Every finding on record at Aviata at the Bay

Based on interviews and records review the facility failed to protect the resident's right to be free from neglect related to elopement for one resident (#5) out of three residents reviewed for elopement risk. On 8/30/25 Resident #5 exited the facility at approximately 4:15 p.m., unnoticed by staff. Resident #5 had severely impaired cognition, ambulated independently, had wandering behaviors, and did not have an electronic monitoring device on. Resident #5 was able to get from the fourth floor to the first floor, access a stairwell door that should have been locked, and then exit the facility. Another resident observed Resident #5 walking around the west side of the building to the front parking lot and directed her back to the building. Staff did not know Resident #5 was off the fourth floor. This failure created a situation that resulted in a worsened condition and the likelihood for serious injury and or death to Resident #5 and resulted in the determination of Immediate Jeopardy on 1/27/26. The findings of Immediate Jeopardy were determined to be corrected on 9/3/25.Findings included:Review of Resident #5's progress notes showed:8/30/25 4:46 p.m. Nursing Progress Note Resident alert with confusion noted exiting the side door. Resident escorted back into facility. No signs of pain or discomfort noted. Skin assessment completed. No skin alterations noted. Safety measures in place. Placed on 1:1. Psych services currently pending. [Electronic monitoring device] applied and functioning properly. Review of admission Records showed Resident #5 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including but not limited to unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, unspecified psychosis not due to a substance or known physiological condition, other symptoms and signs involving cognitive functions and awareness, depression, and anxiety. Review of Resident #5's Quarterly Minimum Data Set (MDS), dated [DATE], Section C, Cognitive Patterns, showed a Brief interview for Mental Status (BIMS) was unable to be completed due to her rarely/never being understood. Section GG, Functional Abilities, showed she could walk 150 feet with supervision or touching assistance. Section P, Restraints and Alarms, showed a wander/elopement alarm was not used. Review of Resident #5's physician orders showed:-Check for electronic monitoring device placement to LLE (left lower extremity) each shift for elopement. Started: 2/19/25 Ended: 5/28/25. Review of Resident #5's active care plan on 8/30/25 showed a focus area of elopement risk/wandering r/t [related to] dementia, initiated 5/2/25. Interventions included Monitor [electronic monitoring device] to RLL [right lower extremity] frequently for function, initiated 2/19/25 and Identify pattern of wandering: Is wandering purposeful, aimless, or escapist? Is resident looking for something? Does it indicate the need for more exercise? Intervene as appropriate, initiated 2/19/25. Review of Resident #5's Elopement Risk Evaluations dated 2/1/25 and 5/29/25, identified she was an elopement risk. Review of Resident #5's Progress notes showed:-7/16/25 Primary Care Provider 30-day Follow-up Ambulatory, conversational, but with severely decreased orientation/insight into situation and circumstances.-7/21/25 Psychiatry Provider Progress Note: Staff reports increase in agitation, refusing care and combativeness. Review of Symptoms: Anxiety: Irritability, Restless/feeling keyed up. Mania: Acts with potential for painful consequences, Expansive or irritable mood Aggravating factors: Being in the facility, ongoing medical problems and life stressors Physical Exam: Neurologic: Other: alert to self, confused at baseline. Psychiatric: Cooperative, appropriate mood and affect, other: decreased insight, engaged in conversation but unable to express herself clearly.-8/23/25 12:07 a.m. Skilled Note: Level of consciousness noted as oriented to person .Behavioral problem are wandering.-8/28/25 3:23 a.m. Skilled Note: Level of consciousness noted as oriented to person.Behavioral problems are hallucinations and wandering.-8/28/25 3:12 p.m. Standards of Care Note: Resident is alert to self only, with confusion noted Resident ambulates independently, full weight-bearing, with steady gait. Resident has a primary diagnoses ofdementia [sic]. Resident exhibits wandering behavior throughout the unit and requires frequent redirection for safety. Resident demonstrates episodes of verbal and physical aggression toward staff during provision of care. Review of Resident #5's physical therapy notes showed: -8/29/25 Ambulation: Gait Distance =275 feet with no assistive device. An interview was conducted on 1/27/26 at 2;24 p.m. with Staff Q, Registered Nurse (RN). She said she worked with Resident #5 on 8/30/25. She said Resident #5 typically wandered around the fourth floor and staff would reorient her to her room regularly, but she had never seen Resident #5 off the fourth floor. Staff Q said on 8/30/25 she saw the resident at change of shift then again in the hall a short time later. She said she redirected Resident #5 to her room then 10-15 minutes or so later the supervisor, Staff R, RN came on the unit and said Resident #5 had been outside. Staff Q said she had no idea how the resident got off the unit and outside. She said she did not recall Resident #5 having an electronic monitoring device on before this incident, but confirmed one was placed on her after she returned to the unit on 8/30/25. She said normally nurses do an Elopement Risk Assessment every three months, if the resident is determined to be at risk, the supervisor or DON is notified. She said the supervisor or DON will bring an electronic monitoring device to the nurse to put on the resident or they will put it on the resident. An interview was conducted on 1/27/26 at 3:00 p.m. with Staff R, RN. She confirmed she was the supervisor on duty on 8/30/25 when Resident #5 eloped. She said Resident #5 was always confused, but she had no idea how the resident got out of the facility, but 'she didn't go far. Staff R said, we weren't able to figure out what door she went out. She said an alarm did go off downstairs and staff were trying to figure out why. She said you can kind of pinpoint the area the alarm was coming from. She said it was like on the backside of the building. She then said it was on the west side of the building. Staff R said when the alarm went off staff did not know why it was going off or if a resident went out the door, but they started looking. She said while staff were looking to see if a resident went outside, another resident (Resident #13) saw Resident #5 in the parking lot and brought her to the front of the building. Staff R said she went out front and helped get Resident #5 back in the building. She said Resident #5 did not have any injuries. Staff R said Resident #5 did not have an electronic monitoring device on because she usually just kind of stayed on the unit. It wasn't warranted for her to have one. She said the resident had an electronic monitoring device placed after the incident. An interview was conducted on 1/26/26 at 3:41 p.m. with Resident #13. He said a few months ago he was out in front of the facility on leave of absence. He said he saw a lady walking around from the west side of the building by the generators. He said he didn't know her, but she was in a hospital gown with a blanket wrapped around her. He said it looked like she knew where she was headed, but it didn't look right to him. He said he walked over to her, and she was confused so he got her to come sit on the bench in front of the building. He said when she sat on the bench a staff member saw them through the front door and came outside. He said that staff member knew who the lady was.Review of admission Records showed Resident #13 was admitted on [DATE]. Review of Resident #13's Annual MDS, Section C, Cognitive Patterns, showed a BIMS score of 13, indicating he was cognitively intact.An interview was conducted on 1/27/26 3:35 p.m. with Staff S, Licensed Practical Nurse (LPN). Staff S said he was working on the third floor on the day Resident #5 eloped (8/30/25). He said no alarm ever went off for the doors that he heard. Staff S said Resident #5 normally wandered around the unit but never really left.An interview was conducted on 1/27/26 at 5:09 p.m. with the Nursing Home Administrator (NHA) and Director of Nursing (DON). They said on 8/30/25 around 4:30 p.m. they received a call from the weekend supervisor letting them know Resident #5 had gotten out of the building but was back safely. They said Resident #13 had seen Resident #5 outside and directed her back to the building safely. They said the resident had been an elopement risk when she first came to the building in January 2025, but she declined and went out to the hospital in May. They said when she returned, she was not an elopement risk because she could not get out of bed. The DON said the Elopement Risk Assessment completed in May 2025 was incorrect because the nurse did it based on information prior to the resident going to the hospital. They said there were three residents in the elopement books on 8/30/25, but Resident #5 was not one of them. The DON said it wasn't until August that Resident #5 started walking good. She said the resident did not have an electronic monitoring device placed when she started walking again because she was not exit seeking. The NHA and DON reviewed Resident #5's care plan and confirmed she had been care planned for an electronic monitoring device from February through September 2025. They said during their investigation they could not determine how Resident #5 got downstairs or into the stairwell. They said they interviewed residents and staff and did not find anyone that saw Resident #5 on the elevator or that possibly rode the elevator down with her. The NHA said after getting downstairs Resident #5 somehow got into the stairwell which was only accessible from a locked door with a keypad code. They said from the stairwell there is an exit door to the outside and that is where the resident exited. The NHA said they knew she exited that door because the alarm was going off on that door, however she said the alarm was just a beeping sound that could only be heard in the stairwell or just outside of the stairwell doors . The NHA said the receptionist in the front did not hear the alarm from down the hall. The NHA and DON said the staff did not know Resident #5 had gotten downstairs and outside until Resident #13 brought her to the front of the building and the receptionist saw them. They said she had not gone missing and there was no elopement code called. They said they did do an elopement drill that evening after the incident. The NHA confirmed that Resident #5 was not observed exiting the facility and Resident #13 was the only person to see the resident outside. She said Resident #13 found Resident #5 and brought her back to the facility. A follow-up interview was conducted on 1/29/26 at 12:48 p.m. with the NHA. She stated that the electronic monitoring device is a nursing intervention and did not require a physician's order. She said they do typically put an order in the system to ensure the electronic monitoring device is checked daily by staff. An interview was conducted on 1/28/26 at 12:42 p.m. with Staff T, Occupational Therapist (OT). Staff F said Resident #5 was in the late stages of dementia and had trouble sequencing tasks. He said she would wander the halls and constantly went into other residents' rooms. Staff T said Resident #5 might go towards the elevators to get on, but she was easily redirected. He said she did follow other residents where they were going. Staff T said Resident #5 would have had the strength to open doors, but he didn't feel like she could have walked down four flights of stairs without falling. He said Resident #5 was alert and oriented to person only. Staff T said he didn't feel like staff are educated enough on treatment of dementia residents. An interview was conducted on 1/28/26 at 2:44 p.m. with Resident #5's Psychiatric-Mental Health Nurse Practitioner (PMHNP). She said Resident #5 was only oriented to person and was not able to care for herself. She said she didn't necessarily think of the resident as exit seeking because she was on the fourth floor, but the resident might follow other people out. An interview was conducted on 1/28/26 at 3:39 p.m. with Resident #5's primary care Advanced Registered Nurse Practitioner (ARNP). The ARNP said Resident #5 roamed the hallways and was only oriented to person. She said the resident couldn't answer questions appropriately, could walk independently, and would not be able to take care of herself. She said cognitively she didn't think Resident #5 would know what to do to care for herself. The ARNP said she could see Resident #5 waiting and following someone on the elevator. She said Resident #5 was easily redirected. The ARNP said she was honestly not able to answer as to why Resident #5 didn't have an electronic monitoring device on. An interview was conducted on 1/28/26 at 2:58 p.m. with Resident #5's primary care provider (PCP). He said Resident #5 was ambulatory and definitely confused; I think from that point of view she was an elopement risk. The PCP said he did not feel that Resident #5 was capable of caring for herself outside the facility. An interview was conducted on 1/28/26 at 7:38 a.m. with the Resident Representative (RR) for Resident #5. The RR said Resident #5 did go out to the hospital and declined drastically in May but she bounced back quickly and was up and moving weeks later. The RR said she had been told by staff before that the resident tried to get out of the building, but she didn't know she ever did actually get out. The RR said she [Resident #5] was always trying to escape and was always wandering around. The RR said Resident #5 could get around good and would have been able to go down the stairs in August 2025. An interview was conducted on 1/28/26 at 12:01 p.m. with Resident Representative #2 for Resident #5. He said he was notified that the resident got out of the facility, but the facility really downplayed it. He said Resident #5 was free to do whatever she wanted here and staff didn't watch her. He said the resident had worked night shift throughout her life and would wander around all evening and night, going in and out or other resident rooms messing with their stuff and taking items. He said she was always wandering around, and he believed she was trying to get to the door/elevators to get out. He said staff told him multiple times that Resident #5 tried to get out. He said, I think she was doing it [trying to get to the doors and elevators] all the time. He said she was not watched or taken good care of. Review of a facility policy titled Abuse, Neglect, Exploitation & Misappropriation, revised 11/16/2022, showed:POLICY:It