**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure adequate supervision was provided to prevent accidents for 1 of 6 residents (Resident #1) reviewed for accidents. The facility did not prevent Resident #1 who had a history of wandering from leaving the facility unsupervised. On or about 07/28/2024, Resident #1 was found approximately 50 feet away from the entrance of the facility around 4:00 AM. The facility failed to ensure Resident #1 received adequate supervision to prevent elopement. The facility failed to investigate resident #1's three separate elopements that occurred in July 2024, October 2024, and January 25, 2025. The facility failed to put interventions in place to prevent Resident #1 from eloping. This failure resulted in an identification of an Immediate Jeopardy (IJ) at 4:48 PM. on 01/30/2025. While the IJ was removed on 01/31/2025, the facility remained out of compliance at a potential for more than minimal harm with a scope identified as isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. These failures could place residents at risk of accidents, injury, or death. Findings included: Record review of a face sheet dated 11/26/2024 indicated Resident #1 was [AGE] year-old female, admitted to the facility on [DATE], with diagnoses including transient cerebral ischemic attack (brief blockage of blood flow to the brain), pain, dementia (degenerative brain disease - loss of memory, language) and urinary tract infection. Record review of the comprehensive MDS dated [DATE] indicated Resident #1 had a BIMS of 06 and was severely cognitively impairment. Resident #1's MDS indicated wandering behavior was not exhibited. Resident #1 required supervision for eating, maximal assistance for toileting, showering, dressing and personal hygiene. Resident #1 required touching and supervision for ambulation and transfers. Record review of the care plan dated 06/19/2024 indicated Resident #1 experienced wandering with the interventions of clear pathways, avoid over stimulation and equipped with a device that alarms when wanders. Record review of the consolidated physician orders dated 01/01/2025 - 01/31/2025 indicated Resident #1 had an order for a wander guard with daily functional checks with a start date of 05/01/2024. Record review of the elopement assessment dated [DATE] indicated Resident #1 was a moderate risk for elopement with a score of 14. Record review of an elopement risk book titled Happy Feet kept at the nurses' station indicated Resident #1 was identified as an elopement risk. Record review of the facility's Incidents and Accidents Reports dated 06/01/2024 - 01/27/2025 did not indicate any elopements. Record review of Resident #1's chart did not indicate incidents of elopement, exit seeking behaviors, or notification to her family or physician regarding any elopements or exit seeking behaviors. Record review of unsigned progress note dated 07/29/2024 at 10:00 AM indicated Resident #1 was COVID positive and weak. Record review of progress noted dated 07/29/2024 at 09:30 PM signed by LVN N indicated Resident #1 was being sent to the emergency room per physician orders due to weakness. Record review of the schedule dated 07/27/2024 for 6 PM to 6 AM indicated the following: LVN K - 6PM - 6AM LVN B - 6PM - 6AM LVN E - 6PM - 6AM CNA A - 2PM - 6AM CNA F - 2PM - 6AM CNA G - 10PM - 3:30AM Record review of the wander guard bracelet daily checklist dated 07/2024 to 01/2025 indicated no issues. Record review of the alarm door battery monthly checklist dated 02/2024 - 01/2025 indicated no issues. During an interview on 01/28/2025 at 11:30 AM, Resident #1 said she got in trouble by the staff for going outside. Resident #1 said she could not remember when those incidents occurred, or which staff member got on to her for going outside of the facility. Resident #1 stated she did not want to talk about it and looked away from the surveyor. During an interview on 01/28/2025 at 11:35 AM, Resident #1's roommate said Resident #1 had gotten out of the facility at least three times that she could recall. Resident #1's roommate said she usually tried to get out at nighttime. Resident #1's roommate said Resident #1 would wait for someone to go out of the door and then she walked out behind them. Resident #1's roommate said she had seen the staff bring Resident #1 back to the room and put her to bed after she had been outside of the facility. Resident #1's roommate stated she overheard staff talking to Resident #1, when she was returned to the room. Resident #1's roommate said she was unable to recall the staff involved or the dates of those incidents, but it was more than a month ago. During a telephone interview on 01/28/2025 at 01:40 PM, Resident #1's family member stated they had not received any calls from the facility regarding incidents of elopement or exiting seeking behaviors. During an interview on 01/28/2025 at 03:36 PM, CNA A stated she had worked at the facility for over a year. CNA A said she worked the 2 PM to 6 AM shift. CNA A said Resident #1 got out of the facility and was found out in the grass by one of the kitchen aides when reporting to work between 4 AM or 5 AM. CNA A said that the kitchen aide had told one of the nurses that a resident was laying on the ground in the grass beside the parking lot when she entered the facility that morning. CNA A said she later saw LVN B assist Resident #1 to her room. CNA A said Resident #1 had ambulated with her rollator back to her room. CNA A said she always redirected a resident if they were too close to the doors. CNA A said if she had any difficulty with redirecting or felt like the resident's safety was in jeopardy, she would immediately report to the nurse. CNA A stated the nurses were responsible for the reports and notifying the family and doctor, but all staff were responsible for the safety of the residents. CNA A said communicating the residents' needs was very important, so the right care was given to the residents. During an interview on 01/28/2025 at 09:00 PM, an anonymous staff member stated Resident #1 had a significant change of condition on 07/29/2024, after it was reported she was found outside in the early hours of 07/28/2024 by staff. During a telephone interview on 01/29/2025 at 09:15 AM, the Transportation Aide stated she had completed the wander guard checks daily with the remotes to the doors and 3 days weekly of the resident at the doors. The Transportation Aide stated she took over checking the wander guard system sometime in July 2024 when the facility received the new upgraded system. The Transportation Aide stated there had been some issues when the upgraded system was installed because it would not stay programmed. The Transportation Aide stated the issue with the wander guard system may have occurred in July 2024. During an interview on 01/29/2025 at 09:45 AM, the Administrator stated he wanted to be clear that the facility had not had any elopement incidents. During an observation and interview on 01/29/2025 at 10:15 AM, the Maintenance Supervisor stated when he checked the door alarms on the 200 hall, it alarmed when the door was opened but the alarm tuned off within 1 minute prior to deactivating it. The Maintenance Supervisor stated it appeared the red metal box of the alarm, which hung on the door, had been damaged, and he did not know how it was damaged. The Maintenance Supervisor stated the system was not working correctly, and that could result in an elopement. The Maintenance Supervisor said it could result in an elopement because the alarm could turn off before the staff were alerted a resident went out, and the resident leaving would go unnoticed. The Maintenance Supervisor stated the door alarm batteries are checked monthly. During a telephone interview on 01/29/2025 at 10:50 AM, LVN E stated she worked at the facility as needed. LVN E stated she had worked on 07/27/2024 on the 6 PM to 6 AM shift. LVN E stated around 4:30 AM - 5:00 AM, a female kitchen aide entered the facility and said, there was a resident outside lying in the grass. LVN E stated she and a male CNA followed the kitchen aide approximately 50 yards outside of the facility's entrance door to the left side of the building to Resident #1, who was lying in the grass. LVN E stated Resident #1 was lying in a grass area between the sidewalk and parking lot with the rollator slightly positioned on top of her. LVN E stated Resident #1 appeared confused but had no complaints of pain or any visible injuries. LVN E stated she left the two staff members with Resident #1 and went inside the facility to get LVN B. LVN E stated LVN B was Resident #1's nurse. LVN E stated she assisted LVN B and the male CNA to get Resident #1 off from the ground and back into the facility. LVN E stated at the beginning of her shift around 7:00 PM on 07/27/2024 , she had noted Resident #1 was in the hall. LVN E stated LVN B reminded Resident #1 that she was COVID positive and walked Resident #1 back to her room at that time. LVN E stated she could not identify the male CNA by name or the kitchen staff aide because it was a large facility and she had only worked on an as needed basis. LVN E recalled that the male CNA identified Resident #1 once they were outside. LVN E remembered the male CNA stated Resident #1 did not reside on the hall he was working, and he was not familiar with her baseline status. LVN E stated Resident #1 had on the wonder guard bracelet. LVN E stated no alarms had gone off in the facility. LVN E said the alarms were very loud and noticeable. LVN E stated the nurses had a key and the key had to be inserted and the code entered to turn the alarms off once activated. LVN E stated she offered to help LVN B, but she declined her offer. LVN E stated it was important to document the incident in the resident's chart and complete an incident report, as well as report the incident to the DON, family, and physician. LVN E said the importance of following the protocol was for continuity of the resident's care. LVN E stated the incident would need to be investigated to determine how the resident exited the facility, and new interventions should be updated to be specific for that resident. LVN E stated she had not completed the incident report regarding Resident #1 because LVN B stated she would take care of it. During an interview on 01/29/2025 at 11:57 AM, Kitchen Aide C stated she had worked at the facility for approximately three years. Kitchen Aide C stated she arrived at work on a Sunday around 5:00 AM when Resident #1 was ambulating with a rollator on the sidewalk with staff members. Kitchen Aide C stated she recognized Resident #1 from previously working the halls. Kitchen Aide C said that Kitchen Aide D told her she had found Resident #1 out by the parking lot when she arrived at work. Kitchen Aide C could not remember the exact date but recalled it was on a Sunday several months back. Attempted telephone interview on 01/29/2025 at 12:15 PM to Kitchen Aide D. A voice message was left requesting a call back. (Kitchen Aide D was no longer employed at the facility.) During an interview on 01/29/2025 at 12:17 AM, the Administrator stated there are no recorded videos of the facility. The Administrator stated the videos record over and over after a 24-hour period. During an interview and observation on 01/29/2025 at 03:35 PM, the maintenance supervisor tripped the alarm on hall 200 by opening the door. The alarm remained on until the key and code were entered appropriately. Attempted telephone call on 01/29/2025 at 06:46 PM to Kitchen Aide D. A voice message was left requesting a call back. (Kitchen Aide D was no longer employed at the facility.) During a telephone interview on 01/29/2025 at 06:49 PM, CNA F stated he heard the kitchen aide (he did not know the kitchen aide's name) tell LVN E that a resident was lying outside on the ground. CNA F stated he and LVN E followed the kitchen aide outside and found Resident #1 lying on the grass with her rollator toppled over her. CNA F stated LVN E assessed the resident and then went back into the facility and got LVN B. CNA F stated they assisted Resident #1 off the ground. CNA F stated Resident #1 walked back to the facility using her rollator. CNA F stated Resident #1 seemed confused but was not injured. CNA F stated LVN B took Resident #1 back to her room. Attempted telephone interview on 01/29/2025 at 07:00 PM to Kitchen Aide D. A voice message was left requesting a call back. (Kitchen Aide D was no longer employed at the facility.) During an interview on 01/29/2025 at 07:35 PM, LVN B stated she had worked at the facility for 2 years on the 6 PM to 6 AM shift. LVN B stated she had never had a resident leave out of the facility or exit seek. LVN B stated the alarms may activate but the residents turned away from the door or she had redirect them to another activity, but the residents had never gone outside of the facility. LVN B stated if a resident went outside of the facility that would be considered an elopement. LVN B stated if a resident got outside the facility that could result in serious harm even death due to being hit by a vehicle in the parking lot or the roadway. LVN B stated if a resident left out of the facility or exhibited exit seeking behaviors, it would be documented in the resident's chart, an incident report would be completed, and the family and physician would be notified. LVN B stated the purpose of documenting incidents and notifications was so the physician