the Social Services Director (Grievance Officer) or Social Services Assistant will contact the respective responsible party or guardian, for those residents with a BIMS of eight (8) or less, to identify if they have any concerns and address the concern(s) following the Grievance Standard of Practice and Compliance guideline. Any concerns/grievance(s) voiced will be addressed following the Grievance Standard of Practice and Compliance guideline. B) Grievances identified Monday through Friday will be addressed by the Social Services Director, who is the Grievance Official, and/or the Social Services staff. All grievances will be addressed per the Grievance Standard of Practice and Compliance Guidelines and submitted to the Administrator for review. The Administrator will log the grievance for review and recommendations in Quality Assurance/Performance Improvement (QAPI). The Social Services Director will send a letter to the resident's representative and/or resident with resolution per guidelines. C) By [DATE], the Administrator will post a copy of the Grievance Process summary along with the facility's administration contacts throughout the facility. Copies of blank grievance forms will accompany the posting. D) By [DATE], the Admissions Director will add a copy of the Grievance Standards of Practice and Compliance in the admission packets to provide information to any new residents/families. 3. On [DATE], the Regional Quality Manager (RQM) provided education to the Director of Nursing (DON) and the Administrator regarding the facility's Grievance Standards of Practice and Compliance Guidelines, which included, but was not limited to, ensuring investigation and resolution of a grievance per regulation. Beginning [DATE], the facility's Administrator educated the Education Training Director (ETD) regarding the facility's Grievance Process. Education was provided to the Department Heads (Business Office Manager, Social Services, DON, Activities Director, MDS, Unit Manager, Dietary Manager, Housekeeping Supervisor, Maintenance, Marketing, and Payroll) on the Grievance Process by the Administrator on [DATE]. 4. A) On or before [DATE], education was provided by the Administrator and Education Training Director on Grievance Standards of Practice and Compliance Guidelines to all facility staff. A post test accompanied the education to validate understanding of the materials. Newly hired staff will receive education during orientation regarding Grievance Standards of Practice and Compliance Guidelines, including a post test. Any employee who has not received the education and passed the post test will not be allowed to return to work after [DATE]. The facility does not use agency staff. B) Beginning [DATE], the Administrator, DON, Unit Manager (UM), or Grievance Officer will interview three (3) residents with a BIMS score of nine (9) or greater, three (3) random employees, and three (3) representatives of residents with a BIMS score of eight (8) or less weekly for four (4) weeks to ensure staff and residents understand the grievance process. Results of the audits will be reported to the Quality Assurance Committee for its review and recommendations. The Administrator will assign follow-up as needed. C) Beginning [DATE], the facility's Administrator will submit the grievance log, with completed concern/grievance investigation, and follow up daily with a member of the Regional Team for review. Any discrepancy noted during the review will be immediately addressed with the Administrator by the Regional Team Member. 5. A) On or before [DATE], the Nurse Management team, consisting of the Director of Nursing, RN Education Training Director, Unit Manager, MDS Coordinator(s), and/or Respiratory Therapist, completed a one hundred (100) percent (%) audit of respiratory care needs for each in-house resident having a tracheostomy, which included a review of their care plans. On or before [DATE], the respiratory care plans will be revised by the DON, if indicated, to include individualized care and services to be furnished related to their tracheostomy/respiratory needs. This will include, but not be limited to, tracheostomy care, suctioning, and specialized services related to respiratory care for their tracheostomy and in line with the resident's goals and desired outcomes. B) Any new admissions, or readmissions, with tracheostomy needs for care and services, will be reviewed by the Nursing Administrative Team, Respiratory Therapist, and/or MDS Coordinator(s) within twenty-four (24) hours. This review will include individualized care approaches and services to be implemented related to their ongoing tracheostomy/respiratory needs. This will include, but not be limited to, tracheostomy care, suctioning, and specialized services related to respiratory care and in line with the resident's goals and desired outcomes. C) On or before [DATE], each resident will have their ADL (Activities of Daily Living) status reviewed for the level of assistance required, including toileting. The ADL comprehensive baseline and State Registered Nurse Aide (SRNA) care plan were audited to ensure ADL interventions described the appropriate level of assistance and/or supervision needed. This will be completed by the Nurse Management Team (Director of Nursing, Education Training Director, RN, and Unit Manager), MDS Coordinator(s), and nursing staff (nurses and SRNAs) and, if applicable, the resident by [DATE]. These will be resident-centered to reflect the amount of assistance and or supervision necessary to complete ADL tasks to attain or maintain his/her highest practicable physical, mental, and psychosocial well-being. 6. A) On or before [DATE], the Regional Quality Manager completed education for the Nurse Management Team (Director of Nursing, Education Training Director, RN, MDS Coordinator(s), and Unit Manager) regarding completion and review of resident-centered respiratory care plans for tracheostomy care. The Respiratory Care plan will be initiated by the Interdisciplinary Team (IDT) Team, in conjunction with Respiratory Therapy, consisting of, but not limited to, Administrator, DON, Unit Managers, Social Services, MDS Coordinator(s), Activities, and Dietary Manager. B) On or before [DATE], the Regional Quality Manager completed education to the Nurse Management Team (Director of Nursing, Education Training Director, RN, MDS Coordinator(s), and Unit Manager) on completing a tracheostomy patient admission questionnaire. The questionnaire consists of the name of the resident, resident specific tracheostomy orders, including care and suctioning, other services needed and who will provide any specialty services. On Saturday and Sunday, the clinical manager will initiate the respiratory care plan completing a tracheostomy patient admission questionnaire. The MDS Coordinator(s) will review the plan to ensure it is appropriate and implemented within forty-eight (48) hours. This education includes referencing the respiratory care plan for specific interventions regarding trach care, revision of care plans, if indicated, to include individualized care and services furnished related to their tracheostomy/respiratory needs and what, at a minimum, will be provided on the respiratory care plan. The care plan will include, but may not be limited to, tracheostomy care, suctioning, and specialized services. Education includes communication of the respiratory care plan to licensed nurses and Respiratory Therapist (RT)s and changes in interventions by the IDT (Admin, DON, Unit Managers, Social Services, MDS Coordinator, Activities, and Dietary Manager) if indicated. The Regional Quality Manager will educate the outside Vendor Respiratory Therapy by [DATE]. C) A post test will be given to the Director of Nursing by the Regional Quality Manager on [DATE], to ensure understanding of the tracheostomy care plans and expectations of care. The Director of Nursing will provide education to the Education Training Director, MDS Coordinators, Unit Manager, and Respiratory Therapist to ensure understanding of the material related to respiratory care plans. Education will be completed and post test passed prior to working by [DATE]. D) On or before [DATE], the Regional Reimbursement Nurse (RRN) provided an in-service for the Interdisciplinary Team (IDT) consisting of the Director of Nursing, Social Services, Assistant Dietary Manager, Activities Director, and Registered Nurse (RN) Education Training Director regarding person-centered care plan development related to ADLs for transferring and toileting. E) On or before [DATE], the Education Training Director will provide education to the nursing staff, to include SRNAs, regarding the comprehensive care plan, or baseline care plan, to include respiratory/tracheostomy care. Education was provided regarding the SRNA care plan to include ADL interventions for the level of assistance and/or supervision needed. This education will include the expectation that the nursing staff (Nurses and SRNAs) use the SRNA care plan to determine the ADL status and level of assistance or supervision required for their assignment. A post test will be given to the nurses and SRNAs on the education provided to ensure understanding of the material by [DATE]. After [DATE], licensed nurses and SRNAs will not be allowed to work without receiving the required education. This same education will be added to the new hire orientation packet for training during orientation. The facility does not use agency staff. 7. Beginning [DATE], direct observation audits will be conducted five (5) times weekly times four (4) weeks, of twenty (20) different residents each week to ensure that the comprehensive care plan, baseline care plan, and SRNA care plan is being followed while care is being provided. Observation audits will be completed by Nursing Administration (Director of Nursing, Education Training Director, RN Unit Manager, or MDS Coordinators) and will encompass observations of at least ten (10) SRNAs, on varying shifts a week. The auditor will address any discrepancy noted during the audit at that time and re-educate staff as needed. 