**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record reviews, the facility failed to comply with the requirements specified in 42 CFR part 489, subpart I (Advance Directives). The facility was not relieved of its obligation to provide this information to the individual once he or she was able to receive such information. Follow-up procedures must be in place to provide the information to the individual directly at the appropriate time for 1 of 1 (Resident #1) reviewed for Advanced Directives, in that: Resident #1's RP wished to have a DNR code status for Resident #1. Resident #1's OOHDNR was not valid, and Resident #1 was administered CPR by LVN A and RN B on 4/26/20204. This deficient practice could affect residents with an OOH-DNR and could result in residents not getting their Do Not Resuscitate wishes honored. The noncompliance was identified as PNC. The IJ (Immediate Jeopardy) began on 4/26/2024 and ended on 4/26/2024. The facility had corrected the noncompliance before the survey began. The findings included: Record review of Resident #1's admission Record, dated 5/2/2024, revealed the resident was admitted to the facility on [DATE] with diagnoses that included: ESRD (end stage renal disease, pulmonary edema, diabetes II (a chronic (long-lasting) health condition that affects how your body turns food into energy.), altered mental status, anemia (a problem of not having enough healthy red blood cells or hemoglobin to carry oxygen) in chronic kidney disease, vascular dialysis catheter, peripheral vascular disease (a slow and progressive disorder of the blood vessels. Narrowing, blockage, or spasms in a blood vessel can cause PVD), acquired absence of right leg below the knee, dependence on renal dialysis, cognitive communication deficit disorder of brain. Further review revealed the resident expired on 05/06/2024. Record review of Resident #1's electronic chart revealed in red lettering (on the banner of the resident electronic chart on top)- DNR. Record review of Resident #1's consolidated physician orders for April 2024 revealed an order for a code status of DNR order date was 4/25/2024. Record review of Resident #1's OOHDNR, dated 4/24/2024, revealed the document had no physician signature in the electronic chart. Record review of Resident #1's telephone order, dated 4/25/2024, revealed an order for the resident's code status to be change to DNR was created by ADON/RN N. Further review revealed this order for DNR was not signed by the physician until 4/30/2024. Record review of Resident #1's admission MDS, dated [DATE], revealed the resident had a BIMS score of 2, which indicated the resident was severely cognitively impaired. Further review revealed MDS section I Active Diagnoses indicated the resident had diagnoses of: PVD (peripheral vascular disease), renal insufficiency renal failure, or end stage renal disease (ESRD), Diabetes, Alzheimer's disease, cerebrovascular accident (CVA)/transient ischemic attack (TIA) or stroke, non-Alzheimer's Dementia, asthma, and anemia in chronic kidney disease. Record review of Resident #1's care plan, dated 4/25/2024, revealed the resident's care plan indicate a code status of DNR (dated 4/25/2024). Further review revealed interventions for the resident's DNR code status was: do not perform CPR, should resident be found without pulse, respiration. Record review of Resident #1 progress notes, dated 4/26/2024, revealed it was documented Resident #1 was pronounced dead on 4/26/2024 at 4:43 AM by EMS. Record review of Resident #1 progress note dated 4/26/2024 at 5:30 PM by LVN A, revealed LVN A documented on 04/26/2024 at approximately at 3:58 AM RN B came down the hall and asked if Resident #1 was a full code or DNR. LVN A looked it up on the computer and thought LVN A saw that Resident #1 was a full code. At that time, facility staff started CPR and LVN A came back the desk to call 911. EMS arrived approximately 10 minutes later and took ever CPR. LVN A stayed with Resident #1 to help and provide information as needed. Approximately 15 minutes later, RN N came to the room and stated Resident #1 was a DNR not a full code. By that time CPR had been in progress for approximately 30 minutes. So, EMS continued the CPR also the OOHDNR form EMS requested was not signed by a DR. So, they (EMS) continued the code until they called the local emergency room and spoke to the DR who called the code and time of death at 4:43 AM. LVN A then contacted [Resident #2's family member] and explained to them the Resident #1 had passed away. Resident #1's family member arrived at the facility soon afterwards. During an interview with LVN A on 5/3/2024 at 4:55 PM, LVN A stated he was the night nurse who cared for Resident #1 on 04/26/2024. LVN A stated the last time he saw Resident #1 earlier that night Resident #1 had vomited (Mexican food brought in by the resident's family member), nurse cleaned Resident #1 up and changed the resident's clothes. LVN A stated Resident #1 seemed to be quiet and brought the resident his pain medications. LVN A stated the Resident #1's family member had brought the resident food that night and maybe it did not set well in his stomach. LVN A stated Resident #1 was normal for him not to eat too much. LVN A stated Resident #1 was in and out of the hospital and left home and then came back to the facility. LVN A stated Resident #1 was re-admitted from home because the resident's family member could not care for him. LVN A stated he did CPR which entailed compressions, called 911, and EMS, and further stated when EMS had placed the AED pads-did not advise to shock the resident and continued to be unresponsive. LVN A stated RN B, who was working as a CNA that night, found Resident #1 and came to get him. LVN A stated Resident #1 was found unresponsive with no pulse, and when he looked at the resident's chart and he thought the resident was a full code. During an interview with RN B on 5/3/2024 at 9:21 AM, RN B stated she worked as needed and was working in a CNA slot that