and the facility staff would know how to take care of the resident appropriately. LVN B said an elopement should be reported to the DON for further investigation to prevent the situation from happening again. LVN B stated Resident #1 had not exhibited exit seeking behaviors. LVN B stated Resident #1 had not been outside the facility. LVN B denied any incidents of Resident #1 being outside of the facility for an undetermined time or being found outside by the kitchen staff. LVN B denied she had assisted LVN E or CNA F when Resident #1 was found outside in the parking lot. LVN B stated Resident #1 had never gone outside of the facility without their knowledge. LVN B stated she had no idea why the other staff reported her involvement with Resident #1 outside of the facility because she had no recollection of that situation. LVN B stated that one time Resident #1 had gone outside the facility but only to the picnic table. LVN B stated this incident had occurred in the month of October 2024 around the time she was doing morning rounds at 6:00 AM. LVN B stated Resident #1 had used the door on hall 5 to exit the facility and had sat down at the picnic table when she and the CNA reached her. LVN B said she and other staff had followed see Resident #1 exit the building and had followed her out. LVN B stated she never lost sight of Resident #1 and she was approximately 10 steps away from the door on hall 5. LVN B stated CNA G had assisted her to get Resident # 1 back into the building to her room. LVN B said she placed Resident #1 into her bed after she changed her socks because they were covered in grass, washed the mud from her legs, combed out Resident #1's hair because it was wet, and changed her gown because the bottom of it was soaked. LVN B stated she had filled out an incident report and documented in Resident #1's chart and notified her doctor and family member. LVN B was unable to locate the documented incident report or documentation in Resident #1's chart regarding the incident. LVN B stated she may not have documented anything because she was exhausted and needed to get home for sleep so she could return for the following night shift. LVN B said Resident #1 was fine, so there was really not anything to report anyway. During an interview on 01/29/2025 at 08:15 PM, CNA G stated he had not assisted LVN B with Resident #1 in changing her gown or socks after Resident #1 had been outside of the facility. LVN B stated he had no information about that incident. CNA G stated he was not at work when that incident occurred. CNA G stated that on Saturday, January 25th, 2025, Resident #1 had opened the door on hall 200 and had gone out the door. CNA G stated that the alarms went off. CNA G said he saw Resident #1, LVN B, and LVN H at the corner of the building about 5 steps outside the door leading Resident #1 back into the building. CNA G stated that incident occurred around 7:00 PM, and he had spent the remainder of his shift until 10:00 PM on 1:1 with Resident #1 per the instruction of LVN B. CNA G stated LVN B placed Resident #1 back in the bed. CNA G said Resident #1 had not attempted to get out of bed during the 1:1 care. CNA G said he could not think of any times he had personally been involved with Resident #1 eloping. During an observation and interview on 01/29/2025 at 08:35 PM, LVN B stated if CNA G was not who helped her with Resident #1 when she sat at the picnic table back in October 2024, she could not remember who had helped her. LVN B said she remembered Resident #1 at the corner of the building approximately 5 steps outside the door, when LVN B and LVN H had guided Resident #1 back inside the building. LVN B denied any 1:1 care provided by CNA G. LVN B stated Resident #1 was fine, and that incident was not considered exit seeking behaviors or elopement because she had been able to redirect Resident #1 and had never lost sight of Resident #1. LVN B stated Resident #1 was not hurt, and she was fine. LVN B stated she was sure she had notified Resident #1's family but guessed she did not document it. LVN B stated she should have documented the incident and notified the doctor and family. LVN B stated if she had not reported and documented the events, the doctor would not know Resident #1 required a more secured unit, which could cause potential harm to the resident. During an observation of the picnic table located outside of hall 500 approximately 10 ft. from the door, LVN B agreed there was no grass in the area only dirt and concrete. During an interview on 01/29/2025 at 09:15 PM, LVN K stated she had worked at the facility for 3 years. LVN K stated if a resident got outside the facility that would be considered an elopement. LVN K stated if a resident eloped, after she ensured the resident was safe, she would complete the required incident report, document in the resident's chart, notify the family, physician, and DON. LVN K stated it was important to document and report exit seeking behaviors and elopements to protect the resident and provide the most appropriate person-centered care to keep the residents safe. LVN K defined exit seeking behaviors as going to the door repeatedly, fiddling with the door handles, and window locks and setting off the alarms. LVN K defined elopement as requesting to go home, packing up their items, and getting out of the facility's door. LVN K stated if a resident eloped, the resident could suffer from physical injuries, falls, or being hit by car, or environmental injuries, heat or cold weather exposure. Therefore, reporting the incidents would result in an investigation to figure out how to prevent another occurrence of that nature. LVN K stated all the nurses at the facility regardless of shift, full- time or part time have a group chat for communication also. LVN K stated she could not recall receiving information in the group chat regarding Resident #1 being out of the building lying near the parking lot. LVN K said she worked on 7/27/2024 from 6 PM to 6 AM and was the charge nurse. LVN K said she did remember Resident #1 exited the facility and was found lying near the parking lot. LVN K said she vaguely recalled someone coming into the facility saying a resident was outside. LVN K said she could not recall any more details. During an interview on 01/29/2025 at 09:35 PM, CNA L stated she vaguely remembered someone had reported a resident outside the facility around 5:00 AM or 6:00 AM. CNA L stated she immediately verified that the residents on halls 100 and 400 were accounted for. She stated she had heard it was Resident #1, but she had not seen it for herself. CNA L stated she was not for sure of when it occurred. CNA L stated she could barely remember that incident. CNA L stated it was important to report to the charge nurse any exit seeking behaviors. CNA L stated if an elopement occurred, always ensure resident safety, then notify the nurse for assessments and reports to be completed. CNA L stated it was important to communicate the residents' required care to protect the residents from harm. Attempted telephone interview on 01/30/2025 at 09:50 AM to Kitchen Aide D. A voice message was left requesting a call back. (Kitchen Aide D was no longer employed at the facility.) Attempted telephone interview on 01/30/2025 at 09:53 AM to LVN M. A voice message was left requesting a call back. During an interview 01/30/2025 at 11:45 AM, the ADON stated there had not been any incidents of elopement. The ADON stated if a resident attempted to leave or made the alarm go off those were considered exit seeking behaviors. The ADON stated if a resident opened the door, and stepped outside the facility that was considered elopement. The ADON stated both exit seeking behaviors and elopements should be reported, documented, and the family and doctor should be notified. The ADON said this communication helped ensure the safety and continuity of care. The care plan should be updated to accurately reflect the needs of the residents so the staff can provide appropriate interventions. The ADON stated Resident #1 wandered. The ADON stated she was not aware of any incidents involving exit seeking behaviors or elopements with Resident #1. During a telephone interview on 01/30/2025, the Medical Director stated that he nor his physician assistant had been notified recently of any elopements from the facility or of Resident #1 exhibiting exit seeking behaviors. The Medical Director stated he could not be for sure, but he thought he was notified of a resident that got out of the facility on hall 5 but that had been several months ago. The Medical Director stated he expected the facility staff to notify him of any types of elopements and of exit seeking behaviors. The Medical Director stated he also expected appropriate incident reports and documentation to be completed and investigated so that the residents' care plans could be updated to meet their needs. The Medical Director stated without that vital information, the resident was at risk of injury and harm, and he could not properly assess the residents' needs. During an interview on 01/30/2025 at 03:45 PM, the Administrator defined elopement as a resident that constantly asked and stated they wanted to go home - packing items, cannot be redirected, and she realized she was coming back to the facility. The Administrator stated he need more education and had some regrouping to do and stated the documentation should have been completed and reflected on the reports and in Resident #1's chart. The Administrator stated he was never told that Resident #1 had attempted to elope or exhibited exit seeking behaviors by attempting to leave out of the facility. The Administrator stated he stayed at the facility from 9 AM to 5 PM daily and found it hard to believe the reported incidents only occurred when LVN B was working. The Administrator stated he felt targeted by staff that had been terminated. The Administrator stated LVN B had been terminated. The Administrator stated Resident #1 was in the process of being transferred to a secure unit at this time. The Administrator stated if an elopement occurred or a resident was exhibiting exit seeing behaviors, it was important to properly document it, complete an incident report, start an investigation, and notify the family and the physician to ensure the residents' safety. An undated facility policy titled Nursing Policies and Procedures - Elopement/Missing Resident indicated: .To safely and timely redirect patients/residents to a safe environment. A prompt investigation and search will be conducted if a patient/resident is considered missing . (6) When the patient/resident is located, the charge nurse completes a head-to-toe assessment. The Social Service Designee assess the patient/resident for emotional distress The Administrator was notified on 01/30/2025 at 04:48 PM that an Immediate Jeopardy situation was identified due to the above failure. The Administrator was provided the Immediate Jeopardy template on 01/30/2025 at 04:53 PM. The facility's Plan of Removal was accepted on 01/31/2025 at 08:12 AM. and included: Residents who have suffered or are likely to suffer a serious adverse outcome as a result of noncompliance. The failure to ensure that staff were following our elopement Policy had the potential to adversely affect all residents. Actions the facility will take. Regional Nurse provided in-service training to Administrator in person on the following topics. Inservice completed on 1/30/25 5:50 pm with Administrator, Director of nurses is currently outside of the country. Regional nurse will complete the same training before Director of nurses returns to next scheduled workday. Identifying an Elopement The importance of training staff to Document any elopements, Notifications required when elopements do occur. Importance of facility investigating each elopement and placing intervention to prevent reoccurrence which could result in injury or harm to the resident. The importance of facility elopement screening and assessments being completed accurate to determine wanderguard placement or potential secure unit placement. How to report an Elopement to HHSC. Completed at 5:50 pm In-services to all Staff were iniated1/30/25 @ 6:15 pm. Training will be conducted by administrator, ADONS and Regional nurses. Topics covered include Facility revised elopement policy. Policy addresses required assessments, documentation to complete and Notifications employees should contact. All in servicing will be completed by 1/31/25 @ 10am. No employee will be allowed to work until in servicing is completed. Elopement policy will be included in new hire training packets. All resident's elopement screens, and care plans were updated to ensure accuracy. Facility will follow elopement screen assessment guidelines for identifying level of risk. Facility screening tool provides a risk level numerical value based on key questions. All high-risk residents will be placed on Wander guard System. Audit and updates were completed by unit managers and ADONS Initiated 1/30/25 @7pm to be completed on 1/31/25 @ 8am. All residents that are on wanderguard will be identified in a binder at the nurse's station, with resident demographics (face sheet) to identify each. Completed by Unit managers and ADONS Initiated on 1/30/24 Resident # 1 was assigned a designated sitter until secure unit placement can be arranged.1/30/25 @ 5pm Facility adopted a new Elopement policy on 1/30/25. The Updated