is inherent in the nature and dignity of each resident at the center that he/she be afforded basic human rights, including the right to be free from abuse, neglect, mistreatment, exploitation and/or misappropriation of property. The management of the facility recognizes these rights and hereby establishes the following statements, policies, and procedures to protect these rights and to establish a disciplinary policy, which results in the fair and timely treatment of occurrences of resident abuse.Employees of the center are charged with a continuing obligation to treat residents so they are free from abuse, neglect, mistreatment, and/or misappropriation of property.No employee may at any time commit an act of physical, psychological, or emotional abuse, neglect, mistreatment, and/or misappropriation of property against any resident. Violation of this standard will subject employees to disciplinary action, including dismissal, provided herein.Definitions:Neglect is the failure of the center, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. Examples include but are not limited to; Failure to provide adequate nutrition and fluids. Failure to take precautionary measures to protect the health and safety of the resident. Intentional lack of attention to physical needs including, but not limited to, toileting and bathing. Failure to provide services that result in harm to the resident, such as not turning a bedfast resident or leaving a resident in a soiled bed. Failure or refusal to provide a service for the purpose of punishing or disciplining a resident, unless withholding of a service is being used as part of a documented integrated behavioral management program. Failure to notify a resident's legal representative in the event of a significant change in the resident's physical, mental or emotional condition that a prudent person would recognize. Failure to notify a resident's legal representative in the event of an incident involving the resident, such as failure to report a fall or conflict between residents that result in injury or possible injury. Failure to report observed or suspected abuse, neglect or misappropriation of resident property to the proper authorities. Failure to adequately supervise a resident known to wander from the facility without the staff knowledge. Review of a facility policy titled Missing Patient/Resident, revised 8/1/2020 showed:Overview:Staff will investigate cases of missing patient/resident and possible elopement. An elopement occurs when a patient/resident leaves the premises or a safe area without authorization and or any necessary supervision to do so, placing the patient at risk for harm or injury. Review of a facility policy titled Elopement/Wandering Risk Guideline, revised 8/1/2020, showed:Overview:To evaluate and identify patient/residents that are at risk for elopement and develop individualized interventions.Process:-Patient/Residents to be evaluated on admission, re-admission, 7 days post admission, quarterly, with a significant change in condition, and elopement event using the risk tool. -If a patient/resident is identified as being at risk complete an Elopement Risk Alert and obtain a photograph. -Initiate individualized interventions based on Patient/Residents' risk. -Document individualized interventions in the patient/resident Care Plan and Kardex [a quick reference document used by staff to provide care that contains essential resident information]. -If utilizing a wander monitoring system device check placement of the device every shift and functionality every day. -Maintain the Elopement Risk Alerts in an easily accessible location. -Complete routine elopement drills monthly and review in QAPI [Quality Assurance Performance Improvement] meeting. The facility's immediate actions to remove the Immediate Jeopardy included: Identified resident #5 was returned to facility on 8/30/2025 by Weekend Supervisor. On 8/30/2025 Resident #5 had a skin assessment, pain assessment, and change of condition completed with no negative findings. On 8/30/2025 Resident #5 Attending Physician was notified on 8/30/2025 and gave new orders for labs that resulted with ESBL [Extended-Spectrum Beta-Lactamase - a bacteria that produces enzymes resistant to most common antibiotics] in urine, new meds ordered 9/5/2025. Psych services was completed via telehealth visit was completed with resident no new orders received. On 8/30/2025 Resident #5 was placed on 1:1 and elopement assessment was completed placing a [electronic monitoring device] to her lower extremity. Resident remained on 1:1 until 9/12/25 On 8/30/2025 Weekend Supervisor completed [electronic monitoring device] function and placement for all current residents that are at risk for elopement with no negative findings. All residents' demographics were found in each resident elopement binder at nurse station, receptionist and therapy gym. On 8/30/2025 Resident #5 demographics and picture was added to the elopement binder by DON. On 8/30/2025 Door checks were completed by NHA to ensure all doors worked properly with no negative findings. On 8/30/2025 a 100% head count was completed by Weekend supervisor to ensure all residents were in facility with no negative findings. On 8/30/2025 100% of residents were re-assessed for elopement risk by DON and Designee. No new residents were identified. On 8/30/2025 an initial Elopement drill was complete on 8/30/2025 by NHA & Designee reviewed results and documented them on Elopement Drill QAPI [Quality Assurance Performance Improvement] Worksheet with no negative findings. On 8/30/2025 NHA and DON gathered witness statements from residents and staff. On 8/31/2025 DON notified DCF [Department of Children and Families] & police of allegation of neglect and they did not accept the case. On 9/2/2025 Resident #5 was seen by psych services. She was alert with confusion, denied any distress, or intent to harm herself or others with no injuries with no complaints from the event. On 9/12/2025 Identified resident #5 discharged to a memory care unit as planned with IDT [Interdisciplinary Team], Family and Medical Director On 8/30/2025 Door guard was placed at door by NHA to ensure no one was able to leave from facility until screamers were installed. On 8/31/2025-9/7/2025 Elopement drills were completed every day, 3 times a day randomly. On 9/8/2025-9/30 Elopement drills were completed 1 time a week on random days. Monthly Drills have been completed monthly from October 2025- Current on random shifts and days. Results have been reviewed with QAPI Team. On 9/3/2025 Screamers were shipped from manufacturing company verified by Maintenance Director On 9/23/2025 a contractor came to facility to install cameras and new secure care boxes. Maintenance Director completed door checks to ensure they are functioning properly. On 9/23/2025 IDT & Clinical Consultant met to discuss removal of Door Guard. All agree On 9/23/2025 Security company came to facility to access possible amber alarm system and they were installed 10/7/2025 Security cameras were set up in the facility with main station located in NHA office. On 8/30/2025, 9/12/2025, 9/19/2025, and 9/26/2025 IDT including Medical Director met to review ADHOC [for this specific purpose] /QAPI plan with no negative findings. Medical Director reviewed and recommended no changes. On 8/30/2025 Education was initiated via phone [telephone] and in person with 100% of staff to include contract employees related to abuse & neglect, missing persons policy, elopement policy that included care plans and KARDEX for those at risk for wandering/elopement, and staff response to door alarms by ED and Designee. Completed on 8/31/2025 On 8/30/2025 elopement drills were initiated for 100% of staff to include contracted employees by DON and Designee. Verification of the facility's removal plan was conducted by the survey team on 1/28 and 1/29/26. - Interviews were conducted with forty staff members, who worked across all shifts, including housekeeping, dietary, administrative/clerical, therapy, social services, CNA's, licensed nurses. The staff members were able to state that they had been trained and were knowledgeable about the new policies and procedures initiated by the facility. - A tour of the facility with the Director of Maintenance (DOM) and staff interviews confirmed alarms and cameras had been installed and were functioning - A review of in-service documentation revealed 100% of staff had acknowledged education and training related to abuse, neglect, and exploitation, resident supervision, elopement protocols, and following care plans. Based on verification of the facility's Immediate Jeopardy removal plan the immediate jeopardy was determined to be corrected on 9/3/25.

Based on interviews and records review the facility failed to provide supervision to prevent elopement for one resident (#5) out of three residents reviewed for elopement risk. On 8/30/25 Resident #5 exited the facility at approximately 4:15 p.m., unnoticed by staff. Resident #5 had severely impaired cognition, ambulated independently, had wandering behaviors, and did not have an electronic monitoring device on. Resident #5 was able to get from the fourth floor to the first floor, access a stairwell door that should have been locked, and then exit the facility. Another resident observed Resident #5 walking around the west side of the building to the front parking lot and directed her back to the building. Staff did not know Resident #5 was off the fourth floor. This failure created a situation that resulted in a worsened condition and the likelihood for serious injury and or death to Resident #5 and resulted in the determination of Immediate Jeopardy on 1/27/26. The findings of Immediate Jeopardy were determined to be corrected on 9/3/25. Findings included: Review of Resident #5's progress notes showed:8/30/25 4:46 p.m. Nursing Progress Note Resident alert with confusion noted exiting the side door. Resident escorted back into facility. No signs of pain or discomfort noted. Skin assessment completed. No skin alterations noted. Safety measures in place. Placed on 1:1. Psych services currently pending. [Electronic monitoring device] applied and functioning properly. Review of admission Records showed Resident #5 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including but not limited to unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, unspecified psychosis not due to a substance or known physiological condition, other symptoms and signs involving cognitive functions and awareness, depression, and anxiety. Review of Resident #5's Quarterly Minimum Data Set (MDS), dated [DATE], Section C, Cognitive Patterns, showed a Brief interview for Mental Status (BIMS) was unable to be completed due to her rarely/never being understood. Section GG, Functional Abilities, showed she could walk 150 feet with supervision or touching assistance. Section P, Restraints and Alarms, showed a wander/elopement alarm was not used. Review of Resident #5's physician orders showed:-Check for electronic monitoring device placement to LLE (left lower extremity) each shift for elopement. Started: 2/19/25 Ended: 5/28/25. Review of Resident #5's active care plan on 8/30/25 showed a focus area of elopement risk/wandering r/t [related to] dementia, initiated 5/2/25. Interventions included Monitor [electronic monitoring device] to RLL [right lower extremity] frequently for function, initiated 2/19/25 and Identify pattern of wandering: Is wandering purposeful, aimless, or escapist? Is resident looking for something? Does it indicate the need for more exercise? Intervene as appropriate, initiated 2/19/25. Review of Resident #5's Elopement Risk Evaluations dated 2/1/25 and 5/29/25, identified she was an elopement risk. Review of Resident #5's Progress notes showed:-7/16/25 Primary Care Provider 30-day Follow-up Ambulatory, conversational, but with severely decreased orientation/insight into situation and circumstances.-7/21/25 Psychiatry Provider Progress Note: Staff reports increase in agitation, refusing care and combativeness. Review of Symptoms: Anxiety: Irritability, Restless/feeling keyed up. Mania: Acts with potential for painful consequences, Expansive or irritable mood Aggravating factors: Being in the facility, ongoing medical problems and life stressors Physical Exam: Neurologic: Other: alert to self, confused at baseline. Psychiatric: Cooperative, appropriate mood and affect, other: decreased insight, engaged in conversation but unable to express herself clearly.-8/23/25 12:07 a.m. Skilled Note: Level of consciousness noted as oriented to person .Behavioral problem are wandering.-8/28/25 3:23 a.m. Skilled Note: Level of consciousness noted as oriented to person.Behavioral problems are hallucinations and wandering.