night. RN B stated Resident #1's family member had brought Mexican food in and Resident #1 had vomited once that night. RN B stated the resident's vitals were normal and had been cleaned by her and LVN A around 11:30 PM. RN B stated Resident #1 had behaviors of yelling out for help and when staff went to check on him, the resident had forgotten what he needed. RN B stated she would check on Resident #1 every 30 minutes. RN B stated LVN A administered Resident #1 pain medications around 11:30 PM. RN B stated she found Resident #1 unresponsive about 3:55 AM and notified LVN A. RN B stated Resident #1 had no pulse, and he had not fallen. RN B stated LVN A checked the computer for Resident #1's code status, and replied the resident was a full code, so they got the crash cart, vital machine, compressions, and 911 was contacted. RN B stated they had started CPR compressions, then EMS arrived and took over- maybe around 4-5 AM. RN B stated another nurse brought Resident #1's OOHDNR form, and EMS stated it was not valid since the physician signature was missing. EMS preceded to do CPR on Resident #1, then she left the room. RN B stated LVN A was still in Resident #1's room with EMS. During an interview Resident #1's family member on 5/3/2024 at 11:00 AM, Resident #1's family member stated she had signed the OOHDNR due to Resident #1 being in poor health and was too weak. During an interview with the Admission/Marketer on 5/3/2024 at 11:50 AM, the Admission/Marketer stated Resident #1's family member had requested Resident #1 to have an OOHDNR form due the hospital physician stated Resident #1 was in poor health. The Admission/Marketer stated she let Resident #1 family member know the OOHDNR had to be completed before the resident was considered a DNR. The Admission/Marketer stated she gave the OOHDNR, that had two witnesses' signatures, and then gave the OOHDNR to one of the ADON/RN/Medical Records D. The Admission/Marketer stated she uploaded Resident #1's OOHDNR and in parentheses added OFS (out for signature). During an interview with ADON/RN/Medical Records D on 5/3/2024 at 12:08 PM, ADON/RN/Medical Records D stated when the Admission/Marketer gave her a OOHDNR she would take it to the physician's office to have the physician sign the OOHDNR for residents and then would upload the OOHDNR form in the resident record. ADON/RN/Medical Records D stated she would notify the ADM, DON, and charge nurse of the OOHDNR was completed and in the resident's chart. ADON/RN/Medical Records D stated she did not remember receiving Resident #1's OOHDNR form or uploading it to the resident's chart in the computer. ADON/RN/Medical Records D stated, in Resident #1's chart, under Advanced Directive and initial OFS, ADON/RN/Medical Records D stated she was not sure what OFS initial meant. During an interview with the DON on 5/3/2024 at 1:45 PM, the DON stated the staff had notified her of Resident #1's death and she had come to the facility. The DON stated nursing staff was responsible in making sure all residents had the correct code status in their charts. The DON stated Resident #1 did not have an OOHDNR form completed, so the resident would remain full code. The Administrator and DON were notified on 5/3/2024 at 10:23 PM, that a past non-compliance IJ situation had been identified due to the above failures. The facility course of action prior to entrance included: PNC IJ verification: F578 During an interview with ADON/LVN C on at 5/3/2024 at 5:33 PM, ADON/ LVN C stated she did the staff training with nursing staff on OODNR/CPR/change of conditions on 4/26/2024. Record review revealed 84 of 84 direct care staff were in serviced on 4/26/2024 Code Status/change of condition with ADON/RN/Medical Records D and ADON C. Nurses, CNA, MA where to find the location of the code status. Non-clinical staff refer to charge nurse for assistance with code status, If you do not have access to matrix. If at any time these do not match you must notify the ADON, DON and Administrator immediately. Interviews with nursing staff revealed they had received trainings for OOHDNR forms, resident code status location, and chance of condition - nursing staff were able to state what trained on: During an interview with the Administrator on 5/3/2024 at 7:17 PM, the Administrator stated she was trained on where to locate a resident's code status on [the electronic medical records system] (face sheet, order, care plan, OOHDNR). The Administrator stated if the code status's does not match, then let the charge nurse know. During an interview with RN D on 5/3/204 at 7:58 PM, RN D stated she worked here for about one month and had worked here in the past. RN D stated she was trained on where they could find the code status for residents in different locations in chart, could find in orders, could find in the POC for aides, make sure the OODNR was completed. RN D stated staff were to notify the Administrator, DON, or ADON if a resident's code status did not match. During an interview with CNA E on 5/3/2024 at 8:01 PM with CNA E had worked here for 1 year. Yes, she was trained was on residents POC [the electronic medical records system] (residents care plan on the POC). CNA E stated she would notify the charge nurse if change in resident. During an interview with on 5/3/2024 at 8:08 PM with ADON/ LVN F worked here for 7 months. Yes, she was trained was about advanced directives, where to find the code status for residents [the electronic medical records system] and how to access it. If the code status does not match, she would look for the OODNR in documents. The OODNR was valid with Resident/RP signature, 2 witnesses' signatures and physician signature. If missing a signature, it would not be valid. Notify Admin, DON, ADON if do not match. During an interview with on 5/3/2024 at 8:15 PM with MA G had worked here for 4 yrs. Yes, she was trained on code status, [the electronic medical records system] (resident on banner at top of chart, face sheet) Also, trained on notifying charge