**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure the resident environment remained as free of accident hazards as possible and that each resident received adequate supervision and assistance devices to prevent accidents for 1 out of 1 resident (CR #1) reviewed for adequate supervision. The facility failed to provide adequate supervision to residents and adequate training of the staff regarding monitoring and documenting resident whereabouts (location) to mitigate accidents such as elopement when CR#1 eloped on 01/02/2025 and was found to have laceration to nose that required 3 sutures, a closed fracture to left wrist with splint in place, and a closed fracture to nasal bone. This noncompliance was identified as Past Non-Compliant Immediate Jeopardy (PNC IJ) was identified on 07/09/2025. The noncompliance began on 01/02/2025 and ended 01/31/2025. The facility corrected the noncompliance before the investigation began. The IJ began on 07/09/2025 and ended on 07/09/2025. The facility corrected the noncompliance by providing in-servicing and hands-on training regarding elopement for facility staff prior to surveyor entrance. This deficiency failure exposed residents living in the facility to safety hazards.Findings included: Review of face sheet dated 08/04/2022 reflected CR #1 was an [AGE] year-old female who admitted to the facility on [DATE] and discharged to a secure facility on 01/08/2025. Record review of CR #1 was admitted with the following diagnosis Alzheimer disease, Major Depressive Disorder, Anxiety disorder, Psychotic disorders with delusions due to known physiological condition, Osteoarthritis, Dysphagia, Ataxic gait, Generalized anxiety disorder, Insomnia, Dementia mild with psychotic disturbance, Deficiency of specified B group vitamins, Unspecified abnormalities of Gait and Mobility, Pain. Review of CR #1's initial nursing evaluation indicated she was alert to person, displayed some cognitive and communication deficits RT DX Alzheimer Dementia. A BIMS score was conducted upon admission on [DATE]. The results were 6 out of 15 and on 11/14/2024 another BIMS score was conducted which indicated a 5 out of 15 which indicated severe cognitive impairment. CR #1 was ambulatory. Her initial wandering evaluation conducted on 08/04/2022 indicated she was not a wandering risk. Record review of closed chart for CR #1 on 12/21/2024 at 12:26 PM indicated CR# 1 had a change of condition reported Altered Mental Status suspected UTI. On 01/01/2025 indicated Urinalysis results were negative. Review of exit seeking tool on 1/2/2025 reflected it was completed indicating CR #1 was wondering and exit seeking behaviors and on 1 or more occasions attempted to exit or has exited the facility to wander away, whether intentionally or due to confusion. Record review of CR #1's nursing note dated 01/02/25 indicated during shift Resident was seen walking around nurses' station with a bag stating that she was looking for her mom. shortly after resident walked to front desk looking for her mother and was redirected back to her room x2. At 2:15PM I was notified that resident was down the street past the daycare. Another resident's family member came into the facility and ask the front desk if we had a resident by the name of CR#1, front desk agreed. witness stated that CR#1 was down the street past the daycare in the middle of the street on the ground. Front desk quickly rushed to scene with phone in had calling administrator. By the time she made it to scene EMS and ADNS was on site. She then returned to facility and notified Nurse of what had happened. Activity Director stated that while working front desk a lot of family and new hires were there and she did not see resident go out the door, after redirecting her x2. Resident was transported to ER for further evaluation. MD and RP were notified. Record review of progress notes of CR #1 dated 1/3/2025, nurse notes indicated CR #1 returned to facility via EMS on 01/02/25 at 7:21PM. RP, NP, and DON notified of return. Resident has no new orders. Resident vitals 130/79, 73, 94% O2, 18, 97.5. Resident has laceration to nose with 3 sutures, closed fracture to left wrist with splint in place, and closed fracture to nasal bone. Resident has no complaints of pain or discomfort at this time. Resident was put on 1:1 with CNA at CR #1 bedside and as CR #1 walked around facility. Record review of CR #1's nurses notes dated 1/3/2025 at 12:19AM indicated CR #1 Resident continues 1:1 service. Resident currently walking around facility with sitter. Resident states she is waiting on her mom to pick her up. Resident redirected to bed. Record review of nurse progress notes CR#1 revealed CR#1 was on 1:1 until discharge date of 01/08/2025. Interview on 07/08/2025 at 2:45PM with Activity Director who said around 1:30PM on 01/02/2025 CR #1 went out the front door like she does all the time to sit on the front porch, it was very busy that day there was new hires and trainings going on. CR #1 usually just sits in the front and then comes back into the building. That day a unidentified person came into the facility and reported that it was a lady sitting in the median that look like she was from the nursing home I went outside to check and it was CR #1 in the median and she was sitting on the ground. I came and got the charge nurse, and the administrator was called also, and the EMS was already there when we all arrived. CR #1 look like she had a cut on her forehead, and she was put into the ambulance. I know I saw CR #1 in the dining room when she had just come back from the therapy. If a resident was exit seeking and got out, they could get hurt or be lost and be in danger. Interview on 07/08/2025 at 4:30PM with the Unit manager who stated CR #1 had a history of looking for her mom. She would always have a bag with her stating she was looking for mom she would sit on the front porch all the time but would come back. Along with the receptionist and nursing staff it was our responsibility to check on all residents all the time while they are sitting outside in the front or the back of the facility. The receptionist should always call and ask if a resident was able to be outside by themselves. If a resident gets out it could be serious. Interview on 07/08/2025 at 5:30PM with previous Assistant Director of Nursing who said that day of 1/2/2025. I was working, and she was on the porch but was found at the car wash next door. When I got there the EMS was there and CR #1 was being accessed by the paramedics and was transported to the hospital for further evaluations. CR #1 had a laceration to her head, it had blood on it, and she was alert. When CR#1 came back that night, I called her FM who said she was received a call earlier. On 1/3/2025 (CR # 1) was put on a 1;1. She said the Activity Director, or the receptionist should have asked a nurse prior to letting CR #1 out of the building. It's something major if a resident that get out the building with memory issues because they can get hurt or worse. Interview on 07/08/2025 at 5:45PM with CNA A who said she saw CR #1 sitting outside around 11:30 am and tried to convince her to come inside because it was cold, and CR #1 resisted to return into the facility. CNA A said she tried to get another CNA to help to bring CR #1 to the facility, but she started to become aggressive. So, I let the front desk lady know, and I returned to the floor. Interview on 07/09/2025 at 11:30 AM with the regional nurse who stated that the facility conducted in-services on a quarterly basis prior to incident with CR #1 and after incident with CR #1 in-services were done monthly along with elopement drills which was done on 1/31/2025 with another drill planned for 7/31/2025. Elopement drills are done every 6 months per company policy. Record review of facility's Elopement policy dated Revised May 2024 revealed the Following: Review of the facilities meeting documentation reflected they completed an AD HOC QAPI on 01/03/25 which was attended by the Administrator, DON, and Medical Director. The following was discussed:1. Elopement wandering/leaving the facility training.2. Abuse/neglect training,3. Resident right rights training4. Updated the elopement book Performance improvement plan with immediate intervention which included: 1. Head count, 2. Resident returned to facility at 9:20 PM on the same day from the hospital ER3. Medical Director/RP notified.4. Head to assessment completed.5. Exit Seeking Tool was completed.6. Audit on all residents to identify residents at risk for elopement. 7. CR #1 was transferred to a secure facility.8. Elopement binder reviewed and updated.9. Residents' BIMS updated in binder. Review of Components of the PIP/QAPI dated 01/03/2025 were reviewed by the survey team. The QAPI recommendations were completed and included the following: The front door and all side/back doors are locked 24 hours a day. Residents are closely monitored that are seating in front porch area every 15 minutes by the receptionist. Facility is in the process of hiring hospitality aide to assist with the facility concierge program. Inservice was done the day of incident and every month after incident. Any residents that are at risk for elopement are evaluated upon admission and if necessary, will be placed on 1:1. Facility conducted elopement drill on 1/31/2025. Per company policy elopement drills are recurrence every 6 months. Record review of facility's elopement policy dated 01/03/2025 Record review of facility's grievance log did not reveal any concerns for potential elopement. Record review on 07/08/2025 of all elopement in-services and drills were conducted on 1/3/2025 and thereafter every 3 months. Completed with no concerns. Record review of incident and accidents did reveal resident with a potential to elope, resident was placed on 1:1 until discharged . Record review of facility's Reporting incidents and accidents in-service acknowledgement dated 05/24/2024 revealed nursing staff including RN and LVN's, MA's, and CNA's received training for how to investigate and follow up on incidents and accidents and completing incident and accident documentation. Record review of facility's Ensuring doors are locked behind staff entering and exiting facility in-service acknowledgement dated 7/31/2024 revealed nursing staff/nursing administration received education on alarms sounds and doors security. The signature page included Administration, DON, all nursing staff who was assigned for duty the afternoon of the elopement and thereafter education was provided for current and new staff. Record review of facility's Abuse and Neglect in-service acknowledgement dated 1/3/2025 revealed nursing staff received education on being expected to follow federal guidelines for ANE, prevention of ANE, reporting of ANE, and investigating allegations of ANE. The signature page included ADON, the nurse who was assigned to CR #1 on 1/31/2025 the afternoon of the elopement. On 07/09/2025 at 3:18 pm, facility administrator was notified of past noncompliance IJ. A plan of removal was not requested. An IJ template was provided to the administrator via email with signature requested. The noncompliance began on 01/02/2025 and ended on 01/31/2025. The facility corrected the noncompliance before the investigation began.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure personnel provided basic life support, including CPR, to a resident requiring such emergency care prior to the arrival of emergency medical personnel for 1 of 77 residents (CR #1) reviewed for CPR. LVN A failed to call out a change in condition and obtain assistance from available staff when CR #1 was found unresponsive. This led to a delay of approximately 3 minutes before CPR was started on CR #1 on [DATE]. LVN B failed to enter CR #1's DNR code status at the time of admission which resulted in LVN A making multiple phone calls to determine code status prior to initiating CPR. An IJ was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 12:16 p.m. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of isolated with the severity level of potential harm that was not immediate jeopardy because all staff had not been trained on [DATE]. These failures placed residents at risk of experiencing worsening of condition, extended pain, and death from possible delays in the initiation of an emergency response and improper implementation of CPR. Findings included: Record review of CR #1's face sheet dated [DATE] revealed she was an [AGE] year-old female who was admitted to the facility originally on [DATE] and readmitted on [DATE] at 2:00 p.m. CR #1's diagnoses included Urinary tract infection, severe obesity, hypertension (high blood pressure), and diabetes (high blood sugar levels). Record review of CR #1's Entry MDS dated [DATE] was not completed and did not reveal a BIMS. Attempted record review of CR #1's care plan revealed it was not completed on [DATE]. Record review of CR #1's DNR code status reflected Resident #1 had a DNR dated [DATE]. Record review of progress notes dated [DATE] by LVN A revealed the following in part: Note Text: 3.00am: [CR #1] found unresponsive during rounds, no breath sounds or respirations, skin slightly warm to touch. Resident re admitted yesterday, no new code status entered in the system and no DNR in the folder noted. Progress notes states that resident was admitted under [Hospice]. Called [Hospice] and spoke to the [Hospice Nurse], notified her of change of condition and enquired on code status. They stated that resident was pending on their side, and they had no code status. Attempted to call [RP A] but call went to voicemail. Called the [ADMIN] and call went to voicemail. CPR started and 911 called. EMTs arrived to find CPR in progress, continued CPR and this nurse attempted to call [RP B] and he picked up, spoke to EMT who stated [RP B] requested to stop CPR and that they had signed a DNR at [Hospital]. CPR ceased and resident pronounced at 3.34am. 4.18am: [Hospice] nurse in the facility residents time of death is 3:34 a.m. Record review of advance directives for the facility census of 123 residents revealed there was 77 Full Code residents and 50 DNR residents. Interview on [DATE] at 2:41 p.m., the ADMIN and Reg. RN said the facility did not have a CPR policy. Reg. RN said the facility had a change in condition policy. Interview on [DATE] at 3:40 p.m., DON said she was notified on [DATE] (early morning hours) by voicemail that CR #1 had a change in condition and 911 was called. The DON said the facility did not have a CPR policy but had a CPR process. She said they did not have a documented policy of the CPR process. She said the CPR process should have been a team effort. The DON said she was told CNA A found CR #1 and notified LVN A. She said she later was informed LVN A left CR #1 after an initial pulse check, which CR #1 did not have a pulse, went to the nurses' station to check the code status. She said because LVN B had not put in CR #1's code status at admission ([DATE]), LVN A had to two separate locations, in the electronic record and a code status binder located at the nurses' station, before the attempted code status verification. Interview on [DATE] at 3:55 p.m., LVN B said she did not put in the code status for CR #1 at admission. She said when LVN A looked for the code status, it was not in the electronic health record or binder for hall 200. She said she was not working when CR #1 was found unresponsive. She said when the code status was unknown, the nurse should verify the code status and start CPR. She said she would leave the resident to check the code status and then tell the team (facility staff) to assist with calling 911 and assist with getting the crash cart. She said she was not trained by the facility staff on how to respond to an unresponsive resident but used her nursing school knowledge. She said she was not sure if there a risk to the resident if staff left an unresponsive resident to check the code status, rather than yell out, alerted staff for help with calling 911, getting the crash cart, and other staff verify the code status. Interview on [DATE] at 4:30 p.m., with LVN A said she was notified by CNA A, CR #1 was unresponsive. LVN A said she went to CR #1's room, attempted to arouse her and checked her pulse. She said CR #1 did not have a pulse. LVN A said she left CR #1 and went to the nurse's station to check CR #1's code status in the electronic health record. She said she told LVN C and LVN D that CR #1 did not have pulse. She said both, LVN A and LVN D looked in the binder and said there was not an advance directive for CR #1 and she should be treated as full code. LVN A said LVN D got the crash cart on the way to CR #1's room along with LVN C. LVN A said she stayed at the nurses' station and called hospice and the hospice representative said the code status was pending. LVN A said called the CR #1's RP and the ADMIN and the calls went to voicemail. LVN A called 911. LVN A said she after she left CR #1's room, looked for the code status, told LVN C and LVN D, and made the phone calls took approximately three minutes. She said she saw LVN C and LVN D perform CPR and EMS arrived in approximately 5-7 minutes after she called. She said EMS took over CPR. She said while EMS performed