8. On or before [DATE], the Education Training Director, Unit Manager, Director of Nursing, and the MDS Nurses completed education for all the nursing staff regarding comprehensive, baseline, and SRNA care plan. The education provided included following the care plan to provide adequate supervision and assistance to prevent accidents. It also included educating staff that each resident's ADL care plan is located in the kiosk and a printed version will be available in a book at the nurses' station. This same education will be added to the new hire orientation packets. After [DATE], licensed nurses and SRNAs will not be allowed to work without receiving the required education and passing a post test. The facility does not use agency staff. 9. The Nurse working the 7PM-7AM shift on [DATE] was in-serviced by the DON regarding performing tracheostomy care as per physician order per plan of care. The nurse was in-serviced on the responsibility of the nurse of the 7PM-7AM shift. The nurse was provided with verbal instruction, by the DON, regarding following physician orders related to medication administration and appropriate medication documentation. This verbal education was provided on [DATE] by the DON. 10. A) On or before [DATE], a one-time assessment was completed by the Education Training Director (RN), which consisted of a head to toe clinical assessment of four (4) in-house tracheostomy residents. Residents were in no distress and no issues were identified. B) On or before [DATE], a one-time audit was completed by the RN Unit Manager on all residents with tracheostomies to validate orders. Any discrepancies noted were immediately corrected by notifying the MD. On or before [DATE], the Director of Nursing reviewed the MARs, for dates of service from [DATE] to [DATE], consisting of two (2) in-house tracheostomy residents. The audits included verified documentation of tracheostomy care in the medical record. No issues were identified. Any readmission will have documentation reviewed within 24 hours of return. On or before [DATE], a one-time audit was completed by the Respiratory Therapist to ensure all tracheostomy residents with oxygen had valid orders. Any discrepancies noted were immediately corrected by notifying the MD by a licensed nurse. 11. A) On [DATE], the Contracted Respiratory Therapist (RT) completed education and skills competency for the Director of Nursing, Education Training Director, RN Unit Manager, and a Staff Respiratory Therapist to validate they were competent in tracheostomy care and the suctioning process. B) On or before [DATE], the Respiratory Vendor (RT) and/or Nursing Management team, consisting of the DON, Education Training Director, and/or UM, began education for the licensed nurses on following the physician orders regarding tracheostomy care/suctioning and on the respiratory policies provided by the respiratory therapy vendor regarding tracheostomy care and suctioning. This education will be completed by [DATE]. This education has been added to the new hire-licensed nurse orientation packet. Facility staff will be in-serviced by [DATE]. The facility does not use agency staff. C) On or before [DATE], the Nurse Management Team (Director of Nursing, Education Training Director, RN, and Unit Manager) will complete return demonstration competencies for each licensed nurse on tracheostomy care and suctioning. In addition, nursing administration (the Nurse Management Team (Director of Nursing, Education Training Director, RN, and Unit Manager)) will provide in-servicing regarding the facility Respiratory Therapist (RT) services availability for tracheostomy care and suctioning. The in-service also educated regarding nursing responsibility to provide tracheostomy care and suctioning if and/or when a RT is not available or on the schedule to provide such treatments. This education material will be added to the new hire-licensed nurse orientation packet. The facility does not use agency staff. No employees will work after [DATE] until educated and passing post test. 12. A) Beginning [DATE], the Nurse Management Team (Director of Nursing, Education Training Director, RN, and Unit Manager) MDS Nurses, or Contract Respiratory Therapy and/or facility Respiratory Therapist, will conduct audits of five (5) nurses and/or RTs each week, on varying shifts, using the tracheostomy competency validation tool. 13. On or before [DATE], the Nursing Management Team, consisting of the DON, Unit Manager(s), and licensed nurses from sister facilities, completed a one-time audit on all residents with insulin orders starting [DATE] to identify if any insulin was not given per physician orders and/or not signed timely. Any issues/concerns identified during the audit were discussed with the attending physician including a clinical assessment/observation to ensure there were no adverse reactions by the Director of Nursing and/or Nursing Management. It is the practice of the facility for insulin to be administered correctly, according to physician orders, and per the expected timeframe to prevent significant insulin medication errors. 14. On or before [DATE], the DON or Education Director will provide education to all licensed nurses regarding physician orders for administration/time parameters of medication, following physician orders for insulin administration and documenting doses administered at the time of administration. The education also included the notification of the physician if the administration fell outside the time parameters, incorrect dose given/omitted, and an assessment of the resident to ensure no adverse effects. A post education quiz for licensed nurses included education regarding the five (5) Rights of Medication administration, following physician's orders for medication administration, and insulin administration. Documentation will be completed by the nursing management team by each licensed nurse by [DATE]. Licensed nurses must pass the quiz with 100% score or be re-educated by nursing administration and retake the quiz with a 100% score before returning to work on their next shift. No licensed staff will be permitted to work until test is passed as of [DATE]. 15. Beginning [DATE], the Nursing Management Team (Director of Nursing, Education Training Director, RN, and Unit Manager) and MDS Coordinator(s) will complete audits, related to insulin administration, to include if any insulin was not given per physician orders and/or not signed timely. All residents with insulin orders will have Medication Administration documentation checked to ensure the insulin is documented given in accordance with physician orders and following professional standards of practice within time restrictions. The audit will be conducted five (5) days per week for four (4) weeks, then weekly times four (4) weeks, and then monthly. Any discrepancy identified during the audit, which consists of any insulin not given per physician orders and/or not signed timely, will be corrected immediately with MD and family notification and an assessment of the resident to ensure no adverse effects at the time the discrepancy is identified. 16. Beginning [DATE], the Nursing management team (DON, Education Training Director, Unit Manager, and MDS Nurses) will observe medication pass opportunities for 5 residents with insulin, to validate that licensed nurses are giving insulin per physician orders and within the timeframe. Any discrepancy identified will be corrected[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and review of the facility's medication administration policy, it was determined the facility failed to ensure that one (1) of forty-seven (47) sampled residents (Resident #117) was free of significant medication errors. Resident #117 had a Physician's order for Humulin R insulin (regular, fast acting insulin that starts lowering your blood sugar within 30 minutes of being injected) to be administered every six (6) hours, but to hold the insulin for blood sugar results below 140 mg/dl (milligrams per deciliter). According to the resident's medication record, Humulin R insulin was due at 12:00 AM on [DATE]; however, interview with staff revealed the medication was not administered until 2:00 AM. Further review of the resident's medication record revealed staff administered another dose of Humulin R insulin four (4) hours later at 6:00 AM on [DATE], when the resident's blood sugar was 111 mg/dl, even though the resident had a Physician's Order to hold the medication if the resident's blood sugar was below 140 mg/dl. Resident #117 was found on the floor on [DATE], at 6:40 AM, unresponsive and not breathing. The resident was transferred to the hospital where he/she was pronounced dead at 7:32 AM on [DATE]. The facility's failure to ensure residents were free of significant medication errors 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 (F585), 42 CFR 483.21 Comprehensive Person-Centered Care Plans (F656), 42 CFR 483.25 Quality of Care (F689 and F695), 42 CFR 483.45 Pharmacy Services (F760), and 42 CFR 483.70 Administration (F835). The facility was notified of the Immediate Jeopardy on [DATE]. 