-8/28/25 3:12 p.m. Standards of Care Note: Resident is alert to self only, with confusion noted Resident ambulates independently, full weight-bearing, with steady gait. Resident has a primary diagnoses ofdementia [sic]. Resident exhibits wandering behavior throughout the unit and requires frequent redirection for safety. Resident demonstrates episodes of verbal and physical aggression toward staff during provision of care.Review of Resident #5's physical therapy notes showed: -8/29/25 Ambulation: Gait Distance =275 feet with no assistive device.An interview was conducted on 1/27/26 at 2;24 p.m. with Staff Q, Registered Nurse (RN). She said she worked with Resident #5 on 8/30/25. She said Resident #5 typically wandered around the fourth floor and staff would reorient her to her room regularly, but she had never seen Resident #5 off the fourth floor. Staff Q said on 8/30/25 she saw the resident at change of shift then again in the hall a short time later. She said she redirected Resident #5 to her room then 10-15 minutes or so later the supervisor, Staff R, RN came on the unit and said Resident #5 had been outside. Staff Q said she had no idea how the resident got off the unit and outside. She said she did not recall Resident #5 having an electronic monitoring device on before this incident, but confirmed one was placed on her after she returned to the unit on 8/30/25. She said normally nurses do an Elopement Risk Assessment every three months, if the resident is determined to be at risk, the supervisor or DON is notified. She said the supervisor or DON will bring an electronic monitoring device to the nurse to put on the resident or they will put it on the resident. An interview was conducted on 1/27/26 at 3:00 p.m. with Staff R, RN. She confirmed she was the supervisor on duty on 8/30/25 when Resident #5 eloped. She said Resident #5 was always confused, but she had no idea how the resident got out of the facility, but 'she didn't go far. Staff R said, we weren't able to figure out what door she went out. She said an alarm did go off downstairs and staff were trying to figure out why. She said you can kind of pinpoint the area the alarm was coming from. She said it was like on the backside of the building. She then said it was on the west side of the building. Staff R said when the alarm went off staff did not know why it was going off or if a resident went out the door, but they started looking. She said while staff were looking to see if a resident went outside, another resident (Resident #13) saw Resident #5 in the parking lot and brought her to the front of the building. Staff R said she went out front and helped get Resident #5 back in the building. She said Resident #5 did not have any injuries. Staff R said Resident #5 did not have an electronic monitoring device on because she usually just kind of stayed on the unit. It wasn't warranted for her to have one. She said the resident had an electronic monitoring device placed after the incident. An interview was conducted on 1/26/26 at 3:41 p.m. with Resident #13. He said a few months ago he was out in front of the facility on leave of absence. He said he saw a lady walking around from the west side of the building by the generators. He said he didn't know her, but she was in a hospital gown with a blanket wrapped around her. He said it looked like she knew where she was headed, but it didn't look right to him. He said he walked over to her, and she was confused so he got her to come sit on the bench in front of the building. He said when she sat on the bench a staff member saw them through the front door and came outside. He said that staff member knew who the lady was. Review of admission Records showed Resident #13 was admitted on [DATE]. Review of Resident #13's Annual MDS, Section C, Cognitive Patterns, showed a BIMS score of 13, indicating he was cognitively intact. An interview was conducted on 1/27/26 3:35 p.m. with Staff S, Licensed Practical Nurse (LPN). Staff S said he was working on the third floor on the day Resident #5 eloped (8/30/25). He said no alarm ever went off for the doors that he heard. Staff S said Resident #5 normally wandered around the unit but never really left. An interview was conducted on 1/27/26 at 5:09 p.m. with the Nursing Home Administrator (NHA) and Director of Nursing (DON). They said on 8/30/25 around 4:30 p.m. they received a call from the weekend supervisor letting them know Resident #5 had gotten out of the building but was back safely. They said Resident #13 had seen Resident #5 outside and directed her back to the building safely. They said the resident had been an elopement risk when she first came to the building in January 2025, but she declined and went out to the hospital in May. They said when she returned, she was not an elopement risk because she could not get out of bed. The DON said the Elopement Risk Assessment completed in May 2025 was incorrect because the nurse did it based on information prior to the resident going to the hospital. They said there were three residents in the elopement books on 8/30/25, but Resident #5 was not one of them. The DON said it wasn't until August that Resident #5 started walking good. She said the resident did not have an electronic monitoring device placed when she started walking again because she was not exit seeking. The NHA and DON reviewed Resident #5's care plan and confirmed she had been care planned for an electronic monitoring device from February through September 2025. They said during their investigation they could not determine how Resident #5 got downstairs or into the stairwell. They said they interviewed residents and staff and did not find anyone that saw Resident #5 on the elevator or that possibly rode the elevator down with her. The NHA said after getting downstairs Resident #5 somehow got into the stairwell which was only accessible from a locked door with a keypad code. They said from the stairwell there is an exit door to the outside and that is where the resident exited. The NHA said they knew she exited that door because the alarm was going off on that door, however she said the alarm was just a beeping sound that could only be heard in the stairwell or just outside of the stairwell doors . The NHA said the receptionist in the front did not hear the alarm from down the hall. The NHA and DON said the staff did not know Resident #5 had gotten downstairs and outside until Resident #13 brought her to the front of the building and the receptionist saw them. They said she had not gone missing and there was no elopement code called. They said they did do an elopement drill that evening after the incident. The NHA confirmed that Resident #5 was not observed exiting the facility and Resident #13 was the only person to see the resident outside. She said Resident #13 found Resident #5 and brought her back to the facility. A follow-up interview was conducted on 1/29/26 at 12:48 p.m. with the NHA. She stated that the electronic monitoring device is a nursing intervention and did not require a physician's order. She said they do typically put an order in the system to ensure the electronic monitoring device is checked daily by staff. An interview was conducted on 1/28/26 at 12:42 p.m. with Staff T, Occupational Therapist (OT). Staff F said Resident #5 was in the late stages of dementia and had trouble sequencing tasks. He said she would wander the halls and constantly went into other residents' rooms. Staff T said Resident #5 might go towards the elevators to get on, but she was easily redirected. He said she did follow other residents where they were going. Staff T said Resident #5 would have had the strength to open doors, but he didn't feel like she could have walked down four flights of stairs without falling. He said Resident #5 was alert and oriented to person only. Staff T said he didn't feel like staff are educated enough on treatment of dementia residents. An interview was conducted on 1/28/26 at 2:44 p.m. with Resident #5's Psychiatric-Mental Health Nurse Practitioner (PMHNP). She said Resident #5 was only oriented to person and was not able to care for herself. She said she didn't necessarily think of the resident as exit seeking because she was on the fourth floor, but the resident might follow other people out. An interview was conducted on 1/28/26 at 3:39 p.m. with Resident #5's primary care Advanced Registered Nurse Practitioner (ARNP). The ARNP said Resident #5 roamed the hallways and was only oriented to person. She said the resident couldn't answer questions appropriately, could walk independently, and would not be able to take care of herself. She said cognitively she didn't think Resident #5 would know what to do to care for herself. The ARNP said she could see Resident #5 waiting and following someone on the elevator. She said Resident #5 was easily redirected. The ARNP said she was honestly not able to answer as to why Resident #5 didn't have an electronic monitoring device on. An interview was conducted on 1/28/26 at 2:58 p.m. with Resident #5's primary care provider (PCP). He said Resident #5 was ambulatory and definitely confused; I think from that point of view she was an elopement risk. The PCP said he did not feel that Resident #5 was capable of caring for herself outside the facility. An interview was conducted on 1/28/26 at 7:38 a.m. with the Resident Representative (RR) for Resident #5. The RR said Resident #5 did go out to the hospital and declined drastically in May but she bounced back quickly and was up and moving weeks later. The RR said she had been told by staff before that the resident tried to get out of the building, but she didn't know she ever did actually get out. The RR said she [Resident #5] was always trying to escape and was always wandering around. The RR said Resident #5 could get around good and would have been able to go down the stairs in August 2025. An interview was conducted on 1/28/26 at 12:01 p.m. with Resident Representative #2 for Resident #5. He said he was notified that the resident got out of the facility, but the facility really downplayed it. He said Resident #5 was free to do whatever she wanted here and staff didn't watch her. He said the resident had worked night shift throughout her life and would wander around all evening and night, going in and out or other resident rooms messing with their stuff and taking items. He said she was always wandering around, and he believed she was trying to get to the door/elevators to get out. He said staff told him multiple times that Resident #5 tried to get out. He said, I think she was doing it [trying to get to the doors and elevators] all the time. He said she was not watched or taken good care of. Review of a facility policy titled Missing Patient/Resident, revised 8/1/2020 showed:Overview:Staff will investigate cases of missing patient/resident and possible elopement. An elopement occurs when a patient/resident leaves the premises or a safe area without authorization and or any necessary supervision to do so, placing the patient at risk for harm or injury. Review of a facility policy titled Elopement/Wandering Risk Guideline, revised 8/1/2020, showed:Overview:To evaluate and identify patient/residents that are at risk for elopement and develop individualized interventions.Process:-Patient/Residents to be evaluated on admission, re-admission, 7 days post admission, quarterly, with a significant change in condition, and elopement event using the risk tool. -If a patient/resident is identified as being at risk complete an Elopement Risk Alert and obtain a photograph. -Initiate individualized interventions based on Patient/Residents' risk. -Document individualized interventions in the patient/resident Care Plan and Kardex [a quick reference document used by staff to provide care that contains essential resident information]. -If utilizing a wander monitoring system device check placement of the device every shift and functionality every day. -Maintain the Elopement Risk Alerts in an easily accessible location. -Complete routine elopement drills monthly and review in QAPI [Quality Assurance Performance Improvement] meeting. The facility's immediate actions to remove the Immediate Jeopardy included: Identified resident #5 was returned to facility on 8/30/2025 by Weekend Supervisor. On 8/30/2025 Resident #5 had a skin assessment, pain assessment, and change of condition completed with no negative findings. On 8/30/2025 Resident #5 Attending Physician was notified on 8/30/2025 and gave new orders for labs that resulted with ESBL [Extended-Spectrum Beta-Lactamase - a bacteria that produces enzymes resistant to most common antibiotics] in urine, new meds ordered 9/5/2025. Psych services was completed via telehealth visit was completed with resident no new orders received. On 8/30/2025 Resident #5 was placed on 1:1 and elopement assessment was completed placing a wanderguard to her lower extremity. Resident remained on 1:1 until 9/12/25 On 8/30/2025 Weekend Supervisor completed wanderguard function and placement for all current residents that are at risk for elopement with no negative findings. All residents' demographics were found in each resident elopement binder at nurse station, receptionist and therapy gym. On 8/30/2025 Resident #5 demographics and picture was added to the elopement binder by DON. On 8/30/2025 Door checks were completed by NHA to ensure all doors worked properly with no negative findings. On 8/30/2025 a 100% head count was completed by Weekend supervisor to ensure all residents were in facility with no negative findings. On 8/30/2025 100% of residents were re-assessed for elopement risk by DON and Designee. No new residents were identified. On 8/30/2025 an initial Elopement drill was complete on 8/30/2025 by NHA & Designee reviewed results and documented them on Elopement Drill QAPI [Quality Assurance Performance Improvement] Worksheet with no negative findings. On 8/30/2025 ED and DON gathered witness statements from residents and staff. On 8/31/2025 DON notified DCF [Department of Children and Families] & police of allegation of neglect and they did not accept the case. On 9/2/2025 Resident #5 was seen by psych services. She was alert with confusion, denied any distress, or intent to harm herself or others with no injuries with no complaints from the event. On 9/12/2025 Identified resident #5 discharged to a memory care unit as planned with IDT [Interdisciplinary Team], Family and Medical Director On 8/30/2025 Door guard was placed at door by NHA to ensure no one was able to leave from facility until screamers were installed. On 8/31/2025-9/7/2025 Elopement drills were completed every day, 3 times a day randomly. On 9/8/2025-9/30 Elopement drills were completed 1 time a week on random days. Monthly Drills have been completed monthly from October 2025- Current on random shifts and days. Results have been reviewed with QAPI Team. On 9/3/2025 Screamers were shipped from manufacturing company verified by Maintenance Director On 9/23/2025 a contractor came to facility to install cameras and new secure care boxes. Maintenance Director completed door checks to ensure they are functioning properly. On 9/23/2025 IDT & Clinical Consultant met to discuss removal of Door Guard. All agree On 9/23/2025 Security company came to facility to access possible amber alarm system and they were installed 10/7/2025 Security cameras were set up in the facility with main station located in NHA office. On 8/30/2025, 9/12/2025, 9/19/2025, and 9/26/2025 IDT including Medical Director met to review ADHOC [for this specific purpose] /QAPI plan with no negative findings. Medical Director reviewed and recommended no changes. On 8/30/2025 Education was initiated via phone [telephone] and in person with 100% of staff to include contract employees related to abuse & neglect, missing persons policy, elopement policy that included care plans and KARDEX for those at risk for wandering/elopement, and staff response to door alarms by NHA and Designee. Completed on 8/31/2025 On 8/30/2025 elopement drills were initiated for 100% of staff to include contracted employees by DON and Designee. Verification of the facility's removal plan was conducted by the survey team on 1/28 and 1/29/26. - Interviews were conducted with forty staff members, who worked across all shifts, including housekeeping, dietary, administrative/clerical, therapy, social services, CNA's, licensed nurses. The staff members were able to state that they had been trained and were knowledgeable about the new policies and procedures initiated by the facility. - A tour of the facility with the Director of Maintenance (DOM) and staff interviews confirmed alarms and cameras had been installed and were functioning - A review of in-service documentation revealed 100% of staff had acknowledged education and training related to abuse, neglect, and exploitation, resident supervision, elopement protocols, and following care plans. Based on verification of the facility's Immediate Jeopardy removal plan the immediate jeopardy was determined to be corrected on 9/3/25.