nurse if the code status does not match. During an interview with on 5/3/2024 at 8:18 PM with CNA H worked here for 2 weeks. Yes, she was trained on OODNR. CNA H sated she would check the residents POC [the electronic medical records system] for the code status. Also, CNA H would ask nurse about a resident code status. CNA H would notify the charge nurse for change in resident condition. During an interview with on 5/3/2024 at 8:25 PM with ADON/LVN I had worked here for 5 months. Yes, she was trained on where to find code status [the electronic medical records system]. ADON/LVN I was trained on where to find who initiated the code status in residents' chart. For OODNR's when admitting she would view the OODNR form to make sure all signatures were completed. ADON/LVN I stated until the OODNR was completed, staff should not create the order. If the code status does not match look at OODNR form and verify its valid. If not validated she would let the floor manager know and correct the code status with DON/ADON and Resident/family. If OODNR form not valid then resident was still considered a full code. During an interview on 5/3/2024 at 8:31 PM with LVN J had been working here for 2 years. Yes, she was trained on advanced directives and mock CPR. This entailed staff check resident code status, [the electronic medical records system] staff brought crash cart, who would call 911, and ADON's monitored. LVN J stated she was trained on advanced directives where to find in the resident chart, the definition, how the OODNR form needs to be filled out completely and where to go to access it. If transferring print out the OODNR form, so it will go with resident. If code status does not match in the resident chart, you have to perform CPR if resident was not responsive. LVN J stated she would notify the ADM, DON, ADON if the resident code status did not match and change of resident condition. During an interview on 5/3/2024 at 8:36 PM with LVN K stated she had worked here for 3.5 yrs. Yes, she was trained on computer. LVN K stated she was trained on where to find the code status, [the electronic medical records system] (on top banner of resident chart, face sheet, and in documents-advanced directive). Also, trained on where to find crash cart and mock CPR. If the OODNR form had to have all signatures to be competed. If the OODNR form was not completed the resident remained full code. If code status does not match, LVN K would double check the OODNR. Resident remains full code until DNR status was completed/valid. LVN K she was trained on who to notify for resident change of conditions. During an interview on 5/3/2024 at 8:48 PM with CNA L had worked here for 4 yrs. Yes, she was trained on where to find code status on residents POC [the electronic medical records system]. CNA L stated she was trained on who can do CPR or not. CNA L stated she was trained to talk to nurse about any change in the resident. During an interview on 5/3/2024 at 8:51 PM with CNA M had worked here for 1.5 yrs. Yes, she was trained on resident code status where to find on POC [the electronic medical records system]. CNA M stated if resident was a DNR, it would be in red and had resident picture. If she sees something wrong with resident, she alerts a nurse. If resident had a change of condition, she would get the nurse. During an interview on 5/3/2024 on 9 AM DON had worked here for 2 weeks. Yes, she was trained on code status, where to find it. The DON stated she could find the resident code status on [the electronic medical records system] (top of banner in resident chart, face sheet, order, OODNR). If the residents code status did not match and when she would follow the OODNR form. The DON stated, if the OODNR form was missing signatures the resident was a full code. The DON stated she was trained on change of condition of a resident- she would complete the SBAR and prompt nurse. Record review of the facility's policy titled, Emergency Procedure- Cardiopulmonary Resuscitation, dated 02/2018, revealed, 6. If an individual is found unresponsive and not breathing normally, a license staff member who is certified in CPR/BLS shall initiate CPR unless: a. is known that a DNR order that specifically prohibits CPR and/or external defibration exist for that individual: 7. If the resident's DNR status is unclear, CPR will be initiated until it is determined that there is a valid OOHDNR. The noncompliance was identified as PNC. The IJ began on 4/26/2204 and corrected on 4/26/2024. The facility had corrected the noncompliance before the survey began on 5/2/2024.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 9 residents (Resident #1) reviewed for accidents and hazards, in that: CNA A did not request assistance from a second staff when providing incontinent care and changing bed linens for Resident #1, resulting in the resident falling out of bed on 09/05/2023 and fracturing her right leg. An Immediate Jeopardy (IJ) was identified on 9/9/23 at 5:05 p.m. While the IJ was removed on 9/11/23, the facility remained out of compliance at a scope of isolated and and a severity level of no actual harm with potential for more than minimal harm because of residents' safety. This deficient practice could place the residents at risk for serious injury. The findings included: Record review of Resident #1's face sheet, dated 11/8/22, revealed Resident #1 was admitted to the facility on [DATE] with diagnoses of Alzheimer's Disease (progressive disease that destroys memory and other mental functions), Muscle Wasting, Abnormalities of Gait and Mobility, and Morbid Obesity (being more than 80-100 pounds above ideal body weight). Record review of Resident #1's admission MDS, dated [DATE], revealed Resident #1 had a BIMS score of 10, signifying moderate cognitive impairment, extensive assistance with two+ physical assistance for bed mobility, total dependence with two+ physical assistance for transfers, substantial/maximal assistance (helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort) for