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 on [DATE], which lowered the scope and severity to D level at 42 CFR 483.10 Resident Rights (F585), 42 CFR 483.21 Comprehensive Person-Centered Care Plans (F656), 42 CFR 483.25 Quality of Care (F689 and F695), 42 CFR 483.45 Pharmacy Services (F760), and 42 CFR 483.70 Administration (F835), while the facility monitors the effectiveness of systemic changes and quality assurance activities. The findings include: Review of the facility's policy titled Medication Administration General Guidelines, dated [DATE], revealed medications were required to be administered within 60 minutes of the scheduled time. Further review of the policy revealed medications were required to be administered in accordance with the written orders of the prescriber. Review of Resident #117's closed medical record revealed the facility admitted the resident on [DATE] with diagnoses that included Cerebral Infarction (Stroke), Chronic Obstructive Pulmonary Disease, Chronic Kidney Disease, Tracheostomy status, Gastrostomy status (feeding tube), Dysphagia (trouble swallowing), Hypertension, Heart Failure, Atrial Fibrillation, Anxiety Disorder, and Type II Diabetes. Review of Resident #117's Annual Minimum Data Set (MDS) assessment dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) score of five (5), which indicated the resident was severely cognitively impaired. Review of Resident #117's Physician's Orders dated [DATE] revealed an order for fifteen (15) units of Lantus insulin (100 units per milliliter) every night. In addition, the resident had Physician's Orders for Humulin R insulin eight (8) units (100 units per milliliter) every six (6) hours, with an additional amount of Humulin R ordered per sliding scale (amount of insulin to be administered is based on the blood sugar result). Further review of Resident #117's Physician's Orders revealed an order to hold the resident's insulin if the resident's blood sugar was less than 140 mg/dl. Review of Resident #117's Nurse Medication Administration Record (MAR) revealed the resident's Humulin R insulin was due at 12:00 AM and 6:00 AM. The MAR revealed on [DATE] at 12:00 AM, the resident's blood sugar was 222 mg/dl and staff documented that Humulin R insulin was administered in the resident's abdomen in the right lower quadrant (RLQ). Further review revealed on [DATE] at 6:00 AM, staff documented Resident #117's blood sugar was 111 mg/dl. Staff documented Humulin R insulin was administered in the left lower quadrant (LLQ) of the resident's abdomen, even though the Physician's Order was to hold the resident's insulin for a blood sugar less than 140 mg/dl. Interview on [DATE] at 2:04 PM with Registered Nurse (RN) #3, who was also the Unit Manager, revealed she provided care for Resident #117 on [DATE] at 7:00 PM until 7:00 AM on [DATE], to cover for another nurse. RN #3 stated she recalled administering Lantus insulin to Resident #117 at 9:00 PM on [DATE]. RN #3 further stated she did not administer the resident's Humulin R insulin that was due at 12:00 AM, until 2:00 AM, two (2) hours late, because she was busy. According to the RN, she did not remember administering insulin to Resident #117 at 6:00 AM on [DATE]; however, the nurse documented that the medication was administered. Review of Resident #117's Nursing Notes revealed on [DATE] at 6:40 AM, forty (40) minutes after the second dose of insulin was administered, RN #3 found the resident lying face down on the floor beside a bedside commode. The Note stated the resident had a faint pulse, but was not breathing and the resident's fingers were blue. According to the Nursing Note, staff initiated Cardiopulmonary Resuscitation (CPR) until paramedics arrived and transferred the resident to the hospital. Review of Resident #117's hospital medical record revealed the resident presented to the Emergency Department on [DATE] at 7:25 AM, and was pronounced dead at 7:32 AM. There was no documented evidence that the hospital tested the resident's blood sugar or any other laboratory testing. Interview with Physician #1 on [DATE] at 8:00 PM revealed Resident #117 was too far gone when the resident arrived at the Emergency Department. **The facility alleged the following actions removed the Immediate Jeopardy on [DATE]: 1. Resident #117 was transported to the hospital on [DATE] and no longer resides in the facility. 2. A) On [DATE], the Activities Director conducted a resident council meeting to review with the residents the Grievance Process and guidelines. By [DATE] the Activities Director, Social Services Director, or facility Administrator will provide education on the Grievance Standard of Practice and Compliance guideline for those resident(s) with a Brief Interview for Mental Status (BIMS) score of nine (9) or higher, who did not attend the resident council meeting. By [DATE] the Social Services Director (Grievance Officer) or Social Services Assistant will interview current in-house residents with a BIMS of nine (9) or higher to identify if there are any current grievances. By [DATE] the Social Services Director (Grievance Officer) or Social Services Assistant will contact the respective responsible party or guardian, for those residents with a BIMS of eight (8) or less, to identify if they have any concerns and address the concern(s) following the Grievance Standard of Practice and Compliance guideline. Any concerns/grievance(s) voiced will be addressed following the Grievance Standard of Practice and Compliance guideline. B) Grievances identified Monday through Friday will be addressed by the Social Services Director, who is the Grievance Official, and/or the Social Services staff. All grievances will be addressed per the Grievance Standard of Practice and Compliance Guidelines and submitted to the Administrator for review. The Administrator will log the grievance for review and recommendations in Quality Assurance/Performance Improvement (QAPI). The Social Services Director will send a letter to the resident's representative and/or resident with resolution per guidelines. C) By [DATE], the Administrator will post a copy of the Grievance Process summary along with the facility's administration contacts throughout the facility. Copies of blank grievance forms will accompany the posting. D) By [DATE], the Admissions Director will add a copy of the Grievance Standards of Practice and Compliance in the admission packets to provide information to any new residents/families. 3. On [DATE], the Regional Quality Manager (RQM) provided education to the Director of Nursing (DON) and the Administrator regarding the facility's Grievance Standards of Practice and Compliance Guidelines, which included, but was not limited to, ensuring investigation and resolution of a grievance per regulation. Beginning [DATE], the facility's Administrator educated the Education Training Director (ETD) regarding the facility's Grievance Process. Education was provided to the Department Heads (Business Office Manager, Social Services, DON, Activities Director, MDS, Unit Manager, Dietary Manager, Housekeeping Supervisor, Maintenance, Marketing, and Payroll) on the Grievance Process by the Administrator on [DATE]. 4. A) On or before [DATE], education was provided by the Administrator and Education Training Director on Grievance Standards of Practice and Compliance Guidelines to all facility staff. A post test accompanied the education to validate understanding of the materials. Newly hired staff will receive education during orientation regarding Grievance Standards of Practice and Compliance Guidelines, including a post test. Any employee who has not received the education and passed the post test will not be allowed to return to work after [DATE]. The facility does not use agency staff. B) Beginning [DATE], the Administrator, DON, Unit Manager (UM), or Grievance Officer will interview three (3) residents with a BIMS score of nine (9) or greater, three (3) random employees, and three (3) representatives of residents with a BIMS score of eight (8) or less weekly for four (4) weeks to ensure staff and residents understand the grievance process. Results of the audits will be reported to the Quality Assurance Committee for its review and recommendations. The Administrator will assign follow-up as needed. C) Beginning [DATE], the facility's Administrator will submit the grievance log, with completed concern/grievance investigation, and follow up daily with a member of the Regional Team for review. Any discrepancy noted during the review will be immediately addressed with the Administrator by the Regional Team Member. 5. A) On or before [DATE], the Nurse Management team, consisting of the Director of Nursing, RN Education Training Director, Unit Manager, MDS Coordinator(s), and/or Respiratory Therapist, completed a one hundred (100) percent (%) audit of respiratory care needs for each in-house resident having a tracheostomy, which included a review of their care plans. On or before [DATE], the respiratory care plans will be revised by the DON, if indicated, to include individualized care and services to be furnished related to their tracheostomy/respiratory needs. This will include, but not be limited to, tracheostomy care, suctioning, and specialized services related to respiratory care for their tracheostomy and in line with the resident's goals and desired outcomes. B) Any new admissions, or readmissions, with tracheostomy needs for care and services, will be reviewed by the Nursing Administrative Team, Respiratory Therapist, and/or MDS Coordinator(s) within twenty-four (24) hours. This review will include individualized care approaches and services to be implemented related to their ongoing tracheostomy/respiratory needs. This will include, but not be limited to, tracheostomy care, suctioning, and specialized services related to respiratory care and in line with the resident's goals and desired outcomes. C) On or before [DATE], each resident will have their ADL (Activities of Daily Living) status reviewed for the level of assistance required, including toileting. The ADL comprehensive baseline and State Registered Nurse Aide (SRNA) care plan were audited to ensure ADL interventions described the appropriate level of assistance and/or supervision needed. This will be completed by the Nurse Management Team (Director of Nursing, Education Training Director, RN, and Unit Manager), MDS Coordinator(s), and nursing staff (nurses and SRNAs) and, if applicable, the resident by [DATE]. These will be resident-centered to reflect the amount of assistance and or supervision necessary to complete ADL tasks to attain or maintain his/her highest practicable physical, mental, and psychosocial well-being. 