Based on observations, record review and interviews, the facility failed to serve Dinner meals in a timely manner and per the daily meal service timeframe for fourteen of seventeen meals reviewed (days 1/10/26, 1/11/26, 1/12/26, 1/13/26, 1/14/26, 1/15/26, 1/18/26, 1/19/26, 1/20/26, 1/21/26, 1/22/26, 1/23/26, 1/25/26, and 1/26/26). Findings included: On 1/26/2026 at 8:45 a.m. an interview was conducted with Resident #25. He stated he normally eats lunch in the dining room but eats his breakfast and dinner in his room by choice. The resident stated as of the past few months dinner comes up late per the meal service times. Resident #25 stated on his floor/unit he is supposed to get his meal served around 5:00 p.m. and most times he receives his meal anywhere from thirty minutes to two hours late. Resident #25 stated he has expressed this concern to the Director of Nursing and Nursing Home Administrator. The resident stated the issue has not been corrected. A medical record review revealed Resident #25 was admitted at the facility on 7/14/2022. Review of the most current Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed; (Cognition/Brief Interview Mental Status score 15 of 15, which indicated the resident was able to speak related to his medical care and services). On 1/26/2026 at 10:08 a.m. an interview was conducted with Resident #23. The resident stated he acts as the Resident Council President and he has been hearing complaints at resident meetings the past couple of months of meals not being brought to rooms in a timely manner. Resident #23 stated residents had complained meals are late all three meals to include Breakfast, Lunch, and Dinner and there are time meals do not get to the rooms for almost two hours late. Resident #23 confirmed he too receives meals late and will come late routinely around forty-five minutes to two hours late. Resident #23 stated he has spoken to the Dietary Manager about this issue and things have not been getting any better. A medical record review revealed Resident #23 was admitted at the facility on 3/25/2019. Review of the most current Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed; (Cognition/Brief Interview Mental Status score 15 of 15, which indicated the resident was able to speak related to his medical care and services). On 1/26/2026 at 1:40 p.m. an interview was conducted with Resident #12). She stated meals to include dinner is routinely served late routinely with meals served as late as two hours after the scheduled times. Resident #12 stated she is supposed to get dinner to her room around 5:00 p.m. and there are many time when times range from thirty minutes, forty-five minutes and many times up to two hours late. Resident #12 had notified the Dietary Manager of this concern a couple of months ago and things have not gotten any better. A medical record review revealed Resident #12 was admitted at the facility on 12/26/2025. Review of the most current Medicare 5 day Minimum Data Set (MDS) assessment dated [DATE] revealed; (Cognition/Brief Interview Mental Status score 15 of 15, which indicated the resident was able to speak related to his medical care and services). On 1/26/2026 at 2:20 p.m. an interview was conducted with Resident #24. He stated since he has been at this facility for about ten months, the meals come out late all the time. Resident #24 stated he has complained to aides, nurses, social worker, and Dietary Manager many times and the situation has not corrected. Resident #24 stated there are many times they do not get their dinner until 7:00 p.m. and sometimes after 8:00 p.m. Resident #24 stated he has overheard the kitchen cant keep staff and on his floor he should be receiving his dinner meal at around 5:00 p.m. Resident #24 stated he chooses to eat in his room for all three meals. A medical record review revealed Resident #24 was admitted at the facility on 3/26/2025. Review of the most current Annual Minimum Data Set (MDS) assessment dated [DATE] revealed; (Cognition/Brief Interview Mental Status score 13 of 15, which indicated the resident was able to speak related to his medical care and services). On 1/27/2026 at 8:11 a.m. The kitchen was entered and staff were still in process of plating breakfast trays. The kitchen was observed with one cook Staff O, and two aides Staff D and E. It had been addressed from the Nursing Home Administrator on 1/26/2026 the total resident census was 144. The cook Staff O was asked if the Dietary Manager was in and she could not say. Staff C stated he was not in yet but the Regional Dietary Manager was in the building. At 8:19 a.m. the Regional Dietary Manager Staff A walked into the kitchen after walking tray carts to floor/units. He stated he usually comes to assist the facility twice a week and the Dietary Manager was on his way in. The Regional Dietary Manager Staff A stated the kitchen staff are contracted and he has been coming to the facility frequently to assist as they have not been able to keep staff in the kitchen. The Regional Dietary Manager stated staff to include cooks and dietary aides are hired but they do not stay, so they routinely have shortages but he helps out with dietary needs to include cooking, prepping, plating trays, passing meal tray carts out to the floor and also with cleaning and paperwork. The Regional Dietary Manager stated he is a chef so he has been filling in at times to cook meals at the facility. The Regional Dietary Manager reveled Dietary staff start coming in the building to prep and cook breakfast at 6:00 a.m. and Dietary staff stay until around 9:30 p.m. Mondays - Sundays.At 10:32 a.m. met with the facility's Dietary Manager Staff B and he stated he works at the facility as the Dietary Manager six days a week and he tries to cover all three meal shifts. The Dietary Manager stated he has an Assistant Dietary Manager Staff P and that he covers the days he (Dietary Manager) is off. The Dietary Manager stated the kitchen staff are contracted services and he employs at the facility eleven (11) staff to include 3 Cooks for Breakfast, Lunch and Dinner but they are not at the facility at the same time, and 6 Dietary Aides to support breakfast, lunch and dinner meals. The Dietary Manager was not sure how many staff he should have total but did confirm he has been having staffing issues to include cooks mainly, but some Dietary Aides as well. The Dietary Manager stated he mainly has been having issues with getting meals out timely during mainly dinner service, and has been working with his Regional Dietary Manager to get fully staffed. When asked why he is having staffing issues, The Dietary Manger replied, I am not sure, but I hire cooks and they don't stay long. He continued to say; I have hired about 3 cooks the past two weeks and they never tell me why they leave. He stated he is having Dietary Aide staffing issues as well, but not as bad as the cooks staffing. The Dietary Manager Staff B stated his boss, the Regional Dietary Manager Staff A does come in at least twice a week to help with various things to include cooking, preparing food items, cleaning, serving/plating, and assists with paperwork, and has been doing so for over a month. The Dietary Manager confirmed they have been getting meals out late to residents during mainly the dinner meal service since around 11/2025 and they are trying to correct the issue. The Dietary Manager was unaware if residents were communicated with in relation to kitchen concerns and not being able to get meals out timely on a consistent basis. He confirmed the Nursing Home Administrator was aware but it was the contracted services department to staff the kitchen. Further interview with the Dietary Manager stated meals are sent out from the kitchen during the dinner meal service at: 1. Main dining room, residents do not use the dining room for this meal service; 2. Second floor - Hall Low at 5:30 p.m., Hall Hight at 5:45 p.m.; 3. Third floor - Hall Low at 6:30 p.m., Hall High at 6:45 p.m.; 4. Fourth floor - Hall Low at 6:00 p.m., and Hall High at 6:15 p.m. The Dietary Manager stated he generally will supervise the entire meal service to include the food preparation, food cooking, food plating, and meal trays sent out from the kitchen. He stated he does this most days and does come in for dinner meal services to supervise and help as well. The Dietary Manager did not have any documentation to support completed supervisory audits. He also stated for the entire month of 1/2026, about half or more of the dinner meals have been sent out and provided to residents late. He confirmed there were times where the dinner meal service was over an hour to an hour and a half late and he was trying to correct that. The Dietary Manager reveled that he has been in contact with his supervisor who was the Regional Dietary Manager and the Nursing Home Administrator and are trying to figure out ways to keep staffing and without so much turnover. At this point they (Regional Dietary Manager and Facility Dietary Manager) are continuing with hiring staff. The Dietary Manger stated he felt he should be and should have communicated with the Nursing Home Administrator more with the issues the kitchen is having with staffing. On 1/27/2026 at 12:00 p.m., review of the following documentation with the Dietary Manager revealed; Meal Cart Delivery Schedule document (not dated), currently used by Dietary Services. The document revealed meal times to include:Dinner meal service;Second Floor Low 4:45 p.m.; Second Floor High 4:30 p.m.; Fourth Floor Low 5:15 p.m., Fourth Floor High 5:00 p.m., Third Floor Low 5:45 p.m., Third Floor High 5:30 p.m. However, review of the daily Dining Services Cart Delivery Log, the meal cart delivery service times included for dinner; Second Low 5:30 p.m.; Second High 5:45 a.m.; Fourth Low 6:00 p.m., Fourth High 6:15 p.m.; Third Low 6:30 p.m., Third High 6:45 p.m.The Dietary Manager stated though they have the Meal Cart Deliver Schedule sheet posted in the kitchen, they generally use the times reflected in the Dining Services Care Delivery Log. The Dietary Manager provided the Dining Services Cart Delivery Log for review and stated meal delivery dates and times for the dinner meal services during the entire month of 1/2026; 1/10/2026 (Dinner Meal Service)a . Second Low hall Scheduled delivery at 5:30 p.m. Cart left kitchen at 6:32 p.m. (32 minutes after scheduled time).b . Second High hall Scheduled delivery at 5:45 p.m. Cart left kitchen at 6:41 p.m. (56 minutes after scheduled time).c . Fourth Low hall Scheduled delivery at 6:00 p.m. Cart left kitchen at 6:57 p.m. (57 minutes after scheduled time).d . Fourth High hall Scheduled delivery at 6:15 p.m. Cart left kitchen at 7:15 p.m. (60 minutes after scheduled time).e . Third Low hall Scheduled delivery at 6:30 p.m. Cart left kitchen at 7:30 p.m. (60 minutes after scheduled time).f . Third High hall Scheduled delivery at 6:45 p.m. Not documented when left kitchen 1/11/2026 (Dinner Meal Service)a . Second Low hall Scheduled delivery at 5:30 p.m. Cart left kitchen at 6:09 p.m. (39 minutes after scheduled time).b . Second High hall Scheduled delivery at 5:45 p.m. Cart left kitchen at 6:24 p.m. (39 minutes after scheduled time).c . Fourth Low hall Scheduled delivery at 6:00 p.m. Cart left kitchen at 6:42 p.m. (42 minutes after scheduled time). d . Fourth High hall Scheduled delivery at 6:15 p.m. Cart left kitchen at 6:45 p.m. (45 minutes after scheduled time).e . Third Low hall Scheduled delivery at 6:30 p.m. Cart left kitchen at 7:15 p.m. (45 minutes after scheduled time).f . Third High hall Scheduled delivery at 6:45 p.m. Cart left kitchen at 7:33 p.m. (48 minutes after scheduled time). 1/12/2026 (Dinner Meal Service)a . Second Low hall Scheduled delivery at 5:30 p.m. Cart left kitchen at 5:48 p.m. (18 minutes after scheduled time) b . Second High hall Scheduled delivery at 5:45 p.m. Cart left kitchen at 6:01 p.m. (16 minutes after scheduled time).c . Fourth Low hall Scheduled delivery at 6:00 p.m. Cart left kitchen at 6:26 p.m. (26 minutes after scheduled time).d . Fourth High hall Scheduled delivery at 6:15 p.m. Cart left kitchen at 6:41 p.m. (26 minutes after scheduled time).e . Third Low hall Scheduled delivery at 6:30 p.m. Cart left kitchen at 7:00 p.m. (30 minutes after scheduled time).f . Third High hall Scheduled delivery at 6:45 p.m. Cart left kitchen at 7:23 p.m. (38 minutes after scheduled time). 1/13/2026 (Dinner Meal Service)a . Second Low hall Scheduled delivery at 5:30 p.m. Cart left kitchen at 6:54 p.m. (24 minutes after scheduled time). b . Second High hall Scheduled delivery at 5:45 p.m. Cart left kitchen at 7:11 p.m. (1 hour and 26 minutes after scheduled time).c . Fourth Low hall Scheduled delivery at 6:00 p.m. Cart left kitchen at 7:32 p.m. (1 hour and 32 minutes after scheduled time).d . Fourth High hall Scheduled delivery at 6:15 p.m. Cart left kitchen at 7:45 p.m. (1 hour and 30 minutes after scheduled time).e . Third Low hall Scheduled delivery at 6:30 p.m. Cart left kitchen at 7:57 p.m. (27 minutes after scheduled time).f . Third High hall Scheduled delivery at 6:45 p.m. Cart left kitchen at 8:15 p.m. There was a note that read, Aide no show. (1 hour and 30 minutes after scheduled time). 1/14/2026 (Dinner Meal Service)a . Second Low hall Scheduled delivery at 5:30 p.m. Cart left kitchen at 6:39 p.m. (9 minutes after scheduled time).b . Second High hall Scheduled delivery at 5:45 p.m. Cart left kitchen at 6:53 p.m. (8 minutes after scheduled time).c . Fourth Low hall Scheduled delivery at 6:00 p.m. Cart left kitchen at 7:06 p.m. (1 hours and 6 minutes after scheduled time).d . Fourth High hall Scheduled delivery at 6:15 p.m. Cart left kitchen at 7:22 p.m. (1 hour and 7 minutes after scheduled time).e . Third Low hall Scheduled delivery at 6:30 p.m. Cart left kitchen at 7:37 p.m. (1 hour and 7 minutes after scheduled time). f . Third High hall Scheduled delivery at 6:45 p.m. Cart left kitchen at 8:01 p.m. There was a note that read, 0 Cook. (1 hours and 16 minutes after scheduled time). 1/15/2026 (Dinner Meal Service)a . Second Low hall Scheduled delivery at 5:30 p.m. Cart left kitchen at 5:53 p.m. (23 minutes after scheduled time). b . Second High hall Scheduled delivery at 5:45 p.m. Cart left kitchen at 6:05 p.m. (20 minutes after scheduled time).c . Fourth Low hall Scheduled delivery at 6:00 p.m. Cart left kitchen at 6:15 p.m. (15 minutes after scheduled time).d . Fourth High hall Scheduled delivery at 6:15 p.m. Cart left kitchen at 6:36 p.m. (21 minutes after scheduled time).e . Third Low hall Scheduled delivery at 6:30 p.m. Cart left kitchen at 6:50 p.m. (20 minutes after scheduled time).f . Third High hall Scheduled delivery at 6:45 p.m. Cart left kitchen at 7:14 p.m. (29 minutes after scheduled time). 