toileting hygiene and was always incontinent of bowel and bladder. Record review of Resident #1's annual MDS, dated [DATE], revealed Resident #1 had a BIMS score of 10, signifying moderate cognitive impairment, total dependence with two+ physical assistance for bed mobility/transfers and dependent (Helper does ALL of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity) for toileting hygiene and was frequently incontinent of bowel and always incontinent of bladder. Record review of Resident #1's care plan, dated 12/1/22, revealed the following Focus area: [Resident #1], have an ADL self-care performance and mobility deficit related to intrinsic and extrinsic factors such as: limited mobility, impaired cognition, depression, heart failure, anxiety, pain, contracture of left ankle/foot. This Focus area had the following interventions: The resident requires extensive assistance by 2 staff to turn and reposition in bed and in chair at least every 2 hours and as necessary . Resident requires total assistance by 2 staff .The resident requires extensive assistance by 2 staff with personal hygiene .The resident requires extensive assistance by 2 staff for toileting Record review of Resident #1's Kardex, dated 11/8/22, revealed the following: Bathing - Resident requires total assistance by 2 staff; Bed Mobility - The resident requires extensive assistance by 2 staff to turn and reposition in bed and in chair at least every 2 hours and as necessary; The resident requires extensive assistance by 2 staff for toileting. Record review of Resident #1's incident report, dated 9/5/23 at 4:25 a.m. and written by LVN O, revealed the following verbiage: CNA called [sic] me to residents [sic] room, upon entering residents [sic] room I observed resident lying on the floor on her right side. The CNA said that as she was changing residents [sic] bed linens resident was holding onto her bedside dresser for support and her legs were hanging off the bed then she slid off the bed. I observed resident for any injuries and resident has redness to her right cheek and bridge of nose. Resident c/o pain to right knee. Residents [sic] right leg appears to be turned inward. I called [DON's name], DON . I notified .administrator. MD and called [county] EMS (911) for Transport to ER. Residents [sic] RP notified as well. Record review of Resident #1's progress note, dated 9/5/23 at 5:20 a.m. and written by LVN O, revealed the following verbiage: CNA called [sic] me to residents [sic] room, upon entering residents [sic] room I observed resident lying on the floor on her right side. The CNA said that as she was changing residents [sic] bed linens resident was holding onto her bedside dresser for support and her legs were hanging off the bed then she slid off the bed. I observed resident for any injuries and resident has redness to her right cheek and bridge of nose. Resident c/o pain to right knee. Residents [sic] right leg appears to be turned inward. I called [DON's name], DON . I notified .administrator. MD and called [county] EMS (911) for Transport to ER. Residents [sic] RP notified as well. Record review of facility's electronic medical record system's 24-hour communication bulletin revealed: 9/5/23 [Resident #1] - witnessed fall out of bed, sent to ER for evaluation and treatment. During an attempted interview and observation on 9/8/23 at 3:26 p.m., Resident #1 was observed in ICU of Hospital A with family at bedside. Resident #1 was observed to have bruising to right hand and arm, swelling and bruising to the left hand, and bruising to the left elbow. Resident #1 was unable to respond to surveyor's questions. During an interview with Hospital Representative T on 9/8/23 at 3:26 p.m., Hospital Representative T stated Resident #1 was extubated (removal of breathing tube) at 11:30 a.m., placed on a face mask with oxygen at 40%. Hospital Representative T further stated the resident's wrists were restrained due to confusion and to avoid pulling of tubes and IV. Record review of Resident #1's radiology report of right femur (the bone that runs from the hip to the knee), dated 9/5/23 at 6:32 am, revealed the following: CLINICAL HISTORY: Trauma/Injury . IMPRESSION: 1. Comminuted [fragmented], displaced and angulated fracture involving the right distal femoral metaphysis [neck portion of a long bone]. 2. Marked soft tissue swelling. Record review of Resident #1's hospital Physician's Order Sheet, dated 9/5/23 at 9:01 a.m., revealed the following: Admit Status: ICU .Diagnosis: Right femoral fracture. Record review of Resident #1's radiology report of right femur (the bone that runs from the hip to the knee), dated 9/6/23 at 4:10 p.m., revealed the following: . IMPRESSION: Intraoperative open reduction internal fixation [operation to repair broken bones] involving the right femur . During a telephone interview on 9/8/23 at 11:32 a.m. Resident #1's RP stated the resident arrived at the hospital with swelling of the right leg and was diagnosed with a fracture, Resident #1 subsequently had surgery to repair the fracture and is now in the ICU and on a ventilator. Resident #1's RP stated the resident was able to follow directions but was 100% bedridden, and further stated the resident did not move or get up. Resident #1's RP stated Resident #1 needed extensive assistance and during the incident there was only one person in the room and the resident was holding on to the dresser. Observation on 9/9/23 at 12:13 p.m. of Resident #1's room revealed there was a side table located to the side of Resident #1's bed at the head of the bed, which placed the side table to the right side of the resident when in the bed. Phone interviews were attempted with CNA R on 9/8/23 at 4:52 p.m. and 9/9/23 at 4:17 p.m. but no return call was received prior to the end of the investigation. During an interview with the DON on 9/8/23 at 5:04 p.m., the DON stated CNA A was suspended immediately following the incident with Resident #1's injury. The DON stated the facility had begun