6. A) On or before [DATE], the Regional Quality Manager completed education for the Nurse Management Team (Director of Nursing, Education Training Director, RN, MDS Coordinator(s), and Unit Manager) regarding completion and review of resident-centered respiratory care plans for tracheostomy care. The Respiratory Care plan will be initiated by the Interdisciplinary Team (IDT) Team, in conjunction with Respiratory Therapy, consisting of, but not limited to, Administrator, DON, Unit Managers, Social Services, MDS Coordinator(s), Activities, and Dietary Manager. B) On or before [DATE], the Regional Quality Manager completed education to the Nurse Management Team (Director of Nursing, Education Training Director, RN, MDS Coordinator(s), and Unit Manager) on completing a tracheostomy patient admission questionnaire. The questionnaire consists of the name of the resident, resident specific tracheostomy orders, including care and suctioning, other services needed and who will provide any specialty services. On Saturday and Sunday, the clinical manager will initiate the respiratory care plan completing a tracheostomy patient admission questionnaire. The MDS Coordinator(s) will review the plan to ensure it is appropriate and implemented within forty-eight (48) hours. This education includes referencing the respiratory care plan for specific interventions regarding trach care, revision of care plans, if indicated, to include individualized care and services furnished related to their tracheostomy/respiratory needs and what, at a minimum, will be provided on the respiratory care plan. The care plan will include, but may not be limited to, tracheostomy care, suctioning, and specialized services. Education includes communication of the respiratory care plan to licensed nurses and Respiratory Therapist (RT)s and changes in interventions by the IDT (Admin, DON, Unit Managers, Social Services, MDS Coordinator, Activities, and Dietary Manager) if indicated. The Regional Quality Manager will educate the outside Vendor Respiratory Therapy by [DATE]. C) A post test will be given to the Director of Nursing by the Regional Quality Manager on [DATE], to ensure understanding of the tracheostomy care plans and expectations of care. The Director of Nursing will provide education to the Education Training Director, MDS Coordinators, Unit Manager, and Respiratory Therapist to ensure understanding of the material related to respiratory care plans. Education will be completed and post test passed prior to working by [DATE]. D) On or before [DATE], the Regional Reimbursement Nurse (RRN) provided an in-service for the Interdisciplinary Team (IDT) consisting of the Director of Nursing, Social Services, Assistant Dietary Manager, Activities Director, and Registered Nurse (RN) Education Training Director regarding person-centered care plan development related to ADLs for transferring and toileting. E) On or before [DATE], the Education Training Director will provide education to the nursing staff, to include SRNAs, regarding the comprehensive care plan, or baseline care plan, to include respiratory/tracheostomy care. Education was provided regarding the SRNA care plan to include ADL interventions for the level of assistance and/or supervision needed. This education will include the expectation that the nursing staff (Nurses and SRNAs) use the SRNA care plan to determine the ADL status and level of assistance or supervision required for their assignment. A post test will be given to the nurses and SRNAs on the education provided to ensure understanding of the material by [DATE]. After [DATE], licensed nurses and SRNAs will not be allowed to work without receiving the required education. This same education will be added to the new hire orientation packet for training during orientation. The facility does not use agency staff. 7. Beginning [DATE], direct observation audits will be conducted five (5) times weekly times four (4) weeks, of twenty (20) different residents each week to ensure that the comprehensive care plan, baseline care plan, and SRNA care plan is being followed while care is being provided. Observation audits will be completed by Nursing Administration (Director of Nursing, Education Training Director, RN Unit Manager, or MDS Coordinators) and will encompass observations of at least ten (10) SRNAs, on varying shifts a week. The auditor will address any discrepancy noted during the audit at that time and re-educate staff as needed. 8. On or before [DATE], the Education Training Director, Unit Manager, Director of Nursing, and the MDS Nurses completed education for all the nursing staff regarding comprehensive, baseline, and SRNA care plan. The education provided included following the care plan to provide adequate supervision and assistance to prevent accidents. It also included educating staff that each resident's ADL care plan is located in the kiosk and a printed version will be available in a book at the nurses' station. This same education will be added to the new hire orientation packets. After [DATE], licensed nurses and SRNAs will not be allowed to work without receiving the required education and passing a post test. The facility does not use agency staff. 9. The Nurse working the 7PM-7AM shift on [DATE] was in-serviced by the DON regarding performing tracheostomy care as per physician order per plan of care. The nurse was in-serviced on the responsibility of the nurse of the 7PM-7AM shift. The nurse was provided with verbal instruction, by the DON, regarding following physician orders related to medication administration and appropriate medication documentation. This verbal education was provided on [DATE] by the DON. 10. A) On or before [DATE], a one-time assessment was completed by the Education Training Director (RN), which consisted of a head to toe clinical assessment of four (4) in-house tracheostomy residents. Residents were in no distress and no issues were identified. B) On or before [DATE], a one-time audit was completed by the RN Unit Manager on all residents with tracheostomies to validate orders. Any discrepancies noted were immediately corrected by notifying the MD. On or before [DATE], the Director of Nursing reviewed the MARs, for dates of service from [DATE] to [DATE], consisting of two (2) in-house tracheostomy residents. The audits included verified documentation of tracheostomy care in the medical record. No issues were identified. Any readmission will have documentation reviewed within 24 hours of return. On or before [DATE], a one-time audit was completed by the Respiratory Therapist to ensure all tracheostomy residents with oxygen had valid orders. Any discrepancies noted were immediately corrected by notifying the MD by a licensed nurse. 11. A) On [DATE], the Contracted Respiratory Therapist (RT) completed education and skills competency for the Director of Nursing, Education Training Director, RN Unit Manager, and a Staff Respiratory Therapist to validate they were competent in tracheostomy care and the suctioning process. B) On or before [DATE], the Respiratory Vendor (RT) and/or Nursing Management team, consisting of the DON, Education Training Director, and/or UM, began education for the licensed nurses on following the physician orders regarding tracheostomy care/suctioning and on the respiratory policies provided by the respiratory therapy vendor regarding tracheostomy care and suctioning. This education will be completed by [DATE]. This education has been added to the new hire-licensed nurse orientation packet. Facility staff will be in-serviced by [DATE]. The facility does not use agency staff. C) On or before [DATE], the Nurse Management Team (Director of Nursing, Education Training Director, RN, and Unit Manager) will complete return demonstration competencies for each licensed nurse on tracheostomy care and suctioning. In addition, nursing administration (the Nurse Management Team (Director of Nursing, Education Training Director, RN, and Unit Manager)) will provide in-servicing regarding the facility Respiratory Therapist (RT) services availability for tracheostomy care and suctioning. The in-service also educated regarding nursing responsibility to provide tracheostomy care and suctioning if and/or when a RT is not available or on the schedule to provide such treatments. This education material will be added to the new hire-licensed nurse orientation packet. The facility does not use agency staff. No employees will work after [DATE] until educated and passing post test. 12. A) Beginning [DATE], the Nurse Management Team (Director of Nursing, Education Training Director, RN, and Unit Manager) MDS Nurses, or Contract Respiratory Therapy and/or facility Respiratory Therapist, will conduct audits of five (5) nurses and/or RTs each week, on varying shifts, using the tracheostomy competency validation tool. 13. On or before [DATE], the Nursing Management Team, consisting of the DON, Unit Manager(s), and licensed nurses from sister facilities, completed a one-time audit on all residents with insulin orders starting [DATE] to identify if any insulin was not given per physician orders and/or not signed timely. Any issues/concerns identified during the audit were discussed with the attending physician including a clinical assessment/observation to ensure there were no adverse reactions by the Director of Nursing and/or Nursing Management. It is the practice of the facility for insulin to be administered correctly, according to physician orders, and per the expected timeframe to prevent significant insulin medication errors. 14. On or before [DATE], the DON or Education Director will provide education to all licensed nurses regarding physician orders for administration/time parameters of medication, following physician orders for insulin administration and documenting doses administered at the time of administration. The education also included the notification of the physician if the administration fell outside the time parameters, incorrect dose given/omitted, and an assessment of the resident to ensure no adverse effects. A post education quiz for licensed nurses included education regarding the five (5) Rights of Medication administration, following physician's orders for medication administration, and insulin administration. Documentation will be completed by the nursing management team by each licensed nurse by [DATE]. Licensed nurses must pass the quiz with 100% score or be re-educated by nursing administration and retake the quiz with a 100% score before returning to work on their next shift. No licensed staff will be permitted to work until test is passed as of [DATE]. 