1/18/2026 (Dinner Meal Service)a . Second Low hall Scheduled delivery at 5:30 p.m. Cart left kitchen at 5:57 p.m. (27 minutes after the scheduled time). b . Second High hall Scheduled delivery at 5:45 p.m. Cart left kitchen at 6:10 p.m. (25 minutes after scheduled time).c . Fourth Low hall Scheduled delivery at 6:00 p.m. Cart left kitchen at 6:30 p.m. (30 minutes after scheduled time).d . Fourth High hall Scheduled delivery at 6:15 p.m. Cart left kitchen at 6:41 p.m. (26 minutes after scheduled time).e . Third Low hall Scheduled delivery at 6:30 p.m. Cart left kitchen at 6:54 p.m. (24 minutes after scheduled time).f . Third High hall Scheduled delivery at 6:45 p.m. Cart left kitchen at 7:09 p.m. (24 minutes after scheduled time). 1/19/2026 (Dinner Meal Service)a . Second Low hall Scheduled delivery at 5:30 p.m. Cart left kitchen at 7:00 p.m. (30 minutes after scheduled time). b . Second High hall Scheduled delivery at 5:45 p.m. Cart left kitchen at 7:12 p.m. (1 hour and 27 minutes after scheduled time).c . Fourth Low hall Scheduled delivery at 6:00 p.m. Cart left kitchen at 7:33 p.m. (1 hour and 33 minutes after scheduled time.).d . Fourth High hall Scheduled delivery at 6:15 p.m. Cart left kitchen at 7:46 p.m. (1 hour and 31 minutes after scheduled time).e . Third Low hall Scheduled delivery at 6:30 p.m. Cart left kitchen at 7:57 p.m. (27 minutes after scheduled time).f . Third High hall Scheduled delivery at 6:45 p.m. Cart left kitchen at 8:13 p.m. (1 hour and 28 minutes after scheduled time). 1/20/2026 (Dinner Meal Service)a . Second Low hall Scheduled delivery at 5:30 p.m. Cart left kitchen at 5:40 p.m. (10 minutes after the scheduled time). b . Second High hall Scheduled delivery at 5:45 p.m. Cart left kitchen at 5:52 p.m. (7 minutes after the scheduled time).c . Fourth Low hall Scheduled delivery at 6:00 p.m. Cart left kitchen at 6:23 p.m. (23 minutes after the scheduled time).d . Fourth High hall Scheduled delivery at 6:15 p.m. Cart left kitchen at 6:36 p.m. (21 minutes after the scheduled time).e . Third Low hall Scheduled delivery at 6:30 p.m. Cart left kitchen at 7:02 p.m. (32 32 minutes after scheduled time).f . Third High hall Scheduled delivery at 6:45 p.m. Cart left kitchen at 7:13 p.m. (28 minutes after scheduled time. 1/21/2026 (Dinner Meal Service)a . Second Low hall Scheduled delivery at 5:30 p.m. Cart left kitchen at 5:46 p.m. (16 minutes after the scheduled time). b . Second High hall Scheduled delivery at 5:45 p.m. Cart left kitchen at 6:01 p.m. (16 minutes after the scheduled time).c . Fourth Low hall Scheduled delivery at 6:00 p.m. Cart left kitchen at 6:17 p.m. (17 minutes after the scheduled time).d . Fourth High hall Scheduled delivery at 6:15 p.m. Cart left kitchen at 6:31 p.m. (16 minutes after the scheduled time).e . Third Low hall Scheduled delivery at 6:30 p.m. Cart left kitchen at 6:48 p.m. (18 minutes after the scheduled time).f . Third High hall Scheduled delivery at 6:45 p.m. Cart left kitchen at 7:01 p.m. (16 minutes after the scheduled time). 1/22/2026 (Dinner Meal Service)a . Second Low hall Scheduled delivery at 5:30 p.m. Cart left kitchen at 6:12 p.m. (42 minutes after the scheduled time). b . Second High hall Scheduled delivery at 5:45 p.m. Cart left kitchen at 6:24 p.m. (39 minutes after the scheduled time).c . Fourth Low hall Scheduled delivery at 6:00 p.m. Cart left kitchen at 6:43 p.m. (43 minutes after the scheduled time). d . Fourth High hall Scheduled delivery at 6:15 p.m. Cart left kitchen at 7:01 p.m. (16 minutes after the scheduled time).e . Third Low hall Scheduled delivery at 6:30 p.m. Cart left kitchen at 7:15 p.m. (30 minutes after the scheduled time).f . Third High hall Scheduled delivery at 6:45 p.m. Cart left kitchen at 7:39 p.m. (54 minutes after scheduled time). 1/23/2026 (Dinner Meal Service)a . Second Low hall Scheduled delivery at 5:30 p.m. Cart left kitchen at 6:45 p.m. (1 hour and 15 minutes after scheduled time).b . Second High hall Scheduled delivery at 5:45 p.m. Cart left kitchen at 7:00 p.m. (1 hour and 15 minutes after scheduled time).c . Fourth Low hall Scheduled delivery at 6:00 p.m. Cart left kitchen at 7:17 p.m. (1 hour and 17 minutes after scheduled time).d . Fourth High hall Scheduled delivery at 6:15 p.m. Cart left kitchen at 7:40 p.m. (1 hour and 25 minutes after scheduled time).e . Third Low hall Scheduled delivery at 6:30 p.m. Cart left kitchen at 8:02 p.m. (1 hour and 32 minutes after scheduled time).f . Third High hall Scheduled delivery at 6:45 p.m. Cart left kitchen at 8:25 p.m. (1 hour and 40 minutes after scheduled time). 1/25/2026 (Dinner Meal Service)a . Second Low hall Scheduled delivery at 5:30 p.m. Cart left kitchen at 6:34 p.m. (1 hour and 4 minutes after scheduled time).b . Second High hall Scheduled delivery at 5:45 p.m. Cart left kitchen at 6:46 p.m. (1 hour and 1 minute after scheduled time).c . Fourth Low hall Scheduled delivery at 6:00 p.m. Cart left kitchen at 7:06 p.m. (1 hours and 6 minutes after scheduled time).d . Fourth High hall Scheduled delivery at 6:15 p.m. Cart left kitchen at 7:20 p.m.e . Third Low hall Scheduled delivery at 6:30 p.m. Cart left kitchen at 7:33 p.m. (1 hour and 3 minutes after scheduled time).f . Third High hall Scheduled delivery at 6:45 p.m. Cart left kitchen at 7:54 p.m. (1 hour and 9 minutes after scheduled time). 1/26/2026 (Dinner Meal Service)a . Second Low hall Scheduled delivery at 5:30 p.m. Cart left kitchen at 6:02 p.m. (32 minutes after scheduled time).b . Second High hall Scheduled delivery at 5:45 p.m. Cart left kitchen at 6:12 p.m. (27 minutes after scheduled time).c . Fourth Low hall Scheduled delivery at 6:00 p.m. Cart left kitchen at 7:00 p.m. (1 hour after scheduled time).d . Fourth High hall Scheduled delivery at 6:15 p.m. Cart left kitchen at 6:20 p.m. (5 minutes after scheduled time).e . Third Low hall Scheduled delivery at 6:30 p.m. Cart left kitchen at 6:38 p.m. (8 minutes after scheduled time).f . Third High hall Scheduled delivery at 6:45 p.m. Cart left kitchen at 7:03 p.m. (18 minutes after scheduled time). On 1/27/2026 at 2:00 p.m. an interview with the Nursing Home Administrator confirmed the kitchen has been having problems maintaining staff to include cooks and dietary aides. She revealed the kitchen staff is through a contracted service and she does communicate between the Dietary Manager, and the Regional Dietary Manager. The Nursing Home Administrator stated they continue to advertise and hire new staff, but they do not stay long. On 1/28/2026 at 8:15 a.m. an interview with the Nursing Home Administrator stated the facility did not have a specific Policy and Procedure related to honoring meal service times. The Nursing Home Administrator confirmed residents have the right to receive their meals timely, and per the meal service schedule.

Based on observations, interviews, and record review, the facility failed to protect the resident's right to be free from neglect for four residents (#47, #114, #124, #126) out of thirty-one sampled residents related to no access to wheelchairs, no assistance getting out of bed, and residents not receiving proper ADL (activities of daily living) care including hair care and dressing. Findings included: 1. An interview was conducted on 6/26/24 at 2:17 p.m. with a family member for Resident #114. He said when he brought the resident to this facility, he was looking for a place with more interaction. He said she was only staying in her bed. He said he brought Resident #114's custom wheelchair to the facility for them to use. He said he was told therapy would have to evaluate her before she could use it. He said next, he was told she was not getting up because the chair did not have a seat belt. He said if someone had just lifted the cushion, they would have seen the seatbelt was there. He said when Resident #114 got angry enough she would shake the bed to get staff attention. He said he would like her to get out of bed and have some interaction. Review of Admission Record showed Resident #114 was admitted on [DATE] with diagnoses including aphasia, multiple sclerosis, bipolar disorder, quadriplegia, unspecified intellectual disabilities, anxiety disorder, major depressive disorder, post-traumatic stress disorder, and autistic disorder. Resident #114 was observed to be in her bed with a hospital style gown on throughout the day on 6/25/24, 6/26/24, 6/27/24 and 6/28/24. Her wheelchair was observed in the closet in her room. Review of Resident #114's quarterly MDS, dated [DATE], Section C, Cognitive Patterns, was not able to be completed due to resident rarely/never being understood. Section GG, Functional Abilities and Goals, was not completed due to the questions being disabled. Review of Resident #114's care plan showed a focus area of ADL self-care deficit related to decreased mobility, incontinence, cerebral vascular accident with aphasia, multiple sclerosis, spinal cord injury, and quadriplegia. Interventions included: resident was totally dependent for bathing/showering, dressing, and transfers. 2. An interview was conducted on 6/26/24 at 5:10 p.m. with Resident #47. She said she would like to get out of bed, but no one would help her. During a follow-up interview on 6/27/24 at 3:23 p.m., the resident said she had been in her bed for a long time and just wanted to get up. She said she had asked staff multiple times for a wheelchair. Resident #47 said she did not know if she was getting depressed or senile. She said she was surprised she is not in a deep depression from just sitting in her bed all the time. She said her television (T.V.) was the only thing that saved her. Resident #47 said she would love to get up and be involved in life because she could not last another several years lying in her bed. Review of the Admission Record showed Resident #47 was admitted on [DATE] with diagnoses including non-Hodgkin lymphoma, anxiety disorder, low back pain, and seizures. Review of Resident #47's care plan showed a focus area of ADL self-care deficit related to limited mobility and musculoskeletal impairment. Interventions included: resident is totally dependent on staff for transferring. Requires assist of 2 staff with mechanical lift. 46498 3. During an observation on 06/25/24 at 9:30 a.m., Resident # 124 was observed lying down in her bed. She was dressed in her night gown with her call light within her reach. Resident #124 said the staff had not assisted her with her ADLs, they would not get her out of bed. She said she had asked staff to put her on the toilet when she had to have a bowel movement, but she was told to go in her brief. She said she would like to go to activities or even get up out of bed to visit with other residents, but staff would not get her up out of bed. Resident #124 started crying as she was expressing her frustration about the lack of assistance she received from the staff. She said she had told her nurse, but they had not done anything about it. During multiple observations on 6/25/2024 and 6/26/2024 at 11:00 a.m., 1:45 p.m., and 5:00 p.m., Resident # 124 was observed dressed in her night gown, with her call light within reach. She continued to express her frustration about staff not getting her up out of bed. During an interview on 6/27/2024 at 1:45 p.m., Resident #124 was observed lying down in bed, dressed in her nightgown with her call light within reach. Staff E, Registered Nurse (RN)/Weekend Supervisor and Staff J, Licensed Practical Nurse (LPN)/Unit Manager came to Resident #124's room for an observation. Resident #124 stated that she wanted to say something. She began to express to the weekend supervisor and the unit manager about how she had repeatedly asked staff to get her out of bed so she could participate in activities and socialize with other residents. Resident #124 began to cry as she was expressing how she felt about being left in bed all the time. She stated she had not been out of her bed for three months. She said she felt like she was declining due to not being able to get up out of the bed. She stated that she did not want to turn crippled due to her not getting up out of the bed. Review of a Resident Information Record dated 06/28/2024 showed Resident #124 was admitted to the facility on [DATE] with diagnoses to included but not limited to Muscle weakness (generalized), difficulty in walking, not elsewhere classified, other lack of coordination, cerebral palsy, unspecified. Review of a Minimum Data Set (MDS) dated [DATE] showed Resident #124 had a Brief Interview Mental Status (BIMS) score of 14, which indicated she was cognitively intact. Review of a care plan dated 3/29/2024, revealed a care plan focus showing Resident #124 was dependent on staff for meeting emotional, intellectual, physical, and social needs. Review of a care plan goal showed Resident #124 would maintain involvement in cognitive stimulation, social activities as desired through review date. Review of a care plan intervention showed to invite the resident to scheduled activities. Date initiated: 04/10/2023, date revised on 04/10/2024. During an interview on 06/27/24 at 9:33 a.m., with the Advanced Registered Nurse Practitioner, ARNP. The ARNP stated that she was assigned to all the residents at this facility. She said she had spoken with the staff about residents not getting out of their beds. She said the staff told her most of the residents did not have access to wheelchairs so they could not get out of bed. During an interview on 6/27/2024 at 2:00 p.m., with Staff E and Staff J, Staff J stated her expectations were that staff assisted their residents with their ADLs and got them out of bed, unless the resident refused to get up. If a resident refused, staff should report it to the nurse so the situation could be documented. She stated it was not acceptable that so many residents were in their beds but some of the residents did not have wheelchairs so they could not get up. She said, her and Social Services were supposed to do an audit to see which resident did not have wheelchairs, but it was not done. She said she was not able to conduct the audits because of her workload with being responsible for the lower part of the 300 hall and the 400 unit located upstairs. She stated everyone in the facility knew they did not have enough wheelchairs to get residents up. Staff E and Staff J stated that they had reported residents did not have enough wheelchairs to get out of the bed to the Director of Nursing and the Nursing Home Administrator during their meetings and nothing had been done about it. During an interview on 6/27/2024 at 2:30 p.m., with Staff G, Certified Nursing Assistant (CNA). She stated that she assisted residents with their ADLs. She only got residents up and dressed them if they asked her to. Some residents could not get out of bed because they did not have wheelchairs. During an interview on 6/27/2024 at 5:30 p.m., with the Nursing Home Administrator. She stated if a resident needed a wheelchair, she or the Director of Nursing could have a wheelchair to the resident by the next day. Her expectations were for all residents to be assessed for what type of chair they needed. She stated she was not aware that there were residents without wheelchairs. She stated she did an audit a couple of times a week on the 