CPR for approximately 15 minutes, CR #1's RP was contacted and advised EMS to discontinue CPR because an out of hospital DNR was signed LVN A said she was not trained by the facility on how to respond to an unresponsive resident when CPR or 911 had to be called. LVN A said she responded as a prudent [acting with or showing care and thought for the future] nurse would do. She said she did not think there was a risk to CR #1 with her response to leave CR #1 and check for the code status herself. She said as a licensed nurse, she had to verify the CR #1's code status. She said she did not consider calling out for assistance. Interview on [DATE] at 4:49 p.m., with LVN C said he was near the nurses' station. LVN C said he saw LVN A at the nurses' station and she said CR #1 did not have a pulse. He said LVN A checked the electronic health record for CR #1's code status. He said LVN A did not find once in the electronic record and then looked in code status binder and there was not one. He said LVN A called multiple people to verify CR #1's code status unsuccessfully. He said LVN D and CNA (agency unknown) got the crash cart and went to CR #1's room. He said after LVN A found a code status for CR #1 from her February 2025 admission, which stated CR #1 was a full code. He said he went to CR #1's room. He said CNA (agency unknown) was holding the ambu bag (medical device that forces air into the lungs) and LVN D was in the process of connecting the oxygen. He said he started chest compressions. He said he was not able to recall how long he provided CPR before EMS arrived and they took over. He said he left out of the room immediately after EMS took over. He said he remembered LVN A was in the room with EMS. He said the CNA (agency unknown) and LVN D left out of the room after him too. He said the facility had not trained him on a code or protocol to follow when a resident was found unresponsive. He said he used his nurse knowledge on how to respond. He said there could have been a delay in responding to the resident when the code status was being verified in various ways before the CPR process was started. Interview on [DATE] at 1:36 p.m. with RN A said she was the weekend supervisor and duties included reviewing admissions and ensured they were accurate. She said the admissions process protocol was a checklist that included verification of code status. She said the facility had not trained her on the process after a resident was found unresponsive. Interview on [DATE] at 6:23 p.m. with CNA A said she went into CR #1's room, observed her and attempted to find a pulse. She said she left the room at a fast pace and notified LVN A that CR #1 was unresponsive. CNA A (agency staff) said LVN A went to CR #1's room and came back to the nurses' station to check CR #1's code status. She said when LVN A returned to the station she told another nurse (name unknown to CNA A) about CR #1. CNA A said both of the nurses looked through papers and tried to find the code status for CR #1. She said there was a male nurse at the nurses' station (name unknown to CNA A). She said LVN A told her to go and clean CR #1's face with CNA B. She said she went back to the room. She said LVN C and LVN D came into the room. She said she could not remember how long it was. She said CNA B assisted with the ambu bag. She said the male nurse (LVN C) did chest compressions and LVN D connected the oxygen. She said she did not assist. She said she had not been trained by the facility on how to assist with an unresponsive resident who needed CPR. Interview on [DATE] at 7:31 p.m. with LVN D said she was at the nurse's station and LVN A told her CR #1 was not breathing. LVN D said she flipped through the code status binder and did not see anything for [CR #1]. She said LVN A checked the electronic health record for CR #1 and did not see a code status for the resident. LVN D said she and LVN C went to the room where there was two cnas (CNA A and CNA B). LVN D said LVN C came to the room and assisted with chest compressions. LVN D said she connected the oxygen to the ambu bag that was help by CNA B. She said the event occurred at approximately between 3:00 a.m. and 3:30 a.m. She said she had been trained to check the code status books. She said there was one binder for each hall. She said the new company took over the facility and she had not been trained on a code or the protocol when a resident was found unresponsive. She said everything happened fast and she did not think there was a risk to the resident. Interview on [DATE]at 8:34 a.m. with CNA B said she saw LVN D get the crash cart and she followed her into CR #1's room. She said LVN C came in and assisted with chest compressions. She said she held the ambu bag. She said she was not able to recall how long CPR was performed. She said left after CNA A took over the ambu bag and she went back to her assigned hall. She said she was not trained on the CPR protocol. Record review of American Heart Association dated [DATE] (https://cpr.heart.org/en/resources/what-is-cpr) revealed the following in part: Check for responsiveness. Shout for nearby help Activate emergency response (via mobile device - if appropriate) Get AED and emergency equipment (send someone to do so) . Record review of the facility policy for Changes in Resident Condition (date implemented 5/2017 and revised 1/2023) revealed the policy did not address what steps the facility staff should take when a resident is found unresponsive. Record review of the facility policy for Advanced Directive (date implemented 2/2017 and revised 1/2023) revealed in part the following: .The medical record and resident plan of care should reflect the resident's wishes as well as the physician orders in order to meet the directives described . it is the community's responsibility. to ensure that it has current copies of all advance directives. Record review of facility in-service for Admissions/Re-Admissions dated [DATE] revealed the following in part: .Full-Code will be applied to all resident without a completed and signed OOH DNR . An IJ was identified on [DATE]. The IJ template was provided to the ADMIN on [DATE] at 12:16 p.m. The following Plan of Removal submitted by the facility was accepted on [DATE] at 7:32 a.m.: Allegation: The facility failed to ensure that a resident received CPR in accordance with professional standards of practice. F678 CPR IJ Plan of Removal for F678 [DATE] [Facility Name]o f Removal F678 Cardiopulmonary Resuscitation Immediate Response: Corporate nurse educated the Administrator/Director of Nursing/Assistant Director of Nursing/Social Worker on the expected practice of confirming all new admissions have advance directives elections indicated within the medical record. o 1. All residents should have a code status election physician's order in place upon admission. o 2. Any resident who has an advance directive election change should have the election documented and a physician's order should be obtained at the time the election has been voiced. DNR elections will be honored upon the resident/representative having voiced the advanced directive care election and if DNR the OOH-DNR form will be initiated and completed timely, then uploaded into the electronic health record. o 3. Licensed Nurses both on-coming, and off-going nurses will review/audit the code status designation for any new admission, re-admission and new order or changes to code status during the 24-hour report. Any identified discrepancies or absence of code status will be reported to the attending MD, DNS and/or ADMIN. Should there not be an election of advanced directives or code status, will result in the individual being full code until otherwise directed. o 4.The Administrator/Director of Nursing/Assistant Director of Nursing/Social Worker will conduct an initial review of the admission/readmission orders to validate that the advanced directive election for code status is in place. This audit will take place the next business day during the morning meeting and the RN Supervisor on duty will conduct the audit on the weekends. In the absence of the RN Supervisor on duty, the Director of Nursing or Assistant Director of Nursing will be responsible for conducting the audit to validate code status election orders are in place. Any discrepancies will be immediately clarified with the resident, authorized representative and the appropriate order will be obtained by the attending physician. Date completed: [DATE] Corporate nurse educated the Administrator/Director of Nursing/Assistant Director of Nursing on response times when performing immediate assessments/interventions for residents with changes in condition. Anytime a resident experiences a change in condition and it appears the heart has stopped, pulseless or not breathing, with a Full Code Order or No code status, you must immediately initiate the CPR process, until the code status is validated. The other present licensed nurses in the community must assist with the change in condition by immediately verifying code status, calling 911, notifying MD and RP. As well as assisting with the required paperwork for a hospital transfer. Date completed: [DATE] The Administrator/Director of Nursing/Assistant Director of Nursing conduct re-education with the identified nurses as well as all other licensed nurses regarding the expected practice of confirming all new admissions, re-admissions have advance directives elections indicated within the medical record. o 1. All residents should have a code status election physician's order in place upon admission or re-admission. All licensed nurses will receive the education regarding the process of reconciling physician orders into the electronic health record accurately and timely to include but not limited to code status upon admission, re-admission and any changes in code status election/advanced directives. No nurse will be allowed to work until the in-service training has been completed. o 2. Any resident who has an advance directive election change should have the election documented and a physician's order should be obtained at the time the election has been voiced. o DNR elections will be honored upon the resident/representative having voiced the advanced directive care election and if DNR the OOH-DNR form will be initiated and completed with physician's signatures timely (next business day, not to exceed 3 business days), then uploaded into the electronic health record. o Nurses are expected to validate the code status election within the electronic health record orders to determine code status ordered, upon identifying that a resident presents with altered signs of life, i.e. absence of detectable vital signs, no s/s of life. Nurse should immediately validate code status order in order to confirm advance directive/code status election prior to initiating CPR. After code status has been swiftly confirmed, the nurse should adhere to the code status election (Full Code = swiftly initiating CPR accordingly or DNR-do not resuscitate the nurse would swift proceed with notifications of no s/s of life to the physician and representative. If full code: The available licensed nurses within the community should assist with the code status response by swiftly verifying the code status order, implementing CPR according to the physician's order, calling 911, and notification to MD and RP, as well as assisting with the required paperwork for a hospital transfer. If you find a resident is found unresponsive, the nurse must yell for help, and then proceed to validate the code status, if the cart with the computer is at the door of the room. In the event the cart is not at the door of the room, the charge nurse must also yell for a team member to bring the computer, the crash cart, and the AED machine. Nurses are expected to immediately review the code status orders within the electronic health record in order to identify the resident's code status. This should be immediately with the closest nurse's station computer or closest laptop available. The nurse should respond with urgency, immediately confirming code status and implementing resuscitative measures accordingly. o Nurses are expected to document findings, interventions/response and notifications within the medical record. o Nurses are expected to notify the Administrator and/or Director of Nurses for all emergent events, deaths within the facility, significant changes in condition and any concerns regarding CPR emergent response as well as any resident without an identified code status election order. Date Completed: [DATE] The Administrator/Director of Nursing/Assistant Director of Nursing conduct re-education with the identified nurses initially then re-education is provided to all licensed nurses regarding on response times when performing immediate assessments/interventions for residents with changes in condition. Anytime a resident experiences a change in condition and it appears the heart has stopped, pulseless or not breathing, with a Full Code Order or No code status, you must immediately initiate CPR until the code status is validated. The other present licensed nurses in the community must assist with the change in condition by immediately verifying code status, calling 911, notifying MD and RP. As well as assisting with the required paperwork for a hospital transfer. Date completed: [DATE] Director of Nursing/Assistant Director of Nursing conducted an audit to validate all orders have been entered into [facility electronic record system] accurately and timely from [DATE]-[DATE]. Outcome: 1 of 123 residents did not have designated advanced directive/code status orders in place. Issue was resolved, physician provided orders as per resident/representative's code status election. Date completed: [DATE] The Administrator/Director of Nursing/Assistant Director of Nursing out of an abundance of caution, provided re-education to all team members on Abuse /Neglect and Residents Rights. Date completed:[DATE] Going forward the identified trainings above will also be conducted with new hires accordingly. Community will ensure all staff on leave/agency/PRN staff are in serviced prior to working their shift. Community will ensure administrative nursing staff in the community to provide in-service/education prior team members working their assigned shift. These trainings will also be conducted with new hires. Risk: All residents who currently admit or re-admit to the community have the potential to be affected by this practice. Community will ensure all staff on leave/agency/PRN staff are in serviced prior to working their shift. Community will ensure administrative nursing staff in the community to provide in-service/education prior team members working their assigned shift. These trainings will also be conducted with new hires. Systemic Response: Director of Nursing/Assistant Director of Nursing conducted 100% re-education was extended to all nurses regarding the expected practice of confirming all new admissions have advance directives elections indicated within the medical record. The Administrator/Director of Nursing/Assistant Director of Nursing conduct re-education with the identified nurses as well as all other licensed nurses regarding the expected practice of confirming all new admissions, re-admissions have advance directives elections indicated within the medical record. o All residents should have a code status election physician's order in place upon admission or re-admission. All licensed nurses educated regarding the process of reconciling physician orders into the electronic health record accurately and timely to include but not limited to code status upon admission, re-admission and any changes in code status election/advanced directives. o Any resident who has an advance directive election change should have the election documented and a physician's order should be obtained at the time the election has been voiced. o DNR elections will be honored upon the resident/representative having voiced the advanced directive care election and if DNR the OOH-DNR form will be initiated and completed with physician's signatures timely (next business day, not to exceed 3 business days), then uploaded into the electronic health record. o Code Status Response: Upon a resident being identified with an acute change of condition; thus, presenting with no signs of life, the absence of vital signs the nurse will: Nurses are expected to validate the code status election prior to initiating CPR by revieing the code status order within the electronic health record. The nurse should immediately alert staff for assistance and all available nursing staff should immediately respond to that location. The nurse will alert staff by utilizing the call light system, phone and /or verbally calling for emergency response assistance to that location. Upon identifying the code status election via the physician's order, the nurse should then proceed with initiating CPR. If the person is designated as Full Code as per the code status order. The available nurses within the community should assist with the code status response by swiftly verifying the code status order, implementing CPR according to the physician's order, calling 911, and/or conducting proper notification