15. Beginning [DATE], the Nursing Management Team (Director of Nursing, Education Training Director, RN, and Unit Manager) and MDS Coordinator(s) will complete audits, related to insulin administration, to include if any insulin was not given per physician orders and/or not signed timely. All residents with insulin orders will have Medication Administration documentation checked to ensure the insulin is documented given in accordance with physician orders and following professional standards of practice within time restrictions. The audit will be conducted five (5) days per week for four (4) weeks, then weekly times four (4) weeks, and then monthly. Any discrepancy identified during the audit, which consists of any insulin not given per physician orders and/or not signed timely, will be corrected immediately with MD and family notification and an assessment of the resident to ensure no adverse effects at the time the discrepancy is identified. 16. Beginning [DATE], the Nursing management team (DON, Education Training Director, Unit Manager, and MDS Nurses) will observe medication pass opportunities for 5 residents with insulin, to validate that licensed nurses are giving insulin per physician orders and within the timeframe. Any discrepancy identified will be corrected at the time of discrepancy by notifying the MD and Family by the Director of Nursing and/or Unit Manager. 17. On or before [DATE], the Specialized Medical Services (SMS) tracheostomy care and suctioning policy was adopted for use, by the facility, to ensure residents with a tracheostomy receive care per physician order and plan of care. The Director of Nursing developed an ancillary tracheostomy care and suctioning order for licensed nurses to utilize when admitting a resident to ensure that all appropriate physician orders are written for a resident who has a tracheostomy and/or requires oxygen. 18. On or before [DATE], the Regional Director of Operations educated facility management (DON and Administrator) on their responsibilities as it relates to using resources effectively and efficiently to attain or maintain the highest practicable physical well-being for residents in the facility. On or before [DATE], the Regional Director of Operations gave a post test to the Administrator and Director of Nursing on their job duties and what is required daily to ensure the facility is operating in a manner that prompts quality of life for the residents. 19. An ADHOC/Quality Assurance and Performance Improvement (QAPI) meeting was conducted on [DATE] to discuss the alleged deficient practices and corrective actions. The QAPI team met again on [DATE], with at least one Regional team member in attendance (either in person or by phone), and will continue weekly times four (4) weeks and then the facility will continue monthly thereafter. A QAPI meeting was held [DATE], for review of data from ongoing audits and staff education. This data will be reviewed weekly and continue times four (4) weeks and then monthly thereafter ongoing. Members of the facility's Quality Assurance Committee consist of the Administrator, Director of Nursing, Assistant Directors of Nursing, Dietary Manager, Business Office Manager, Activities Director, Director of Rehab, Maintenance Director, Social Services Manager, and Medical Director, who participates at least quarterly and as needed. The plan will be updated, as indicated, by the QAPI Committee. For all audits submitted to the QAPI Committee, the Administrator will assign follow-up as needed. ***The State Survey Agency determined the following removed Immediate Jeopardy on [DATE], as alleged by the facility: 1. Review of the medical records for Resident #117 revealed the resident was discharged from the facility on [DATE]. 2. A) Review of the Resident Council Meeting Minutes, dated [DATE], revealed fourteen (14) residents attended the meeting and education was provided on the grievance process. Interview with Resident #59 on [DATE] at 2:20 PM, revealed the facility staff met with the resident council and reviewed the grievance process, and forms were located throughout the facility for the residents. Review of medical records for Residents #171, #322, and #323 revealed documentation of a social services interview with residents or residents' representatives regarding the grievance process. B) Interview with the Social Services Director on [DATE] at 1:56 PM, revealed she was the Grievance Officer for the facility. She stated grievance forms have been placed in several locations in the facility with a locked grievance box located on the Peach Wing. She further stated she would initiate the grievance process and would assign the grievance to the appropriate department. She added the Administrator was to be informed immediately of all grievances. The Grievance Officer also stated the initial response to the grievance must be within seventy-two (72) hours. Review of the Allegation of Compliance binder revealed the grievance log was up to date and maintained by the Administrator. C) Observations of the Blue, Peach, and [NAME] Units on [DATE], revealed the Grievance Process Summary was posted with grievance forms available to staff and residents. D) Review of the facility's admission packet on [DATE], revealed presence of the Grievance Standards of Practice and Compliance forms. 3. Review of the facility's documentation on [DATE], revealed education on the grievance process was provided to the Director of Nursing (DON) and the Administrator on [DATE], per the sign-in sheet. The facility's documentation also revealed evidence that this education was provided to department heads on [DATE] and to all facility staff on or before [DATE] by the sign-in sheets. Interviews on [DATE], with State Registered Nurse Aide (SRNA) #15 at 1:00 PM, SRNA #16 at 3:44 PM, SRNA #2 at 1:13 PM, SRNA #4 at 1:30 PM, Licensed Practical Nurse (LPN) #7 at 1:25 PM, LPN #1 at 1:00 PM, LPN #3 at 1:15 PM, with Dietary Staff at 1:40 PM, Maintenance Staff at 1:51 PM, the Respiratory Director at 2:33 PM, and the MDS Coordinator at 1:50 PM revealed knowledge of the Grievance Standard of Practice and Compliance process. 4. A) Review of the facility's New Hire Orientation binder on [DATE], revealed presence of the Grievance Standard of Practice and Compliance policy. Review of the binder also revealed evidence of post tests administered to the staff. B) Review of the facility's documentation on 02/06//19, revealed results of the audit interviews, with stated population, related to the knowledge of the grievance process. C) Interview with the Administrator on [DATE] at 3:30 PM, revealed grievance logs and audits are reviewed daily with a Regional team member, who was still on sight. 5. A) Review of the facility's documentation on [DATE], revealed audits completed on 100% of tracheostomy residents' respiratory needs, to include care plans on or before [DATE]. The information also revealed a tracheostomy care plan was initiated on [DATE] on 100% of tracheostomy residents. B) Review of Resident #98's care plan on [DATE], revealed the care plan was updated with tracheostomy and activities of daily living (ADL) assistance on [DATE], upon re-entry from a hospital admission. C) Review of the facility's documentation on [DATE], revealed all facility residents had a review of their ADL assistance needs and were revised as indicated on [DATE]. 6. A) Review of the facility's documentation on [DATE], revealed education was provided to the Nurse Management Team on [DATE], by the Regional Quality Manager (RQM) related to completion and review of respiratory care plans and resident-centered tracheostomy respiratory care needs. B) Review of the facility's documentation on [DATE], revealed the RQM provided education to the Nurse Management Team on [DATE], on completion of the Tracheostomy Patient admission Questionnaire. C) Review of the facility's documentation on [DATE], revealed a post test was administered to the Nurse Management and Respiratory Therapist by [DATE]. Further review of the documentation revealed Nurse Management and the Respiratory Therapist had passed the post test. D) Review of the facility's documentation on [DATE], revealed education was provided by the Regional Reimbursement Nurse to the Interdisciplinary Team (IDT) on creating a person-centered care plan. Members of the IDT were interviewed and confirmed education on person-centered care plans was provided. E) Review of the [TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and review of the facility's policy, it was determined the facility Administrator failed to use resources effectively and efficiently to attain or maintain the highest practicable physical well-being for Resident #117. The facility failed to develop respiratory policies and procedures to ensure Resident #117 received respiratory care as needed. The Administrator also failed to investigate and respond to a grievance presented by a family member of Resident #117 on [DATE], regarding the resident's respiratory care. On [DATE], staff failed to provide respiratory care as ordered by the resident's physician and the resident was found not breathing on [DATE]. The resident was transferred to a hospital where he/she was pronounced dead as a result of Cardiopulmonary Arrest due to Upper Airway Obstruction. The facility's failure to ensure the facility was administered in a manner that enables it to use resources effectively and efficiently 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 (F585), 42 CFR 483.21 Comprehensive Person-Centered Care Plans (F656), 42 CFR 483.25 Quality of Care (F689 and F695), 42 CFR 483.45 Pharmacy Services (F760), and 42 CFR 483.70 Administration (F835). The facility was notified of the Immediate Jeopardy on [DATE]. 