in-servicing regarding ADLs, specifically two-person assistance. During a telephone interview with LVN O on 9/8/23 at 5:40 p.m., LVN O stated she was not in the room when the incident involving Resident #1 on 9/5/23 happened. LVN O stated CNA A called her to the resident's room and LVN O found Resident #1 lying on the floor on her right side. LVN O stated CNA A had said she had been changing the linens on Resident #1's bed when CNA A rolled the resident over and the resident used the dresser for support. LVN O further stated CNA A had said that Resident #1 rolled off the bed and fell. LVN O stated Resident #1 was unable to sit up on her own, was unable to ambulate, and was unable to turn on her side without assistance. LVN O stated staff were expected to follow the individual care plans. During an interview with CNA A on 9/9/23 at 10:35 a.m., CNA A stated that on 9/5/23 she was scheduled to work in the facility's memory care unit, but around 9:45 p.m. she was asked to help on the skilled unit. CNA A stated she asked if there had been any changes in resident conditions and was told no by CNA R. CNA A stated that during the shift Resident #1 voided and she provided incontinent care for the resident and proceeded to change the bed linens because they were soiled. CNA A stated she asked Resident #1 to turn and hold on to the dresser drawer next to the resident's bed, which was opened. CNA A stated Resident #1 was laying on right side holding to the dresser draw, the resident slightly moved her leg, the bed shifted, and Resident #1 rolled off the bed with her leg hitting the floor first. CNA A further stated that Resident #1 was kneeling on the floor while she (CNA A) was on the opposite side of the bed. CNA A stated she ran around to the other side, moved the bed, put her hands under the resident's head and right shoulder, laid her down on the floor and called for the nurse. CNA A stated Resident #1's bed was in a low position due to the resident's short stature and the bed's wheels were locked. CNA A stated she was providing care to Resident #1 alone, and further stated she did not know that Resident #1 required two-person assist for transfers. CNA A stated she always asked for help when providing care to residents that required two-person assistance. CNA A stated she was not trained on how to access the Kardex (a system used to provide a brief overview of each resident and was updated as needed) in the facility's electronic medical records system. CNA A further stated she was informed on 9/9/23, by the DON and Administrator, that the Kardex included everything staff needed to know to care for the residents. CNA A stated she thought the Kardex was for the nurses and repeated that she was never trained how to access it or how to use. CNA A stated had she known how to access the Kardex, she would have reviewed all the residents' plans to know what type of care they required. CNA A stated CNAs reported changes and the care residents required to each other verbally. CNA A stated she had worked at the facility for three years and received one week of training when she was hired and then shadowed another CNA. CNA A further stated that initial training included becoming familiar with the residents, how to provide individual resident care, resident preferences and ADL training, which included scenarios. CNA A stated she also received training regarding ANE and fall prevention. CNA A stated hat abuse was when someone verbally abused a person and neglect was when proper care was not provided to residents, like not changing them or not showering them. CNA A further stated that not following a resident's plan was considered neglect. CNA A stated she was upset because the incident resulting in Resident #1's fall could have been prevented had she known Resident #1 required two-person assistance. CNA A stated there were three other residents she cared for on the night of 9/5/23 that she knew required two-person assistance from having worked with them in the past; and further stated she had asked for assistance when providing care for those three residents and received help, but she stated she was not aware that Resident #1 required more assistance. CNA A stated that otherwise she would have asked for help. During an interview on 9/9/23 at 1:12 p.m., the DON, who started working at the facility on 9/6/23, stated the residents' needs assessments were completed admission and quarterly. The DON stated each residents' needs were included in the individual care plans and that information was then transferred onto the Kardex. The DON stated after the IDT met, agreed and finalized the care plans, the MDS nurse, herself, and the nurse managers were responsible for updating the resident care plans. The DON stated changes/updates to the care plans were relayed to the charge nurse, added to the 24-hour communication bulletin in the facility's electronic medical records system, and the Kardex updated to reflect the care plan; changes were then communicated verbally to the CNAs. The DON stated all staff had access to the information included in the Kardex, and further stated that her expectation was for CNAs to communicate verbally at shift change; however, they were still responsible for checking the Kardex at the start of their shift, before providing care. The DON stated she was told on 9/9/23 by CNA A, that CNA A had not received education regarding access and use of the Kardex. The DON stated she was now responsible for nursing education and verifying competency. During an interview with the Administrator on 9/9/23 at 1:55 p.m., the Administrator stated the expectation was that the DON reviewed the competency of the staff. The Administrator stated competency was reviewed when staff were hired but after that he did not know how often staff competencies was evaluated. During an interview with the OT on 9/9/23 at 2:42 p.m., the OT stated Resident #1 was totally dependent on staff for mobility. During an interview with the Administrator on 9/9/23 at 3:45 p.m., the