policy clearly defines steps for employees to take during an elopement. The new policy directs staff on necessary notifications to make, and all documents to complete. Incident reports and medical record entry are covered as well On 01/31/2025 the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by: During an observation at 01/31/2025 at 11:10 AM, Resident #1 had a 1:1 sitter outside her room door. Record review of in service dated 01/30/2025 provided by the Regional Nurse training to Administrator in person on the following topics. Identifying an Elopement The importance of training staff to Document any elopements, Notifications required when elopements do occur. Importance of facility investigating each elopement and placing intervention to prevent reoccurrence which could result in injury or harm to the resident. The importance of facility elopement screening and assessments being completed accurate to determine wanderguard placement or potential secure unit placement. How to report an Elopement to HHSC. Record review of In-services dated initiated on 1/30/25 provided by administrator, ADONS and Regional nurses. Completed by Topics covered include Facility revised elopement policy. Policy addresses required assessments, documentation to complete and Notifications employees should contact. All in servicing will be completed by 1/31/25 @ 10am. No employee will be allowed to work until in servicing is completed. Elopement policy will be included in new hire training packets. Record Review of all resident's elopement screens and care plans were updated to ensure accuracy. Audit and updates were completed by unit managers and ADONS. Record Review of wanderguard binder located at the nurse's station, with resident demographics (face sheet) to identify each was completed by Unit managers and ADONS. Record Review of new Elopement policy dated 1/30/25. The policy clearly defines steps for employees to take during an elopement which included: directs staff on necessary notifications to make, and all documents to complete. and Incident reports/medical record entry. Record Review of the QAPI Committee Review -committee meeting was completed on 01/30/2025. Interviews of nursing staff: 6 AM - 6 PM - ADON, ADON QQ, MDS Nurse, LVN H, LVN P, LVN Q, LVN R, LVN BB, LVN VV, HA KK, HA LL, HA MM, HA NN, MA S, MA T, CNA U, CNA V, CNA W, CNA X, CNA Y, CNA AA, CNA CC, CNA DD, HA EE, HA FF, HA GG, CNA HHH. Social Worker, Activity Director Assistant, Transport Driver, Maintenance Supervisor, Receptionist, BOM, Medical Records, Laundry Aide SS, Housekeeper UU, Kitchen Aide C, Housekeeper Supervisor, Dietary Aide DDD, Dietary Aide EEE, Dietary FFF, Dietary GGG, Assistant Cook, Dietary Supervisor. 6 PM - 6 AM - LVN K, LVN N, LVN TT, HA PP, HA OO, HA RR, CNA G, CNA L, HA RR, CNA WW, CNA XX, CNA Z, HA HH, CNA A, CNA CCC. During these interviews' staff were able to correctly identify steps to take in the event of an elopement per the facility's policy such as types of exit seeking behaviors, interventions for exit seeking behaviors, required reporting and to whom, documentation of incidents reports and resident chart including care plans, and notifications to the family and physician. On 01/31/2025 at 2:06 PM., the Administrator was informed the IJ was removed; however, the facility remained out of compliance at a potential for more than minimal harm with a scope identified as isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. On 01/31/2025 at 02:06 PM., the Administrator was informed the IJ was removed; however, the facility remained out of compliance at a potential for more than minimal harm with a scope identified as isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure basic life support, including cardiopulmonary resuscitation (CPR), was provided to a resident requiring such emergency care prior to the arrival of emergency medical personnel and subject to related physician orders and the resident's advance directives for 1 of 4 (Resident #1) residents reviewed for CPR. 1. The facility failed to ensure staff utilized the AED (automated external defibrillator, is a medical device that analyzes the heart's rhythm and, if necessary, delivers an electrical shock to the heart in attempt to re-establish an effective rhythm) when Resident #1 was found unresponsive and not breathing because the facility staff could not locate the AED pads (Automated External Defibrillator pads are an essential part of the AED machine. The pads are connected via wire to the AED machine and are placed on the bare chest. The AED pads detect the heart rhythm and deliver electric current [shock] through the chest wall when the AED machine detects a shockable rhythm). 2. The facility failed to ensure staff adequately checked the crash cart to ensure the AED was ready for use and the AED pads were with the AED machine. These failures resulted in an identification of an Immediate Jeopardy (IJ) on [DATE] at 4:30 p.m. While the IJ was removed on [DATE], the facility remained out of compliance at no actual harm with potential for more than minimal harm that is not immediate jeopardy with a scope identified as isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. These failures could place residents at risk of not receiving necessary life-saving measures, decline in health, and death. Findings include: Record review of the face sheet dated [DATE] indicated Resident #1 was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses including fracture of the upper end of the left humerus (upper arm bone), subsequent encounter for fracture with routine healing, end stage renal disease (the last stage of long term kidney disease), convulsions, type 2 diabetes, CAD (coronary artery disease-damage or disease in the heart's major blood vessels caused by plaque), venous insufficiency (improper functioning of the vein valves in the leg), and peripheral vascular disease (circulatory condition in which narrowed blood vessels reduce blood flow to the limbs). The face sheet indicated Resident #1 was a full code (if a person's heart stopped beating and/or they stopped breathing, all resuscitation procedures would be provided to keep them alive. This process can include chest compressions, artificial ventilation and defibrillation and is referred to as CPR.). Record review of MDS assessment dated [DATE] indicated Resident #1 had clear speech, understood others and made herself understood. The MDS indicated Resident #1 had moderately impaired cognitive function (BIMS of 10). The MDS did not indicate Resident had a DNR advanced directive in place. Record review of the care plan last revised on [DATE] indicated Resident #1 was a full code. Record review of the physician order summary report dated [DATE] stated Resident #1 was a full code. Record review of MDS dated [DATE] indicated Resident #1 had clear speech, understood others and made herself understood. The MDS indicated Resident #1 had moderately impaired cognitive function (BIMS of 10). The MDS did not indicate Resident had a DNR advanced directive in place. Record review of the care plan last revised on [DATE] indicated Resident #1 was a full code. Record review of the nursing note dated [DATE] at 6:19 a.m. stated nurse aide called for nurses. Upon entering room resident had no rise or fall of chest. Nurse called for code status. Resident being a full code CPR was initiated. This nurse called 911 at 0621 (6:21 a.m.). This nurse along with fellow coworkers performed CPR taking turns with compressions. This writer was the last nurse to speak to resident at 0510 (5:10 a.m.) while administering morning medication . The nursing note was not signed. Record review of the nursing note dated [DATE] as a late entry at 6:19 a.m. stated, This nurse was called to room by CNA, that resident was not breathing- upon exam there were no resp (respirations) immediately called code status .911 called - all measures taking with CPR administered and continued until EMS arrived at 6:35 a.m. Res (resident) was given 3 rounds of epi (epinephrine) with fluids. Res (resident) was intubated. CPR continued until 6:55 a.m. without success The nursing note was signed by ADON B. During an interview on [DATE] at 1:52 p.m., ADON B said on [DATE] she worked the floor and was assigned Resident #1 on the 6:00 a.m. to 6:00 p.m. shift. ADON B said that morning ([DATE]) she immediately responded when the CNA yelled out that Resident #1 was not breathing. ADON B said Resident #1 was a full code and CPR was started immediately. ADON B said the night shift nurses, LVN A and LVN C were still in the facility and also responded. ADON B said the crash cart was brought in immediately but the AED pads for the AED machine could not be located. ADON B said nurses continued CPR as she attempted to locate the AED pads. ADON B said she could not locate the pads and called the DON for assistance. ADON B said she was told by the DON that extra AED pads were located in one of the cabinets in the medication room. ADON B said she could not find the AED pads in the medication room. ADON B said she never found the AED pads. ADON B said AED pads were not placed on Resident #1 until EMS arrived and placed their AED (the AED brought by EMS) on Resident #1. ADON B said there was no way to know if Resident #1 had a shockable rhythm prior to EMS arrival. ADON B said the AED pads were not located until after the code. The ADON said the DON found the AED pads upon his arrival to the facility. ADON B said she did not know why the AED pads were not on the crash cart on [DATE]. ADON B said the crash cart was checked daily. She said part of those checks were to ensure the AED machine was ready for use and AED pads were attached to the machine. ADON B said a green indicator light flashes on the AED signaling the pads were connected and the AED was ready for use. ADON B said she assumed whoever had performed the daily check on crash cart before the code event had not ensured the green light was flashing /AED pads were connected. While viewing the Crash Cart Checklist from [DATE] to [DATE] ADON B identified all of the signatures on the checklist as herself, LVN C, and LVN E. Record review of the Crash Cart Checklist from [DATE] to [DATE] indicated the crash cart had been checked daily. The checklist contained a check box labeled AED. The crash cart checklist did not specify the crash cart was checked for AED pads or the blinking green indicator light. The Crash Cart Checklist documented the following nurses' signatures on the following specified dates leading up to Resident #1's death; *[DATE]- signed by ADON B; *[DATE]- signed by ADON B; *[DATE]- signed by LVN C; *[DATE]- signed by LVN C; *[DATE]- signed by LVN C; *[DATE]- signed by LVN E; *[DATE]- signed by LVN E; *[DATE]- signed by LVN C; and *[DATE]- signed by LVN C. During an interview on [DATE] at 2:15 p.m., LVN A said she had worked [DATE] from 6:00 p.m. to [DATE] to 6:00 a.m. and was the nurse assigned to Resident #1. LVN A said she was still in the facility completing her charting when Resident #1 was found not breathing by the day shift CNA. LVN A said ADON B was her relief that morning and ran to check Resident #1. LVN A said ADON B yelled out for the Resident #1's code status. LVN A said she checked Resident #1's code status and found she was full code and immediately yelled out to ADON B that Resident #1 was a full code. LVN A said LVN C and LVN D immediately grabbed the crash cart and went to Resident #1's room. LVN #1 said she immediately called 911 and went to the room. LVN A said the AED pads could not immediately be located on the crash cart and there was a delay applying the AED pads to Resident #1 because the pads were not on the crash cart as they should have been. LVN A said she believed the AED pads were located and applied to Resident #1 before the arrival of EMS. Resident #1 said the delay in applying the AED pads was more than one minute but could not have been longer than 5 minutes. LVN A said she was not in the room the entire time the code was in process before the arrival of EMS because she stepped out of the room while on the phone with 911 in order to provide more detailed information regarding Resident #1. During an interview on [DATE] at 2:20 p.m., LVN C said he immediately responded when Resident #1 was found not breathing. LVN C said he initiated chest compressions and was the primary nurse that delivered compressions until EMS arrival. LVN C said he was in the room the entire time the code was in process prior to the arrival of EMS. LVN C said the AED was not used prior to the arrival of EMS because the AED pads could not be located. LVN C said there was no way to know if Resident #1 had a shockable rhythm until EMS arrived because the AED pads could not be found. LVN C said on [DATE]-[DATE] and [DATE]-[DATE], he had just signed the crash cart check list because he trusted the nurses that had signed before him but did not verify the AED had pads connected/green indicator light was flashing. During an interview on [DATE] at 2:40 p.m., LVN D said she was working the morning of [DATE] when Resident #1 was found unresponsive. LVN D said she ran and got the crash cart and by the time she arrived in Resident #1's room with the crash cart, CPR had already been started. LVN D said she remained in Resident #1's room the entire time the code was underway until the arrival of EMS. LVN D said the AED pads could not be found and so the AED was not utilized. LVN D said she heard