4 floors and no one including staff and residents had reported residents not having a wheelchair. She stated had not observed residents dressed in gowns all day. If residents were dressed in gowns all day that would be the preference of the residents. She would expect residents to ask for assistance if they would like to get out of bed or would like to change their clothes. Once the question was clarified she stated her expectation was for the CNAs to ask the resident if they would like to get out of bed or to get dressed. During an interview on 06/28/24 at 11:50 a.m. with the Director of Rehab, he stated when a patient was admitted to the facility Occupational Therapy or Physical Therapy would evaluate the resident for mobility. After the evaluation, it would determine if the resident needed a wheelchair if they were non-weight bearing. When a resident was assigned a wheelchair, they labeled the wheelchair with an ID bracelet to show that the wheelchair was assigned to that resident. Staff have not told the therapy that residents did not have wheelchairs. He said the administrator told him today to start evaluating all the residents to determine their type of mobility. He said he had noticed that there were a lot of residents who remained in their beds and dressed in gowns all day. He said he had mentioned during a Utilization Review (UR) meeting that residents should get out of bed more. He said he explained the risks of residents lying down in bed all the time and how it could cause their skin to breakdown and cause them to have poor circulation. He restated that he was told by the administrator today to re- evaluate all the residents for their wheelchair. He said he did not know what could have happened to the wheelchairs that were assigned to the residents when they were first admitted to the facility. During an Interview on 6/28/2024 at 6:00 p.m., with the Director of Nursing, DON, she stated she had worked at the facility for a year. She stated she was aware that some residents were in bed a lot, but that was because they had refused staff to get them out of the bed. Some residents refused to get up out the bed and some residents did not have wheelchairs. She stated they were aware that residents had not had wheelchairs for a long time, but there was not much they could do about it. They reached out to corporate, and they were denied permission to purchase more wheelchairs. They were told they could only rent about 5 chairs a month. She stated she did not put any interventions in place for those residents who did not have access to wheelchairs. 50434 4. During an observation and interview on 06/25/2024 at 10:15 a.m. Resident #126 was in bed, dressed for the day. Resident #126's hair was matted and unkept and she stated that she was not able to brush her hair on her own, so she got knots in her hair. Resident #126 stated she really would like to go outside and get some sun, but she was always in bed, which caused her neck and back to hurt. She said she did not ask the CNAs for help because they were short staffed and there was no point. During an interview on 06/27/2024 at 4:50 p.m. Resident #126 was lying in bed crying. Her hair was noted to be visibly unkept and matted and she stated no one had offered to help her out of bed, or to brush her hair. Resident #126 stated, I would just like to go outside for a little while, so I can see something other than these walls. 50732 37999

Based on record review, observation and interview the facility failed to ensure the kitchen was clean and free of expired food(s) of one kitchen. Findings included: An initial tour of the kitchen on [DATE] at 9:45 a.m. revealed: *A blue lighter on the top of the handwashing sink; *A silver pan with a brown substance along the enteral edges and sudsy water located on a basket under the hand washing sink; *The first compartment of the three-compartment sink had dirty dishes in it, the second compartment had frozen chicken defrosting with a silver pan and a cutting board located underneath, and the third compartment had dirty dishes soaking in it. (Photographic Evidence Obtained) Further observations during the tour with the Certified Dietary Manager (CDM) on [DATE] at 10:00 a.m. revealed: *In the reach-in cooler: a silver pan filled with a red thick liquid and was covered with a plastic wrap with a white label that showed sauce with a use by date of ,d+[DATE], a white block of an unknown food item with a white label that documented ,d+[DATE] (there was no indication if this was the open date or use by date a bag of open instant mashed potatoes with no date, and two desert bowls with plastic lids and filled with a food item and no date; *A water heater located under the dish machine and with the front panel missing and exposed wires and insulation; *Two dish racks on their side, on the ground with a white bucket in the middle underneath the dish machine and next to the water heater with exposed wires; and *A brown rust likes substance on the outer front bottom corner of the dish machine. (Photographic Evidence Obtained) On [DATE] at 12:00 p.m. the kitchen was toured with the Regional CDM and revealed: *A yellow mop bucket with a mop and gray water touching the white plastic piping of a clean dish rack with clean plate covers; *An unlabeled, opened bag of mashed potatoes mix was on top of the window air conditioning (AC) unit; *An opened bag of grits located under the stove on a shelf; *An AC vent with black bio growth on it and located over clean dishes; *A maroon windbreaker jacket was touching a green wired shelf that contained cups and lids on the green wire shelf; *On a shelf under the food preparation station, an opened blue bag had a pair of shoes that were exposed and next to a jar of peanut butter and two jars of seasoning. (Photographic Evidence Obtained) During an interview on [DATE] at 2:00 p.m. the photographic evidence was shared with the Nursing Home Administrator, Regional CDM, and CDM. The Regional CDM stated he thought the pan under the hand washing sink was from breakfast and was put under the sink to be washed. He stated it was not his expectation for dirty dishes. He stated food that was opened or left over and put into the reach-in cooler has a 5-day shelf life. He stated he was not sure why the water heater had the panel removed. It was requested to be put back on this week and they are working on getting it removed from the kitchen. The CDM stated he was not sure where the lighter came from, and he does not expect to find lighters near the handwashing station. He stated when chicken is being thawed, he would expect it to be in a pan in the refrigerator and not in the sink with dirty dishes. He expected any outdated food to be removed by the use by date or expired date. He stated food was labeled with dates of when the items were opened or put in the fridge. Review of the Kitchen Cleaning Schedule, dated [DATE], revealed: Week 1 ([DATE]rd-7th ) Monday, Thursday, and Friday there were no entries. For Week(s) 2, 3 and 4 there were no entries in any day. Review of the policy titled, Receiving, Procedures, dated ,d+[DATE], revealed: 5. All food items will be appropriately labeled and dated either through manufacturer packaging or staff notation. 6. All food items will be stored in a manner that ensures appropriate and timely utilization based on the principles of first in-first out (FIFO) inventory management. Review of the policy titled, Food Storage: Cold Foods, Procedures, dated ,d+[DATE], revealed: 5. All foods will be stored wrapped or in covered containers, labeled and dated, and arranged in a manner to prevent cross contamination. Review of the policy titled, Equipment, dated ,d+[DATE], revealed the policy statement as, All foodservice equipment will be clean, sanitary, and in proper working order. 1. All equipment will be routinely cleaned and maintained in accordance with manufactures directions and training materials All non-foods contact equipment will be cleaned and free of debris.

Based on observation and interview, the facility failed to provide a safe and homelike environment on three units of three units and one shower room (3rd Floor) out of three shower rooms related to soiled privacy curtains, unpainted/unfinished wall repairs, foul odors, unclean bathroom, disrepair of closets, furniture and light fixture, and a shower chair. Findings included: 1. An observation was conducted on 6/25/24 during a facility tour from 10:00 a.m. until 10:35 a.m. of dirty privacy curtains with gray staining in rooms [ROOM NUMBERS], paint/plaster peeling and cracking around the window and air conditioning unit in room [ROOM NUMBER], an unpainted wall repair was observed above the air conditioning unit in room [ROOM NUMBER] and behind the bed in room [ROOM NUMBER]. These items remained in this condition through the end of the survey on 6/28/24. (Photographic Evidence Obtained) Review of a procedure titled, Cleaning Cubicle Curtains, revised 9/5/17, showed the following: Timing & Method -Examine curtains while doing QCI (Quality Control Inspection) or at discharge. -If curtain is stained, remove immediately. If curtain is torn-replace. -If curtains are off hooks, repair . Additional Information -Have spare curtains on hand to immediately replace dirty or torn curtains. 46498 2. During an observation made on 6/27/24 at 2:00 p.m. Rooms 301, and 307 were observed with stains on the privacy curtains. During an interview on 6/28/24 at 6:24 p.m. the Director of Housekeeping stated his cleaning process is that he deep cleans residents' rooms Monday through Friday. He knows that some residents need new curtains, but he cannot change them out because the facility doesn't have enough curtains. He said he has been aware of the shortage of curtains for five months. He stated he reached out to the Nursing Home Administrator (NHA) to inform her about the facility needing more privacy curtains. 50434 3. An observation of room [ROOM NUMBER] on 6/25/24 at 10:35 a.m. revealed a wall under the window was bare and unpainted. (Photographic Evidence Obtained) An observation on 6/25/24 at 10:45 a.m. of room [ROOM NUMBER]'s bathroom revealed: *A toilet seat with a brown stain, *A brown residue around the bottom of the toilet on the floor, and *Under the sink there was a bare unpainted wall near the pipes of the sink. (Photographic Evidence Obtained) During a tour of room [ROOM NUMBER] and the bathroom on 6/28/24 at 9:00 a.m. the Maintenance Director stated he started with the company in October of 2023 and went through the building and made a list of everything that needed to be completed. He was in the process of getting everything done. He stated the wall had to be patched due to holes. He stated this was not his expectation for a home like environment for residents. 37999 4. On 6/25/24 at 10:04 a.m. a strong odor of stale urine was noticed in room [ROOM NUMBER]. On 6/25/24 at 10:23 a.m. a very strong urine smell continued in room [ROOM NUMBER]. On 6/25/24 at 10:59 a.m. an observation revealed a section of the vinyl cove base was unattached from the bathroom wall in room [ROOM NUMBER] and was lying on the floor. (Photographic Evidence Obtained) On 6/25/24 at 11:26 a.m. an observation revealed in room [ROOM NUMBER] the dresser veneer was torn and the surface underneath was uncleanable. On 6/25/24 at 2:13 p.m. the strong pungent smell of urine continued outside (in the hallway) of room [ROOM NUMBER], which was confirmed by another state agency survey team member. On 6/25/24 at 10:05 a.m. an observation revealed a wire shelf in the closet of room [ROOM NUMBER] had fallen and was lying across the resident's personal items. (Photographic Evidence Obtained) On 6/25/24 at 11:16 a.m. an observation of the third-floor shower room revealed a shower chair with four rusty and uncleanable [NAME] wheels. (Photographic Evidence Obtained) On 6/25/24 at 3:18 p.m. an observation revealed the ceiling light in room [ROOM NUMBER]'s entrance was missing the shade exposing the light bulbs. (Photographic Evidence Obtained) On 6/25/24 at 4:24 p.m. an observation revealed the Packaged Terminal Air Conditioner (PTAC) unit for room [ROOM NUMBER] was plugged into an electrical outlet that did not have a receptacle cover. (Photographic Evidence Obtained) On 6/26/24 at 11:22 a.m. in the hallway outside of room [ROOM NUMBER] there was a strong chlorine-like smell and inside room [ROOM NUMBER] smelled of stale urine. On 6/26/24 at 3:19 p.m. an observation was made of the closet in room [ROOM NUMBER]. The observation showed the closet did not have closet doors and a wire shelf continued to lie on top of the resident's personal items. (Photographic Evidence Obtained) On 6/28/24 at 9:02 a.m. a tour was conducted with the Director of Maintenance (DOM) of the third floor. The DOM observed the missing ceiling light shade in room [ROOM NUMBER] and stated this should have been reported. The DOM observed the missing receptacle cover in room [ROOM NUMBER] and confirmed it should have been reported. The DOM confirmed the closet wire shelf had been fixed and it had fallen three days ago (6/25/24), parts had to be ordered versus going to a neighborhood store to purchase the parts to rehang the shelf due to the facility not having any petty cash. The DOM stated the rusty shower chair wheels were rusty, uncleanable, and could be replaced. During the tour, an observation revealed the metal sheathing used to cover one side of the ice machine motor was on the floor leaning against the ice bin. The DOM stated this was a safety issue as wires were exposed and the DOM was able to replace the sheathing. The DOM observed room [ROOM NUMBER]'s over-bed table's plastic covering was flaking off and confirmed the odor of urine. An interview was conducted on 6/28/24 at 6:40 p.m. with the Housekeeping Director (HD). The HD reported there were two residents in room [ROOM NUMBER] who would urinate on the floor and the urine has moved under the tile. The HD stated housekeeping cleans the room twice a day and has informed the NHA about two weeks ago. A request was made for a policy regarding providing the residents with a homelike environment, the facility did not provide the policy by the exit of the survey team on 6/28/24. A review of the policy titled, Cleaning and Disinfection of Environmental Surfaces, revised August 2019, showed: Environmental surfaces will be cleaned and disinfected according to current Centers for Disease Control and Prevention (CDC) recommendations for disinfection of healthcare facilities and the OSHA (Occupational Safety and Health Administration) bloodborne Pathogens Standard. The interpretation and implementation portion of the policy included the following: 9. Housekeeping surfaces (e.g. floors, tabletops) will be cleaned on a regular basis, when spills occur, and when these surfaces are visibly soiled. 10. Environmental surfaces will be disinfected (or cleaned) on a regular basis(e.g. daily, three times per week) and when surfaces are visibly soiled.