Administrator stated the care plans were available for the staff to review in the facility's electronic medical records system and it was everyone's responsibility to report any changes in residents' condition. The Administrator stated, with regard to the Kardex, staff were expected to review the Kardex at the start of their shift at a minimum. The Administrator stated the facility did not have a policy, but this was the expectation. The Administrator further stated he did not think this expectation had been relayed to the staff by previous management. With regards to the incident, the Administrator stated that per the documentation, CNA A was changing Resident #1 and the resident was holding on to the nightstand when the resident slid down off the bed. The Administrator stated the facility did not use bedrails. The Administrator stated CNA A was immediately suspended, and CNA A was asked to report to the facility and the DON reviewed the Kardex with her. During a telephone interview on 9/10/23 at 1:01 p.m., CNA A stated she had received training on how to regarding how to turn and reposition residents. CNA A stated that when Resident #1 resided in the memory care unit the resident was able to turn on her own and was told that Resident #1 was a one-person assist because the resident was able to turn herself in the bed. CNA A further stated she was familiar with Resident #1 when she resided in the memory care unit. CNA A stated that changes were communicated verbally and that she had asked on 9/5/23 if there were any changes in resident condition and was told by CNA R there were not any. CNA A stated she was asked to work on the skilled unit around 10:00 p.m. on 9/5/23, further stated that she did not work on the skilled unit. CNA A stated she knew how to care for the memory care residents and what their needs were because she had worked with them for almost one year and was familiar with the residents. CNA A stated she was not made aware that she could access the Kardex for all residents in the facility (both memory care and skilled) until 9/9/23. CNA A stated that prior to this she was only able to access the ADLs section. CNA A stated when she worked the night of 9/9/23 she reviewed the Kardex for all her residents, and further stated the Kardex included exactly what was supposed to be done when providing care to the residents and repeated that if she had known about the Kardex, the incident with Resident #1 on 9/5/23 could have been prevented. CNA A stated on 9/9/23, she was asked, by the DON and Administrator, about the Kardex and she told them she had seen it but had been told it was only used by nurses. CNA A stated she was unable to recall when this was or who gave her this information. CNA A stated she did not ask the LVN or other staff on duty on 9/5/23 how to access the Kardex because she thought they were for nurses only. When asked by the surveyor about the training she signed in for in April and November 2022, which included the Kardex, CNA A stated she did not remember that training. During an interview with the DON on 9/10/23 at 1:17 p.m., when asked who monitors whether a staff member was properly trained on how to care for residents, the DON stated she was now responsible for ensuring that staff were properly trained on how to care for the residents. The DON stated that Prior to her starting employment at the facility it was the previous DON's responsibility. During a telephone interview with LVN S on 9/10/23 at 1:23 p.m., LVN S stated she had frequently conducted in-services regarding use of the Kardex. LVN S stated the Kardex in-services included showing staff how to access the Kardex in the facility's electronic medical records system and POC. LVN S stated everyone had access to the Kardex. LVN S stated during the in-service she demonstrated how the nurses accessed the Kardex versus how CNAs accessed the Kardex. LVN S further stated during the in-service she also explained to the staff what the Kardex was used for. LVN S stated these in-services were always in-person and were provided for new employees and as needed. LVN S stated she could not recall when she provided this training to CNA A, but stated if CNA A had signed in that meant she had definitely received the training. During an interview with the ADON on 9/10/23 at 3:21 p.m., the ADON stated staff should never provide care to residents who required two-person assist alone, and further stated there were always other staff in the facility and there was no excuse for not asking for help from a second person. The ADON stated special needs of the residents were found in the Kardex and training regarding the Kardex was provided to staff upon hire. Record review of the facility's Education Bundle in-service, provided by LVN Q on 9/8/23, revealed: .Purpose: staff will follow Kardex for all care given to residents if you are needing 2 people for any task ensure that you find assistance prior to going to do any care. Goal: ensure that resident receive proper care and to prevent any incidents. Subject: kardex and adl care. Further review revealed the sign-in sheet was signed by 7 out of 97 nursing employees. Record review of the facility's In-Service Training Report, dated 4/11/22 and conducted by LVN S, revealed: TOPIC: Kardex/Patient Care .SUMMARY OF TRAINING SESSION .When completing patient care, please ensure to read through Kardex to ensure appropriate patient care is provided. Further review revealed the sign-in sheet for the above-mentioned training included CNA A's signature. Record review of the facility's CNA Orientation Skills Checklist for CNA A, dated 11/22/22 and signed by LVN S, revealed the checklist included Kardex. Further review revealed the checklist also included a statement that read: I certify that the above employee has demonstrated proficiency and/or verbalized an understanding of the skills listed on this form. Record review of the facility's procedure titled, Turning a Resident on His/Her Side Away From You, dated 10/2010, revealed: .Preparation: Review the resident's care plan to assess for any special needs of the resident. The Administrator and the DON were notified of an IJ on 9/9/23 at 5:05 p.m. and were given a copy of the IJ Template and a Plan of Removal (POR) was requested. The facility provided a POR and it was accepted on 9/10/23 at 3:29 p.m. The POR was documented as follows: Plan of Removal: All direct care nursing staff will be in-serviced on the following- - The expectation for all direct care nursing staff is to identify and utilize the Kardex to review resident's care plan to assess for any special needs of the resident. - All direct care nursing staff will demonstrate and acknowledge that they are aware of how to identify and utilize the Kardex to review resident's care plan to assess for any special needs of the resident. Specifically, the Kardex is located in the POC dashboard which is accessible by all direct care nursing staff in the facility. To access the employee will log into their POC, select the resident and then select the Kardex button located on the right hand side of their screen. This will then display any special needs of the resident as directed in their care plan. - DON and designees audited employee roster to ensure 100% of direct care nursing staff are in-serviced regarding identification and utilization of the Kardex. - The training regarding identification and utilization of the Kardex in order to allow direct care nursing staff to review the resident's care plan to assess for any special needs of the resident will be an ongoing continuous training to be conducted quarterly with first training completed 9/9/2023. Training will also be included in new hire process for all direct care nursing staff. - The utilization of [the facility's electronic medical records system] in the facility does not differ from unit to unit, it is displayed in the same format for all direct care nursing staff. - The facility DON/ADON/Designee notified all direct care nursing staff of facility's policy regarding Turning a Resident on His/Her Side Away From You to educate staff on promoting good body alignment. The policy directs the direct care nursing staff to review the resident's care plan to assess for any special needs of the resident. In addition to the policy direct care nursing staff have been made aware that if assistance is needed to provide resident ADL care they should seek assistance prior to providing care. - The training confirmations will be stored with their employee file in the Human Resources department. - On 9/6/23, the Director of Nursing initiated an addendum to the original in-service initiated on 9/5/2023 by Administrator to include visual aids to assist staff with identification of the Kardex location, this is to include all direct care nursing staff to cover the topics of: - Importance of and expectation that all direct care nursing staff will be able to identify and utilize the Kardex to review resident's care plan to assess for any special needs of the resident. - Importance of and expectation that all licensed nurse staff will demonstrate and acknowledge that they are aware of how to identify and utilize the Kardex to review resident's care plan to assess for any special needs of the resident. Demonstration of and acknowledgement that all direct care nursing staff are aware of the above- - DON/ DON Designee will contact all direct care nursing staff to obtain signature and return demonstration on site or via [video conference] with demonstration and acknowledgment, however, if unable to obtain face to face or visual presentation a verbal acknowledgement will be obtained along with 2 signatures by DON/DON Designee to serve as a return demonstration of understanding that- - Kardex is to be utilized to review resident's care plan to assess for any special needs of the resident prior to providing care. Effective 9/9/23 the DON/ADON/designee will randomly observe direct care nursing staff demonstrate how to locate and utilize the Kardex. - The DON/ADON/designee will conduct random observations with all direct care nursing staff of their ability to locate the Kardex and review to assess for any special needs of the resident. - All direct care nursing staff were contacted in person or by phone and verbally in-serviced. - All direct care nursing staff in-services will be completed by 7:30 pm 9/9/23. - All direct care nursing staff will be made aware and provided with a copy of the facility's policy regarding Turning a Resident on His/Her Side Away From You and to also include specific direction that if assistance is needed they should seek assistance prior to providing ADL care by 10:30 pm 9/9/2023. Results of all observations will be reviewed by the Interdisciplinary Team to ensure that proper adherence to this process is met. Any deviations or omissions will be addressed immediately with staff member. This will be reviewed monthly in QAPI until compliance is met. Validation of the POR: On 09/10/2023 at 3:30 p.m., Administrator provided in-service sign-in sheets for all nursing staff, in-service was completed on 9/9/23. Record review of facility Education Bundle in-service on 9/10/23, revealed the following: .Purpose: staff will follow Kardex for all care given to residents if you are needing 2 people for any task ensure that you find assistance prior to going to do any care. Goal: ensure that resident receive proper care and to prevent any incidents. Subject: kardex and adl care. The sign-in sheet was signed by 97 out of 97 nursing employees. In-service documentation included a handout of the POC Shift Dashboard, which includes tabs for the Kardex and Care Plan, as well as an example of a Kardex and information included in the resident Kardex (this included: Bed Mobility, Toileting and Transferring). Record review of facility In-Service Training Report on 9/10/23, revealed the following: TOPIC: Facility Policy re: repositioning, assessing resident care plan, assistance with ADL care .SUMMARY OF TRAINING