to MD and RP, as well as assisting with the required paperwork for a hospital transfer. Should the resident be designated as DNR-do not resuscitate per physician's order and as per the resident's/representative's wishes, the nurse/nurses would proceed with conducting the proper notifications of no s/s of life to the physician and representative. In the event there is no identified code status / advanced directives CPR should be initiated. Resuscitative measures should then only be ceased upon the resident's representative's instruction to stop CPR, confirm the person wished to be DNR and as instructed by physician and/or EMS-medical response team. Director of Nurses/Assistant Director of Nurses will conduct training for licensed nurses, aids and medication aids regarding the process for confirming and implementing CPR. Nursing team members will not work until in-service training has been received. Mock Code Drills: Director of Nurses/Assistant Director of Nurses will conduct monthly mock code response of both full code and DNR on various shifts. The DNS/ADNS will determine competency by evaluating the mock emergency drill. Mock code conducted on [DATE]. It was done correctly. All team members followed the Code Status Process with the Mock Code. Will conduct another mock code on [DATE] the day shift. This will be ongoing and monthly. Date to be completed: [DATE]. o Nurses are expected to document findings, interventions/response and notifications within the medical record. o Licensed Nurses both on-coming, and off-going nurses will review/audit the code status designation for any new admission, re-admission and new order or changes to code status during the 24-hour report. Any identified discrepancies or absence of code status will be reported to the attending MD, DNS and/or ADMIN. Should there not be an election of advanced directives or code status, will result in the individual being full code until otherwise directed. o Nurses are expected to notify the Administrator and/or Director of Nurses for all emergent events, deaths within the facility, significant changes in condition and any concerns regarding CPR emergent response as well as any resident without an identified code status election order. o All Staff: Any staff member should immediately respond to a code status response with the Crash Cart along with the AED to the bedside of identified resident accordingly. Date Completed: [DATE] The Administrator/Director of Nursing/Assistant Director of Nursing out of an abundance of caution, provided re-education to all team members on Abuse /Neglect and Residents Rights. Date completed:[DATE] Going forward the identified trainings above will also be conducted with new hires accordingly. Community will ensure all staff on leave/agency/PRN staff are in serviced prior to working their shift. Community will ensure administrative nursing staff in the community to provide in-service/education prior team members working their assigned shift. These trainings will also be conducted with new hires. Going forward the identified trainings above will also be conducted with new hires accordingly. Monitoring: The Administrator/Director of Nursing/Assistant Director of Nursing/Social Worker will make weekly random audits validating the electronic health record for accurate code status orders as well as appropriate OOH-DNR form within the medical record. This audit will be conducted 1-7 days a week for the next 2 months. The findings will be reviewed and reported to the QAPI committee, to validate compliance or to identify additional training needs. The Director of nurses/Assistant Director of Nurses will conduct weekly skills validations of order entry as well as interview nurses to review the expected practice of validating code status upon admission, validating code status order entry as well as expected process for an emergent response when a significant change in condition (absence of signs of life, no detectable vital signs) has been identified, as well as general interviews with all staff regarding expected response of responding with the crash cart to the designated room accordingly. This expected validation observations and interviews will take place 1-7 days a week for the next 2 months. Mock Code Drills: Director of Nurses/Assistant Director of Nurses will conduct monthly mock code response of both full code and DNR on various shifts at least once a month for the next 2 months. Director of Nurses/Assistant Director of Nurses will review all admission/re-admission orders daily in the clinical meeting to validate orders are transcribed as per required code status admission orders and will review all orders daily in the clinical meeting to validate compliance of code status election has the appropriate code status election physician's order in place. This expected validation observations and interviews will take place 1-7 days a week for the next 2 months. HR/Director of Nurses will conduct CPR certification audit at least once a month for the next 2 months. This corrective action plan will remain in place for the next 2 months to ensure compliance or to identify any further training needs. Findings of those observations will be reported to the QAPI committee during monthly meeting for the next 2 months to establish compliance or identify additional trainings and oversight is required. All audits will be placed in a binder and kept for review by HHSC for the revisit to validate to compliance. The Administrator/Director of Nursing and Medical Director conducted a Ad Hoc QAPI meeting to review this situation, and the immediate corrective action plan implemented. Date of ADHOC : Monitoring of the plan of removal included the following: Record review of In-Service for Administrative Nurses on Advance Directives dated [DATE] revealed DON, ADON A, ADON B, MDS A, MDS B, MDS C, were provided education by Reg. RN regarding Advance Directives and CPR process. Record review of In-Service for Administrative Nurses on "[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for one (CR #1) of four residents reviewed for accidents, hazards, and supervision. -The facility failed to ensure CNA C followed CR#1's care plan when transferring CR#1 who required two staff for transfers. CR#1 slide out of shower chair onto the floor and became unresponsive and later died. -The facility failed to ensure CNA C followed CR#1's care plan when during ambulation. CR#1 ambulated with a walker instead of wheelchair as care planned. CR#1 slide out of shower chair onto the floor and became unresponsive and later died. These failures can place residents at risk of injury due to not being supervised properly. An IJ was identified on [DATE]. The IJ template was provided to the facility Administrator on [DATE] at 7:11 p.m. While the facility Administrator was informed that the IJ was removed on [DATE] at 2:58 PM, the facility remained out of compliance at a severity of no actual harm with potential for more than minimal harm that is not an immediate jeopardy and a scope of isolated because all staff trained on how to pull up resident's care information from the [NAME], notifying the nurse regarding resident care and change in condition. Findings included: Record review of CR #1's face sheet dated [DATE]revealed a [AGE] year-old male was admitted to the facility on [DATE]. CR #1 had diagnoses included: heart failure (heart cannot pulp enough blood and oxygen to the body's organ), morbid obesity (body mass index greater than 35 combined with other health issues), diabetes mellites (body does not manage blood sugar properly), and atrial fibrillation (irregular heartbeat). Record review of CR #1's admission MDS assessment dated [DATE] revealed CR #1 had BIMS score of 15 out of 15 which indicated intact cognition. Further review revealed CR #1 needed moderate assistance with mobility. Record review of Resident #1's care plan dated [DATE] revealed CR#1 revealed resident had a self-care deficit. Interventions: mobility: I use a wheelchair, transfer: gait belt X2 team member CR#1 resident was at risk for shortness of breath. Intervention: alert my nurse for concentrator and/oxygen tank needs to be changed, provide oxygen as ordered by physician. During a telephone interview on [DATE] at 4:15 p.m., LVN T said CNA C called her to the shower room, he saw CR #1 was lying on his back, and CR #1 told him to call the fire department to come and pick him up off the floor. LVN T said he told CNA C to call LVN M, and he went across the hall and brought CR #1's concentrator into the shower room and applied the oxygen to CR #1. LVN T said CR #1 was unresponsive, and his lips and fingertips were blue. LVN T said he could get CR #1's pulse at first, and it was 92, and then there was no pulse. LVN T said all the nurses came and started CPR before the paramedics arrived, and when the paramedic came, they took over but CR #1 expired. During an interview on [DATE] at 4:37 p.m., CNA C said the day CR #1 fell in the shower room was her first time working with him. CNA C said she did not know how CR#1 ambulated or transferred, and she asked CR #1, and he said he walked with a walker. CNA C said CR #1 got up from the bed, took off his oxygen, and walked with his walker to the shower room from his room. CNA C said when CR#1 walked past the door, from the hallway to the shower room to the door in the shower room before the shower stall. CR #1 asked her to turn the shower chair to face him, while she went to turn the shower chair, CR #1 started to slide down and fell before, she could get to him. CNA C said CR #1 fell on his bottom, but he did not hit his head on floor. CNA C said she told CR #1 not to move because she was going to call LVN T. CNA C said she went and called LVN T, and both came back to the bathroom, and CR #1 was still sitting on his buttocks. Then, CNA C said that when she came back with LVN T, CR #1 asked LVN T to go and get his oxygen because he was short of breath. Then LVN T told her to call LVN M. CNA C said some minutes later, CR #1 became unresponsive. CNA C said she would not have ambulated CR #1 with a walker if she knew he was supposed to ambulate with a wheelchair or tried to transfer him by herself to the shower chair if she knew CR #1 was supposed to be transferred by two staff and a gait belt. CNA C said CR #1 would not have fallen if two staff had assisted with the transfer. CNA C said she did not know where to check for how many staff needed to provide care for CR #1. CNA C did not respond when asked about the [NAME] or asking a nurse about care needs for CR#1 During a telephone interview on 01//02/25 at 9:21 a.m., LVN M said CNA C told him to go to the shower room, and when he got to the shower room, CR #1 was lying on his back on the floor, and he was still alive. LVN T went to the CR#1's room, brought the oxygen concentrator to the shower room, and applied the oxygen to CR #1, but CR #1 became unresponsive. LVN M said he called EMS, and a CODE was called. LVN M said other nurses came with a crash cart, and CPR was started. EMS came and took over CPR, but CR #1 expired. LVN M said CNA C should talk to the nurse or look through the [NAME] to find out how CR #1 should be transferred or ambulate. If it was recommended for two staff, then two staff should have transferred CR #1, and maybe CR #1 would not have fallen. CR #1 said the nurse monitored the aides when the nurse made rounds, and the ADON monitored the nurses during random rounds. During an interview on [DATE] at 9:58 a.m., the OT said CR#1 could walk to the restroom and shower room, but he would need his oxygen. The OT said CR#1 kept his oxygen on with any activity, but he could take it off for a little while during the shower. The OT said CR #1 was a fall risk and should ambulate with a wheelchair and be assisted by staff when he ambulates with a walker. The OT said she did not tell the nursing staff to make any changes to CR #1's care plan. During an interview on [DATE] at 10:57 a.m., the ADON said CR #1 should be transferred by two staff and a gait belt because he weighed 554 LB. The ADON said CR #1 could have fallen and been injured if one staff member had transferred the resident. ADON said, one of the nurses called a code blue after the resident fell in the shower room and became unresponsive, but the staff and EMS could not revive CR #1, and he expired. The ADON and the therapist (OT), were responsible for telling the aides how many staff members were needed for transfer. The ADON said the charge nurse monitors the aides and staffing coordinator, and everybody monitors nurses because nursing was a revolving door. The ADON said CNA C should check the [NAME](a system nurses use to access resident care information) to see how CR #1 should be transferred if she had not previously worked with CR #1 or ask the nurse how to care for CR #1. During an interview on [DATE] at 1:31 p.m., the MDS nurse said any change in CR #1's condition would be changed in the care plan and during the quarterly assessment. The MDS nurse said the floor nurse and the DON initiated the care plan for CR#1 upon admission, and when there was a change, she would change the care plan. The MDS nurse said she had not changed CR #1's care plan. The MDS nurse said the therapist (OT), or nursing had not notified her that there were any changes in mobility and transfer for CR#1. The MDS nurse said if CNA C assisted CR #1 from walking to a shower chair, then it was an assisted transfer, and if CR #1 was supposed to be assisted by two staff, then two staff should have assisted. MDS nurse said if CR #1 was not transferred according to the plan of care, the resident could fall and sustain an injury or die. During an interview on [DATE] at 2:47 p.m., LVN T said CNA C could find out what type of care and how many staff were needed to provide care to CR #1 in the POC. LVN T said if CR #1 required two persons' assistance and CNA C transferred CR #1, then the resident could fall, which happened to CR #1. LVN T said the nurses monitored the aides, and the ADON and the DON monitored the nurses during random rounds. LVN T said he had an in-service on admission, transfer, oxygen, and supervision. During an interview on [DATE] at 3:09 p.m., the Administrator said if CR #1 was a two-person transfer, and if CNA C transferred CR #1 by herself, then CR #1 could fall and hurt himself. The Administrator said the nurse monitored the aides during rounds, and the ADON and the DON monitored the nurses during random rounds. During a telephone interview on [DATE] at4:37 p.m., the Physician said he gave intermitter oxygen order and he could not remember how many liters of oxygen he gave, but the nurse could titrate the liter for CR #1 to be comfortable. He said the resident used oxygen intermittently said CR #1 refused to use oxygen sometimes and he had experienced hypoxia and he was still comfortable. The physician said normal order for oxygen was between 2 to 3 liters. The Physician said the nursing or therapy did not communicate to him that CR #1 still has shortness of breath during activities even with oxygen. Record review of the facility accident prevention dated February 2017, Revised [DATE] read in part . adequate supervision and assistance devices to prevent accident .assessment and care plans are used to develop and implement procedures to prevent accidents . The Administrator was informed the following Plan of Removal was accepted on [DATE] at 12:30 PM, PLAN OF REMOVAL: Abatement Plan [DATE] at 7:11pm Immediate Response: o The identified resident expired on [DATE]. o Director of Nursing Services/Assistant Director of Nursing Services identified all residents in the community (12) on continuous oxygen and verified accurate orders were in the electronic health record. All residents with supplemental oxygen (7) have orders in place in the electronic health record. There were no other residents identified in the community who require continuous/supplemental oxygen. Date completed: [DATE]. o Director of Nursing Services/Assistant Director of Nursing Services provided immediate education to all licensed nurses for the process of reconciliation of physician orders from the discharging facility. The charge nurse will then notify the md/np of the admission and review the hospital discharge orders. After this is completed with the md/np, the charge nurse will then enter orders into the electronic health record in PCC for the resident. The Director of Nursing Services/Assistant Director of Nursing will supervise this process and monitor 1-7 days a week for the next 2 months. Date completed:[DATE]. o Director of Nursing Services/Assistant Director of Nursing services will conduct skills validations for all licensed nurses to validate competency for inputting physician orders. Date completed: [DATE]. o Rehabilitation Director will be present in the morning meeting. Director of Nursing Services/Assistant Director of Nursing Services will review all residents who are on oxygen. In addition, the Audit Listing Report for residents on oxygen will we be printed, and a copy given to therapy. This process will be monitored 1-7 days a week for the next 2 months by the Director of Nursing Services/Assistant Director of Nursing Services. Date of completed: [DATE]. o Director