Based on record review and staff interview, the facility failed ensure the Level I Preadmission Screening and Resident Review (PASRR) for residents with a mental disorder and individuals with intellectual disability following qualifying mental health diagnoses were accurate for six residents (#394, #135, #122, #75, #114, and #53), and failed to initiate a Level II PASRR for one resident #53 of 31 residents sampled. Findings included: 1. Review of Resident #394's Admission Record revealed an admitted [DATE] with diagnoses to include depression. Review of a Level I PASRR for Resident #394, dated 06/07/24, revealed a blank PASRR and the qualifying diagnoses were not checked. 2. Review of Resident #135's Admission Record revealed an admitted [DATE] with diagnoses to include major depressive disorder and seizures. Review of a Level I PASRR for Resident #135, dated 04/06/24, revealed a blank PASRR and the qualifying diagnoses were not checked. 46234 3. Review of Admission Record showed Resident #114 was admitted on [DATE] with diagnoses to include bipolar disorder, unspecified intellectual disabilities, anxiety disorder, major depressive disorder, post-traumatic stress disorder, and autistic disorder. Review of Resident #114's PASRR Level I Screen, dated 10/17/23, did not show the diagnoses of depressive disorder, autism, or intellectual disabilities. The screening showed it was not a provisional admission and documented, Individual may not be admitted to an [sic] Nursing Facility. Use this form and required documentation to request a Level II PASRR evaluation because there is a diagnosis of or suspicion of (check one of the following): Serious Mental Illness. No PASRR Level II was found in Resident #114's medical record. Review of Resident #114's care plan showed a focus area of PASSR [PASRR]: [Resident #114] is a PASSR [PASRR] level 2. Initiated 10/30/23. Interventions included: Follow up with community partners as needed in regard to PASRR updates and ensure Brief Interview for Mental Status (BIMS) is in place and up to date at each review. An interview was conducted on 6/27/24 at 10:25 a.m. with the Nursing Home Administrator (NHA). She confirmed they did not have a Level II PASRR for Resident #114. An interview was conducted on 6/27/24 at 10:33 a.m. with the Social Services Director (SSD). She said the unit mangers and herself are responsible for the PASRRs once residents are admitted . She said she started working at the facility in August 2023 and did not have access to the PASRR system until 2-3 weeks ago. She said they did an audit and there was a lot of residents from 2018-2019 that need to be fixed and the plan was to fix those. The SSD said they audited residents on the third and fourth floors. She said if the resident was recently admitted or if they are on the second floor they should have a correct PASRR. The SSD reviewed Resident #114's PASRR and confirmed it documented Resident #114 should not be admitted . She said she cannot say why Resident #114 was admitted to the facility. She said the NHA and DON (Director of Nursing) decides who is admitted . The SSD stated she only reviews them after admission. An interview was conducted on 6/27/24 at 11:08 a.m. with the Admission Director. She said she received the PASRR from the hospital and uploaded them into the system. She said once the resident is in the facility, the PASRR is reviewed by the team members trained to look at them to make sure it is correct; it does not get reviewed pre-admission. She said all she does is make sure the facility name is on the PASRR screening form and the date is correct. The Admission Director reviewed Resident #114's PASRR and said she had not been trained on PASRRs and did not know there was a section on the back saying an individual may not be admitted to a nursing facility. An interview was conducted on 6/27/24 at 4:27 p.m. with the DON. She said the facility admissions department is who should review PASRRs for residents prior to admission; to see if a resident needed a Level II completed. She reviewed Resident #114's PASRR and said the Admission Director should have been trained, and she should have called the hospital about the Level II prior to the resident being admitted . The DON confirmed Resident #114 should not have been admitted to the facility based on her PASRR Level I screen. 4. Review of Admission Records showed Resident #75 was admitted on [DATE] and readmitted on [DATE] with diagnoses including major depressive disorder, seizures, and bipolar disorder. Review of Resident #75's PASRR Level I Screen, dated 3/24/23, did not include the diagnosis of seizures, which was present on admission, bipolar disorder, which was added on 5/4/23, or major depressive disorder, which was added 8/18/23. The facility was unable to provide an updated PASRR Level I Screen completed after the new diagnoses or prior to re-admission on 5/9/24. 50434 5. During an interview on 06/25/2024 at 10:45 a.m. Resident #122 stated that she is happy with her care. Resident #122 was observed lying in bed dressed in a hospital gown. Review of Resident #122's Admission Record showed an admitted [DATE] with diagnoses of major depressive disorder, and anxiety. Review of the Level I PASRR, dated 02/23/2024, showed in Section I-Part A MI (Mental Illness) or suspected MI was blank. Part B. ID (Intellectual disability) or suspected ID was blank. Section III: PASRR Screen Provisional Admission or Hospital Discharge Exemption Not a Provisional Admission was marked no. 6. During an observation and interview on 06/25/24 at 10:15 a.m. Resident #53 sated he was really upset with this facility and feels the care is lacking. Resident #53 was observed to be greasy looking with his hair disheveled. Review of Resident #53's Admission Record showed an admitted [DATE] with diagnoses to include major depressive disorder, and schizophrenia. Review of the Level I PASRR, dated 04/12/24, showed in Section I-Part A MI (Mental Illness) or suspected MI (Mental Illness) that schizophrenia was not marked. Part B. ID (Intellectual disability) or suspected ID (Intellectual disability) was blank. Section II: Other Indications for PASRR Screen Decision-Making questions 1 through 7 were marked no. Section III: PASRR Screen Provisional Admission or Hospital Discharge Exemption Not a Provisional Admission was marked no. Section IV: PASRR Screen Completion, Individual may be admitted to a Nursing Facility (check one of the following): No diagnosis or suspicion of Serious Mental Illness or Intellectual Disability indicated. Level II PASRR evaluation not required was marked. 37999 An interview was conducted on 6/27/24 at 10:33 a.m. with the Social Service Director (SSD). The SSD stated the facility started a Performance Improvement Program (PIP) in early June (2024) regarding the resident's PASRRs. The SSD reported it was the responsibility of the unit managers and social services to review PASRRs, and no one in the facility had access until 2-3 weeks ago (to resubmit the screenings). The SSD reported the facility identified a lot of patients needed changes, some needed Level II evaluations or did not have one in the system. On 6/27/24 at 10:45 a.m. the SSD provided lists that she identified as a full house audit of all resident's PASRR status, which showed if the screenings were correct, action was needed, missing, or a Level II was needed. Review of the list revealed it did not include Residents #394, #135, #122, #75, #114 and #53. On 6/27/24 at 10:53 a.m. the SSD stated the facility did not audit the PASRRs of the residents on the second floor because they were short-term residents, and they would have already gone home. The SSD confirmed that herself and the unit managers review the PASRRs and diagnoses. The SSD stated they check to see if everything is correct and if the resident needs a Level II determination. The SSD stated right now the facility was working on follow up to get PASRRs and the Regional Director had begun working on it, and 2-3 weeks ago they had someone else (working on it). The SSD stated the completion date of the PIP had been 6/20/24. She stated since it had not gotten done the facility decided last week to extend the timeline. The SSD stated PASRRs should be accurate and believed the Regional Director started them two weeks ago. Review of the policy titled, Preadmission Screening and Resident Review (PASRR), revised 11/8/21, revealed, The center will assure that are Seriously Mental Ill (SMI) and Intellectually Disabled (ID) residents receive appropriate pre-admission screenings according to federal/ state guidelines. The purpose is to ensure that the residents with SMI or ID receive the care and services they need in the most appropriate setting. 1. It is the responsibility of the center to assess and assure that the appropriate pre-admission screenings, either Level 1 or Level 2, are conducted and results obtained prior to admission and placed in the appropriate section of the residence medical record. 2. If an individual is declared exempt from a PASRR screening, the center should make sure that the appropriate documentation is on the chart upon admission. Individuals who are exempted from this assessment include: - a. Those who are admitted after a release from an acute hospital for a period not to exceed 30 days as part of a medically prescribed period of recovery. -b. Those who are certified by a physician asked to be terminally ill with a 6-month prognosis and are not a danger to self or others. - c. Those who are comatose, ventilator dependent, functions at significantly disabling Parkinson's disease, Huntington's disease, Amyotrophic Lateral Sclerosis, Congestive Heart Failure (CHF), or Chronic Obstructive Pulmonary Disease (COPD). - d. Those with a diagnosis of dementia or its related disorders with detailed documentation supporting this diagnosis. 3. There are no exceptions for Intellectually Disabled (ID) screenings. 4. If it is learned after admission that a PASSR Level 2 screening is indicated, it will be the responsibility of social services to coordinate and/ or inform the appropriate agency to conduct the screening and obtain the results. 5. Results of the screening evaluation will be placed in the appropriate section of the individual's medical records and any recommendations for services will be followed. 6. Recommendations will be incorporated in the individual residents plan of care and approaches/ interventions developed to meet the identified needs of the individual. 7. Social services will be responsible for coordinating significant change updates of these screenings, conducted by the appropriate agency. These results, along with the results from the previous years will be kept in appropriate sections of the resident's records.

Based on observation, record review, and interview the facility failed to provide life-enriching activities for three residents (#79, #57, and #124) out of 53 sampled residents. Findings included: 1. Review of the posted Community Life Calendar posted outside of the main dining room, in the unit dining rooms revealed the following scheduled activities: 6/25/24: 10 a.m. - Room Visits, 12 p.m. - Taco Tuesday, and 2 p.m. - Ice Cream Social. 6/26/24: 10 a.m. - Trivia with [NAME], 12 p.m. - Room Visits, and 2 p.m. - Bingo. 6/27/24: 10 a.m. - Coffee, Tea, and Me, 12 p.m. - Outdoor Social, and 2 p.m. - Lemonade Stand. 6/28/24: 10 a.m. - Sip & Paint, 12 p.m. - Fish Fry and June Birthday Party, and 2 p.m. - Resident Council Follow Up. Review of Resident #79's Admission Record revealed the resident was admitted on [DATE], 10/18/21, and readmitted on [DATE]. The Admission Record included diagnoses not limited to unspecified low back pain, unspecified recurrent major depressive disorder, unspecified anxiety disorder, and unspecified psychosis not due to a substance or known physiological condition. During an interview on 6/25/24 at 10:48 a.m. Resident #79 stated nobody reads the activity calendar to her. During a review of the activity calendar, which was posted on the wall behind and to the side of the resident , it was noted the upcoming activity of an Ice Cream Social. Resident #79 reported liking ice cream and would get up if she had a wheelchair. On 6/26/24 at 3:58 p.m. Resident #79 was observed lying in bed with the television on the dresser next to her bed and a television remote in front of the television. The remote was not within reach of the resident who was lying flat in bed. Staff W, Registered Nurse (RN) arrived in the room stating she had come to answer Resident #79's call light (the resident's call light was on). Staff W stated Resident #79 asked to get up and go smoke but the resident didn't smoke. The resident asked if Staff W could get her a wheelchair. An interview on 6/26/24 at 4:01 p.m. was conducted with Staff W, RN. Staff W reported working with Resident #79 three days a week and was not sure if the resident had a wheelchair. Staff W did not think the resident had ever gotten out of bed. Review of Resident #79's Quarterly Minimum Data Set (MDS), dated [DATE], revealed the resident's Brief Interview for Mental Status (BIMS) score was 7 out of 15, indicating a severe cognitive impairment. The MDS showed the resident required substantial/maximal assist with bed mobility and transfers. Review of Resident #79's Comprehensive MDS, dated [DATE], showed the resident was interviewed regarding Activity Preferences. The resident voiced keeping up with the news and doing favorite activities were Somewhat important. Review of Resident #79's Community Life Progress Review, dated 1/2/24, showed the resident was content with their activity pursuits, individual/independent activities participation were as needed/wanted. The assessment revealed the resident had the needed supplies to pursue their interests, participated in small and large group activities and outside the center events as needed/wanted. The resident's physical reaction during programming and emotion expressed was Smiling and laughing with the other residents, expresses happiness. The resident has made friends in the facility, did not have any new hobbies or changes to likes or dislikes, no interests/talents that the resident can share, does not actively participate in Resident Council, or have any interest in forming a club. Review of Resident #79's care plan showed the resident was independent of staff for meeting emotional, intellectual, physical, and social needs, revised on 11/17/21. The goals of this focus were the resident would maintain involvement in cognitive stimulation, and social activities as desired through review date, revised on 10/25/23 and a target date of 7/9/24. The interventions included: - Introduce the resident to residents with similar background, interests, and encourage/facilitate interaction. - Invite the resident to scheduled activities. - Provide a program of activities that is of interest and empowers the resident by encouraging/allowing choice, self-expression, and responsibility. - Provide with a Community Life calendar. Notify resident of any changes to the calendar of activities. During an interview with the Activities Coordinator (AC) on 6/28/24 at 10:44 a.m., the AC reported being independent (with activities) meant they did not need staff to assist with social needs. The AC stated she would not consider Resident #79 as independent and reported going to the resident's room to talk, and the resident does not get out of bed. She stated Resident #79 doesn't have a wheelchair; it disappeared. The AC reported seeing Resident #79 twice yesterday (6/27/24) because the call light was on and had to speak to the resident because she was yelling. The AC reported not documenting 1:1 visits but did visit with the resident. The resident has a television and can verbalize what channel she wants to watch. The AC stated the resident liked to socialize with other residents. She stated, been over a month since (the resident) has been out of bed, previously the resident would come down and socialize. A continued interview was conducted on 6/28/24 at 11:39 a.m. with the Activity Coordinator. The AC stated, for an ice cream social she would go floor to floor with a cart and offer it to people who can have a few scoops in a bowl. The AC reported offering ice cream on Resident #79's floor at 10:30 a.m. on 6/25/24. 