someone say Resident #1 had an ICD (implantable cardioverter-defibrillator a small battery-powered device placed in the chest. It detects and stops irregular heartbeats, also called arrhythmias. An ICD continuously checks the heartbeat. It delivers electric shocks, when needed, to restore a regular heart rhythm. ICDs require regular checks to ensure they are operational.) LVN D said when EMS arrived, they used their AED machine on Resident #1. LVN D said she was not sure a shock was delivered because she left the room shortly after EMS arrived. LVN D said the facility AED pads were not found until after the code. During an interview on [DATE] at 3:05 p.m., the Medical Director said Resident #1 had a history of cardiac arrest. The Medical Director said if an ICD is functioning properly an AED would not be needed. The Medical Director said he believed Resident #1 had an ICD but could not say when she (Resident #1) last saw her cardiologist or had the device checked. During an interview at [DATE] at 3:10 p.m., the DON said the AED pads were to be with the AED at all times. The DON said the AED was supposed to checked daily as part of the crash cart daily checks. He explained, there was green indicator light that flashed on the AED indicating the AED was ready for use. The DON said the indicator light would not flash if the AED pads were not connected. The DON said he expected nurses to ensure the AED pads were connected and the AED was ready for use when daily crash cart checks were performed. The DON said ADON B had called him when the AED pads were not with the AED and could not be located on [DATE]. The DON said he tried to instruct ADON B on where to find the replacement AED pads. The DON said he found the AED pads when he arrived to the facility in one of the medication room cabinets. The DON said Resident #1 had an ICD but could not say when the device was last checked. The DON said there was no way to know for sure if Resident #1 had a shockable rhythm before the arrival of EMS as an AED was not utilized prior to their (EMS) arrival. The DON said he ensured after the incident that AED pads were connected to the AED and an extra set of AED pads were placed within the back zipper pocket of the AED case. The DON said other than word of mouth there had been no in-services for staff related to the incident. The DON said he was not sure he had notified the Administrator regarding the incident. During an interview at [DATE] at 3:39 p.m., the Administrator said he had not been notified by anyone that staff could not locate AED pads on the morning of [DATE] when Resident #1 coded. The Administrator said he had not been notified that there had been no use of an AED until the arrival of EMS as a result of staff not having been unable to locate the AED pads. The Administrator said the AED pads should be with the AED at all times and nurses should be checking that the pads are there during daily crash cart checks. Record review of the EMS report dated [DATE] reflected Resident #1's ECG (electrocardiogram, a recording of the heart's electrical activity) displayed a rhythm of asystole (the heart's electrical system fails entirely, which causes the heart to stop pumping. It is also known as flat-line. Asystole is a non-shockable rhythm). The EMS record indicated EMS arrived at approximately 6:30 a.m. and continued resuscitation efforts until 6:52 a.m., at which time efforts were discontinued and Resident #1 was pronounced dead. Record review of the facility policy and procedure titled Automatic External Defibrillator, Use and Care of, revised March of 2015 found the policy and procedure stated, Personnel have completed training on the initiation of cardiopulmonary resuscitation (CPR) and basic life support, including defibrillation, for victims of sudden cardiac arrest. Policy Interpretation and Implementation (1) During a sudden cardiac arrest event, follow guidelines outlined in the procedure for Cardiopulmonary Resuscitation and Basic life Support . (3) The automatic external defibrillator (AED) will be used to try to restore normal cardiac rhythm when arrhythmia is strongly suspected. Recognizing the signs and symptoms of arrhythmia (and when to use the AED) is part of the CPR/BLS training. (4) In general, SCA [sudden cardia arrest] should be suspected if: (a)The victim's symptoms appeared very suddenly; (b) He or she is unresponsive; and (c)His or her breathing has stopped. (5) If an individual is found unconscious and SCA is suspected, begin the AED Protocol below. Initial Assessment and Safety Precautions . (3) Assess the victim: (a)Responsiveness - if unresponsive, retrieve (or direct someone to retrieve) the AED from its location and bring it to the victim .Applying Pads to the Victim .(6) Attach two AED pads to the victim's bare chest (one on the upper right , one on the left) .Defibrillation. (1) After applying pads .The AED will analyze the heart rhythm and indicate whether a shock is needed . (5) Follow the AED prompts until the emergency medical service arrives . The facility policy and procedure titled Emergency procedure- Cardiopulmonary Resuscitation, revised [DATE] found the policy and procedure stated, Policy Statement-Personnel have completed training on the initiation of cardiopulmonary resuscitation (CPR) and basic life support (BLS), including defibrillation, for victims of sudden cardiac arrest. General Guidelines . (4) The chances of surviving SCA may be increased if CPR is initiated immediately upon collapse. (5) Early delivery of a shock with a defibrillator plus CPR within 3-5 minutes of collapse can further increase chances of survival . Preparation for Cardiopulmonary Resuscitation . (6) Maintain equipment and supplies necessary for CPR/BLS in the facility at all times. Emergency Procedures- Cardiopulmonary Resuscitation- . (7) When the AED arrives, assess for need and follow AED protocol as indicated. (8) Continue with CPR/BLS until emergency medical personnel arrive. The Administrator was notified on [DATE] at 4:42 p.m. that an Immediate Jeopardy situation was identified due to the above failures. The Administrator was provided the Immediate Jeopardy template on [DATE] at 4:57 p.m. The facility's plan of removal was requested on [DATE] at 4:57 p.m. The facility's Plan of Removal was accepted on [DATE] at 12:58 p.m. and included: Regional nurse provided in-service to the director of nursing and administrator on regulations of CPR and AED. Topics of in-service included, AED must be checked daily to ensure it is functioning properly and ready to go. Education also provided that the facility must identify a storage area for emergency supplies and ensure staff know the location. Initiated: [DATE] completed: [DATE] 5:25 p.m. In-services on the CPR policy including the use of AED, daily checks verifying pads are connected and ready to use. Location of replacement pads in the facility and importance of replacing immediately if used. daily check sheet updated with checks to include battery connected and replacement pads, in-services were started on [DATE] at 5:45pm by DON for all licensed nursing staff. All licensed nurses will be in-serviced prior to their next shift. No nurse will be allowed to work until in-service is completed. Initiated [DATE] to be completed on [DATE] 1:00 p.m. Administrator and DON verified that the AED is functioning as manufacturer intended, with pads connected. replacement pads added to AED storage compartment. completed on [DATE] 5:30 p.m. An audit of all employees for CPR certification and training was completed by the administrator on [DATE] for CPR compliance. facility audited the last 90days of resident discharges to ensure no other full code residents were affected. no other residents required CPR inside the facility. Initiated: [DATE] completed: [DATE] 7:00 p.m. Facility scheduled a QA with medical director to be held on [DATE] at 8:00 a.m. Initiated: [DATE] completed: [DATE] at 8:30 a.m. Facilities policy and procedure titled Emergency Procedure- Cardiopulmonary Resuscitation was reviewed and updated by administrator and regional nurse on [DATE] to ensure that current policy meets the standards of practice and regulatory requirements on properly trained staff are in the building 24/7. Initiated: [DATE] completed: [DATE] 5:00 p.m. Ongoing systematic change to ensure CPR trained staff are knowledgeable on AED and location of all emergency supplies and equipment on all shifts is that all licensed personnel will receive training at the time of hire. Storage area for AED pads has been identified with a large red sign AED pads here- initiated: [DATE] completed [DATE] 7:30 p.m. The QAPI team, led by the administrator, will meet weekly for 3 weeks to discuss coordination of completion of all in-services, assessments, and interventions are utilized and completed. The medical director was notified on [DATE] of the immediate jeopardy called on facility. Initiated: [DATE] completed: [DATE] 8:00 p.m. On [DATE] the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by: Record review of the signed statement dated [DATE] at 5:30 p.m., verified the crash cart was checked by both the Administrator and DON for AED pads were connected to the AED, the green indicator light was observed flashing, an extra set of AED pads were in place. The expiration dates of the pads were checked and the AED powered on and prompts began without error codes. Record review of the undated facility document titled Future QAPI Dates QAPI plan to meet weekly for 3 weeks ([DATE] at 10:00 a.m., [DATE] at 10:00 a.m., and [DATE] at 10:00 a.m.). Record review of the undated new Crash Cart Checklist displayed the following added check off items: *AED pads connected; *Extra AED pads in bag; and *Expiration date on AED pads checked. The new Crash Cart Checklist had been completed with the new items checked off and signed. Record review of the CPR Certification Audit document reflected AUDIT OF all nurses for CPR certification and training was completed by the administrator on [DATE] for CPR compliance. Record review of the in-service training report dated [DATE], Topic: Potential for Clause reflected the DON and Administrator had received in-service over the importance of actual failures or potential for failures must be reported, investigated, staff in-serviced as necessary to ensure no other residents would be affected, all corrective actions taken and monitored. Record review of the in-service training report dated [DATE], Topic: Importance of Regulation 678 reflected the DON and Administrator and received in-service/instruction that the AED must be checked daily to ensure it is functioning properly and ready to go and that the facility must identify a storage area for emergency supplies /ensure staff know the location. Record review of the in-service training report and accompanied sign in sheet dated [DATE], Topic: Checking the AED and AED pads reflected nurse in-services over; the updated Emergency Procedure -CPR policy; on the use of AED; on daily checks- verifying pads were connected and ready to use; on the location of replacement pads in the facility; and importance of replacing the pads immediately after use; and the updated crash cart check off list had been initiated. Record review of the audit document of deceased residents since [DATE] verified in the last 90 days no additional discharged /deceased residents had required full code interventions. Record review of the facility QA agenda and sign in sheet dated [DATE] reflected a QA meeting with the Medical Director was held on [DATE] at 8:00 a.m. and agenda outline included Medical Director notification of identified system failure and identification of Immediate Jeopardy on [DATE] and corrective actions taken as of [DATE] at 8:00 a.m. The document was signed by the Medical Director. Record review of the updated policy and procedure titled Emergency Procedure- Cardiopulmonary Resuscitation found the policy and procedure had been reviewed and revised and ensured maintain equipment and supplies necessary for CPR/BLS in the facility at all times remained in the policy and procedure. Record review of the undated, AED acknowledgment form found that the new applicants would sign acknowledgement form which stated, The AED must be checked every day. Nurses must ensure the green light is flashing verifying the pads and batteries are connected. Nurses must check to ensure replacement pads are in the storage compartment. Replacement pads are also located in the Med Room in a cabinet with a red sign alerting to the location. If at any time the AED is not functioning properly, the DON and Administrator must be notified immediately. During an observation on [DATE] at 12:40 p.m., a large red sign taped to a cabinet door in medication room alerted the viewer of the location of extra AED pads. Three additional boxes of AED pads were labeled and in place. During an observation on [DATE] at 12:45 p.m., the facility crash cart was found with the AED in place, the green indicator light was flashing on the AED, AED pads were connected to the AED, an additional set of AED pads were found in the attached zipper compartment, and the expiration date checked on both set of pads. The placement and use of the new Crash Cart Checklist was also observed. Staff interviewed on [DATE] between 1:00 p.m. and 3:00 p.m. (LVN F, LVN, G, LVN H, LVN C, RN I, RN J, LVN K, LVN L, LVN M, ADON N, ADON B, ADON, O, LVN P and LVN Q [ these nurses comprise 