of Nursing/Assistant Director of Nursing will provide 100% education to all team members in therapy on notification of changes on condition to the Charge nurse/Assistant Director of Nursing/Director of Nursing. This process will be monitored 1-7 days a week for the next 2 months by the Director of Nursing Services/Assistant Director of Nursing Services. Date of completed: [DATE]. o Director of Nursing/Assistant Director of Nursing will provide education to all direct care staff on notification of changes in condition to report to the charge nurse/Assistant Director of Nursing/Director of Nursing Services. This process will be monitored 1-7 days a week for the next 2 months by the Director of Nursing Services/Assistant Director of Nursing Services. Date of completion: [DATE] o Director of Nursing/Assistant Director provided 100% education to all licensed nurses in regard to resident's changes in condition (shortness of breath, low oxygen saturations and all changes in condition). The nurse will immediately assess the resident and document in the electronic health record, notify the physician and responsible party. The charge nurse will proceed with any new orders from the physician. Date of completion: [DATE] o Director of Nursing/Assistant Director provided 100% education to all direct care team members on use and access of the [NAME] to be informed of the residents needs with activities of daily living prior to providing care of the resident. Date of completion: [DATE] o Director of Clinical Operations provided education to the Director of Nursing Services and Assistant Director of Nursing Services on process and expectation of reconciliation of physician orders from the discharging facility. The charge nurse will then notify the md/np of the admission and review the hospital discharge orders. After this is completed with the md/np, the charge nurse will then enter orders into the electronic health record in PCC for the resident. Director of Nursing Services/Assistant Director of Nursing Services will conduct chart audits the next day of all admissions/readmissions to validate accurate orders were entered into the Electronic Health Record using the hospital discharge summary in collaboration with the admitting physician in the community. The RN supervisor will monitor this process on weekends, holidays, and when the Director of Nursing Services or Assistant Director of Nursing Services is not present in the community. Date completed: [DATE]. Community will ensure all staff on leave/agency/PRN staff are in serviced prior to working their shift. Community will ensure administrative nursing staff in the community to provide in-service/education prior team members working their assigned shift. The community will ensure all residents who require respiratory care are provided such care. Risk Response: All new admissions/readmissions have the potential to be affected by the deficient practice. Systemic Response: o Director of Nursing Services/Assistant Director of Nursing Services identified all residents in the community (12) on continuous oxygen and verified accurate orders were in the electronic health record. All residents with supplemental oxygen (7) have orders in place in the electronic health record. There were no other residents identified in the community who require continuous/supplemental oxygen. Date completed: [DATE]. o Director of Nursing Services/Assistant Director of Nursing Services provided immediate education to all licensed nurses for the process of reconciliation of physician orders from the discharging facility. The charge nurse will then notify the md/np of the admission and review the hospital discharge orders. After this is completed with the md/np, the charge nurse will then enter orders into the electronic health record in PCC for the resident. Date completed:[DATE]. o Director of Nursing Services/Assistant Director of Nursing services will conduct skills validations for all licensed nurses to validate competency for inputting physician orders. Date completed:[DATE]. o Rehabilitation Director will be present in the morning meeting. Director of Nursing Services/Assistant Director of Nursing Services will review all residents who are on oxygen. In addition, the Audit Listing Report for residents on oxygen will we be printed, and a copy given to therapy. This process will be monitored 1-7 days a week for the next 2 months by the Director of Nursing Services/Assistant Director of Nursing Services. Date of completed: [DATE]. o Director of Nursing/Assistant Director of Nursing will provide 100% education to all team members in therapy on notification of changes on condition to the Charge nurse/Assistant Director of Nursing/Director of Nursing. This process will be monitored 1-7 days a week for the next 2 months by the Director of Nursing Services/Assistant Director of Nursing Services. Date of completed: [DATE]. o Director of Nursing/Assistant Director of Nursing will provide education to all direct care staff on notification of changes in condition to report to the charge nurse/Assistant Director of Nursing/Director of Nursing Services. This process will be monitored 1-7 days a week for the next 2 months by the Director of Nursing Services/Assistant Director of Nursing Services. Date of completion: [DATE] o Director of Nursing/Assistant Director provided 100% education to all licensed nurses in regard to resident's changes in condition (shortness of breath, low oxygen saturations and all changes in condition). The nurse will immediately assess the resident and document in the electronic health record, notify the physician and responsible party. The charge nurse will proceed with any new orders from the physician. Date of completion: [DATE] o Director of Nursing/Assistant Director provided 100% education to all direct care team members on use and access of the [NAME] to be informed of the residents needs with activities of daily living prior to providing care of the resident. o Date of completion: [DATE] o Director of Clinical Operations provided education to the Director of Nursing Services and Assistant Director of Nursing Services on process and expectation of reconciliation of physician orders from the discharging facility. The charge nurse will then notify the md/np of the admission and review the hospital discharge orders. After this is completed with the md/np, the charge nurse will then enter orders into the electronic health record in PCC for the resident. Director of Nursing Services/Assistant Director of Nursing Services will conduct chart audits the next day of all admissions/readmissions to validate accurate orders were entered into the Electronic Health Record using the hospital discharge summary in collaboration with the admitting physician in the community. Date completed: [DATE]. Community will ensure all staff on leave/agency/PRN staff are in serviced prior to working their shift. Community will ensure administrative nursing staff in the community to provide in-service/education prior team members working their assigned shift. The community will ensure all residents who require respiratory care are provided such care. Monitoring Response: o The Director of Nurses/Assistant Director of Nurses will conduct weekly skills validations of order entry for 2-3 nurses, 1-7 days a week for 2 months. o Director of Nurses/Assistant Director of Nurses will review all admission/re-admission orders daily in the clinical meeting to validate orders are transcribed per discharge orders for the reconciliation process for 1-7 days a week for 2 months. o Director of Nursing Services/Assistant Director of Nursing Services will review all residents who are on oxygen in the morning meeting. A review of residents who are on oxygen will be reviewed with the rehabilitation representative. In addition, the Audit Listing Report for residents on oxygen will we be printed, and a copy given to therapy. This process will be monitored 1-7 days a week for the next 2 months by the Director of Nursing Services/Assistant Director of Nursing Services. o Director of Nursing/Assistant Director of Nursing will validate the process of reporting changes in condition with 1-3 random therapy team member 1-7 days a week for the next 2 months by the Director of Nursing Services/Assistant Director of Nursing Services. o Director of Nursing/Assistant Director of Nursing will validate the process of reporting changes in condition with 1-3 random therapy team member 1-7 days a week for the next 2 months by the Director of Nursing Services/Assistant Director of Nursing Services. o Director of Nursing Services/Assistant Director of Nursing Services will validate the proper process of use/access of the [NAME] by 1-3 direct care staff 1-7 days a week for 2 months. o Director of Nursing Services/Assistant Director of Nursing Services will validate the process to implement with the notification of a change in condition from 1-3 random licensed nurses 1-7 days a week for 2 months. o All the monitoring will be monitored by the Director of Nursing/Assistant Director of Nursing. This plan will remain in place for the next 2 months to ensure compliance or to identify any further training needs. Findings of those observations will be reported to the QAPI committee during monthly meeting for the next 2 months. Medical Director notified of the Immediate Jeopardy on [DATE] @ 7:22pm per Director of Nursing Services. Surveyor monitored the plan of removal for effectiveness as follows: Observation and interviews starting from [DATE] to [DATE] revealed no concerns with oxygen therapy for Resident #2, Resident #3, Resident #4, Resident #5, and Resident #6. There were no signs of shortness of breath or labored breathing, each resident received oxygen therapy within the parameters of their physician order. Record review of physician orders and care plans for Resident #2, Resident #3, Resident #4, Resident #5, and Resident #6 revealed no concerns, each resident had physician orders and were care planned for oxygen therapy. Record review of [DATE] to [DATE] oxygen saturations and MAR/TAR's for Resident #2, Resident #3, Resident #4, Resident #5, and Resident #6 revealed each resident was being monitored for oxygen therapy. Record review of the facility plan or removal training, skills check-off, and in-service revealed the facility had 12 residents on oxygen, and the DON reviewed and completed their clinical records on [DATE]. Record review of the facility training revealed that the corporate nurse trained the DON, nurse managers, and administrator on physician follow-up chart checks, completed on [DATE]. Record review of the facility training for the nurses on medication reconciliation with the physician from discharged facility order summary report with MD/NP and entering the medication in the PCC. The nurse validated how to enter medication into PCC, completed on [DATE]. A record review of the facility's training revealed that the DON sent all staff training via Care Feed(electronic training system via telephone) on [DATE]. Record review of the facility's oxygen monitoring log revealed that the DON started monitoring on [DATE] and would be monitored 1 - 7 days/week for 1 - 2 months. Record review of the facility's clinical meeting dated [DATE] revealed daily oxygen review for nurse managers, administrators, and physical therapists would be present during morning meetings, residents on oxygen would be reviewed daily. A copy of this report will be given to the therapy representative at this time. Record review of the facility training dated from [DATE] - [DATE] on [NAME]( quick reference to resident care) for all the nursing team revealed how to assess the care provided to the resident, how many staff, and equipment needed during care. Record review of the facility plan of removal training dated from [DATE] - [DATE] revealed the nurses had skills check off on change in condition for oxygen, and any general change in condition. Record review of the facility plan of removal revealed the facility had started monitoring on [DATE]. During interviews conducted on [DATE] between 9:31 a.m. and 2:31 p.m., with staff on shifts (4 CNAs: CNA A, CNA B, CNA D, and CNA E from 6:00 a.m. -to 2:00 p.m. and 4 LVN: LVN C, LVN D, LVN M, and LVN T from 6:00 a.m. -6:00 p.m.) to verify the in-services were conducted and to validate the staff understanding of the information presented to them. No concerns were found regarding the knowledge of verification of admission medication from the discharged facility with the physician. They said any order given by the physician should be entered into the computer, and the nurse managers would follow up with chart checks and clarification of any discrepancies. The LVNs and CNAs said the DON conducted in-service on any change in condition would be reported immediately, and the staff should transport residents on oxygen with their concentrator or oxygen tank. The LVNs and CNAs said they had a skills check-off on [NAME] on how to assess how much staff and equipment are needed for resident care when providing care to any resident. During a telephone interview on [DATE] between 10:48 a.m. and 11:28 a.m., OT and PTA said the DON texted in service on change in condition of any resident during physical therapy. The OT or PTA would fill out stop and watch and sign the form, then give a copy to the nurse and the second copy to the DON. They said the DON called them on the phone and conducted the in-service. She said the physical therapist must report any change in condition, including the resident on oxygen, and the physical director had to attend morning meetings. During interviews conducted on [DATE] between 7:45 a.m., and 8:43 p.m., with staff on shifts (4 CNAs: CNAF, CNA G, CNA H, and CNA I from 2:00 p.m. -10:00 p.m., 3 CNAs: CNA J, CNA K, and CNA L from 6:00 p.m. - 6: 00a.m., and 3 LVN: LVN E, LVN F, and LVN G from 6:00p.m. -6 :00 a.m.) to verify the in-services were conducted and to validate the staff understanding of the information presented to them. No concerns were found regarding the knowledge of verification of admission medication from the discharged facility with the physician. They said any order given by the physician should be entered into the computer, and the nurse managers would follow up with chart checks and clarification of any discrepancies. The LVNs and CNAs said the DON conducted in-service on any change in condition would be reported immediately, and the staff should transport residents on oxygen with their concentrator or oxygen tank. The LVNs and CNAs said they had a skills check-off on [NAME] on how to assess how much staff and equipment are needed for resident care when providing care to any resident. During an interview on [DATE] at 1:45 p.m., ADON L said the corporate nurse did an in-service for the nurse manager and the administrator. ADON L said the in-service and skills checkoff included change in condition, care plans, medication verification, and chart check after admission; [NAME] and oxygen were part of the change in condition. During an interview on [DATE] at 1:57 p.m., the DON, corporate, and administrator were in the room. The DON said she had training from the corporate nurse on change in condition, oxygen, admission process, and the physical therapy director would come to the meetings. The DON said she would monitor the skills check-off and in-service progress for 1 to 7 days for 2 months. During an interview on [DATE] at 2:0 p.m., the Corporate Nurse said she conducted an in-service for the nurse managers, which included the administrator on verification of new resident medication with the physician, and any new order given by the physician would be entered into the computer by the admitting nurse. The Corporate Nurse said the nurse manager would verify the orders in the computer, cross-check them with the admitting orders, and verify from the nurse whether the physician gave an additional order on admission and if the nurse entered the order in the computer. The Corporate Nurse said residents on oxygen were transferred with portable oxygen when they were not in the room. The Corporate Nurse said staff should report immediately when there was any change in condition, including shortness of breath. The Corporate Nurse said she validated the aide's competencies on [NAME]. She also said she reviewed the removal plan with the administrator, DON, and the [NAME] President of operation. During an interview on [DATE] at 2:03 p.m., the Administrator said the Corporate Nurse trained her and the nurse managers on verification of order from the discharged summary report from the transferring facility. The Administrator said the admitting nurse should verify the order with the physician upon admission and enter the order accurately into the computer. She also said if the nurse received any order, such as an oxygen order, the nurse should enter the order accurately in the computer. The Administrator said the next nurse would also check the order, and the ADON would do a chart check and ensure the admitting nurse entered all the orders correctly into the computer. The Administrator said she was also trained on [NAME] and change in condition. The Administrator said the DON would give the names of residents on oxygen to the therapy director so that they could communicate if any of those residents had shortness of breath to the floor nurse and the DON. The Administrator said the nurse manager would monitor the progress of the training for the next two months. During an interview on [DATE] at 2:10 p.m., the Administrator said the error in the system happened when the physician gave an oxygen order for CR #1 and LVN H did not put the order in the computer. The Administrator said that ADON J did not completely check the chart because she did not realize CR #1 was supposed to be on oxygen. During an interview on [DATE] at 2:13 p.m., the DON said the system broke when the LVN H missed entering the oxygen order in the computer, and ADON J, who did the chart check, did not realize LVN H did not enter the oxygen order in the computer. An IJ was identified on [DATE]. The IJ template was provided to the facility Administrator on [DATE] at 7:11 p.m. While the facility Administrator was informed that the IJ was removed on [DATE] at 2:58 PM, the facility remained out of compliance at a severity of no actual harm with potential for more than minimal harm that is not an immediate jeopardy and a scope of isolated because all staff trained on how to pull up resident's care information from the [NAME], notifying the nurse regarding resident care and change in condition.