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 on [DATE], which lowered the scope and severity to D level at 42 CFR 483.10 Resident Rights (F585), 42 CFR 483.21 Comprehensive Person-Centered Care Plans (F656), 42 CFR 483.25 Quality of Care (F689 and F695), 42 CFR 483.45 Pharmacy Services (F760), and 42 CFR 483.70 Administration (F835), while the facility monitors the effectiveness of systemic changes and quality assurance activities. The findings include: Review of the Administrator's job description revealed the Administrator was required to ensure that excellent care for residents was maintained by overseeing and monitoring patient care services delivered. The description also revealed the Administrator was responsible for working with and supervising personnel in the facility by providing opportunities for instruction, guidance, and counseling as necessary to ensure complete understanding of responsibilities. Review of the facility's policy, Resident and Family Grievances, undated, revealed prompt efforts will be made by the facility to resolve grievances. The policy also revealed the grievance would be recorded on a Grievance Form and recording of the grievance would serve as communication to other staff members. Further review of the policy revealed the Administrator or designee should conduct an investigation, if warranted. Interview with the facility Administrator on [DATE] at 12:00 PM revealed the facility did not have policies regarding respiratory care or tracheostomy care/suctioning. Interview with Resident #117's family member on [DATE] at 2:35 PM revealed the facility transferred the resident to the hospital on [DATE] because the resident's oxygen saturation was low. He stated once the resident arrived at the hospital, hospital staff informed him that they suctioned a large amount of secretions from the resident's tracheostomy. The family member stated after suctioning, the resident felt better and was able to rest. Further interview with the family member revealed he met with the Administrator and Director of Nursing (DON) on [DATE], and reported that the hospital physician told him that staff at the facility were not suctioning Resident #117 adequately. Interview with the Administrator on [DATE] at 9:55 AM, revealed Resident #117's family member voiced a grievance on [DATE], stating that the resident was not being suctioned adequately at the facility. She stated she was aware the DON reviewed documentation that the resident only required suctioning as needed, and no concerns were identified. Further interview with the Administrator revealed no further action/investigation was taken, and the family member's grievance was not handled per the facility's policy. Continued interview with the Administrator revealed she was not aware the facility did not have policies or procedures regarding providing tracheostomy care or suctioning a tracheostomy. Interview with Registered Nurse (RN) #3, who was also the Unit Manager, on [DATE] at 12:50 PM and review of Resident #117's Medication Administration Record revealed no documented evidence the Unit Manager completed tracheostomy care/suctioning for Resident #117 on [DATE] at 7:00 PM. In addition, further interview with RN #3 revealed she also failed to suction the resident's tracheostomy on [DATE] at approximately 11:00 PM, when the resident indicated he/she needed to be suctioned. The Unit Manager stated she was not aware that she was required to provide tracheostomy care at 7:00 PM because she thought Respiratory Therapy staff provided the care. Review of Resident #117's Nursing Notes dated [DATE] at 6:40 AM, revealed staff found Resident #117 on the floor, not breathing. Staff initiated Cardiopulmonary Resuscitation (CPR), and the resident was transferred to the hospital. Review of Resident #117's hospital record revealed the resident was pronounced dead on [DATE] at 7:32 AM. According to the resident's Death Certificate, the cause of death was Cardiopulmonary Arrest due to Upper airway obstruction. **The facility alleged the following actions removed the Immediate Jeopardy on [DATE]: 1. Resident #117 was transported to the hospital on [DATE] and no longer resides in the facility. 2. A) On [DATE], the Activities Director conducted a resident council meeting to review with the residents the Grievance Process and guidelines. By [DATE] the Activities Director, Social Services Director, or facility Administrator will provide education on the Grievance Standard of Practice and Compliance guideline for those resident(s) with a Brief Interview for Mental Status (BIMS) score of nine (9) or higher, who did not attend the resident council meeting. By [DATE] the Social Services Director (Grievance Officer) or Social Services Assistant will interview current in-house residents with a BIMS of nine (9) or higher to identify if there are any current grievances. By [DATE] the Social Services Director (Grievance Officer) or Social Services Assistant will contact the respective responsible party or guardian, for those residents with a BIMS of eight (8) or less, to identify if they have any concerns and address the concern(s) following the Grievance Standard of Practice and Compliance guideline. Any concerns/grievance(s) voiced will be addressed following the Grievance Standard of Practice and Compliance guideline. B) Grievances identified Monday through Friday will be addressed by the Social Services Director, who is the Grievance Official, and/or the Social Services staff. All grievances will be addressed per the Grievance Standard of Practice and Compliance Guidelines and submitted to the Administrator for review. The Administrator will log the grievance for review and recommendations in Quality Assurance/Performance Improvement (QAPI). The Social Services Director will send a letter to the resident's representative and/or resident with resolution per guidelines. C) By [DATE], the Administrator will post a copy of the Grievance Process summary along with the facility's administration contacts throughout the facility. Copies of blank grievance forms will accompany the posting. D) By [DATE], the Admissions Director will add a copy of the Grievance Standards of Practice and Compliance in the admission packets to provide information to any new residents/families. 3. On [DATE], the Regional Quality Manager (RQM) provided education to the Director of Nursing (DON) and the Administrator regarding the facility's Grievance Standards of Practice and Compliance Guidelines, which included, but was not limited to, ensuring investigation and resolution of a grievance per regulation. Beginning [DATE], the facility's Administrator educated the Education Training Director (ETD) regarding the facility's Grievance Process. Education was provided to the Department Heads (Business Office Manager, Social Services, DON, Activities Director, MDS, Unit Manager, Dietary Manager, Housekeeping Supervisor, Maintenance, Marketing, and Payroll) on the Grievance Process by the Administrator on [DATE]. 4. A) On or before [DATE], education was provided by the Administrator and Education Training Director on Grievance Standards of Practice and Compliance Guidelines to all facility staff. A post test accompanied the education to validate understanding of the materials. Newly hired staff will receive education during orientation regarding Grievance Standards of Practice and Compliance Guidelines, including a post test. Any employee who has not received the education and passed the post test will not be allowed to return to work after [DATE]. The facility does not use agency staff. B) Beginning [DATE], the Administrator, DON, Unit Manager (UM), or Grievance Officer will interview three (3) residents with a BIMS score of nine (9) or greater, three (3) random employees, and three (3) representatives of residents with a BIMS score of eight (8) or less weekly for four (4) weeks to ensure staff and residents understand the grievance process. Results of the audits will be reported to the Quality Assurance Committee for its review and recommendations. The Administrator will assign follow-up as needed. C) Beginning [DATE], the facility's Administrator will submit the grievance log, with completed concern/grievance investigation, and follow up daily with a member of the Regional Team for review. Any discrepancy noted during the review will be immediately addressed with the Administrator by the Regional Team Member. 5. A) On or before [DATE], the Nurse Management team, consisting of the Director of Nursing, RN Education Training Director, Unit Manager, MDS Coordinator(s), and/or Respiratory Therapist, completed a one hundred (100) percent (%) audit of respiratory care needs for each in-house resident having a tracheostomy, which included a review of their care plans. On or before [DATE], the respiratory care plans will be revised by the DON, if indicated, to include individualized care and services to be furnished related to their tracheostomy/respiratory needs. This will include, but not be limited to, tracheostomy care, suctioning, and specialized services related to respiratory care for their tracheostomy and in line with the resident's goals and desired outcomes. B) Any new admissions, or readmissions, with tracheostomy needs for care and services, will be reviewed by the Nursing Administrative Team, Respiratory Therapist, and/or MDS Coordinator(s) within twenty-four (24) hours. This review will include individualized care approaches and services to be implemented related to their ongoing tracheostomy/respiratory needs. This will include, but not be limited to, tracheostomy care, suctioning, and specialized services related to respiratory care and in line with the resident's goals and desired outcomes. C) On or before [DATE], each resident will have their ADL (Activities of Daily Living) status reviewed for the level of assistance required, including toileting. The ADL comprehensive baseline and State Registered Nurse Aide (SRNA) care plan were audited to ensure ADL interventions described the appropriate level of assistance and/or supervision needed. This will be completed by the Nurse Management Team (Director of Nursing, Education Training Director, RN, and Unit Manager), MDS Coordinator(s), and nursing staff (nurses and SRNAs) and, if applicable, the resident by [DATE]. These will be resident-centered to reflect the amount of assistance and or supervision necessary to complete ADL tasks to attain or maintain his/her highest practicable physical, mental, and psychosocial well-being. 