6 of 7 of the facilities staff day shift nurses, 3 of 7 staff night nurses plus 4 nurses with other primary roles- 3 of which regularly work the floor]), said crash cart checks were to be performed daily and those checks must include ensuring AED pads were connected to the AED machine, the flashing green indicator light was observed, extra pads were in the attached zipper pocket of the AED case and the expiration dates on both sets of the AED pads were checked. The nurses also said in addition to the extra set of AED pads a spare battery was located in the attached zipper pocket. The nurses said that after a code the AED pads were to be replaced immediately after the code. The nurses said the replacement pads could be found in the medication room behind the cabinet labeled with a red sign indicating the location of the AED pads. The nurses said if they went to replace the pads and they were not in those locations they would immediately notify the DON. The nurses correctly identified the changes made to the crash cart checklist as, AED pads connected; Extra AED pads in bag; and Expiration date on AED pads checked. The nurses also said that checking the box marked AED meant the AED was on the crash cart and the AED's blinking green indicator light was observed. The nurses said the flashing green indicator light indicated pads were connected and the AED was ready for use. The nurses also stated if any issues or obstacles were encountered during the course of care for residents that resulted in a bad outcome or potentially could result in a bad outcome, they would notify the DON and Administrator in order for administration and QAPI team to review the situation take any corrective actions and ensure no additional residents were affected. During an interview on [DATE] at 3:06 p.m., the DON said he should have notified the Administrator of the failure to have the AED pads readily available on [DATE] (which resulted in Resident #1 not receiving AED intervention until arrival of EMS). The DON said he should have ensured the notification so that the situation could have been reviewed, all failures identified and all corrective actions put in place, including staff in-services. The DON said going forward the facility would implement a system to ensure DON was notified any time the crash cart was pulled for use, even if after pulling the cart it was discovered/determined the resident was a DNR and the cart was not used. The DON said perhaps this was the situation that resulted in the AED pads not being in place when Resident #1 coded on [DATE] as the facility audit for the past 90 days discovered no other resident that been administered a full code. The DON said anytime the cart is pulled the entire crash cart would be audited to ensure all essential equipment (including AED pads) were replaced. He said in addition spots checks would be initiated to ensure nurses completed crash cart checks appropriately. The DON said all new staff hired would read and sign the AED acknowledgement form and in addition, all staff would have to sign the acknowledgement annually. The DON said there had also been discussion of mounting the AED machine, making it visible from the nursing station to ensure the green indicator light could be easily and readily viewed. The DON said all nurses that have worked since the identification of the IJ had received in-services and that no nurse would be allowed to return to work until in-services were completed. During an interview on [DATE] at 3:13 p.m., the Administrator said all nurses that have worked since the identification of the IJ had received in-services and that no nurse would be allowed to work until in-services were completed. While the IJ was removed on [DATE] at 3:22 p.m., the facility remained out of compliance at no actual harm with potential for more than minimal harm that is not immediate jeopardy with a scope identified as isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 of 7 residents (Resident #98) and 2 of 4 medication storage location (medication storage #1 and #2) reviewed for pharmacy services. 1. The facility failed to clarify the open-ended order for Lovenox (an anticoagulant medication used to prevent blood clots) therapy when Resident #98 returned from his hospital admissions on 1/25/23 and again on 2/7/23. 2. The facility failed to have system in place to ensure appropriate medication reconciliation was performed for Resident #98. 3. The facility failed to have a system in place to ensure accurate duration of anticoagulant therapy for Resident #98. 4. The facility failed ensure Resident #98 was assessed (and those assessments documented) for signs and symptoms of complications from anticoagulant therapy. 5. The facility failed ensure Glucosamine Chondroitin (a dietary supplement indicated to reduce symptoms of osteoarthritis) was not expired in medication storage location #1. 6. The facility failed to ensure One Daily Vitamin, Folic Acid (important in red blood cell formation and for healthy cell growth and function) 400 mcg, Famotidine (used to prevent and treat heartburn due to acid indigestion and sour stomach caused by eating or drinking certain foods or drinks) 10mg, Geri-Kot (used to treat constipation) 8.6mg were not expired in medication storage #2. These failures resulted in an identification of an Immediate Jeopardy (IJ) on 3/2/23. While the IJ was removed on 3/4/23, the facility remained out of compliance at actual harm that is not immediate with a scope identified as isolated, due to the facilities need to complete in-services and evaluate the effectiveness of the corrective systems. These failures could place residents requiring anticoagulant therapy at risk of severe anemia, hemorrhage, or death and adverse effects and reduced therapeutic effects of medication and supplies. Findings included: Record review of Resident #98's physician orders indicated he was [AGE] years old and admitted to the facility on [DATE] with diagnoses including displaced spiral fracture of shaft of the right femur (fracture of the right thigh bone), dependance on renal dialysis, Hypertensive urgency (marked elevation in blood pressure without evidence of target organ damage), anemia, type II diabetes, chronic respiratory failure (slow developing respiratory failure that happens when the airways that carry air to your lungs become narrow and damaged), chronic obstructive pulmonary disease (group of lung diseases that block airflow and make it difficult to breathe) and end stage renal disease ( final, permanent stage of chronic kidney disease, where kidney function has declined to the point that the kidneys can no longer function on their own. A patient with end-stage renal failure must receive dialysis or kidney transplantation). Record review of the MDS assessment dated [DATE] indicated Resident #98 was understood and made himself understood. The MDS indicated he was cognitively intact as evidence by a BIMS score of 14. The MDS indicated he had no behavior of rejecting care. The MDS indicated he required extensive assistance with transfers, walking, dressing, personal hygiene and bathing. The MDS indicated he was always continent of bowel and bladder. The MDS indicated he had active diagnoses of renal insufficiency, renal failure, or end stage renal disease, as well as anemia, diabetes and hip fracture. The MDS indicated Resident #98 had a major surgical procedure during the prior inpatient hospital stay that required active care. The MDS indicated he underwent orthopedic surgery for repair of fracture(s) of the pelvis, hip, leg, knee or ankle. The MDS indicated Resident # 98 had received anticoagulant therapy 3 days during the seven days look back period. Record review of Resident #98's care plan dated 1/27/23 indicated Resident #98 was on anticoagulant therapy. The care plan interventions included adjust medications per facility protocol, and observe for signs of active bleeding (nosebleeds, bleeding gums, petechiae [ small red or purple spot caused by bleeding into the skin], purpura [ rash of purple spots on the skin caused by internal bleeding from small blood vessels], ecchymotic areas [bruising], hematoma [solid swelling of clotted blood within the tissues], blood in urine, blood in stools, hemoptysis [coughing up blood], elevated temp, pain in joints, abdominal pain). Record review of the Operative Report from the hospital dated 1/20/23 dictated by the Orthopedic Surgeon indicated Resident #98 underwent Open reduction (open reduction involves open incision to access the bone and realign it, so it heals properly) internal fixation (internal fixation involves piecing the bone fragments together with hardware such as pins, plates, rods, screws, or a combination of these) of a right subtrochanteric femur (area just below [within 5cm] where the thigh bone connects to the pelvis) fracture. Record review of the Orthopedic Follow Up Note written on 1/23/23 from the hospital by the Orthopedic Surgeon indicated Resident #98 was to be discharged to SNF (skilled nursing facility) and administered anticoagulation therapy for 1 month. Record review of the Discharge Home Medication List dated 1/24/23 at 5:06 p.m., from the hospital indicated Resident #98 was to be administered Lovenox 30 mg injection subcutaneously (means beneath, or under, all the layers of the skin) once a day. Record review of the active physician order with a start date of 1/25/23 indicated Resident #98 was to be administered Lovenox 30 mg injection subcutaneously once a day at 6:00 a.m. due to diagnosis of displaced spiral fracture of the right femur. The physician order had no stop date. Record review of Resident #98's medication administration record from 1/25/23 to 1/28/23 indicated he was administered Lovenox daily at 6:00 a.m. on the following dates: 1/26/23 to 1/28/23. Record review of the nursing notes from 1/25/23 to 1/28/23 for Resident #98 did not indicate he had been monitored for complications of anticoagulant therapy. Record review of the MAR and TAR for Resident #98 from 1/25/23 to 1/28/23 did not indicate he had been monitored for complications of anticoagulant therapy. Record review of the nursing note dated 1/28/23 at 12:00 p.m., indicated Resident #98 was sent to the ER for uncontrolled pain. Record review of the nursing note dated 1/28/23 at 2:30 p.m., indicated Resident #98 had returned to facility from the emergency room. Record review of the physician order dated 1/28/23 from the hospital indicated Resident #98 was to resume previous physician orders. Record review of Resident #98's medication administration record from 1/28/23 to 1/31/23 indicated he was administered Lovenox daily at 6:00 a.m. on the following dates: 1/28/23 to 1/31/23. Record review of the nursing notes from 1/28/23 to 1/31/23 for Resident #98 did not indicate he had been monitored for complications of anticoagulant therapy. Record review of the MAR and TAR for Resident #98 from 1/28/23 to 1/31/23 did not indicate he had been monitored for complications of anticoagulant therapy. Record review of the nursing note dated 1/31/23 indicated Resident #98 had been sent to the hospital for decreased level of consciousness, decreased oxygen saturation and decreased blood pressure. Record review of the nursing note dated 2/7/23 at 3:40 p.m. by RN C indicated Resident #98 had been readmitted to the facility from the hospital. Record review of the discharge home medication list dated 2/7/23 from the hospital indicated Resident #98 was to continue taking Lovenox 30 mg injections daily at 6:00 a.m. There was no stop dated listed on the discharge home medication list. Record review of Resident #98's medication administration record from 2/7/23 to 2/28/23 indicated he was administered Lovenox daily at 6:00 a.m. on the following dates: 2/9/23 to 2/27/23. Record review of the nursing notes from 2/7/23 to 2/10/23 for Resident #98 did not indicate he had been monitored for complications of anticoagulant therapy. Record review of the nursing note dated 2/11/23 at 3:30 p.m. written by RN C indicated Resident #98 had blood coming from his dialysis shunt after he (Resident #98) removed the dressing from the site. The note indicated the nurse (RN C) cleaned the site and applied a new dressing and would continue to monitor for bleeding. There were no additional nursing notes for 2/11/23. Record review of the nursing notes from 2/12/23 to 2/28/23 for Resident #98 did not indicate he had been monitored for complications of anticoagulant therapy. Record review of the MAR and TAR for Resident #98 from 2/7/23 to 2/28/23 did not indicate he had been monitored for complications of anticoagulant therapy. During an observation on 2/27/23 at 11:45 a.m., Resident #98 was sitting in his wheelchair. Resident #98 had no visible bruising and indicated he had no problems with the care he received at the facility. Record review of the nursing note dated 2/28/23 at 5:08 p.m. written by LVN D, indicated Resident #98 was sent to the emergency room due to dark red .bloody stool coming from his rectum non-stop. Record review of Gastroenterology Consultation note from the hospital dated 3/1/23 indicated Resident #98 was brought to the hospital with an acute GI bleed and low blood pressure. The consolation note indicated he had been on Lovenox therapy and was having frank (clinically evident) red blood from his rectum. The note indicated he underwent imaging studies that showed active bleeding in his stomach. The note indicated