**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice that would meet the resident's physical needs for 2 of 6 (Residents #22 and #5) residents reviewed for quality of care, in that: 1. The facility failed to ensure Resident #22 had a follow-up appointment with a GI doctor within 4-6 weeks from 05/25/24 for a esophageal stent removal, as recommended. Resident #22 did not have an appointment until 10 weeks later where the stent had migrated into the stomach causing an unanticipated need for removal of the stent from the stomach. 2. The facility failed to ensure Resident #5 had a follow-up appointment with a cardiologist in 4 weeks from January 25th. Resident #5 did not see a cardiologist until her 07/17/24 hospitalization for heart health issues. An Immediate Jeopardy (IJ) situation was identified on 08/29/24. The IJ template was provided to the facility on [DATE] at 02:58 PM. While the IJ was removed on 08/30/24, the facility remained out of compliance at a scope of pattern with the potential for more than minimal harm, due to the facility's continuation of in-servicing and monitoring the Plan or Removal. This failure could place residents at risk for delay in needed treatment and diminished quality of care. The findings included: 1. Record Review of Resident #22's admission Record, dated 08/28/24, reflected a [AGE] year-old male initially admitted [DATE] with diagnoses to include esophageal obstruction (a blockage or narrowing of the esophagus, the tube that connects the mouth to the stomach), severe protein-calorie malnutrition, surgical aftercare following surgery on the digestive system, dysphagia (difficulty swallowing), gastric ulcer, (open sores on the inner lining of the stomach and the upper part of the small intestine) and gastrostomy status (an opening into the stomach from the abdominal wall, made surgically for the introduction of food). Record Review of Resident #22's quarterly MDS assessment, dated 07/23/24, reflected Resident #22 had a BIMS score of 13 out of 15, indicating intact cognition. It further revealed Resident #22 had a feeding tube while a resident. Record Review of Resident #22's care plan, dated 08/28/24, reflected, [Resident #22] requires tube feeding r/t Weight Loss, esophageal obstruction, Severe protein calorie malnutrition., initiated 06/28/24, with an intervention, Obtain and monitor lab/diagnostic work as ordered. Report results to MD and follow up as indicated., initiated 06/28/24. Record review of Resident #22's hospital discharge records for 05/18/24-05/25/24, dated 05/25/24, reflected patient was evaluated by gastroenterology due to recommendations per speech therapist secondary to high risk for aspiration due to esophageal stricture Patient with PEG placement with esophageal stent and patient has been cleared to discharge with instructions to have this esophageal stent removed in 6 weeks. And FOLLOW UP: [gastroenterologist] and GI will [coordinate] GI f/u with [GI doctor] to schedule EGD for esophageal stent removal in 4-6 wks. Record Review of Nurses Note, dated 05/26/24 at 02:32 AM and authored by LVN A, reflected Pt [Resident #22] is a readmit arrived at 4pm . Follow up with GI in 4 weeks to remove stent Record Review of Resident #22's hospital documents, dated 08/07/24, reflected reason for visit with the GI doctor was foreign body removal dysphagia. It further reflected the procedure as follows The stent had migrated into the stomach causing an unanticipated need for removal of the stent from the stomach. This removal caused some significant traumatic dilation of the esophagus at the level of the stricture and the stricture was widely patent at the end of the procedure. During an interview on 08/28/24 at 03:05 PM, LVN A was not able to provide specific details about Resident #22 being readmitted in May. She stated she did not recall who needed to make Resident #22's GI appointment, the facility or the GI doctor. During an interview on 08/28/24 at 03:27 PM, the DON revealed if a follow-up doctor's appointment was needed to be made in 4 to 6 weeks and the deadline was approaching, the facility would intervene and make this appointment to include finding a different doctor in the same specialty to have a resident seen in the time frame recommended from hospital discharge paperwork. The DON revealed LVN A could have created a doctor's order for a GI follow up appointment in 4 to 6 weeks from re-admission. She further revealed LVN B, who was to follow a clinical admission checklist to include reading the entirety of residents' hospital discharge paperwork that would allow for necessary doctor's appointments to be made timely. The DON revealed she oversaw these processes and should have caught that a follow up for the GI doctor was needed to be made for Resident #22 in a timely manner. She further revealed the receptionist was making medical appointments; however, the nursing staff were now [after survey investigations] going to start making medical appointments for residents as the nursing staff understood the urgency of making medical appointments. 