6. A) On or before [DATE], the Regional Quality Manager completed education for the Nurse Management Team (Director of Nursing, Education Training Director, RN, MDS Coordinator(s), and Unit Manager) regarding completion and review of resident-centered respiratory care plans for tracheostomy care. The Respiratory Care plan will be initiated by the Interdisciplinary Team (IDT) Team, in conjunction with Respiratory Therapy, consisting of, but not limited to, Administrator, DON, Unit Managers, Social Services, MDS Coordinator(s), Activities, and Dietary Manager. B) On or before [DATE], the Regional Quality Manager completed education to the Nurse Management Team (Director of Nursing, Education Training Director, RN, MDS Coordinator(s), and Unit Manager) on completing a tracheostomy patient admission questionnaire. The questionnaire consists of the name of the resident, resident specific tracheostomy orders, including care and suctioning, other services needed and who will provide any specialty services. On Saturday and Sunday, the clinical manager will initiate the respiratory care plan completing a tracheostomy patient admission questionnaire. The MDS Coordinator(s) will review the plan to ensure it is appropriate and implemented within forty-eight (48) hours. This education includes referencing the respiratory care plan for specific interventions regarding trach care, revision of care plans, if indicated, to include individualized care and services furnished related to their tracheostomy/respiratory needs and what, at a minimum, will be provided on the respiratory care plan. The care plan will include, but may not be limited to, tracheostomy care, suctioning, and specialized services. Education includes communication of the respiratory care plan to licensed nurses and Respiratory Therapist (RT)s and changes in interventions by the IDT (Admin, DON, Unit Managers, Social Services, MDS Coordinator, Activities, and Dietary Manager) if indicated. The Regional Quality Manager will educate the outside Vendor Respiratory Therapy by [DATE]. C) A post test will be given to the Director of Nursing by the Regional Quality Manager on [DATE], to ensure understanding of the tracheostomy care plans and expectations of care. The Director of Nursing will provide education to the Education Training Director, MDS Coordinators, Unit Manager, and Respiratory Therapist to ensure understanding of the material related to respiratory care plans. Education will be completed and post test passed prior to working by [DATE]. D) On or before [DATE], the Regional Reimbursement Nurse (RRN) provided an in-service for the Interdisciplinary Team (IDT) consisting of the Director of Nursing, Social Services, Assistant Dietary Manager, Activities Director, and Registered Nurse (RN) Education Training Director regarding person-centered care plan development related to ADLs for transferring and toileting. E) On or before [DATE], the Education Training Director will provide education to the nursing staff, to include SRNAs, regarding the comprehensive care plan, or baseline care plan, to include respiratory/tracheostomy care. Education was provided regarding the SRNA care plan to include ADL interventions for the level of assistance and/or supervision needed. This education will include the expectation that the nursing staff (Nurses and SRNAs) use the SRNA care plan to determine the ADL status and level of assistance or supervision required for their assignment. A post test will be given to the nurses and SRNAs on the education provided to ensure understanding of the material by [DATE]. After [DATE], licensed nurses and SRNAs will not be allowed to work without receiving the required education. This same education will be added to the new hire orientation packet for training during orientation. The facility does not use agency staff. 7. Beginning [DATE], direct observation audits will be conducted five (5) times weekly times four (4) weeks, of twenty (20) different residents each week to ensure that the comprehensive care plan, baseline care plan, and SRNA care plan is being followed while care is being provided. Observation audits will be completed by Nursing Administration (Director of Nursing, Education Training Director, RN Unit Manager, or MDS Coordinators) and will encompass observations of at least ten (10) SRNAs, on varying shifts a week. The auditor will address any discrepancy noted during the audit at that time and re-educate staff as needed. 8. On or before [DATE], the Education Training Director, Unit Manager, Director of Nursing, and the MDS Nurses completed education for all the nursing staff regarding comprehensive, baseline, and SRNA care plan. The education provided included following the care plan to provide adequate supervision and assistance to prevent accidents. It also included educating staff that each resident's ADL care plan is located in the kiosk and a printed version will be available in a book at the nurses' station. This same education will be added to the new hire orientation packets. After [DATE], licensed nurses and SRNAs will not be allowed to work without receiving the required education and passing a post test. The facility does not use agency staff. 9. The Nurse working the 7PM-7AM shift on [DATE] was in-serviced by the DON regarding performing tracheostomy care as per physician order per plan of care. The nurse was in-serviced on the responsibility of the nurse of the 7PM-7AM shift. The nurse was provided with verbal instruction, by the DON, regarding following physician orders related to medication administration and appropriate medication documentation. This verbal education was provided on [DATE] by the DON. 10. A) On or before [DATE], a one-time assessment was completed by the Education Training Director (RN), which consisted of a head to toe clinical assessment of four (4) in-house tracheostomy residents. Residents were in no distress and no issues were identified. B) On or before [DATE], a one-time audit was completed by the RN Unit Manager on all residents with tracheostomies to validate orders. Any discrepancies noted were immediately corrected by notifying the MD. On or before [DATE], the Director of Nursing reviewed the MARs, for dates of service from [DATE] to [DATE], consisting of two (2) in-house tracheostomy residents. The audits included verified documentation of tracheostomy care in the medical record. No issues were identified. Any readmission will have documentation reviewed within 24 hours of return. On or before [DATE], a one-time audit was completed by the Respiratory Therapist to ensure all tracheostomy residents with oxygen had valid orders. Any discrepancies noted were immediately corrected by notifying the MD by a licensed nurse. 11. A) On [DATE], the Contracted Respiratory Therapist (RT) completed education and skills competency for the Director of Nursing, Education Training Director, RN Unit Manager, and a Staff Respiratory Therapist to validate they were competent in tracheostomy care and the suctioning process. B) On or before [DATE], the Respiratory Vendor (RT) and/or Nursing Management team, consisting of the DON, Education Training Director, and/or UM, began education for the licensed nurses on following the physician orders regarding tracheostomy care/suctioning and on the respiratory policies provided by the respiratory therapy vendor regarding tracheostomy care and suctioning. This education will be completed by [DATE]. This education has been added to the new hire-licensed nurse orientation packet. Facility staff will be in-serviced by [DATE]. The facility does not use agency staff. C) On or before [DATE], the Nurse Management Team (Director of Nursing, Education Training Director, RN, and Unit Manager) will complete return demonstration competencies for each licensed nurse on tracheostomy care and suctioning. In addition, nursing administration (the Nurse Management Team (Director of Nursing, Education Training Director, RN, and Unit Manager)) will provide in-servicing regarding the facility Respiratory Therapist (RT) services availability for tracheostomy care and suctioning. The in-service also educated regarding nursing responsibility to provide tracheostomy care and suctioning if and/or when a RT is not available or on the schedule to provide such treatments. This education material will be added to the new hire-licensed nurse orientation packet. The facility does not use agency staff. No employees will work after [DATE] until educated and passing post test. 12. A) Beginning [DATE], the Nurse Management Team (Director of Nursing, Education Training Director, RN, and Unit Manager) MDS Nurses, or Contract Respiratory Therapy and/or facility Respiratory Therapist, will conduct audits of five (5) nurses and/or RTs each week, on varying shifts, using the tracheostomy competency validation tool. 13. On or before [DATE], the Nursing Management Team, consisting of the DON, Unit Manager(s), and licensed nurses from sister facilities, completed a one-time audit on all residents with insulin orders starting [DATE] to identify if any insulin was not given per physician orders and/or not signed timely. Any issues/concerns identified during the audit were discussed with the attending physician including a clinical assessment/observation to ensure there were no adverse reactions by the Director of Nursing and/or Nursing Management. It is the practice of the facility for insulin to be administered correctly, according to physician orders, and per the expected timeframe to prevent significant insulin medication errors. 