the Gastroenterologist ordered for Resident #98 to be intubated and administered agents to reverse anticoagulation. The note indicated the GI team was called for emergent endoscopic (endoscopy procedure uses an endoscope to examine the interior of a hollow organ or cavity of the body) evaluation. Record review of Gastroenterology Procedure note from the hospital dated 3/1/23 indicated Resident #98 had endoscopic intervention to treat his upper GI bleed. The procedure note indicated Resident #98 had suffered hemorrhagic shock and would continue blood transfusion. The procedure note indicated he would remain intubated in case repeat endoscopic evaluation was needed during the night. During an interview on 3/2/23 at 9:05 a.m., LVN J said CMA GG was responsible to ensure orders were entered for residents who have returned from or admitted from the hospital. During an interview on 3/2/23 at 9:08 a.m., CMA GG said she reconciled resident orders when they returned from the hospital. CMA GG said she entered orders for residents who admitted from the hospital. CMA GG said she puts the orders in as they come from (as they are) from the hospital unless the admitting nurse directed otherwise. CMA GG said if a resident had an open ended (an order with no stop date) order for Lovenox she would have clarified with the nurse that admitted the resident because Lovenox was not a long-term use medication. CMA GG said a resident on anticoagulant therapy would also have orders for anticoagulant monitoring to ensure nurses assessed and documented whether or not a resident had signs of complications for anticoagulant therapy such as bleeding and bruising. CMA GG said she could not say for sure if she questioned or clarified with the admitting nurse regarding Resident #98's Lovenox order. During an interview on 3/2/23 at 9:20 a.m., the DON indicated there was no process in place to double check orders/reconcile orders that had come from the hospital when a resident admitted from or returned from the hospital. The DON said Resident #98's Lovenox should have had a stop date and said she would ensure that going forward there was a process in place to clarify open ended anticoagulant therapy. The DON said she expected nurses to assess and document anticoagulant monitoring for every resident on anticoagulant therapy. The DON said the documentation should have been on the MAR/TAR or in the nurses' notes. During an interview on 3/2/23 at 9:30 a.m., the Corporate Nurse said there was a system in place to double check orders/reconcile orders that had come from the hospital when a resident admitted from the hospital. The Corporate Nurse indicated CMA GG was to use the admission checklist as a double check to ensure admission orders were appropriately reconciled. Record review of the undated, untitled internal communication form (the checklist provided by the Corporate Nurse) did not address orders for anticoagulant therapy or include any process/ verification for open ended orders of anticoagulant therapy. During an interview on 3/2/23 at 9:35 a.m., RN C said she regularly took care of Resident # 98 on 6:00 a.m. to 6:00 p.m. shift. RN C said she knew Resident #98 was on Lovenox but said the medication was administered on the 6:00 p.m., to 6:00 a.m. shift. RN C said she did monitor Resident #98 for complications of anticoagulant therapy and indicated he (Resident #98) had some bruising to his stomach from the injections. RN C said she could not say if she documented the monitoring. RN C said some residents have a check off on their MAR/TAR to document anticoagulant monitoring but could not say if that was the case for Resident #98. RN C said she had questioned open ended Lovenox therapy in the past with other residents and sought clarification but did not do so on Resident #98 because the Lovenox was administered on the 6:00 p.m. to 6:00 a.m. shift. During an interview on 3/2/23 at 9:41 a.m., MD 4's nurse said there was nothing in communication notes related to the facility seeking clarification regarding Resident #98's Lovenox therapy. During an interview on 3/2/23 at 11:00 a.m., MD 3 said the normal duration for Lovenox therapy was 15- 35 days but said he would defer to the expertise of Orthopedic Surgeon regarding the intended duration of therapy for Resident #98. During an interview on 3/2/23 at 11:10 a.m., LVN D said she regularly took care of Resident # 98 on 6:00 a.m. to 6:00 p.m. shift. LVN D indicated she had monitored Resident #98 for complications regarding anticoagulant therapy and said it should have been documented on the TAR/MAR. LVN D said she thought she had documented Resident #98's monitoring for anticoagulant therapy. LVN D said the usual length of anticoagulant therapy was 30 days. LVN D said she believed Resident #98 was getting close to that length of administration (30 Days) but could not say for sure because night shift administered the medication. LVN D said she took care of Resident #98 on 2/28/23 and was called to his room when he was found to have blood steadily coming out of his rectum upon his return from dialysis. LVN D said he was promptly sent to the emergency room. LVN D said earlier that day Resident #98 was fine and had no symptoms of complications of anticoagulant therapy. During an interview on 3/2/23 at 11:27 a.m., LVN U said she worked the 6:00 p.m. to 6:00 a.m. shift and regularly took care of Resident #98. LVN U said Resident #98 received Lovenox therapy but could not say why he was on the medication. LVN U said the usual duration for Lovenox therapy was 30 days but would administer the medication for whatever duration the physician order directed. LVN U said she was not sure how long Resident #98 had been on Loveonx therapy. LVN U said she could not say that she had questioned or sought clarification regarding Resident #98's Lovenox therapy. LVN U said she had only given Resident #98 his Lovenox a few times. LVN U said she monitored Resident #98 for complications of anticoagulant therapy and documented the monitoring in the nursing notes. During an interview on 3/2/23 at 12:00 p.m., RN FF said she worked the 6:00 p.m. to 6:00 a.m. shift and regularly took care of Resident #98. RN FF indicated she usually worked opposite of LVN U. RN FF said she was not sure how long Resident #98 had been on Lovenox therapy. RN FF said the usual duration for Lovenox therapy was 28 days. RN FF said there was usually a stop date on an order for Lovenox therapy. RN FF said Resident #98 was on Lovenox therapy for DVT (deep venous thrombosis, blood clots) prevention after having hip surgery. RN FF said she did not question Resident #98's open ended order for Lovenox because she assumed he was perhaps on a longer duration of therapy related to his dialysis. During an interview on 3/6/23 at 10:19 a.m., the Orthopedic Surgeon indicated Resident # 98 was to have received Lovenox therapy for 1 month as written in his progress note on 1/23/23. The Orthopedic Surgeon said the additional days of Lovenox therapy Resident #98 received, would not have caused his GI bleed but would have certainly contributed to the amount of blood loss he suffered. During an observation with the interim DON on 02/27/23 at 10:20 a.m., in medication storage location #1, revealed one unopened bottle of Glucosamine Chondroitin with expiration date of 12/22. During an observation with the interim DON on 02/27/23 at 10:28 a.m., in medication storage location #2, revealed one bottles of One Daily, Folic Acid 400mcg, Famotidine 10mg, and Geri-Kot 8.6mg with expiration date of 01/23 was found. During an interview on 03/01/23 at 4:17 p.m., RN C said nurses, MA, and the pharmacy consultant checked the carts and medication room for expired medications. She said the facility checked the medication cart and storeroom once a month; first of the month. RN C said staff members do not sign a checklist proving it was done but the expired medication was placed in the sink of the storeroom and staff notified the DON of meds that needed to be destroyed. She said expired medication was not as good and could lose potency. She said administering expired medications could cause residents to not get what the needed from the medication such as vitamins for vitamin deficiency. RN C said she did not know who would be responsible for ensuring staff did not administer or store expired medication but assumed it was the DON. During an interview on 03/03/23 at 9:51 a.m., MA DD said everyone check for expired medications during med pass before administration. She said the MAs and nurses should check the medication storeroom at least once a month for expired medications but would also check when you grabbed a new bottle.MA DD said expired medication should not be given because they were out of date and could make the resident sick. During an interview on 03/03/23 at 10:05 a.m., MA EE said she was not sure who would be responsible for checking the med carts and storeroom for expired medications, but she did know the pharmacy consultant came once a month and completed cart audits. She said she tried to check her medication cart once a week for expired meds. MA EE said medications were less effective when expired and would not get the desired results the medication was given for. During an interview on 03/03/23 at 12:50 p.m., the interim DON said she expected staff to check medication carts and the storeroom monthly for expired medications. She said the nurses and MAs was responsible for checking for expiration dates, but she would be taking it over. The interim DON said she thought the Pharmacy consultant was also checking for expiration dates when she came once a month. She said expired medication could be ineffective and the resident risked mot getting the desired affect for why the med was prescribed. The interim DON said there was not a formal process in place for checking for expired medication which she was already putting one in place. She said she was responsible for ensuring the staff were not administering or storing expired medications. During an interview on 03/03/23 at 1:32 p.m., the Pharmacy Consultant said she came to the facility mid-month and stayed for 2-3 days. She said she completed monthly audits of the storeroom and medication carts. The PC said during her visit completed gradual dose reduction for certain medication, watched med pass, checked for expired medications, medication destruction, and provided a recommendation of findings. She said she checked for expiration dates of medications, but it was not a complete check and if her report stated she found expired medications then they should do a thorough check. The PC said her report was emailed after her visit to the ADM and DON for review and to make corrections she found or observed. During an interview on 03/03/23 at 2:19 p.m., the ADM said he expected the nursing staff not to administer expired medications. He said LVNs and MAs should check for expired medication weekly and the DON monthly. The ADM said he also expected staff to properly discard expired medication. Record review of the in-service with Topic: Expectation, dated 12/22/22, revealed .nursing check offs .insulin administration checks off .insulin Pen administration check off .flushing PICC line .G-tube med administration check off . Medication storage check off was not noted. Record review of a facility Storage of Medications policy dated 04/07 revealed .the nursing staff shall be responsible for maintaining medication storage .the facility shall not use discounted, outdated .drugs or biologicals . The Administrator was notified on 3/2/23 at 4:40 p.m. that an Immediate Jeopardy situation was identified due to the above failures. The Administrator was provided the Immediate Jeopardy template on 3/2/23 at 4:48 p.m. The facility's Plan of Removal was accepted on 3/3/23 at 1:42 p.m., and included: THE ADMINISTRATOR AND DON WERE IN-SERVICED ON 3/02/23 AT 8:00 PM BY THE REGIONAL NURSE ON THE POLICY AND PROCEDURE OF ACCURATELY TRANSCRIBING PHYSICIAN ORDERS AND THE IMPORTANCE OF ORDER VERIFICATION. IN-SERVICE ON MONITORING OF RESIDENT FOR SIGNS AND SYMPTOMS OF ANTICOAGULANT THERAPY, WHICH INCLUDES BRUISING AND BLEEDING. IN-SERVICED ON HAVING A SYSTEM IN PLACE THAT CHECKS FOR ACCURACY AND TIMELINESS. NURSING UNIT MANAGERS WILL NOW ENTER ALL INFORMATION INTO MATRIX. CLINICAL MEETING WILL BE HELD EACH MORNING TO DISCUSS ALL ADMISSIONS, DISCHARGES, HOSPITALIZATIONS AND NEW ORDERS. EACH ORDER RECEIVED WILL BE VERIFIED THAT MONITORING AND ASSESSMENTS ARE COMPLETES AS WELL. INTIATED: 03/02/23 COMPLETED: 3/02/23 8:00 P.M. IN-SERVICES DONE BY THE DON, ADMIN, OR DESIGNEE ON THE IMPORTANCE OF MONITORING RESIDENTS ON ANTICOAGULANTS. IDENTIFYING SIGNS AND SYMPTOMS OF ADVERSE OUTCOMES RELATED TO ANTICOAGULANT THERAPY. STAFF TRAINED ON MEDICATION FOLLOW-UP AND COMMUNICATION WITH A PHYSICIAN TO ESTABLISH THE LENGTH OF TREATMENT WHEN NECESSARY. IN-SERVICE PROVIDED TO ALL LICENSED NURSING STAFF. ALL LICENSED NURSES WILL BE IN-SERVICED BEFORE THE NEXT SCHEDULED SHIFT. INITIATED: 3/02/23 COMPLETED: 3/03/23 11:55 P.M. REGIONAL NURSES PROVIDED IN-SERVICE TO LICENSED NURSES IN MANAGEMENT POSITIONS ON THE IMPORTANCE OF CHECKING EVERY PHYSICIAN ORDER FOR ACCURACY; WILL INCLUDE ALL REQUIRED INFORMATION. ENSURING ALL RESIDENTS HAVE THE APPROPRIATE DIAGNOSIS FOR PRESCRIBED TREATMENT. MEDICATION AIDE WILL NO LONGER WORK IN DATA ENTRY. ASSIGNED UNIT MANAGERS WILL ENTER PHYSICIAN'S ORDERS INTO MATRIX GOING FORWARD. ALL UNIT MANAGERS ARE LICENSED