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, and record review the facility failed to immediately consult with the resident's physician when there is a significant change in the resident's physical status for 1 of 4 residents (CR #1) reviewed for notification of changes. The facility failed to ensure CR #1's physician was consulted when he was short of breath while receiving oxygen treatment. This failure could place residents at risk of respiratory distress or significant decline in physical or mental functioning. An IJ was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 7:11 p.m. While the IJ was removed on [DATE], the facility remained out of compliance at a severity of no actual harm with potential for more than minimal harm that was not an immediate jeopardy and a scope of pattern because all staff had not been trained on notification of changes to the physician. The findings included: Record review of Resident #1's face sheet dated [DATE] revealed a [AGE] year-old male was admitted to the facility on [DATE]. Resident #1 had diagnoses included: heart failure, (heart cannot pulp enough blood and oxygen to the body's organ), morbid obesity (body mass index greater than 35 combined with other health issues), diabetes mellites (body does not manage blood sugar properly), and atrial fibrillation (irregular heartbeat). Record review of CR#1's admission MDS assessment dated [DATE] revealed Resident #1 had a BIMS score of 15 out of 15 which indicated intact cognition. Further review revealed Resident #1 needed moderate assistance with mobility. Record review of CR#1's care plan dated [DATE] revealed Resident #1 resident was at risk for shortness of breath. Intervention: alert my nurse for concentrator and/oxygen tank needs to be changed, provide oxygen as ordered by physician. Record review of CR#1's order summary report did not reveal that the resident had an order for oxygen administration. Record review of CR#1's NEMAR for [DATE] revealed there was no order found for Respiratory(oxygen). Record review of CR#1 progress notes from 11/27/ 24 to [DATE] revealed there was no documentation that CR #1 was in any distress. Record review of CR #1 hospital discharge record printed [DATE] did not reveal any order for oxygen. During an interview on [DATE] at 2:07 p.m., RN G said CR #1 was on PRN oxygen. RN G said CR #1 would feel winded when he stood up for her during wound care and he would put his oxygen on. RN G said she was unsure if CR #1 had an order for oxygen. RN G said oxygen should be administered with a physician's order to ensure CR #1 received the appropriate liters of oxygen. RN G said if CR #1 did not receive adequate oxygen, he could go into respiratory distress. RN G said nurse managers monitored the nurses when they made random rounds. During a telephone interview on [DATE] at 4:15 p.m., LVN T said CR #1 had oxygen in his room and believed CR #1 had an order for oxygen. LVN T said CR #1 had an order for oxygen; the nurses would document it on the NEMAR. LVN T said CR #1 must have an order before oxygen would be administered because if CR #1 did not have an order, CR #1 may not receive the required liters of oxygen to prevent respiratory complications such as shortness of breath or a crisis. LVN T said she had an in-service on oxygen administration, and the nurse managers monitored the nurses during random rounds. During an interview on [DATE] at 5:27 p.m., LVN H said she verified the admission orders with the physician, and the physician gave an order for oxygen. LVN H was supposed to put the oxygen order in but did not know she did not put the oxygen order in the computer, and she could not remember how many liters of oxygen the physician prescribed for CR #1. LVN H said oxygen was a medication, and she should have put the order in the computer. LVN H also said if CR #1 did not get the prescribed liters of oxygen, CR #1 could have respiratory distress. LVN H said she had a skill- check off on the admission process, and the nurse manager should have checked the paperwork the day after admission. During an interview on [DATE] at 9:58 a.m., the OT said CR#1 could walk to the restroom and shower room, but he would need his oxygen. The OT said CR#1 kept his oxygen on with any activity, but he could take it off for a little while during the shower. During an interview on [DATE] at 10:38 a.m., PTA said she had worked with CR #1 during therapy and he wore an oxygen tank. She said they worked with him at his pace because of his size, he was mobility obese. She said he wore his oxygen at all times during therapy and he runs out of breath (SOB) and she would let him rest and continued again. She said that when the resident was able to walk to the bathroom in his room, and they told the resident he would have to have staff with him if he wants to walk past the bathroom in his room. During an interview on [DATE] at 10:57 a.m., the ADON said CR #1 did not have an order for oxygen from the hospital. The ADON said the nurse managers should have done chart checks and checked the orders to ensure CR #1's medication was correct the next day. The ADON said LVN H should have put in a PRN order because CR #1 had oxygen, but LVN H did not transcribe the oxygen order. The ADON said CR #1 should not have oxygen on without an order. The ADON said CR #1 could go into respiratory distress if he did not get adequate liters of oxygen, and if CR #1 got more than required, it could cause CR #1 to depend on oxygen. During an observation and interview on [DATE] at 1:55 p.m., the State Surveyor and the MDS Nurse reviewed CR #1's physician orders, and the MDS nurse said she did not see the order for oxygen. The MDS nurse said CR#1 should have an order for oxygen before the nurses could administer oxygen to him. The MDS nurse said it was a medication error because LVN H had to enter the physician's orders before nurses could administer oxygen to CR #1. The MDS nurse said there could be a negative effect on CR #1 if the nurse's administered oxygen to CR#1 without an order. The MDS nurse said the negative effect could cause CR #1 to depend on oxygen or could have an adverse respiratory crisis if he did not receive the recommended liters of oxygen. The MDS nurse said CR #1 was care planned by LVN H, not her. During an interview on [DATE] at 3:02 p.m., the Administrator said that for a resident to be on oxygen, the resident should have an order for oxygen. The Administrator said she was sure there could be some side effects, but she did not think it would be dangerous. The Administrator said the DON monitored the nurses to ensure the nurses transcribed the orders correctly. During an interview on [DATE] at 4:16 PM 4: 16 p.m., the DON said CR #l 's 02 was RPN the nurse would make the decision if the resident could take off the oxygen. The DON said the therapy dept did not tell her that CR#1 got winded during activity even with oxygen. During a telephone interview on [DATE] at4:37 p.m., the Physician said he gave intermitter oxygen order and he could not remember how many liters of oxygen he gave, but the nurse could titrate the liter for CR #1 to be comfortable. He said the resident used oxygen intermittently said CR #1 refused to use oxygen sometimes and he had experienced hypoxia and he was still comfortable. The physician said normal order for oxygen was between 2 to 3 liters. The Physician said the nursing or therapy did not communicate to him that CR #1 still has shortness of breath during activities even with oxygen. He said maybe the nursing staff spoke to the NP about the resident having SOB with oxygen during activity. He said it was his understanding that the resident was on oxygen while he was in the facility. During a telephone interview on [DATE] at 4:58 p.m., the NP refused to answer questions regarding CR #1. Record review of the facility oxygen administration dated [DATE], Revised [DATE] read in part . a resident receives oxygen therapy when there is an order by a physician. The resident's disease, physical condition, and age will help determine the most appropriate method of administration and should be reflected in the physician . The following Plan of Removal was accepted on [DATE] at 12:30 PM, PLAN OF REMOVAL: Abatement Plan Immediate Response: o The identified resident expired on [DATE]. o Director of Nursing Services/Assistant Director of Nursing Services identified all residents in the community (12) on continuous oxygen and verified accurate orders were in the electronic health record. All residents with supplemental oxygen (7) have orders in place in the electronic health record. There were no other residents identified in the community who require continuous/supplemental oxygen. Date completed: [DATE] . o Director of Nursing Services/Assistant Director of Nursing services will conduct skills validations for all licensed nurses to validate competency for inputting physician orders. Date completed: [DATE]. o Rehabilitation Director will be present in the morning meeting. Director of Nursing Services/Assistant Director of Nursing Services will review all residents who are on oxygen. In addition, the Audit Listing Report for residents on oxygen will we be printed, and a copy given to therapy. This process will be monitored 1-7 days a week for the next 2 months by the Director of Nursing Services/Assistant Director of Nursing Services. Date of completed: [DATE]. o Director of Nursing/Assistant Director of Nursing will provide 100% education to all team members in therapy on notification of changes on condition to the Charge nurse/Assistant Director of Nursing/Director of Nursing. This process will be monitored 1-7 days a week for the next 2 months by the Director of Nursing Services/Assistant Director of Nursing Services. Date of completed: [DATE]. o Director of Nursing/Assistant Director of Nursing will provide education to all direct care staff on notification of changes in condition to report to the charge nurse/Assistant Director of Nursing/Director of Nursing Services. This process will be monitored 1-7 days a week for the next 2 months by the Director of Nursing Services/Assistant Director of Nursing Services. Date of completion: [DATE] o Director of Nursing/Assistant Director provided 100% education to all licensed nurses in regard to resident's changes in condition (shortness of breath, low oxygen saturations and all changes in condition). The nurse will immediately assess the resident and document in the electronic health record, notify the physician and responsible party. The charge nurse will proceed with any new orders from the physician. Date of completion: [DATE] . Community will ensure all staff on leave/agency/PRN staff are in serviced prior to working their shift. Community will ensure administrative nursing staff in the community to provide in-service/education prior team members working their assigned shift. The community will ensure all residents who require respiratory care are provided such care. Risk Response: All new admissions/readmissions have the potential to be affected by the deficient practice. Systemic Response: o Director of Nursing Services/Assistant Director of Nursing Services identified all residents in the community (12) on continuous oxygen and verified accurate orders were in the electronic health record. All residents with supplemental oxygen (7) have orders in place in the electronic health record. There were no other residents identified in the community who require continuous/supplemental oxygen. Date completed: [DATE] . o Director of Nursing Services/Assistant Director of Nursing services will conduct skills validations for all licensed nurses to validate competency for inputting physician orders. Date completed:[DATE]. o Rehabilitation Director will be present in the morning meeting. Director of Nursing Services/Assistant Director of Nursing Services will review all residents who are on oxygen. In addition, the Audit Listing Report for residents on oxygen will we be printed, and a copy given to therapy. This process will be monitored 1-7 days a week for the next 2 months by the Director of Nursing Services/Assistant Director of Nursing Services. Date of completed: [DATE]. o Director of Nursing/Assistant Director of Nursing will provide 100% education to all team members in therapy on notification of changes on condition to the Charge nurse/Assistant Director of Nursing/Director of Nursing. This process will be monitored 1-7 days a week for the next 2 months by the Director of Nursing Services/Assistant Director of Nursing Services. Date of completed: [DATE]. o Director of Nursing/Assistant Director of Nursing will provide education to all direct care staff on notification of changes in condition to report to the charge nurse/Assistant Director of Nursing/Director of Nursing Services. This process will be monitored 1-7 days a week for the next 2 months by the Director of Nursing Services/Assistant Director of Nursing Services. Date of completion: [DATE] o Director of Nursing/Assistant Director provided 100% education to all licensed nurses in regard to resident's changes in condition (shortness of breath, low oxygen saturations and all changes in condition). The nurse will immediately assess the resident and document in the electronic health record, notify the physician and responsible party. The charge nurse will proceed with any new orders from the physician. Date of completion: [DATE] . Community will ensure all staff on leave/agency/PRN staff are in serviced prior to working their shift. Community will ensure administrative nursing staff in the community to provide in-service/education prior team members working their assigned shift. The community will ensure all residents who require respiratory care are provided such care. Monitoring Response: o The Director of Nurses/Assistant Director of Nurses will conduct weekly skills validations of order entry for 2-3 nurses, 1-7 days a week for 2 months. o Director of Nurses/Assistant Director of Nurses will review all admission/re-admission orders daily in the clinical meeting to validate orders are transcribed per discharge orders for the reconciliation process for 1-7 days a week for 2 months. o Director of Nursing Services/Assistant Director of Nursing Services will review all residents who are on oxygen in the morning meeting. A review of residents who are on oxygen will be reviewed with the rehabilitation representative. In addition, the Audit Listing Report for residents on oxygen will we be printed, and a copy given to therapy. This process will be monitored 1-7 days a week for the next 2 months by the Director of Nursing Services/Assistant Director of Nursing Services. o Director of Nursing/Assistant Director of Nursing will validate the process of reporting changes in condition with 1-3 random therapy team member 1-7 days a week for the next 2 months by the Director of Nursing Services/Assistant Director of Nursing Services. o Director of Nursing/Assistant Director of Nursing will validate the process of reporting changes in condition with 1-3 random therapy team member 1-7 days a week for the next 2 months by the Director of Nursing Services/Assistant Director of Nursing Services . o Director of Nursing Services/Assistant Director of Nursing Services will validate the process to implement with the notification of a change in condition from 1-3 random licensed nurses 1-7 days a week for 2 months. o All the monitoring will be monitored by the Director of Nursing/Assistant Director of Nursing. This plan will remain in place for the next 2 months to ensure compliance or to identify any further training needs. Findings of those observations will be reported to the QAPI committee during monthly meeting for the next 2 months. Medical Director notified of the Immediate Jeopardy on [DATE] @ 7:22pm per Director of Nursing Services. Surveyor monitored the plan of removal for effectiveness as follows: Observation and interviews starting from [DATE] to [DATE] revealed no concerns with oxygen therapy for Resident #2, Resident #3, Resident #4, Resident #5, and Resident #6. There were no signs of shortness of breath or labored breathing, each resident received oxygen therapy within the parameters of their physician order. Record review of physician orders and care plans for Resident #2, Resident #3, Resident #4, Resident #5, and Resident #6 revealed no concerns, each resident had physician orders and were care planned for oxygen therapy. Record review of [DATE] to [DATE] oxygen saturations and MAR/TAR's for Resident #2, Resident #3, Resident #4, Resident #5, and Resident #6 revealed each resident was being monitored for oxygen therapy. Record review of the facility plan or removal training, skills check-off, and in-service revealed the facility had 12 residents on oxygen, and the DON reviewed and completed their clinical records on [DATE]. Record review of the facility training revealed that the corporate nurse trained the DON, nurse managers, and administrator on physician follow-up chart checks, completed on [DATE]. Record review of the facility training for the nurses on changes of condition and notifications to physicians completed on [DATE]. A record review of the facility's training revealed that the DON sent all staff training via Care Feed(electronic training system via telephone) on [DATE]. Record review of the facility's oxygen monitoring log revealed that the DON started monitoring on [DATE] and would be monitored 1 - 7 days/week for 1 - 2 months. Record review of the facility's clinical meeting dated [DATE] revealed daily oxygen review for nurse managers, administrators, and physical therapists would be present during morning meetings, residents on oxygen would be reviewed daily. A copy of this report will be given to the therapy representative at this time. Record review of the facility training dated from [DATE] - [DATE] on [NAME]( quick reference to resident care) for all the nursing team revealed how to assess the care provided to the resident, how many staff, and equipment needed during care. Record review of the facility plan of removal training dated from [DATE] - [DATE] revealed the nurses had skills check off on change in condition for oxygen, and any general change in condition. Record review of the facility plan of removal revealed the facility had started monitoring on [DATE]. During interviews conducted on [DATE] between 9:31 a.m. and 2:31 p.m., with staff on shifts (4 CNAs: CNA A, CNA B, CNA D, and CNA E from 6:00 a.m. -to 2:00 p.m. and 4 LVN: LVN C, LVN D, LVN M, and LVN T from 6:00 a.m. -6:00 p.m.) to verify the in-services were conducted and to validate the staff understanding of the information presented to them. No concerns were found regarding the knowledge of verification of admission medication from the discharged facility with the physician. They said any order given by the physician should be entered into the computer, and the nurse managers would follow up with chart checks and clarification of any discrepancies. The LVNs and CNAs said the DON conducted in-service on any change in condition would be reported immediately, and the staff should transport residents on oxygen with their concentrator or oxygen tank. The LVNs and CNAs said they had a skills check-off on [NAME] on how to assess how much staff and equipment are needed for resident care when providing care to any resident. During a telephone interview on [DATE] between 10:48 a.m. and 11:28 a.m., OT and PTA said the DON texted in service on change in condition of any resident during physical therapy. The OT or PTA would fill out stop and watch and sign the form, then give a copy to the nurse and the second copy to the DON. They said the DON called them on the phone and conducted the in-service. She said the physical therapist must report any change in condition, including the resident on oxygen, and the physical director had to attend morning meetings. During interviews conducted on [DATE] between 7:45 a.m., and 8:43 p.m., with staff on shifts (4 CNAs: CNAF, CNA G, CNA H, and CNA I from 2:00 p.m. -10:00 p.m., 3 CNAs: CNA J, CNA K, and CNA L from 6:00 p.m. - 6: 00a.m., and 3 LVN: LVN E, LVN F, and LVN G from 6:00p.m. -6 :00 a.m.) to verify the in-services were conducted and to validate the staff understanding of the information presented to them. No concerns were found regarding the knowledge of verification of admission medication from the discharged facility with the physician. They said any order given by the physician should be entered into the computer, and the nurse managers would follow up with chart checks and clarification of any discrepancies. The LVNs and CNAs said the DON conducted in-service on any change in condition would be reported immediately, and the staff should transport residents on oxygen with their concentrator or oxygen tank. The LVNs and CNAs said they had a skills check-off on [NAME] on how to assess how much staff and equipment are needed for resident care when providing care to any resident. During an interview on [DATE] at 1:45 p.m., ADON L said the corporate nurse did an in-service for the nurse manager and the administrator. ADON L said the in-service and skills checkoff included change in condition, care plans, medication verification, and chart check after admission; [NAME] and oxygen were part of the change in condition. During an interview on [DATE] at 1:57 p.m., the DON, corporate, and administrator were in the room. The DON said she had training from the corporate nurse on change in condition, oxygen, admission process, and the physical therapy director would come to the meetings. The DON said she would monitor the skills check-off and in-service progress for 1 to 7 days for 2 months. During an interview on [DATE] at 2:0 p.m., The Corporate Nurse said staff should report immediately when there was any change in condition, including shortness of breath. The Corporate Nurse said she validated the aide's competencies on [NAME]. She also said she reviewed the removal plan with the administrator, DON, and the [NAME] President of operation. During an interview on [DATE] at 2:03 p.m., the Administrator said the Corporate Nurse trained her and the nurse managers on [NAME] and change in condition. The Administrator said the DON would give the names of residents on oxygen to the therapy director so that they could communicate if any of those residents had shortness of breath to the floor nurse and the DON. The Administrator said the nurse manager would monitor the progress of the training for the next two months. During an interview on [DATE] at 2:13 p.m., the DON said the system broke when the LVN H missed entering the oxygen order in the computer, and ADON J, who did the chart check, did not realize LVN H did not enter the oxygen order in the computer. An IJ was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 7:11 p.m. While the IJ was removed on [DATE], the facility remained out of compliance at a severity of no actual harm with potential for more than minimal harm that is not an immediate jeopardy and a scope of isolated because all staff had not been trained on consulting the physician during a change of condition.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, and record review the facility failed to ensure that a resident who needed respiratory care and services, including oxygen administration was provided such care, consistent with professional standards of practice for 1 of 4 residents (CR #1) reviewed for respiratory therapy. The facility failed to ensure CR #1 was provided with repiratory services to meet his needs. CR #1 ambulated with a walker approximately 30 feet without oxygen, slid out of a shower chair onto the floor and became unresponsive and later died. The facility failed to ensure CR #1 who was admitted with a verbal order for oxygen administration was documented, verified, and communicated to staff for proper implementation. This failure could place residents at risk of respiratory distress or dependency. An IJ was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 7:11 p.m. While the IJ was removed on [DATE], the facility remained out of compliance at a severity of no actual harm with potential for more than minimal harm that was not an immediate jeopardy and a scope of pattern because all staff had not been trained on the process of medication reconciliation from the discharged facility with the physician during admission. The admitting nurse would enter the orders in PCC, and the nurse manager would conduct chart audits to validate accurate orders were entered into the computer using the discharge summary in collaboration with the admitting physician in the community. All staff trained on how to pull up residents care information from the Kardex, and change in condition. The findings included: Record review of Resident #1's face sheet dated [DATE] revealed a [AGE] year-old male was admitted to the facility on [DATE]. Resident #1 had diagnoses included: heart failure, (heart cannot pulp enough blood and oxygen to the body's organ), morbid obesity (body mass index greater than 35 combined with other health issues), diabetes mellites (body does not manage blood sugar properly), and atrial fibrillation (irregular heartbeat). Record review of CR#1's admission MDS assessment dated [DATE] revealed Resident #1 had a BIMS score of 15 out of 15 which indicated intact cognition. Further review revealed Resident #1 needed moderate assistance with mobility. Record review of CR#1's care plan dated [DATE] revealed Resident #1 resident was at risk for shortness of breath. Intervention: alert my nurse for concentrator and/oxygen tank needs to be changed, provide oxygen as ordered by physician. Record review of CR#1's order summary report did not reveal that the resident had an order for oxygen administration. Record review of CR#1's NEMAR for [DATE] revealed there was no order found for Respiratory(oxygen). Record review of CR#1 progress notes from 11/27/ 24 to [DATE] revealed there was no documentation that CR #1 was in any distress. Record review of CR #1 hospital discharge record printed [DATE] did not reveal any order for oxygen. Record review of CR #1's Nurse Practitioner visit note dated [DATE] read, review of systems : Chief Complaint :seen today for admission visit .respiratory : chronically 02 dependent at 2L. Record review of CR #1's nursing progress note dated [DATE] at 5:45pm read in part, Around 3:40 p.m (CNA C) was in shower room with patient, as he was transfering to the shower chair he began sliding down, C.N.A assisted res to the floor. C.N.A notified this nurse of situation, this nurse observed res laying on bathroom/shower room floor supine. Res was alert and oriented, denied pain and discomfort at this time. Res skin color was within normal limits. Res stated to this nurse that we would need to call the fire department to get him up and that he needed oxygen. Res did not diplay any (signs or symptoms) of distress at this time. This nurse went across hallway to get res O2 concentrator. 45 seconds after returning to res with supplemental 02, res was unresponsive. lips where a purple coloration, unable to get readable (vital signs). Code blue was called, 911 was called and arrived on scene .Res was pronounced at (4:13pm). During an interview on [DATE] at 2:07 p.m., RN G said CR #1 was on PRN oxygen. RN G said CR #1 would feel winded when he stood up for her during wound care and he would put his oxygen on. RN G said she was unsure if CR #1 had an order for oxygen. RN G said oxygen should be administered with a physician's order to ensure CR #1 received the appropriate liters of oxygen. RN G said if CR #1 did not receive adequate oxygen, he could go into respiratory distress. RN G said nurse managers monitored the nurses when they made random rounds. During an interview on [DATE] at 2:45 p.m., the DON reviewed the discharge report from the hospital with the State Surveyor, and the DON said there was no oxygen order from the discharge summary hospital report. The DON said CR #1 was on oxygen PRN but could not see any order from the facility physician. The DON said CR #1 must have an order for oxygen to ensure the resident received the required liters of oxygen to prevent any respiratory distress for CR #1. During a telephone interview on [DATE] at 4:15 p.m., LVN T said CR #1 had oxygen in his room and believed CR #1 had an order for oxygen. LVN T said CR #1 had an order for oxygen; the nurses would document it on the NEMAR. LVN T said CR #1 must have an order before oxygen would be administered because if CR #1 did not have an order, CR #1 may not receive the required liters of oxygen to prevent respiratory complications such as shortness of breath or a crisis. LVN T said she had an in-service on oxygen administration, and the nurse managers monitored the nurses during random rounds. During an interview on [DATE] at 5:27 p.m., LVN H said she verified the admission orders with the physician, and the physician gave an order for oxygen. LVN H was supposed to put the oxygen order in but did not know she did not put the oxygen order in the computer, and she could not remember how many liters of oxygen the physician prescribed for CR #1. LVN H said oxygen was a medication, and she should have put the order in the computer. LVN H also said if CR #1 did not get the prescribed liters of oxygen, CR #1 could have respiratory distress. LVN H said she had a skill- check off on the admission process, and the nurse manager should have checked the paperwork the day after admission. During an interview on [DATE] at 9:58 a.m., the OT said CR#1 could walk to the restroom and shower room, but he would need his oxygen. The OT said CR#1 kept his oxygen on with any activity, but he could take it off for a little while during the shower. During an interview on [DATE] at 10:38 a.m., PTA said she had worked with CR #1 during therapy and he wore an oxygen tank. She said they worked with him at his pace because of his size, he was mobility obese. She said he wore his oxygen at all times during therapy and he runs out of breath (SOB) and she would let him rest and continued again. She said that when the resident was able to walk to the bathroom in his room, and they told the resident he would have to have staff with him if he wants to walk past the bathroom in his room. During an interview on [DATE] at 10:57 a.m., the ADON said CR #1 did not have an order for oxygen from the hospital. The ADON said the nurse managers should have done chart checks and checked the orders to ensure CR #1's medication was correct the next day. The ADON said LVN H should have put in a PRN order because CR #1 had oxygen, but LVN H did not transcribe the oxygen order. The ADON said CR #1 should not have oxygen on without an order. The ADON said CR #1 could go into respiratory distress if he did not get adequate liters of oxygen, and if CR #1 got more than required, it could cause CR #1 to depend on oxygen. During an observation and interview on [DATE] at 1:55 p.m., the State Surveyor and the MDS Nurse reviewed CR #1's physician orders, and the MDS nurse said she did not see the order for oxygen. The MDS nurse said CR#1 should have an order for oxygen before the nurses could administer oxygen to him. The MDS nurse said it was a medication error because LVN H had to enter the physician's orders before nurses could administer oxygen to CR #1. The MDS nurse said there could be a negative effect on CR #1 if the nurse's administered oxygen to CR#1 without an order. The MDS nurse said the negative effect could cause CR #1 to depend on oxygen or could have an adverse respiratory crisis if he did not receive the recommended liters of oxygen. The MDS nurse said CR #1 was care planned by LVN H, not her. During an interview on [DATE] at 3:02 p.m., the Administrator said that for a resident to be on oxygen, the resident should have an order for oxygen. The Administrator said she was sure there could be some side effects, but she did not think it would be dangerous. The Administrator said the DON monitored the nurses to ensure the nurses transcribed the orders correctly. During an interview on [DATE] at 4:16 PM 4: 16 p.m., the DON said CR #l 's 02 was RPN the nurse would make the decision if the resident could take off the oxygen. The DON said the therapy dept did not tell her that CR#1 got winded during activity even with oxygen. During a telephone interview on [DATE] at4:37 p.m., the Physician said he gave intermitter oxygen order and he could not remember how many liters of oxygen he gave, but the nurse could titrate the liter for CR #1 to be comfortable. He said the resident used oxygen intermittently said CR #1 refused to use oxygen sometimes and he had experienced hypoxia and he was still comfortable. The physician said normal order for oxygen was between 2 to 3 liters. The Physician said the nursing or therapy did not communicate to him that CR #1 still has shortness of breath during activities even with oxygen. Record review of the facility oxygen administration dated [DATE], Revised [DATE] read in part . a resident receives oxygen therapy when there is an order by a physician. The resident's disease, physical condition, and