SESSION: Facility policy regarding Turning a Resident on His/Her Side Away From You discusses how to promote good body alignment and for the direct care nursing staff to review the resident's care plan to assess for any special needs of the resident. If staff needs assistance to provide ADL care, they must seek help prior to providing the resident care. Please review attached policy for Turning a Resident on His/Her Side Away From You for the detailed purpose, preparation and steps in the Procedure, Documentation and Reporting. During interview on 9/9/23 at 3:45 p.m., the DON stated that in-service was completed for all staff, those that were not available in person were called via video conference to conduct the ADL, Kardex and Turning/Repositioning in-service. During an interview on 9/10/23 at 4:49 p.m., LVN B stated she had received training that included transfers, Kardex and Care Plans. LVN B stated during the in-service she was told to check the Kardex for any special needs the residents might have and was shown how to access the Kardex in the facility's electronic medical records system. LVN B further stated she had access all records, both SNF and Memory Care. Following the interview LVN B demonstrated how to access the Kardex and Care Plans in the facility's electronic medical records system. During an interview on 9/10/23 at 4:51 p.m., CNA C stated she received an in-service on 9/9/23 that included where to find and how to read the Kardex, transfers and bed mobility which included using proper technique and the right amount of assistance when provided care to the residents. Following the interview CNA C demonstrated how to access the Kardex and Care Plans in the facility's electronic medical records system. During an interview on 9/10/23 at 4:56 p.m. CNA D stated she did receive in-service regarding ADLs, Kardex and transfers. CNA D stated the ADL in-service included resident diets, incontinent and incontinent care, the Kardex in-service included ensuring that it was reviewed every morning before providing care and the transfers in-service included using proper techniques, equipment, and level of resident assistance. Following the interview CNA D demonstrated how to access the Kardex. During an interview on 9/10/23 at 5:00 p.m. CNA E stated she received training on 9/9/23 which included fall prevention, notifying nurses of changes in resident condition, what the Kardex was for and how to access it and following special needs of the residents. CNA E stated she had also received training regarding abuse, neglect and exploitation. Following the interview CNA E demonstrated how to access the Kardex. During an interview on 9/10/23 at 5:04 p.m. LVN F stated she recently received training which included how to access the Kardex to check for updates on resident needs and accessing resident care plans. Following the interview LVN F demonstrated how to access the Kardex and care plans. During an interview on 9/10/23 at 5:07 p.m. CNA G stated she had not received training recently. During a demonstration, CNA G was able to locate the Kardex and stated the Kardex was used to review residents' special needs. CNA G stated she accessed the Kardex weekly and when there were new admits. CNA G stated if a resident has a change in condition the nurses would communicate with the CNAs. CNA G stated the expectation was that she accessed the Kardex every other day, and the DON clarified that her expectation were that the Kardex be accessed every shift before providing patient care. Record review of the in-service training records revealed CNA G had received in-services regarding the Kardex, ADLs, and turning residents on 9/9/23. During an interview on 9/10/23 at 5:13 p.m. CNA H stated she received an in-service this week but could not remember what day. CNA H stated the in-service included Kardex, which includes information regarding the residents, transfers, ADLs, level of assistance, turning, repositioning and level of assistance. CNA H stated she usually accessed the Kardex at least twice during her shift. During an interview on 9/10/23 at 6:50 p.m. LVN I stated she recently received an in-service regarding Kardex, transfers, repositioning, asking for assistance when needed and ANE. Following the interview LVN I demonstrated how to access the Kardex. During an interview on 9/10/23 at 6:56 p.m. CNA J stated she did received training recently which included Kardex, falls, and ANE. CNA J stated the Kardex included resident history, special needs and any changes in condition. CNA J stated during the ANE in-service she was told to report any ANE to the Administrator and if she saw anything she considered ANE to report it. CNA J stated she was required to access the Kardex daily when providing care to residents. Following the interview CNA J was able to demonstrate how to access the Kardex. During an interview on 9/10/23 at 6:58 p.m. CNA K stated she received training regarding ANE, ADLs, turning the resident, fall prevention and protecting the residents. CNA K stated the Kardex included resident history, changes in condition, assistive devices, bowel/bladder status and assistance level. CNA K stated she accessed the Kardex daily when providing care because anything can change. CNA K stated she was able to access all resident records in the facility. CNA K stated that in her opinion they should always have two staff when providing care for the residents' safety. Following the interview CNA K was able to demonstrate how to access the Kardex. During an interview on 9/10/23 at 7:05 p.m. CNA L stated she received training on 9/9/23 which included Kardex, transfers and fall prevention. CNA L stated the Kardex included information regarding resident needs to help provide care. CNA L stated she accessed the Kardex every shift and as needed when she was not sure how to care for a resident. Following the interview CNA L was able to demonstrate how to access the Kardex. During an interview with the DON on 9/10/23 at 7:03 p.m., the DON stated the facility