NURSES AND TRAINED IN MATRIX. ALL 6 NURSE MANGERS WILL BE INSERVICED ON 03/03/23 OR BEFORE THEIR NEXT SHIFT. INITIATED ON 03/02/23 PHARMACY CONSULTANT AWARE AND WILL REVIEW CHARTS AS WELL ON NEXT VISIT. INITIATED PHARMACIST WILL BE AVAILABLE BY PHONE. AND WILL BE IN THE FACILITY ON MARCH 14TH AND 15TH. INITIATED 03/03/23 COMPLETED 03/03/23 11:55 PM QAPI TO ADDRESS FINDINGS ON 03/03/23 INITIATED 03/02/23 COMPLETED 03/03/23. POLICY UPDATED TO INCLUDE VERIFYING THE LENGTH OF TREATMENT AND FREQUENCY WHEN RECEIVING PHYSICIAN'S ORDERS. ALL LICENSED NURSES WILL BE IN SERVICED PRIOR TO WORKING NEXT SHIFT. INITIATED: 3/02/23 COMPLETED: 3/03/23 1:00 p.m. During interviews with staff nurses on 3/4/23 from 10:00 a.m. to 11:45 a.m., (5 of 10 day shift staff nurses [LVN Q, LVN J, LVN D, RN R, LVN II]; 3 of 5 night shift staff nurses [LVN JJ, RN HH, RN Y] ) were performed. During these interviews' the nurses verbalized they understood the importance of monitoring residents on anticoagulant therapy and documenting those findings in the medical record. The nurses verbalized that they would notify the physician if a resident on anticoagulant therapy had excessive bleeding, nosebleeds, blood in the urine (which could look pink, red or coffee colored), bleeding gums, dark red spots under the skin, blood in the stool (which could be dark, almost black, and tarry) or blood in vomit (which may appear black or dark brown like coffee grounds) right away. The nurses indicated there will be a place on the MAR/TAR to document anticoagulant therapy monitoring for all residents receiving anticoagulant therapy. The nurses indicated they would follow up with the physician to establish the desired length of anticoagulant therapy if the order for anticoagulant therapy was open ended. During interviews with Nurse Managers (6 of 6 nurse managers [LVN I, LVN KK, ADON P, ADON M, LVN W, DON]) on 3/4/23 from 10:30 a.m. to 12:02 p.m., the Nurse Managers said every physician order would be checked for accuracy as part of their new process. They indicated they would enter orders/ perform medication reconciliation for their assigned hall when a resident was admitted from the hospital or returned from the hospital. They indicated CMA GG would no longer be responsible for entering medication orders. They indicated they would clarify with the physician regarding any open-ended orders for anticoagulant therapy. During these interviews' the Nurse Managers verbalized they understood the importance of monitoring residents on anticoagulant therapy and ensuring staff nurses had documented those findings in the medical record. The Nurse Managers indicated signs and symptoms that required physician notification with regard to anticoagulant monitoring included; excessive bleeding, nosebleeds, blood in the urine (which could look pink, red or coffee colored), bleeding gums, dark red spots under the skin, blood in the stool (which could be dark, almost black, and tarry) or blood in vomit (which may appear black or dark brown like coffee grounds). The Nurse Managers indicated orders for anticoagulant monitoring would be entered for all residents on anticoagulant therapy and doing so would result in a place on the MAR/TAR for staff nurses to document anticoagulant therapy. The DON indicated the pharmacy consultant had been made aware of the IJ situation and would be in the facility on March 14th and March 15th to ensure compliance. The DON said she had reviewed all residents in the facility for appropriate anticoagulant administration. The DON said the facility would now address all orders in the clinical morning meetings which will include all admissions discharges and hospitalizations. The DON said in addition the clinical morning meetings will review nursing documentation to ensure anticoagulant monitoring was taking place. Record review of the facility QAPI notes for 3/2/23 indicated the QAPI committee addressed the findings of the IJ and indicated going forward all resident receiving anticoagulant therapy would be monitored and all orders for anticoagulant therapy for post operative DVT prevention would have an identified stop date. Record review of the facility in-service log titled In-Service dated 3/2/23 indicated all 6 nurse managers (LVN I, LVN KK, ADON P, ADON M, LVN W, and the DON) had been in-serviced regarding checking physician orders for accuracy; appropriate diagnosis; all appropriate information (such as stop dates). The in-service indicated CMA GG would no longer complete data entry and that Nurse Managers would now enter all orders. Record review of the facility in-service log titled In-Service dated 3/2/23 indicated the DON and Administrator had been in-serviced over the policy and procedure of accurately transcribing physician orders and the importance of order verification. It indicated they were in-serviced on monitoring of residents for signs and symptoms of anticoagulant therapy and in-serviced on having a system in place to check for timeliness and accuracy. Record review of the updated facility policy included verifying the length of treatment and frequency when receiving physician orders. On 3/4/22 at 12:31 p.m., the Administrator was informed the IJ was removed; however, the facility remained out of compliance at actual harm that is not immediate jeopardy with a scope identified as isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents maintained acceptable parameters of nutritional status for 2 of 24 residents (Resident #55 and Resident #90) reviewed for nutrition/weight loss. 1.The facility failed to provide Resident #55 with physician prescribed dietary supplements. Subsequently, Resident #55 developed a pressure wound and low albumin levels. 2.The facility failed to implement dietician recommendations for Resident #90, resulting in significant weight loss. An Immediate Jeopardy (IJ) situation was identified on 03/01/2023 at 4:30 p.m. Th Administrator was notified, and a POR (plan of removal) was requested. These failures could place residents at risk for decreased nutritional status, decline in health, serious illness, or hospitalization. Findings included: 1. Record review of an undated face sheet revealed Resident #55 was a 64- year-old- female, admitted on [DATE] with the diagnoses of dementia (a general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), COPD (a group of lung diseases that make it hard to breathe and get worse over time), and malnutrition (a nutritional status in which reduced availability of nutrients leads to changes in body composition and function). Record review of an MDS assessment dated [DATE] for Resident #55 revealed a BIMS of 08, which indicated a moderate memory impairment. The MDS also revealed Resident #55 required supervision for bed mobility, transfers, and toileting. Resident #55 was independent with eating. The MDS revealed Resident #55's weight as 75 pounds with no significant weight loss or gain. The MDS revealed no skin impairment. Record review of the care plan dated 12/06/2022 for Resident #55 revealed no skin impairment care plan. Record review of the pressure ulcer risk assessment dated [DATE] revealed Resident #55 was at risk for developing pressure ulcers. Record review of the MD telephone orders dated 12/14/2022 revealed an order for the daily administration of a multivitamin with minerals for protein calorie malnutrition for Resident #55. Record review of the MAR for December 2022 revealed no order for daily multivitamin with minerals administered to Resident #55. The order was not transcribed to the MAR. 18 doses of multivitamin with minearls were missed in December 2022 for Resident #55. Record review of the MAR for January 2023 revealed no order for daily multivitamin with minerals administered to Resident #55. The order was not transcribed to the MAR. 31 doses of multivitamin with minerals were missed in January 2023 for Resident #55. Record review of the MD telephone orders dated 02/14/2023 revealed an order for Med Pass 2.0 (dietary supplement) 2 ounces four times daily for protein calorie malnutrition. Record review of the MAR for February 2023 revealed an order for Med Pass 2.0-2oz four times daily with times of 5:00 p.m. and 9:00 p.m. marked for administration times. The MAR revealed Med Pass 2.0-2 oz was administered twice daily beginning on 02/14/2023 at 5:00 p.m. and 9:00p.m. 26 doses of Med Pass 2.0-2 oz. were missed in February 2023. Record review of the MD telephone orders dated 02/14/2023 revealed an order for Prostat (protein supplement) 30 ml three times daily for protein calorie malnutrition. Record review of the MAR for February 2023 revealed an order for Prostat 30 ml three times daily. The MAR revealed Prostat 30ml was administered once daily at 8:00 p.m. marked for administration times. 26 doses of Prostat were missed in February 2023. During an interview on 02/27/2023 at 9:15 a.m., Resident #55 stated the treatment nurse found a pressure ulcer to her right hip while doing a skin assessment on the morning of 02/27/2023. Resident #55 stated she did not refuse any supplements or medications from the nurses. Record review of wound care notes dated 03/01/2023 indicated Resident #55 developed a new pressure ulcer classified as a deep tissue injury to the right hip measuring 5.0 cm x 5.5 cm x undetermined depth on 02/27/2023. Record review of Resident #55's laboratory results dated [DATE] revealed a prealbumin (helps clinicians detect the effectiveness of nutritional support efforts) level of 5. Normal ranges for a prealbumin level are 20-40. 2. Record review of Resident #90's undated face sheet, indicated Resident #90 was a [AGE] year-old male admitted to the facility on [DATE] with the diagnoses of dementia (a general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), malnutrition (a nutritional status in which reduced availability of nutrients leads to changes in body composition and function) and depression (is a common and serious medical illness that negatively affects how you feel, the way you think and how you act). Record review of Resident #90's MDS dated [DATE] revealed Resident #90 had a BIMS of 05 which indicated a severe memory impairment. Resident #90 required extensive assistance for bed mobility, transfers, and toileting, and limited assistance for eating. The MDS revealed Resident #90 had a weight of 151 pounds and was 75 inches tall. The MDS revealed Resident #90 was not on a therapeutic diet and had no significant weight loss or gain. Record review of Resident #90s care plan dated 02/22/2022 revealed Resident #90 was at risk for alteration in nutritional status related to a therapeutic diet. Interventions for Resident #90s care plan included providing supplements as ordered with the goal of preventing weight loss. Record review of the facility's monthly weight sheet dated March 2023 revealed Resident #90 weighted 148 pounds as of 03/01/2023. The weight sheet revealed Resident #90 weighed 151 in February 2023, 165 in December, and 169 in November 2022. 151-148= 3 pounds/ 2% in 30 days 165-148=17 pounds/ 11.5% in 90 days 169-148=21 pounds/ 14.2% in less than 180 days. Record review of the Nutritional Recommendations by RD Consultant form dated 01/03/2023 revealed a dietary recommendation for Resident #90 related to inadequate calcium and protein intake and constipation. The recommendations were as follows: Med Pass 2.0- 90 cc three times daily Prostat 30 ml three times daily Supercereal (cereal with added protein/fat) at breakfast Prune juice with evening meal Record review of MARS dated January 2023 and February 2023 revealed no orders for Med Pass 2.0- 90 cc three times daily and no order for Prostat 30 ml three times daily. During an interview on 03/01/2023 at 3 p.m., ADON I revealed she did not write the orders for Med Pass 2.0 -90 cc three times daily or for Prostat 30 ml three times daily. ADON I stated she was miseducated on how to read the recommendation sheet from the dietician. ADON I stated she thought she was supposed to choose one intervention that the RD recommended. ADON I stated she was not aware that all the listed recommendations were to be transcribed. ADON I stated she chose the supercereal for Resident #90 because he was already on it. ADON I stated not receiving prescribed dietary supplements could lead to weight loss, skin impairment and overall decline in the elderly. During an interview on 03/01/2023 at 3:00p.m., ADON I stated she was the nurse responsible for the weight/nutrition system in the building. ADON I explained the residents were all weighted by the 7th of the month for monthly weights. The weights were then given to her, and she calculated gain and loss percentages. ADON I stated she then notified the MD and RD of the weight loss/gain. ADON I stated when the recommendations were made by the RD or MD, she wrote a telephone order and transcribed the order to the MAR. ADON I stated she alerted the nurses by writing the new order on the 24-hour sheet and called the family of the resident and let them know of the new orders. ADON I stated she must have missed the Multivitamin with Minerals order for Resident #55. ADON I stated she did not write the time the medications were due on the MAR for Med Pass 2.0-2oz. four times daily or Prostat 30ml three times daily resulting in missed doses of both orders. ADON I stated missing a multivitamin, a dietary supplement and a protein supplement could result in weight loss, skin impairment, and overall decline in the resident's