2. Record Review of Resident #5's admission Record, dated 08/29/24, reflected an [AGE] year-old female initially admitted [DATE] and re-admitted [DATE] with diagnoses to include hypertension (high blood pressure), hypercholesterolemia (excess of cholesterol in the bloodstream), atrial fibrillation (a type of irregular heartbeat), and myocardial infarction (heart attack). Record Review of Resident #5's quarterly MDS assessment, dated 08/09/24, reflected Resident #5 had a BIMS score of 12 out of 15, indicating moderate cognitive impairment. Record Review of Resident #5's hospital discharge paperwork, dated 07/27/24, reflected admission date 07/17/24 for dysarthria (slurred speech)/NSTEMI (type of heart attack) with discharge instructions to follow-up with [Cardiologist] within 1-2 weeks, which would be 08/03/24-08/10/24. Record Review of Resident #5's hospital records, dated 08/20/24, with admission date 08/18/24 reflected resident had diagnoses to include stable angina (type of chest pain that happens when your heart muscle needs more oxygen), severe pulmonary HTN (high blood pressure in your pulmonary arteries), CAD (coronary heart disease) status post stents, hypertensive urgency (urgency with elevated blood pressure), and CHF (congestive heart failure). Record Review of Medical Practitioner Note, dated 07/29/24 at 04:44 PM reflected, was originally admitted to [hospital] for NSTEMI . Her hospital stay was complicated with new onset afib, and acute ischemic stroke with transient dysarthria (a type of stroke) which was then resolved . is now admitted here for continuation of medical care and comprehensive (sp) rehabilitation Record Review of Resident #5's doctor's orders, dated 08/27/24, reflected no cardiologist appointment noted. During an interview on 08/28/24 at 06:30 PM, the Facility MD, the facility's Medical Director he stated Resident #22 should have been seen sooner and that geriatric residents were vulnerable. He said residents should be seen by the specialist as requested by the specialist. During an interview on 08/29/24 at 08:56 AM, the medical office specialist at Resident #5's cardiology clinic revealed Resident #5's cardiologist saw Resident #5 on January 25th, 2024 and needed a 4 week follow up appointment. He revealed in the January 25th appointment Resident #5 had acute CHF and needed to come back for her follow up appointment with the cardiologist to see where everything is at with Resident #5's CHF and if her cariologist saw anything alarming, they would have addressed any concerns quickly. He revealed Resident #5 had an appointment February 13th, 2024 but it appeared to be cancelled. He further revealed the nursing facility needed to call back and get this appointment rescheduled. He revealed the nursing facility had not called to make an appointment with Resident #5's cardiologist until 08/05/24. During an interview on 08/29/24 at 11:45 AM, the DON revealed Resident #5 had an appointment on January 25th, 2024 and they did not have paperwork uploaded in Resident #5's medical records to show if there were any follow up appointments needed to be made because the staff member who oversaw medical records did not upload this paperwork appropriately. The DON verbally confirmed after Resident #5's January 25th cardiologist appointment, Resident #5 did not get seen by a cardiologist until her 07/27/24 hospitalization. The DON revealed it was important for the paperwork to be uploaded and pertinent medical appointments to be scheduled to provide necessary care for the health of the residents. During an interview on 08/29/24 at 12:21 PM, the DON and ADON revealed it was important for residents to have doctor's appointments scheduled appropriately so doctors could give appropriate care to their residents. Left voicemail for cardiologist on 08/30/24 at 02:17 PM with no call back. Attempted to interview Resident #5 3 times on 08/30/24. She was not available . Record Review of the facility's policy, undated, Provision of Quality Care, reflected Each resident will be provided care and services to attain or maintain his/her highest practicable physical, mental, and psychosocial well-being. An IJ was identified on 08/29/2024. The IJ template was provided to the Administrator and the DON on 08/29/2024 at 02:58 PM and a POR was requested. The following Plan of Removal submitted by the facility was accepted on 08/30/2024 at 05:58 PM: POR Verification FACILITY: [Facility ID] SURVEY TYPE: Annual