age will help determine the most appropriate method of administration and should be reflected in the physician . The following Plan of Removal was accepted on [DATE] at 12:30 PM, PLAN OF REMOVAL: Abatement Plan F695 Respiratory/Tracheostomy Care and Suctioning [DATE] at 7:11pm Immediate Response: o The identified resident expired on [DATE]. o Director of Nursing Services/Assistant Director of Nursing Services identified all residents in the community (12) on continuous oxygen and verified accurate orders were in the electronic health record. All residents with supplemental oxygen (7) have orders in place in the electronic health record. There were no other residents identified in the community who require continuous/supplemental oxygen. Date completed: [DATE]. o Director of Nursing Services/Assistant Director of Nursing Services provided immediate education to all licensed nurses for the process of reconciliation of physician orders from the discharging facility. The charge nurse will then notify the md/np of the admission and review the hospital discharge orders. After this is completed with the md/np, the charge nurse will then enter orders into the electronic health record in PCC for the resident. The Director of Nursing Services/Assistant Director of Nursing will supervise this process and monitor 1-7 days a week for the next 2 months. Date completed:[DATE]. o Director of Nursing Services/Assistant Director of Nursing services will conduct skills validations for all licensed nurses to validate competency for inputting physician orders. Date completed: [DATE]. o Rehabilitation Director will be present in the morning meeting. Director of Nursing Services/Assistant Director of Nursing Services will review all residents who are on oxygen. In addition, the Audit Listing Report for residents on oxygen will we be printed, and a copy given to therapy. This process will be monitored 1-7 days a week for the next 2 months by the Director of Nursing Services/Assistant Director of Nursing Services. Date of completed: [DATE]. o Director of Nursing/Assistant Director of Nursing will provide 100% education to all team members in therapy on notification of changes on condition to the Charge nurse/Assistant Director of Nursing/Director of Nursing. This process will be monitored 1-7 days a week for the next 2 months by the Director of Nursing Services/Assistant Director of Nursing Services. Date of completed: [DATE]. o Director of Nursing/Assistant Director of Nursing will provide education to all direct care staff on notification of changes in condition to report to the charge nurse/Assistant Director of Nursing/Director of Nursing Services. This process will be monitored 1-7 days a week for the next 2 months by the Director of Nursing Services/Assistant Director of Nursing Services. Date of completion: [DATE] o Director of Nursing/Assistant Director provided 100% education to all licensed nurses in regard to resident's changes in condition (shortness of breath, low oxygen saturations and all changes in condition). The nurse will immediately assess the resident and document in the electronic health record, notify the physician and responsible party. The charge nurse will proceed with any new orders from the physician. Date of completion: [DATE] o Director of Nursing/Assistant Director provided 100% education to all direct care team members on use and access of the Kardex to be informed of the residents needs with activities of daily living prior to providing care of the resident. Date of completion: [DATE] o Director of Clinical Operations provided education to the Director of Nursing Services and Assistant Director of Nursing Services on process and expectation of reconciliation of physician orders from the discharging facility. The charge nurse will then notify the md/np of the admission and review the hospital discharge orders. After this is completed with the md/np, the charge nurse will then enter orders into the electronic health record in PCC for the resident. Director of Nursing Services/Assistant Director of Nursing Services will conduct chart audits the next day of all admissions/readmissions to validate accurate orders were entered into the Electronic Health Record using the hospital discharge summary in collaboration with the admitting physician in the community. The RN supervisor will monitor this process on weekends, holidays, and when the Director of Nursing Services or Assistant Director of Nursing Services is not present in the community. Date completed: [DATE]. Community will ensure all staff on leave/agency/PRN staff are in serviced prior to working their shift. Community will ensure administrative nursing staff in the community to provide in-service/education prior team members working their assigned shift. The community will ensure all residents who require respiratory care are provided such care. Risk Response: All new admissions/readmissions have the potential to be affected by the deficient practice. Systemic Response: o Director of Nursing Services/Assistant Director of Nursing Services identified all residents in the community (12) on continuous oxygen and verified accurate orders were in the electronic health record. All residents with supplemental oxygen (7) have orders in place in the electronic health record. There were no other residents identified in the community who require continuous/supplemental oxygen. Date completed: [DATE]. o Director of Nursing Services/Assistant Director of Nursing Services provided immediate education to all licensed nurses for the process of reconciliation of physician orders from the discharging facility. The charge nurse will then notify the md/np of the admission and review the hospital discharge orders. After this is completed with the md/np, the charge nurse will then enter orders into the electronic health record in PCC for the resident. Date completed:[DATE]. o Director of Nursing Services/Assistant Director of Nursing services will conduct skills validations for all licensed nurses to validate competency for inputting physician orders. Date completed:[DATE]. o Rehabilitation Director will be present in the morning meeting. Director of Nursing Services/Assistant Director of Nursing Services will review all residents who are on oxygen. In addition, the Audit Listing Report for residents on oxygen will we be printed, and a copy given to therapy. This process will be monitored 1-7 days a week for the next 2 months by the Director of Nursing Services/Assistant Director of Nursing Services. Date of completed: [DATE]. o Director of Nursing/Assistant Director of Nursing will provide 100% education to all team members in therapy on notification of changes on condition to the Charge nurse/Assistant Director of Nursing/Director of Nursing. This process will be monitored 1-7 days a week for the next 2 months by the Director of Nursing Services/Assistant Director of Nursing Services. Date of completed: [DATE]. o Director of Nursing/Assistant Director of Nursing will provide education to all direct care staff on notification of changes in condition to report to the charge nurse/Assistant Director of Nursing/Director of Nursing Services. This process will be monitored 1-7 days a week for the next 2 months by the Director of Nursing Services/Assistant Director of Nursing Services. Date of completion: [DATE] o Director of Nursing/Assistant Director provided 100% education to all licensed nurses in regard to resident's changes in condition (shortness of breath, low oxygen saturations and all changes in condition). The nurse will immediately assess the resident and document in the electronic health record, notify the physician and responsible party. The charge nurse will proceed with any new orders from the physician. Date of completion: [DATE] o Director of Nursing/Assistant Director provided 100% education to all direct care team members on use and access of the Kardex to be informed of the residents needs with activities of daily living prior to providing care of the resident. o Date of completion: [DATE] o Director of Clinical Operations provided education to the Director of Nursing Services and Assistant Director of Nursing Services on process and expectation of reconciliation of physician orders from the discharging facility. The charge nurse will then notify the md/np of the admission and review the hospital discharge orders. After this is completed with the md/np, the charge nurse will then enter orders into the electronic health record in PCC for the resident. Director of Nursing Services/Assistant Director of Nursing Services will conduct chart audits the next day of all admissions/readmissions to validate accurate orders were entered into the Electronic Health Record using the hospital discharge summary in collaboration with the admitting physician in the community. Date completed: [DATE]. Community will ensure all staff on leave/agency/PRN staff are in serviced prior to working their shift. Community will ensure administrative nursing staff in the community to provide in-service/education prior team members working their assigned shift. The community will ensure all residents who require respiratory care are provided such care. Monitoring Response: o The Director of Nurses/Assistant Director of Nurses will conduct weekly skills validations of order entry for 2-3 nurses, 1-7 days a week for 2 months. o Director of Nurses/Assistant Director of Nurses will review all admission/re-admission orders daily in the clinical meeting to validate orders are transcribed per discharge orders for the reconciliation process for 1-7 days a week for 2 months. o Director of Nursing Services/Assistant Director of Nursing Services will review all residents who are on oxygen in the morning meeting. A review of residents who are on oxygen will be reviewed with the rehabilitation representative. In addition, the Audit Listing Report for residents on oxygen will we be printed, and a copy given to therapy. This process will be monitored 1-7 days a week for the next 2 months by the Director of Nursing Services/Assistant Director of Nursing Services. o Director of Nursing/Assistant Director of Nursing will validate the process of reporting changes in condition with 1-3 random therapy team member 1-7 days a week for the next 2 months by the Director of Nursing Services/Assistant Director of Nursing Services. o Director of Nursing/Assistant Director of Nursing will validate the process of reporting changes in condition with 1-3 random therapy team member 1-7 days a week for the next 2 months by the Director of Nursing Services/Assistant Director of Nursing Services. o Director of Nursing Services/Assistant Director of Nursing Services will validate the proper process of use/access of the Kardex by 1-3 direct care staff 1-7 days a week for 2 months. o Director of Nursing Services/Assistant Director of Nursing Services will validate the process to implement with the notification of a change in condition from 1-3 random licensed nurses 1-7 days a week for 2 months. o All the monitoring will be monitored by the Director of Nursing/Assistant Director of Nursing. This plan will remain in place for the next 2 months to ensure compliance or to identify any further training needs. Findings of those observations will be reported to the QAPI committee during monthly meeting for the next 2 months. Medical Director notified of the Immediate Jeopardy on [DATE] @ 7:22pm per Director of Nursing Services. Surveyor monitored the plan of removal for effectiveness as follows: Observation and interviews starting from [DATE] to [DATE] revealed no concerns with oxygen therapy for Resident #2, Resident #3, Resident #4, Resident #5, and Resident #6. There were no signs of shortness of breath or labored breathing, each resident received oxygen therapy within the parameters of their physician order. Record review of physician orders and care plans for Resident #2, Resident #3, Resident #4, Resident #5, and Resident #6 revealed no concerns, each resident had physician orders and were care planned for oxygen therapy. Record review of [DATE] to [DATE] oxygen saturations and MAR/TAR's for Resident #2, Resident #3, Resident #4, Resident #5, and Resident #6 revealed each resident was being monitored for oxygen therapy. Record review of the facility plan or removal training, skills check-off, and in-service revealed the facility had 12 residents on oxygen, and the DON reviewed and completed their clinical records on [DATE]. Record review of the facility training revealed that the corporate nurse trained the DON, nurse managers, and administrator on physician follow-up chart checks, completed on [DATE]. Record review of the facility training for the nurses on medication reconciliation with the physician from discharged facility order summary report with MD/NP and entering the medication in the PCC. The nurse validated how to enter medication into PCC, completed on [DATE]. A record review of the facility's training revealed that the DON sent all staff training via Care Feed(electronic training system via telephone) on [DATE]. Record review of the facility's oxygen monitoring log revealed that the DON started monitoring on [DATE] and would be monitored 1 - 7 days/week for 1 - 2 months. Record review of the facility's clinical meeting dated [DATE] revealed daily oxygen review for nurse managers, administrators, and physical therapists would be present during morning meetings, residents on oxygen would be reviewed daily. A copy of this report will be given to the therapy representative at this time. Record review of the facility training dated from [DATE] - [DATE] on Kardex( quick reference to resident care) for all the nursing team revealed how to assess the care provided to the resident, how many staff, and equipment needed during care. Record review of the facility plan of removal training dated from [DATE] - [DATE] revealed the nurses had skills check off on change in condition for oxygen, and any general change in condition. Record review of the facility plan of removal revealed the facility had started monitoring on [DATE]. During interviews conducted on [DATE] between 9:31 a.m. and 2:31 p.m., with staff on shifts (4 CNAs: CNA A, CNA B, CNA D, and CNA E from 6:00 a.m. -to 2:00 p.m. and 4 LVN: LVN C, LVN D, LVN M, and LVN T from 6:00 a.m. -6:00 p.m.) to verify the in-services were conducted and to validate the staff understanding of the information presented to them. No concerns were found regarding the knowledge of verification of admission medication from the discharged facility with the physician. They said any order given by the physician should be entered into the computer, and the nurse managers would follow up with chart checks and clarification of any discrepancies. The LVNs and CNAs said the DON conducted in-service on any change in condition would be reported immediately, and the staff should transport residents on oxygen with their concentrator or oxygen tank. The LVNs and CNAs said they had a skills check-off on Kardex on how to assess how much staff and equipment are needed for resident care when providing care to any resident. During a telephone interview on [DATE] between 10:48 a.m. and 11:28 a.m., OT and PTA said the DON texted in service on change in condition of any resident during physical therapy. The OT or PTA would fill out stop and watch and sign the form, then give a copy to the nurse and the second copy to the DON. They said the DON called them on the phone and conducted the in-service. She said the physical therapist must report any change in condition, including the resident on oxygen, and the physical director had to attend morning meetings. During interviews conducted on [DATE] between 7:45 a.m., and 8:43 p.m., with staff on shifts (4 CNAs: CNAF, CNA G, CNA H, and CNA I from 2:00 p.m. -10:00 p.m., 3 CNAs: CNA J, CNA K, and CNA L from 6:00 p.m. - 6: 00a.m., and 3 LVN: LVN E, LVN F, and LVN G from 6:00p.m. -6 :00 a.m.) to verify the in-services were conducted and to validate the staff understanding of the information presented to them. No concerns were found regarding the knowledge of verification of admission medication from the discharged facility with the physician. They said any order given by the physician should be entered into the computer, and the nurse managers would follow up with chart checks and clarification of any discrepancies. The LVNs and CNAs said the DON conducted in-service on any change in condition would be reported immediately, and the staff should transport residents on oxygen with their concentrator or oxygen tank. The LVNs and CNAs said they had a skills check-off on Kardex on how to assess how much staff and equipment are needed for resident care when providing care to any resident. During an interview on [DATE] at 1:45 p.m., ADON L said the corporate nurse did an in-service for the nurse manager and the administrator. ADON L said the in-service and skills checkoff included change in condition, care plans, medication verification, and chart check after admission; Kardex and oxygen were part of the change in condition. During an interview on [DATE] at 1:57 p.m., the DON, corporate, and administrator were in the room. The DON said she had training from the corporate nurse on change