condition. ADON I stated there was no one designated to check behind her to ensure nothing was missed During an interview on 03/01/2023 at 3:15 p.m., the Nurse Consultant stated that all recommendations listed on the Nutritional Recommendations by RD Consultant report were to be followed unless an allergy was noted. The Nurse Consultant stated ADON I failed to write the times on the MARS for Resident #55 to indicate when the dietary supplements should have been administered and the nurses failed to read the orders on the MAR and carry them out. The Nurse Consultant stated ADON# I failed to transcribe the RD recommendations for Resident #90 and Resident #90 had lost significant weight at the 90 day and less than 180-day marks. The Nurse Consultant stated weight loss greater than 7.5% in 90 days and greater than 10% in 180 days indicated a significant weight loss. During an interview on 03/01/2023 at 3:30 p.m., the interim DON stated ADON #I oversaw the weight/nutrition system and had been doing it for over a year. The DON stated the weight discrepancies were discussed in morning meetings but prior to the DON's arrival a few months ago, she was unsure if the weights were discussed in the morning meetings. The DON stated she knew for certain the weights were discussed for the last 4-6 weeks in morning meetings. The DON stated dietary recommendations were not discussed. The DON stated she expected ADON #I to transcribe the order, call the family, ensure the medication was on the MAR, ensure diet changes were communicated to the kitchen, and note the entire process in the resident's clinical record. The DON stated there was no system to follow up behind the ADON to ensure nothing was missed. The DON stated nutrition in the elderly was important to prevent weight loss, muscle loss, skin integrity impairment, and overall decline. During an interview on 03/01/2023 at 3:34 p.m., the Administrator stated the ADON I oversaw the weight/nutrition system. The Administrator stated that nutrition in the elderly was highly important to prevent a decline in their health status. The Administrator named weight loss and skin impairment as side effects of poor nutrition in the elderly. During an interview on 03/02/2023 at 10:00 a.m., the RD revealed she was informed of weight loss and gain each month by the 7th. She then calculated weight loss and gain for each resident. The RD stated she often asked for reweighs if the weight fell in the category of significant loss or gain. The RD stated once the significant losses and gains were identified, she reviewed the charts for recent labs, looked at ADL sheets to see how each resident was eating, and looked at mediations added and taken away from each resident. The RD stated once all aspects of nutrition had been considered, she made dietary recommendations and gave a copy of the recommendations to the DON and ADON# I. The RD stated all recommendations were expected to be followed. The RD stated not following the dietary recommendations made could result in further weight loss and skin impairment. The RD stated Resident #55 had a less than ideal nutritional status upon admission weighing less than 80 pounds, and that was why she made the recommendations for the supplements to prevent to weight loss and loss of skin integrity. The RD stated if supplements had been administered as they were ordered for Resident #55, she would have had a better chance not to develop pressure ulcers. The RD stated Resident #90 needed added calories because of fluctuating food intake between 25-75%. The RD stated she recommended the supplements two months prior to prevent further weight loss by adding calories and protein to Resident #90's diet daily. During an interview on 03/02/2023 at 11:50 a.m., MD #3 stated he left all nutrition and nutritional support recommendations to the RD. MD #3 stated it was not his area of expertise and the facility had a dietician to make nutritional recommendations to meet the resident's needs. MD#3 stated weight loss and skin impairment could occur when a resident did not have optimal nutrition. MD#3 stated he was uncertain if the supplements ordered for Resident #55 and Resident #90 would have prevented skin breakdown or weight loss. Record review of an undated Weight Monitoring policy indicated based on the resident's comprehensive assessment, the facility will ensure that all residents maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance A significant change in weight is defined as: a. 5% change in one month, b. 7.5% change in 3 months, c. 10% change in 6 months. Documentation: a. The physician should be informed of a significant change in weight and may order nutritional interventions. No policy was provided related to nutritional status. The Administrator was notified on 03/01/2023 at 5:30 p.m. that an Immediate Jeopardy (IJ) with actual harm was identified due to the above failures. The Administrator was provided with the IJ template on 03/01/2023 at 5:45 p.m. and a POR (plan of removal) was requested. The following Plan of Removal submitted by the facility. The plan of removal was accepted on 03/02/2023 at 1:16 p.m. and included the following: THE ADMINISTRATOR AND DON WERE IN-SERVICED ON 3/01/23 AT 6:50 PM BY THE REGIONAL NURSE ON THE POLICY AND PROCEDURE OF ACCURATELY TRANSCRIBING PHYSICIAN ORDERS AND THE IMPORTANCE OF NUTRITION, HYDRATION, AND WEIGHT MANAGEMENT IN LONG-TERM CARE.?INTIATED: 03/01/23 COMPLETED: 3/01/23 6:55 P.M.?? IN-SERVICES DONE BY THE DON, ADMIN, OR DESIGNEE ON THE IMPORTANCE OF HYDRATION AND NUTRITION NEEDS IN THE ELDERLY AND ACCURATELY WEIGHING RESIDENTS. THE ADVERSE OUTCOMES TO A RESIDENT WITH POOR NUTRITION COULD LEAD TO WEIGHT LOSS, WOUNDS, AVOIDABLE HOSPITALIZATIONS, AND POSSIBLY DEATH. IN-SERVICE PROVIDED TO ALL DIRECT CARE STAFF.?ALL STAFF WILL BE IN-SERVICED PRIOR TO NEXT SCHEDULED SHIFT. INITIATED: 3/01/23 COMPLETED: 3/02/23 11:55 PM. IN-SERVICES DONE BY DON, ADMIN, OR DESIGNEE TO ALL LICENSED NURSES ON THE IMPORTANCE OF ACCURATE PHYSICIAN ORDER TRANSCRIPTION, INCLUDING ACCURANCY OF TIMES, LENGTH OF DURATION, AND VERIFYING THE CORRECT SCHEDULED TIME IS ASSIGNED ACCORDING TO FREQUENCY OF ADMINISTRATION ON MEDICATION ADMINISTRATION RECORD. THE IMPORTANCE OF TIMELY NOTIFICATION TO THE PHYSICIAN WITH DIETARY RECOMMENDATIONS.?ALL NURSES WILL BE IN-SERVICED PRIOR TO NEXT SCHEDULED SHIFT. INITIATED: 3/01/23 COMPLETED: 3/02/23 11:55 P.M. ADMINISTRATOR VERIFIED THAT A REGISTERED DIETICIAN WOULD COME to the facility on [DATE] AT APPROXIMATELY 9 AM TO RECONCILE ALL DIETARY INTERVENTIONS AND RECOMMENDATIONS.?INITIATED: 3/02/23 COMPLETED: 3/02/23 11:55 P.M. PHYSICIAN OF RESIDENTS #55 AND #90, WILL BE AT THE FACILITY ON 03/02/2023 AT 9:00 AM TO RE-ASSESS BOTH RESIDENTS IDENTIFIED.?INITIATED: 3/02/23 COMPLETED: 3/02/23 11:55 P.M THE DON OR ADONS WILL WEIGH 100% OF RESIDENTS STARTING ON 03/01/2023. ALL RESIDENTS WITH WEIGHT VARIANCES WILL BE ADDRESSED BY A DIETICIAN IN-HOUSE.?INITIATED: 3/02/23 COMPLETED: 3/02/23 11:55 P.M. WOUND CARE NURSE, WILL COMPLETE A SKIN ASSESSMENT ON RESIDENTS #55 AND #90 TO ENSURE RESIDENTS HAVE APPROPRIATE TREATMENTS IN PLACE.?INITIATED: 3/01/23 COMPLETED: 3/01/23 8:30 P.M. ADON WAS IN-SERVICED BY DON ON THE IMPORTANCE OF PROMPTLY NOTIFYING THE PHYSICIAN WITH ALL RECOMMENDATIONS AND REQUEST, SUCH AS DIETARY OR PHARMACY. THE IMPORTANCE OF ACCURATELY COMMUNICATING ALL SUGGESTED RECOMMENDATIONS TO THE TO THE PHYSICIAN. ACCURATELY RECEIVING THE PHYSICIANS ORDER AND TRANSCRIBING ACCURATELY TO THE MAR INCLUDING ASSIGNING DESIGNATED ADMINISTRATION TIMES ON THE MAR. INIATED 03/01/23 COMPLETED 03/01/23 8PM THE DON WILL BE RESPONSIBLE FOR ENSURING ALL RESIDENTS ARE IDENTIFIED AND REFERRED TO REGISTERED DIETICIAN, ALL RECOMMENDATIONS ARE DISCUSSED WITH PHYSICIAN PROMPTLY AND THAT THE RESIDENT RECEIVES THE APPROPRIATE TREATMENT AND VERIFICATION THAT RESIDENT IS RECEIVING BY VERIFICATION OF ACCURATE ADMINISTRATION ON MAR. INITIATED: 3/01/23 COMPLETED: 3/01/23 11:55 P.M. QAPI ON WEIGHTS, NUTRITION AND HYDRATION SCHEDULED 03/02/23. THE [NAME] NURSE NOTIFIED THE MEDICAL DIRECTOR ON 03/01/2023 AT 5:59 P.M. OF IMMEDIATE JEOPARDY SITUATION. INITIATED: 3/01/23 COMPLETED: 3/02/23 1:00 P.M. FACILITIES POLICY AND PROCEDURE TITLED WEIGHT LOSS PROTOCOL ASSESSMENT WAS REVIEWED AND UPDATED BY THE ADMINISTRATOR AND REGIONAL NURSE ON 3/01/2023 TO ENSURE THAT THE CURRENT POLICY MEETS THE STANDARDS OF PRACTICE AND REGULATORY REQUIREMENTS.?FACILITY REPLACED PRIOR POLICY WITH NEW ADDOPTED POLICY TILTED NUTRITION/UNPLANNED WEIGHT LOSS CLINICAL PROTOCOL. INITATED: 3/01/23 COMPLETED: 3/01/23 12:00 P.M. NEW ADOPTED POLICY IDENTIFIES THE THRESHOLD FOR SIGNIFICANT AND UNPLANNED WEIGHT LOSS WITH MORE CURRENT PARAMATERS. NEW POLICY ALSO NOW REFLECTS CAUSE IDENTIFICATION OF WEIGHT LOSS. NEW POLICY UPDATED TO INCLUDE TREAMTMENT AND MANAGEMENT GUIDEANCE. NEW POLICY NOW IDENTIFIES MONITORING. Monitoring for the implementation of the POR initiated on 03/02/2023 Record review of the Monthly Weight Sheet dated 03/02/2023 indicated 100% of residents were weighed for March 2023 by ADON I, Staffing Coordinator H, and Director of Transportation S. During an observation on 03/02/2023 at 8:00 a.m., Director of Transporation S and Staffing Coordinator H were observed properly weighing, documenting , and reporting the daily weight of 4 residents. Record review of monthly weight variance record dated 03/01/2023 indicated 12 residents had weight variances identified. Record review of the physician orders indicated the physician had implemented supplements, dietician referrals, and weekly weight monitoring for all 12 residents with weight variances. Record review of the facility's weight variance policy indicated it was revised and updated on 03/02/2023 and was changed to Nutrition/Unplanned Weight Loss Clinical Protocol The new policy included threshold for significant and unplanned weight loss with parameters, included identifcation of weightloss procedures, treatment and management guidance, and identifed monitoring. Record review of progress notes dated 03/02/2023 indicated MD#3 assessed and evaluated Resident #55 and Resident #90. Record review of skin assessments dated 03/02/2023 indcated Resident #55 and Resident #90 were assessed and evaluated. Record review of in-service training report dated 03/01/2023 indicated the DON and Administrator had been in serviced on accurate transcription of an MD order and the importance of nutrition in the elderly. Record review of in-service training report dated 03/02/2023 indicated ADON# I received training on accurate transcription of MD orders and the importance of nutrition and hydration in the elderly. Record review of in-service training report dated 03/02/2023 indicated to implement all orders in a timely manner. 1. Receiving and noting MD orders about nutrition, and any other orders must be implemented in a timely manner. 2. Importance of nutrition and hydration in the elderly with risk factors of poor nutrition. Interviews on 03/03/2023 from 10:00 a.m. until 1:48 p.m. the surveyor confirmed the facility implemented their plan of removal. Interviews with 5 (6am-6pm) nurses LVN J, LVN W and LVN Q, LVN D, and RN E and interviews with 2 (6pm-6am) nurses RN Y and RN C said they were in-serviced on obtaining weights, reporting weight changes to the physician, transcription of MD orders, and communicated adverse effects of poor nutrition. The nurses were educated separately and demonstrated understanding of transcription of MD orders and nutrition and hydration in the elderly. Interviews with 4 (6am-2pm) CNAs- CNA A, CNA F, CNA N, and CNA O and interviews with 3 (2pm-10am) CNAs -CNA T, CNA V, CNA W and 1(10p.m. to 6 a.m.) CNA- HA B indicated they were in-serviced on obtaining weights on admission, to record them and to report them to the nurses and all CNAs identified adverse effects of poor nutrition. The CNAs were educated separately and demonstrated understanding of nutrition and hydration in the elderly. The education included how to weigh residents, who to report the weight to, offering supplements with meal refusals, and signs of malnutrition and dehydration in the elderly. Interviews with the Director of Transportation S, Staffing Coordinator H, therapy PTA K and COTA L indicated they were in-serviced on the proper way to obtain weights, recording, and reporting the weights. All identified adverse effects of poor nutrition in the elderly. The staff were educated separately and demonstrated understanding of nutrition and hydration in the elderly The education included how to weigh residents, who to report the weight to, offering supplements with meal refusals, and signs of malnutrition and dehydration in the elderly. Interviews with the interim DON and the Administrator indicated they were in-serviced on the proper way to obtain weights, recording, and reporting the weights. All identified adverse effects of poor nutrition in the elderly. The DON and Administrator were in serviced separately and demonstrated understanding of nutrition and hydration in the elderly The education included how to weigh residents, who to report the weight to, offering supplements with meal refusals, and signs of malnutrition and dehydration in the elderly. The interim DON and Administrator were informed the Immediate Jeopardy was removed on 03/03/2023 at 12:00 p.m. The facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy and a scope of pattern due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.