Survey ABATEMENT PLAN: F684 Quality of Care 8/29/24 This abatement plan is submitted to meet the applicable OBRA regulations. It is not to be construed as an admission of the truth of the factual allegations of the survey or the Department's theories of violation. Plan to remove immediate jeopardy Resident #22 was assessed by licensed nurse on 8/29/24, no adverse reactions noted. Resident #5 was assessed by licensed nurse on 8/29/24, no adverse reactions noted. On 8/29/24, licensed nurses physically present were educated in person regarding the community process for scheduling consults and medical appointments. Training conducted by DON and/or ADON. On 8/29/24 licensed nursing staff not physically present, to include those that are PRN and on leave, were contacted by the Administrator, ADON and/or DON via phone and provided education regarding the communities process on scheduling consults and medical appointments. Above mentioned training will be completed on 8/29/24, all licensed staff will be required to have training on community process of resident appointments before assuming resident care responsibilities. Process: New Residents: Licensed nurse, ADON and/or DON will review documentation from the hospital to confirm appointments are scheduled in the timeframe requested. Current Residents: Upon return from appointments Licensed nurse, ADON and/or DON will review documentation from resident appointments to confirm appointments are scheduled in the timeframe requested if follow up is documented. Once documentation mentioned above is received after resident returns from appointment or resident admits to the community it will be reviewed the Licensed Nurse, ADON or DON and will enter an order immediately upon notification/review into Point Click Care that will include the appointment details per the documentation received from the hospital and/or the appointment. Example: Consult needed for Dr. ABC in 4-6 weeks. DON and/or ADON will review orders the following business day and ensure that appointments are made per the recommendations of the physician. DON, ADON or Licensed Nurse will enter progress note after appointment is confirmed to ensure staff have the details for the appointment, this will be an ongoing process. If doctor/clinic is unable to coordinate in the specified timeframe DON, ADON or Licensed Nurse will work with the resident/family and physician to locate a different provider that can accommodate their needs if physician deems necessary. If an appointment is made outside of the timeframe requested by the physician the DON, ADON or Licensed Nurse will enter a progress note explaining the reason for the delay and confirm attending physician. The DON, ADON, MDS Coordinator or other designee will review re-admission paperwork as a secondary review from admitting nurse to ensure that residents care is followed up. Concerns found will be immediately reported to administrator and re-education provided. When the community is notified of a cancelled appointment, they will follow the process and enter a new order into PCC, stating that appointment was cancelled and needs to be rescheduled. This will alert DON or ADON when orders are reviewed the following business day. Appointments will be maintained in a calendar book to be located at nurses' station for appointment tracking. DON, ADON or other designee will be responsible for ensuring calendar is up to date and will be reviewed no less than three times a week. This new process will be effective immediately, 8/29/24, for current residents and any new residents. All residents that have appointments or consults outside the community have the potential to be affected by this alleged deficient practice. The process outlined above was reviewed by the Director of Nursing, Nursing Home Administrator and Medical Director during an Ad Hoc QAPI meeting on 8/29/24. The medical director was involved with the review and the plan of removal. All licensed staff will be required to have training on community process of resident appointments before assuming resident care responsibilities, to include new hires. The Administrator will be responsible for monitoring the above actions for compliance which will be an ongoing process. The Administrator will be responsible for oversight to ensure the process is being completed and will complete an audit no less than one time per month and a report of findings will be reported to the facility's QAPI committee no less than one time per month for six months. The Administrator will ensure the plan is completed in full by 8/29/24. POR verification was as follows: A record review of resident #22's medical record revealed LVN C assessed on 08/30/2024 resident #22 without injuries. During an interview on 08/30/2024 