14. On or before [DATE], the DON or Education Director will provide education to all licensed nurses regarding physician orders for administration/time parameters of medication, following physician orders for insulin administration and documenting doses administered at the time of administration. The education also included the notification of the physician if the administration fell outside the time parameters, incorrect dose given/omitted, and an assessment of the resident to ensure no adverse effects. A post education quiz for licensed nurses included education regarding the five (5) Rights of Medication administration, following physician's orders for medication administration, and insulin administration. Documentation will be completed by the nursing management team by each licensed nurse by [DATE]. Licensed nurses must pass the quiz with 100% score or be re-educated by nursing administration and retake the quiz with a 100% score before returning to work on their next shift. No licensed staff will be permitted to work until test is passed as of [DATE]. 15. Beginning [DATE], the Nursing Management Team (Director of Nursing, Education Training Director, RN, and Unit Manager) and MDS Coordinator(s) will complete audits, related to insulin administration, to include if any insulin was not given per physician orders and/or not signed timely. All residents with insulin orders will have Medication Administration documentation checked to ensure the insulin is documented given in accordance with physician orders and following professional standards of practice within time restrictions. The audit will be conducted five (5) days per week for four (4) weeks, then weekly times four (4) weeks, and then monthly. Any discrepancy identified during the audit, which consists of any insulin not given per physician orders and/or not signed timely, will be corrected immediately with MD and family notification and an assessment of the resident to ensure no adverse effects at the time the discrepancy is identified. 16. Beginning [DATE], the Nursing management team (DON, Education Training Director, Unit Manager, and MDS Nurses) will observe medication pass opportunities for 5 residents with insulin, to validate that licensed nurses are giving insulin per physician orders and within the timeframe. Any discrepancy identified will be corrected at the time of discrepancy by notifying the MD and Family by the Director of Nursing and/or Unit Manager. 17. On or before [DATE], the Specialized Medical Services (SMS) tracheostomy care and suctioning policy was adopted for use, by the facility, to ensure residents with a tracheostomy receive care per physician order and plan of care. The Director of Nursing developed an ancillary tracheostomy care and suctioning order for licensed nurses to utilize when admitting a resident to ensure that all appropriate physician orders are written for a resident who has a tracheostomy and/or requires oxygen. 18. On or before [DATE], the Regional Director of Operations educated facility management (DON and Administrator) on their responsibilities as it relates to using resources effectively and efficiently to attain or maintain the highest practicable physical well-being for residents in the facility. On or before [DATE], the Regional Director of Operations gave a post test to the Administrator and Director of Nursing on their job duties and what is required daily to ensure the facility is operating in a manner that prompts quality of life for the residents. 19. An ADHOC/Quality Assurance and Performance Improvement (QAPI) meeting was conducted on [DATE] to discuss the alleged deficient practices and corrective actions. The QAPI team met again on [DATE], with at least one Regional team member in attendance (either in person or by phone), and will continue weekly times four (4) weeks and then the facility will continue monthly thereafter. A QAPI meeting was held [DATE], for review of data from ongoing audits and staff education. This data will be reviewed weekly and continue times four (4) weeks and then monthly thereafter ongoing. Members of the facility's Quality Assurance Committee consist of the Administrator, Director of Nursing, Assistant Directors of Nursing, Dietary Manager, Business Office Manager, Activities Director, Director of Rehab, Maintenance Director, Social Services Manager, and Medical Director, who participates at least quarterly and as needed. The plan will be updated, as indicated, by the QAPI Committee. For all audits submitted to the QAPI Committee, the Administrator will assign follow-up as needed. ***The State Survey Agency determined the following removed Immediate Jeopardy on [DATE], as alleged by the facility: 1. Review of the medical records for Resident #117 revealed the resident was discharged from the facility on [DATE]. 2. A) Review of the Resident Council Meeting Minutes, dated [DATE], revealed fourteen (14) residents attended the meeting and education was provided on the grievance process. Interview with Resident #59 on [DATE] at 2:20 PM, revealed the facility staff met with the resident council and reviewed the grievance process, and forms were located throughout the facility for the residents. Review of medical records for Residents #171, #322, and #323 revealed documentation of a social services interview with residents or residents' representatives regarding the grievance process. B) Interview with the Social Services Director on [DATE] at 1:56 PM, revealed she was the Grievance Officer for the facility. She stated grievance forms have been placed in several locations in the facility with a locked grievance box located on the Peach Wing. She further stated she would initiate the grievance process and would assign the grievance to the appropriate department. She added the Administrator was to be informed immediately of all grievances. The Grievance Officer also stated the initial response to the grievance must be within seventy-two (72) hours. Review of the Allegation of Compliance binder revealed the grievance log was up to date and maintained by the Administrator. C) Observations of the Blue, Peach, and [NAME] Units on [DATE], revealed the Grievance Process Summary was posted with grievance forms available to staff and residents. D) Review of the facility's admission packet on [DATE], revealed presence of the Grievance Standards of Practice and Compliance forms. 3. Review of the facility's documentation on [DATE], revealed education on the grievance process was provided to the Director of Nursing (DON) and the Administrator on [DATE], per the sign-in sheet. The facility's documentation also revealed evidence that this education was provided to department heads on [DATE] and to all facility staff on or before [DATE] by the sign-in sheets. Interviews on [DATE], with State Registered Nurse Aide (SRNA) #15 at 1:00 PM, SRNA #16 at 3:44 PM, SRNA #2 at 1:13 PM, SRNA #4 at 1:30 PM, Licensed Practical Nurse (LPN) #7 at 1:25 PM, LPN #1 at 1:00 PM, LPN #3 at 1:15 PM, with Dietary Staff at 1:40 PM, Maintenance Staff at 1:51 PM, the Respiratory Director at 2:33 PM, and the MDS Coordinator at 1:50 PM revealed knowledge of the Grievance Standard of Practice and Compliance process. 4. A) Review of the facility's New Hire Orientation binder on [DATE], revealed presence of the Grievance Standard of Practice and Compliance policy. Review of the binder also revealed evidence of post tests administered to the staff. B) Review of the facility's documentation on 02/06//19, revealed results of the audit interviews, with stated population, related to the knowledge of the grievance process. C) Interview with the Administrator on [DATE] at 3:30 PM, revealed grievance logs and audits are reviewed daily with a Regional team member, who was still on sight. 5. A) Review of the facility's documentation on [DATE], revealed audits completed on 100% of tracheostomy residents' respiratory needs, to include care plans on or before [DATE]. The information also revealed a tracheostomy care plan was initiated on [DATE] on 100% of tracheostomy residents. B) Review of Resident #98's care plan on [DATE], revealed the care plan was updated with tracheostomy and activities of daily living (ADL) assistance on [DATE], upon re-entry from a hospital admission. C) Review of the facility's documentation on [DATE], revealed all facility residents had a review of their ADL assistance needs and were revised as indicated on [DATE]. 6. A) Review of the facility's documentation on [DATE], revealed education was provided to the Nurse Management Team on [DATE], by the Regional Quality Manager (RQM) related to completion and review of respiratory care plans and resident-centered tracheostomy respiratory care needs. B) Review of the facility's documentation on [DATE], revealed the RQM provided education to the Nurse Management Team on [DATE], on completion of the Tracheostomy Patient admission Questionnaire. C) Review of the facility's documentation on [DATE], revealed a post test was administered to the Nurse Management and Respiratory Therapist by [DATE]. Further review of the documentation revealed Nurse Management and the Respiratory Therapist had passed the post test. D) Review of the facility's documentation on [DATE], revealed education was provided by the Regional Reimbursement Nurse to the Interdisciplinary Team (IDT) on creating a person-centered care plan. Members of the IDT were interviewed and confirmed education on person-centered care plans was provided. E) Review of the facility's documentation on [DATE], revealed education was provided by the Education Training Director to all nursing staff, to include SRNAs, regarding comprehensive care plan and baseline care plan to include respiratory/tracheostomy care and SRNA care plan to define level of assistance required for ADL care. The information also revealed evidence that post tests were completed. Review of the new hire orientation packet revealed information on respiratory and ADL care planning. Observation on [DATE] at 4:05 PM, revealed a resident was being transferred from a wheelchair to a toilet, using the le[TRUNCATED]