in condition, oxygen, admission process, and the physical therapy director would come to the meetings. The DON said she would monitor the skills check-off and in-service progress for 1 to 7 days for 2 months. During an interview on [DATE] at 2:0 p.m., the Corporate Nurse said she conducted an in-service for the nurse managers, which included the administrator on verification of new resident medication with the physician, and any new order given by the physician would be entered into the computer by the admitting nurse. The Corporate Nurse said the nurse manager would verify the orders in the computer, cross-check them with the admitting orders, and verify from the nurse whether the physician gave an additional order on admission and if the nurse entered the order in the computer. The Corporate Nurse said residents on oxygen were transferred with portable oxygen when they were not in the room. The Corporate Nurse said staff should report immediately when there was any change in condition, including shortness of breath. The Corporate Nurse said she validated the aide's competencies on Kardex. She also said she reviewed the removal plan with the administrator, DON, and the [NAME] President of operation. During an interview on [DATE] at 2:03 p.m., the Administrator said the Corporate Nurse trained her and the nurse managers on verification of order from the discharged summary report from the transferring facility. The Administrator said the admitting nurse should verify the order with the physician upon admission and enter the order accurately into the computer. She also said if the nurse received any order, such as an oxygen order, the nurse should enter the order accurately in the computer. The Administrator said the next nurse would also check the order, and the ADON would do a chart check and ensure the admitting nurse entered all the orders correctly into the computer. The Administrator said she was also trained on Kardex and change in condition. The Administrator said the DON would give the names of residents on oxygen to the therapy director so that they could communicate if any of those residents had shortness of breath to the floor nurse and the DON. The Administrator said the nurse manager would monitor the progress of the training for the next two months. During an interview on [DATE] at 2:10 p.m., the Administrator said the error in the system happened when the physician gave an oxygen order for CR #1 and LVN H did not put the order in the computer. The Administrator said that ADON J did not completely check the chart because she did not realize CR #1 was supposed to be on oxygen. During an interview on [DATE] at 2:13 p.m., the DON said the system broke when the LVN H missed entering the oxygen order in the computer, and ADON J, who did the chart check, did not realize LVN H did not enter the oxygen order in the computer. An IJ was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 7:11 p.m. While the IJ was removed on [DATE], the facility remained out of compliance at a severity of no actual harm with potential for more than min[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide pharmaceutical services, including procedures that assured the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of each resident for one resident (CR #1) of five residents (CR #1) reviewed for pharmacy services. 1. The facility failed to ensure CR #1's discharge orders from a transferring hospital were transcribed to the facility orders. 2. The facility failed to ensure CR #1's two anti-rejection medications were obtained by the facility. 3. The facility failed to ensure CR #1 received daily anti-rejection medications as ordered by the hospital from [DATE] to 05/23/24, when she was re-hospitalized and admitted to the ICU. 4. The facility failed to ensure CR #1, who had a liver transplant, was provided with two anti-rejection medications. An Immediate Jeopardy (IJ) situation was identified on 05/29/24. While the IJ was removed on 05/30/24 at 5:13 p.m., the facility remained out of compliance at a scope of pattern and a severity of no actual harm with potential for more than minimal harm that was not immediate jeopardy, due to the facility's need to evaluate the effective of the corrective systems. The deficient practice resulted in CR #1 exhibiting a change of condition that resulted in hospitalization. Findings include: Record review of CR #1's face sheet reflected a 73- year old female who was admitted to the facility on [DATE]. CR #1 had diagnoses which included, but were not limited to, unspecified cirrhosis of the liver, unspecified liver disease, and liver transplant status (July 2022). Record review of CR #1's admission MDS assessment, dated 04/11/2024, reflected CR #1 had moderately impaired cognition. CR #1 had a feeding tube for nutrition and medications . Record review of the hospital discharge instructions, dated [DATE] , for CR #1 reflected the resident was to receive, in addition to her other medications, the following two anti-rejection medications related to her liver transplant: 1. Tactrolimus (Prograf) 0.5 mg/ml oral suspension, 2 ml (1mg) two times daily for 30 days. The Instructions read, in part, .This medication is very important: It prevents organ rejection. 2. Mycophenolate (Cellcept) 200mg/ml suspension, 2.5 ml (500 mg) two times daily for 360 days. The Instructions read, in part, .This medication is very important: It prevents organ rejection. Record review of CR #1's Physician's Order List (facility) reflected the two anti-rejection medications were not on the list. Record review of a Progress Note, dated 05/22/24 at 12:50 p.m., reflected CR #1 appeared jaundiced. The NP was notified and CBC, BMP, and Ammonia level labs were ordered . Record review of a Progress Note, dated 05/22/24 at 11:02 p.m., reflected the NP called the facility and ordered CR #1 be sent to the hospital due to elevated Ammonia level of 159 micromols per liter. Record review of a Progress Note, dated 05/23/24 at 3:24 a.m., reflected CR #1 was sent to the hospital via ambulance. In an interview on 05/24/24 at 5:10 p.m. the DON said she was notified this morning that CR #1 was sent to the hospital. She said the hospital asked if CR #1 received her anti-rejection medications. The DON said the anti-rejection medications were not entered into the facility order system when the resident was admitted on [DATE]. The DON said when CR #1 was admitted , her payor source was private pay. She said LVN A notified a family member that he needed to bring CR #1's anti-rejection medications. The medications never arrived at the facility. The resident was sent to the hospital yesterday (05/23/24) due to abnormal labs (high Ammonia level), and she appeared jaundiced. She was transferred to the hospital. There were no other residents in the facility that were status-post transplant. The DON said the admission nurse (LVN A) and the Unit Manager (RN B) were both suspended. She said LVN A informed RN B she had difficulty entering CR #1's orders. She said she has begun in-servicing nurses regarding family members bringing or not bringing medications. In an interview via telephone on 05/29/24 at 9:08 a.m., CR #1's family member said CR #1 was still in the hospital. He said the resident was going to have a biopsy conducted to see if the transplanted liver was still being rejected. He said CR #1 had the transplant in July of 2022. He said she was taking the anti-rejection medications prior to going to this facility. He said she was transferred from a hospital to the facility. The family never had the anti-rejection medications. He said he, nor any other family members received a call from the facility asking for medications. She was at a different facility prior to going to that hospital. In an interview via telephone on 05/29/24 at 12:00 p.m. the family member said CR #1 was transferred from the ICU to the transplant unit at the hospital . In an interview via telephone on 05/29/24 at 12:40 p.m. RN B said the protocol for new admissions at the facility was for the Charge Nurse (in this case it would be LVN A) to process the admission. She said the next day the ADON (RN B) would conduct a 'chart check.' RN B said when she conducted the chart check for CR #1 she noticed a couple of medications were not entered into the system . She said she informed the DON, and the DON said to see if the family could bring the medicine in. RN B said she called the family but could not recall whom she spoke with. She said she did not document the conversation with the DON or family member. She said she waited for the family to bring the medications in, but they did not. She said there was no additional follow-up regarding the medications. In an interview on 05/29/24 at 3:19 p.m., LVN A said she did not verify CR #1's admission orders with the physician or NP. She said she thought RN B had done that. LVN A said she had difficulty entering two medication orders. She said she called the family member and was told another family member had recently passed, and he (the family member) would 'figure it out.' She said she told RN B about the two medications . In an interview via telephone on 05/29/24 at 3:55 p.m. the NP said she was not aware CR #1 was not receiving the two anti-rejection medications. She said not administering the anti-rejection medications for a long period of time could cause organ failure . This was determined to be an Immediate Jeopardy (IJ) on 05/29/24 at 4:00 p.m. The Administrator was notified. The Administrator was provided with the IJ template on 05/29/24 at 4:00 p.m. The following Plan of Removal submitted by the facility and was accepted on 05/30/26 at 2:00 p.m.: PLAN OF REMOVAL Name of facility: _____ [Facility] ID # _____ Date: 5/29/24 Immediate action: F-755 Pharmacy Services 5/24/24 Medication Error report was completed This was completed by _____ [DON] 5/24/24 5/24/24 Charge nurse _____ [LVN A] and ADON _____ [RN B] received disciplinary notice and suspended pending investigation. This was completed by _____ [DON] 5/24/24 5/24/24 Patient was assessed by charge nurse on 5/23/23 patient was noted to have jaundiced eyes and abdomen. Patient lab returned with abnormal values related to liver. MD was notified and was sent to _____ [Hospital] ER. This was completed by _____ [RN B], ADON 5/23/24 Facilities Plan to ensure compliance quickly 5/24/24 Facility reviewed the admission policy/ procedures. No changes were required. This was completed by _____ Administrator, _____DON 5/24/24 5/29/24 _____ [Medical Director] our medical director and _____ [Pharmacist], _____ [Pharmacy], _____ [Consultant Pharmacist 1], were notified about the plan of removal. This was completed by _____ DON 5/29/24 5/29/24 All licensed nurses will receive in-service on Reconciliations of medications to include faxing the hospital discharge medication list to pharmacy consultant (company name: _____ [Consultant Pharmacist 2], medication transcription on admission, home medication process, 24-hour chart check and follow-up routine. No nurse will report to duty until in-serviced. All new admissions will be reviewed in clinical meeting by ADON/Unit managers for medication reconciliation and availability utilizing the admission audit tool that includes admissions orders completed and verified. (check for transcription errors), medication availability, and fax medication regimen review to _____ [Consultant Pharmacist 1] (our consultant company) for review. DON will spot check admission audit tool & Review _____ [Consultant Pharmacist 1] Review Report for Recommendations. All new admissions will be reviewed by the Department head nursing on call for holidays and weekends utilizing a charge nurse in facility as the second person. This was completed by _____ DON 5/30/24 5/29/24 A root cause analysis was completed by IDT team This was completed by IDT 5/29/24 5/29/24 An audit will be completed on all admissions in the last 30 days for medication reconciliation accuracy. No other discrepancies were identified. This was completed by _____ DON 5/29/24 5/30/24 All new admissions will be reviewed in clinical meeting by ADON/Unit managers for medication reconciliation and availability utilizing the admission audit tool that includes admissions orders completed and verified (check for transcription errors), medication availability, and fax medication regimen review to _____ [Consultant Pharmacist 1] (our consultant company) for review. ADON/Unit Manager in clinical meeting will completed medication reconciliation together (one will read off the hospital discharge orders and the other with review orders in the AHT system.) All new admissions will be reviewed by the Department head nursing on call for holidays and weekends utilizing a charge nurse in facility as the second person. DON will spot check admission audit tool & Review _____ [Consultant Pharmacist 1] Review Report for Recommendations. Ongoing Monitoring of the Plan of Removal included the following: In an interview on 05/30/24 at 2:30 p.m. with the DON revealed she conducted a medication order audit for all of the facility admissions of the past 30 days. She said a Root Cause Analysis was completed. In an interview on 05/30/24 at 3:10 p.m. with LVN C revealed she received the in-service. She said the in-service was to introduce the new admissions packet that included new processes regarding medications. She said the medications were to be verified by the doctor and a copy of the list was to be faxed to the pharmacy. She said if the resident's family had the medications but did not provide them, order them from the pharmacy. In an interview on 05/30/24 at 3:15 p.m. LVN D said the in-service was about admissions. She said the orders were to be verified by the physician, then faxed to the pharmacy. She said if a family member had the medications, ask them to bring them. If they did not, call the DON and order from the pharmacy. For transplant medications she would call the transplant doctor's office to see where they were to be obtained. In an interview on 05/30/24 at 3:20 p.m., LVN E said the in-service was about admissions. She said the orders were to be verified with the physician and then faxed to the pharmacy. She said if a resident's family had the medications at home but did not provide them, call the pharmacy and order them. In an interview on 05/30/24 at 3:30 p.m., LVN A said there was a new form for medications upon admission. She said the other facility discharge orders were to be verified and faxed to the pharmacy. She said if medications were with the family, she was to call them, and follow-up to make sure the medications arrived. Call the pharmacy if not. In an interview on 05/30/24 at 3:40 p.m., LVN F said after the medication list was verified with the physician it was to be faxed to the pharmacy. If the family had the medications, call them. If the family did not bring them, call the DON and order from the pharmacy. In an interview on 05/30/24 at 4:20 p.m. RN B said the orders were to be faxed to the pharmacy after they were verified with the physician. She said if the family did not bring in home medications, she was to check the Pyxis and call the DON, then order from the pharmacy. She said she was re-training with the DON today and will be training at another facility next week. In an interview on 05/30/24 at 4:25 p.m. LVN G said after the medication orders were verified with the physician, the list was to be faxed to the pharmacy. If the family did not bring the medications, she would call the DON and order from the pharmacy. In an interview on 05/30/24 at 4:30 p.m., LVN H said after the orders were verified with the physician they were to be faxed to the pharmacy. If the family did not bring medications, call the DON, the Unit Manager, and let the incoming nurse know. Record review of Resident #2's admission orders, dated 04/26/24, and May 2024 MAR reflected no discrepancies. Record review of Resident #3's admission orders, dated 05/24/24, and May 2024 MAR reflected no discrepancies. Record review of Resident #4's admission orders, dated 05/14/24, and May 2024 MAR reflected no discrepancies. Record review of Resident #5's admission Audit Tool reflected it was completed with no errors noted. Record review of Resident #6's admission Audit Tool reflected it was completed with no errors noted. Record review of the Medication Error Report, dated 05/23/24, reflected it was completed. Record review of the Disciplinary Notices for LVN A and RN B was conducted . Record review of the facility's policy and procedures for new admissions was reviewed. Record review provided verification that the Medical Director and Pharmacist were notified. Record review of the in-services reflected all of the nurses onof the facility-provided staff list had been provided education . The facility implemented a medication reconciliation list of the hospital discharge medication orders form that was to be faxed to the pharmacy. Record review of the admission Audit Tool did not reflect any concerns. The Administrator and the DON were informed the Immediate Jeopardy was removed on 05/03/24 at 5:13 p.m. The facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm that was not immediate jeopardy and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.