at 12:39 pm LVN C stated she assessed Resident #22 without injuries. A record review of resident #5's medical record revealed LVN C assessed resident #5 without injuries. During an interview on 08/30/2024 at 12:39 pm LVN C stated she assessed Resident #5 without injuries. A record review of the facility's in-service Medical Appointments dated 08/29/2024 revealed, New Residents: Licensed nurse, ADON and/or DON will review documentation from the hospital to confirm appointments are scheduled in the timeframe requested. Current Residents: Licensed nurse, ADON and/or DON will review documentation from resident appointments to confirm appointments are scheduled in the timeframe requested if follow up is documented. Once documentation mentioned above is reviewed the Licensed Nurse, ADON or DON will enter an order into Point Click Care that will include the appointment details per the documentation received from the hospital and/or the appointment. Example: Consult needed for Dr. ABC in 4-6 weeks. DON and/or ADON will review orders the following business day and ensure that appointments are made per the recommendations of the physician. DON, ADON or Licensed Nurse will enter progress note after appointment is confirmed to ensure staff have the details for the appointment. If doctor/clinic is unable to coordinate in the specified timeframe DON, ADON or Licensed Nurse will work with the resident/family and physician to locate a different provider that can accommodate their needs if physician deems necessary. If appointment is made outside of the timeframe requested by the physician the DON, ADON or Licensed Nurse will enter a progress note explaining the reason for the delay and confirm attending physician. further review revealed the following nurses received the training on 08/29/2024: o DON o ADON o LVN A o LVN D o LVN K o LVN H o LVN C o LVN L o LVN J o LVN E o LVN F o LVN G o RN M o RN I During an interview on 08/30/2024 at 01:36 PM the DON stated she was trained by the corporate RN and she provided in-service training for all the nursing staff. The DON stated the training covered reviewing residents' discharge / doctors' recommendations paperwork and communicating the recommendations to the medical director for orders to support the residents needs for follow up appointments and or preprocedural orders. On 8/29/24 licensed nursing staff not physically present, to include those that are PRN and on leave, were contacted by the Administrator, ADON and/or DON via phone and provided education regarding the communities process on scheduling consults and medical appointments. Above mentioned training will be completed on 8/29/24, all licensed staff will be required to have training on community process of resident appointments before assuming resident care responsibilities. 14 of 14 licensed nursing staff were interviewed. The breakdown is as follows: Shift 6 AM- 2 PM (5 of 5 licensed nursing staff interviewed, including 1 DON and 1 ADON) Shift 2 PM-10 PM (2 of 2 licensed nursing staff interviewed) Shift 10 PM-6 AM (3 of 3 licensed nursing staff interviewed) Weekend shift (4 of 4 licensed nursing staff interviewed) Shift 6 AM- 2 PM (5 of 5 licensed nursing staff interviewed, including 1 DON and 1 ADON) During an interview on 08/30/24 at 12:37 PM, LVN D revealed she was in-serviced to review all documents when residents returned from clinics, doctor appointments, and / or hospital visits for follow up appointments and new orders. LVN D stated she would SBAR the Medical Director for an order for the follow-up visits and document in the residents' chart. During an interview on 08/30/24 at 12:38 PM, LVN F revealed she received an in-service on 08/29/2024 which covered expectations for nurses to review all residents' documents when a resident was admitted and / or returned from a doctor's visit. LVN F stated if the documents revealed any recommendations like a follow up visit, she would ask the doctor for an order for the appointment and document the appointment in the resident's chart and document the appointment in the calendar appointment book at the nurse's station. During an interview on 08/30/24 at 12:39 PM, LVN C revealed she received in-service training on 08/29/2024 which covered reviewing return from clinic hospital documents for follow up appointments. LVN C stated she would document new orders for follow up appointments in the resident's chart and the calendar appointment book at the nurse's station. During a combined interview on 08/30/24 at 01:26 PM, the DON and the ADON stated they were in-serviced by the corporate RN to review residents' discharge/doctors' recommendations paperwork and create appointments in a timely manner, as recommended. Shift 2 PM-10 PM (2 of 2 licensed nursing staff interviewed) During an interview on 08/30/24 at 02:19 PM, LVN J revealed he received training on 08/29/2024 for reviewing documents when residents return from appointments and or clinics. LVN J stated he would review the documents for any follow-up appointments and if there were he would document the order in the resident's chart and in the appointment book. During an interview on 08/30/24 at 03:46 PM, RN M stated he received training on 08/29/2024 which covered reviewing all documents from residents' doctors' appointments and if the resident needed a follow up appointment, he would document a new doctors order for the follow up appointment in the resident's chart and the appointment book. Shift 10 PM-6 AM (3 of 3 licensed nursing staff interviewed) During an interview on 08/30/24 at 01:10 PM, RN I revealed he received training on 08/29/2024 which covered documenting and supporting residents with their needs with follow-up appointments and or future procedures. RN I stated he would do so by reviewing the documents upon the residents return from the doctor's visit / hospitalization and writing orders and utilizing the appointment book. During an interview on 08/30/24 at 02:57 PM, LVN K revealed she received training on 08/29/2024 which covered reviewing documents after residents were admitted and / or returned from clinic appointments. LVN K stated she would make a doctor's order for follow-up appointments and / or procedures and document the details in the appointment book at the nurse's station. During an interview on 08/30/24 at 03:19 PM, LVN L revealed she was trained on making medical appointments for residents in a timely manner. She further revealed the nursing staff have doctor's orders and a calendar to follow to prepare residents for their appointments. Weekend shift (4 of 4 licensed nursing staff interviewed) During an interview on 08/30/24 at 12:20 PM, LVN E and LVN H revealed they had received training for reviewing and documenting any needed follow up appointments and / or procedures after residents returned from appointments or were admitted . LVN E and LVN H stated they would document the follow-up appointments as orders in the resident's record and document the appointments in the appointment book / calendar at the nurse's station. During an interview on 08/30/24 at 01:10 PM, LVN A revealed she was in-serviced on 08/29/2024 which covered a system to document follow-up appointments and / or procedures by reviewing all documents returned to the facility after an admission and / or a doctor's visit. During an interview on 08/30/24 at 01:27 PM, LVN G revealed she received in-service training on 08/29/2024 which re-enforced residents' documents after a clinic or admission were reviewed for follow-up appointments. LVN G stated she would document the follow-up appointment in the resident's chart and the appointment book. During an interview on 08/30/24 at 03:35 PM, the ADON revealed there were 2 new admissions since 08/29/24, and they did not have any instructions to have any medical appointments scheduled. The ADON presented a calendar book to show how the nursing staff has already used the calendar book at 1 of 1 nurse's station to write down all residents' medical appointments. Record review of 1 of 2 new admissions revealed no medical appointments were needed to be scheduled. Record Review of Resident #5's medical record revealed she was re-admitted [DATE] after a hospitalization from 08/18/24 to 08/28/24. Record Review of Resident #5's Nurses Note, dated 08/29/24 at 09:01 AM and authored by the DON, reflected Resident #5 went to a cardiology appointment at 10:30 AM on 08/29/24. Record Review of Nurses note, dated 08/29/24 at 02:24 PM and authored by LVN D, reflected a 3 month follow up appointment was scheduled for 11/19/24 at 11:00 AM for Resident #5. Record Review of Resident #5's doctor's orders, dated 08/30/24, reflected, 3 month follow up [appointment] on Tuesday 11/19/24 @1100 [cardiologist], receptionist to schedule transportation Observation and record review on 08/30/24 at 03:35 PM at 1 of 1 nurse's station revealed a calendar book with medical appointments. Record review of this calendar book revealed medical appointments have been added for the residents. During an interview on 08/30/24 at 04:05 PM, the administrator revealed they had a QAPI meeting with the DON, ADON, and the doctor to discuss this plan of removal. An Immediate Jeopardy (IJ) situation was identified on 08/29/24. The IJ template was provided to the facility on [DATE] at 02:58 PM. While the IJ was removed on 08/30/24, the facility remained out of compliance at a scope of pattern with the potential for more than minimal harm, due to the facility's continuation of in-servicing and monitoring the Plan or Removal.