2. An observation and interview was conducted with Resident #57 on 6/25/24 at 10:40 a.m. The resident reported not knowing about any activities and would go if asked; depending on the activity. The observation did not show the resident had a viewable activity calendar. The observation revealed the television for the resident was on a bedside dresser at the resident's head of bed, which was behind the resident when the head of bed was elevated. The television was not turned on. Review of Resident #57's Admission Record revealed an admitted [DATE] and re-admission on 11/15/23. The Admission Record included diagnoses not limited to unspecified recurrent major depressive disorder, dementia in other disease classified elsewhere severe without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, and mood disorder due to known physiological condition with mixed features. Review of Resident #57's Comprehensive Minimum Data Set (MDS), dated [DATE], showed the resident was interviewed regarding daily and activity preferences. The interview showed being around animals and doing favorite activities were very important and doing things with groups of people and going outside for fresh air was somewhat important. Review of Resident #57's Community Life Progress Review, dated 4/5/24, revealed Resident #57 was content and happy about activity pursuits. The resident participated in individual/independent, small group, large group, and outside the center events as needed/wanted. The review showed the resident required minimal assistance to complete activities. The resident's reaction to programming was Smiling and laughing during programming, expresses happiness. The resident had made friends in the center, did not have any new hobbies or changes in likes/dislikes, did not have any interests or talents to share with other residents, and was not interested in forming a club. Review of Resident #57's Quarterly MDS assessment, dated 4/22/24, revealed a Brief Interview for Mental Status (BIMS) score of 6 out of 15, indicating severe cognitive impairment. The assessment showed the resident did not utilize any mobility device at admission or currently and required substantial/maximal assistance with chair/bed-to-chair transfers. Review of Resident #57's care plan revealed the following: - Resident has little or no Community Life involvement r/t poor adjustment to the facility/unit, resident wishes not to participate, initiated 7/26/23. The interventions instruct staff to explain to the resident the importance of social interaction, leisure activity time and encourage the resident's participation with daily room visits), revised 11/6/23, remind the resident that the resident may leave activities at any time and is not required to stay for the entire activity. Additional interventions included the resident needs assistance/escort to Community Life functions and to invite/encourage the resident's family members to attend activities with resident in order to support participation. An interview was conducted with the Activity Coordinator (AC) on 6/28/24 at 11:08 a.m. The AC reported she considered Resident #57 was independent for emotional and social needs but dependent with Activities of Daily Living (ADLs). She stated the resident's participation depended on the resident's mood, and she has not seen the resident out of bed and does not provide the resident with any activity. The AC stated a calendar is provided to the resident. She stated depending on the corkboard location she does not know if the resident would be able to read it. She reported there was an activity cart in the dining room of each unit containing crayons, crosswords, and magazines, I will pass out if they ask. She stated the resident does not have a wheelchair to get out of bed. During the continued interview on 6/28/24 at 11:08 a.m. the AC explained that Taco Tuesday on 6/25 was scheduled for noon. She reported buying taco supplies for the independent residents and taking the supplies to the floor, but it did not occur because the facility did not have any petty cash. The AC reported she was supposed to pick up the birthday cake at 9:00 a.m. for the activity of fish fry and birthday party, scheduled for noon on 6/28, but had to participate in the survey. She wasn't able to pick up the cake, and no one else was able to pick up the cake because she had to pay for it out of her pocket. The AC stated she understood about quality of life. The AC stated, All of Us have discussed that the resident's don't have wheelchairs or Geri chairs to get out of bed, and was expected to do a job but didn't have the stuff to do the job. The AC reported not knowing why the activity, Trivia with [NAME], scheduled for 10 a.m. on 6/26 had not occurred. The AC reported she did not document 1:1 room visits, had been coordinator for a year and had received very little training for the job. The AC reported not knowing what time the fish fry on 6/28 was scheduled for and it was not part of the resident's lunch (menu: cornflake-crusted tilapia filet). In regard to the activity of popcorn and movie that had been scheduled for noon on Sunday 6/23, she stated she didn't think popcorn and a movie at noon interfered with nutrition (the noon meal). Review of the Community Life calendar revealed an activity was scheduled at noon every day and no activity started later than 2:30 p.m. (church service on Saturday 6/29). Review of the facility mealtimes showed lunch in the main dining room was served at 12:15 p.m. and residents on the third floor did not receive lunch trays till 1:30 p.m. and 1:45 p.m. 46498 3. During an observation on 6/25/24 at 9:30 a.m. Resident #124 was observed lying down in her bed. She was dressed in her night gown. She said she would like to go to activities or even get up out of bed to visit with other residents, but staff will not get her up out of bed. Review of a Admission Record showed Resident #124 was admitted to the facility on [DATE] with diagnoses to include to muscle weakness (generalized), difficulty in walking, not elsewhere classified, other lack of coordination, cerebral palsy, unspecified. Review of a Minimum Data Set (MDS), dated [DATE], showed Resident #124 had a BIMS score of 14, which indicated she is cognitively intact. Review of a care plan, dated 3/29/24, showed a care plan Focus of Resident #124 is dependent on staff for meeting emotional, intellectual, physical, and social needs. The Goal showed Resident #124 will maintain involvement in cognitive stimulation, social activities as desired through review date. The interventions included to invite the resident to scheduled activities. Date initiated: 04/10/23, date revised on 04/10/24. During an interview on 06/28/24 at 1:30 p.m. the Activities Coordinator stated that she is responsible for the unit Resident #124 resides on. She stated last week when she went to Resident #124's room; the resident told her that she would like to get up out of bed so that she could socialize with other residents, and she wanted to get her hair done. She said she did not do any activities with the resident. She stated she just went to her room to deliver a meal tray. She stated she did not report to anyone that Resident # 124 wanted to get up for activities. She said Resident #124 has not been out of bed for a while. Review of the facility policy titled, Social Activities, effective date 11/30/24, showed: Policy: The Social Activities are modified to meet the basic needs of love and belonging in residents who experience deficits in judgment, reasoning and perception. The activities focus on acceptance of the individual and the stimulation of learned social responses. Purpose: To provide opportunities for socialization regardless of one's cognitive limitations. To provide an atmosphere of acceptance through strategic grouping of residents. To encourage the development of friendships. Procedure: 1. Social Activities shall be offered 3-4 times per day. Review of the facility policy titled, Individual Activities, effective date 11/01/21, showed: Residents who are unwilling and/or unable to attend scheduled group activities are provided with one-to-one individual recreational and Community Life based on their needs, interests and functional ability.

Based on observation, interview and record review, the facility did not ensure residents with limited mobility received restorative services to maintain or improve mobility and/or range of motion (ROM) for three (#129, #31 and #102) of four residents reviewed. Findings included: 1. On 06/25/24 at 10:33 a.m. Resident #129 was observed in his room sitting on his bed. The resident said, I came off from rehab, they said I'm cut off. I'm not on any restorative services. The resident stated he was trying to keep the exercises going by himself. He stated he did not want to lose the momentum. He stated he wished he could receive some kind of therapy. Review of the Admission Record showed Resident #129 was admitted to the facility on [DATE] with diagnoses to include difficulty in walking and encounter for orthopedic aftercare. Review of a document titled, Therapy Communication to Restorative Nursing Program showed on 06/04/24 Resident #129 was assessed for the facility's restorative program for bed mobility. The Problems/Needs section showed to maintain BLE (Bilateral Lower Extremities) strength/endurance and joint flexibility. The Recommendations showed AROM (Active ROM) to BLE 3X15 reps and ambulation 100-200 with 2WW (2 wheeled walker). Perform 3 times a week for 6 weeks. 2. Review of the Admission Record showed Resident #31 was originally admitted to the facility on [DATE] and readmitted on [DATE] with a primary diagnosis of polyneuropathy. Review of a document titled, Therapy Communication to Restorative Nursing Program, showed on 06/20/24 Resident #31 was assessed for the facility's restorative program for feeding, upper body dressing, lower body dressing, shoes and CGA (Contact Guard Assistance) for toilet transfers (SGA). The Problems/Needs section showed Resident #31 was legally blind. The recommendations showed to 1. Raise arms towards the ceiling. 2. Raise arms out to the side, 3. Bend and strengthen elbows and 4. Make a fist and strengthen fingers for 3 times a week for 6 weeks. 3. Review of the Admission Record showed Resident #102 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses to include chronic pain syndrome. Review of a document titled, Therapy Communication to Restorative Nursing Program, showed on 05/27/24 Resident #102 was assessed for the facility's restorative program for moderate assistance for transfers and assistance for bed mobility. The section Problems/Needs showed to maintain functional mobility tissue flexibility and strength. The Recommendations showed to perform Active ROM to BLE in all joints available 2X15. Perform 3 times a week for 6 weeks. On 06/27/24 at 1:02 p.m. an interview was conducted with Staff T, Certified Nursing Assistant (CNA)/ Restorative Aide. She stated she provided restorative therapy to the residents assigned to her. She stated she was familiar with all the residents on her case load but not Resident #129. She said, He is not on my assignment. If he was, I would be seeing him per therapy orders. Staff T shared her restorative Tracking Form for review. It did not include Residents #129, #31, and #102. On 06/27/24 at 1:09 p.m. a follow-up interview was conducted with the Director of Rehabilitation (DOR). He stated he previously worked with Resident #129. He said the resident was no longer on case load because he had reached his maximum potential. He stated he had transitioned him to restorative therapy and put in orders. He stated nursing may have dropped the ball. The DOR said, It is a very simple thing. Nursing did not communicate after the previous ADON [Assistant Director of Nursing] left. We did our part on our end. It should not have taken this long to execute the program. The residents should have transitioned to the restorative program right away. The DOR stated the transition should happen within a couple days to ensure continuation of therapeutic goals, so the resident does not lose their abilities. The DOR confirmed six residents had been affected. On 06/27/24 at 1:15 p.m., an interview was conducted with Staff C, Assistant Director of Nursing (ADON). She stated she was supposed to schedule orientation for herself and the restorative aides to understand her new role. She stated the restorative orders were stored in a binder in her office. Review of the order confirmed therapy orders had been in place. She said, We have not set up the training on the procedures of how to manage the restorative program. I did not know I was supposed to input the orders for the aides to carry out the restorative program. On 06/27/24 at 1:22 p.m. an interview was conducted with the Director of Nursing (DON). She confirmed the restorative program had not been implemented for newly assigned residents since the previous ADON left. An interview was conducted with the Nursing Home Administrator (NHA) on 06/27/24 at 02:15 p.m. She stated the residents requiring restorative should transition to the program easily. She stated the previous ADON was entering the orders. The new ADON has not learned the process yet. The NHA stated the residents should not have gone without restorative therapy. She stated they would educate the new ADON. Review of a policy titled, Restorative Nursing Services, dated 08/24/17 showed restorative nursing will be provided to residents as indicated upon evaluation to assist in achieving the highest practicable level of physical functioning as possible. The procedure showed therapy may refer a resident to restorative upon discharge from therapy services as deemed appropriate. When being referred by a therapist, therapist will complete a communication form to restorative nursing. Therapist will review with the restorative aide. After review the therapist restorative nurse and restorative aid was signed the form. The designated restorative nurse will determine appropriate programs and treatment utilizing information provided by various disciplines and in accordance with the residents plan of care. Restorative programs provided by restorative nursing assistants will be documented each time the program is provided on the restorative tracking form.

Based on observation, interview and record review, the facility did not ensure medication was stored properly for three residents (#129, #141 and #142) related to medications in resident rooms and medications on the floor, and in three medication carts (400 Low, 300 High and 200 Low) out of four medication carts audited related to undated insulin, and an unlocked medication cart. Findings included: 1. An observation was conducted on 6/27/24 at 3:20 p.m. of an unlocked medication cart on the 4th floor resident hall. No staff were in the hallway at the time. At 3:34 p.m. the cart remained unlocked with no staff around. At that time an interview was conducted with Staff J, Licensed Practical Nurse (LPN)/Unit Manager (UM). She said the medication cart should not be unlocked and she would try to find the nurse assigned to that cart. At 3:39 p.m. Staff DD, LPN returned to the floor and said he didn't know his cart was unlocked and knew it shouldn't be. An interview was conducted on 6/27/24 at 5:10 p.m. with the Director of Nursing (DON). She said she would expect medication carts to be locked when the nurse is not with the cart. An observation was conducted on 6/28/24 4:57 p.m. of a pill on the floor of room [ROOM NUMBER]. (Photographic Evidence Obtained.) Staff EE, LPN was brought into the room and was observed picking up the pill. She said she did not know why the pill was on the floor as both residents in that room take their pills crushed. She said it is dangerous for it to be on the floor in the resident room. An interview was conducted on 6/28/24 at 5:11 p.m. with the DON. She said she would not expect there to be pills on the floor in resident rooms. 43453 2. On 6/25/24 at 10:33 a.m. an observation was made of three bottles of medications at the bedside in Resident #129's room. The three bottles of medications were: Zinc, Wild Omega, and Quercetin immune formula. The resident stated a family member had brought the medication in. He stated he took them on his own every day. (Photographic Evidence Obtained). On 6/25/24 at 10:34 a.m. an observation was made of three tablets on the floor in Resident #141's room. The resident did not have any idea there was medication on the floor. (Photographic Evidence Obtained). On 6/25/24 at 1:24 p.m. an observation was made of an Albuterol Sulfate inhaler on Resident #142's walker which was positioned by the side of his bed. The resident stated he used it every 6 hours for shortness of breath (Photographic Evidence Obtained). On 6/25/24 at 10:40 a.m. Staff X, Certified Nursing Assistant (CNA) observed medication on the floor in Resident #141's room. She stated that was not good. Staff X stated if she saw medications on the floor, she would not touch them. She stated she would notify the nurse. Staff X said, The resident must have refused to swallow them. At this time an interview was conducted with Staff I, Licensed Practical Nurse (LPN). She proceeded to remove medications from the floor in Resident #141's bedside. She stated she would call the doctor. She confirmed the three tablets were two Senna tablets and one vitamin D. She stated they were not from her shift. She said, They must have been from last night. The nurse should have stayed with the resident. Staff I, LPN removed the medications from Resident #141's room. She stated she would call the doctor. An interview was conducted on 6/25/24 at10:46 a.m. with the Advanced Registered Nurse Practitioner (ARNP). She stated the resident should not have medications at bedside without orders. She stated they should be removed, and the nurse should notify the doctor to get a script if needed if the medications were not offered. She stated there should be no tablets on the floor. She said, That is not good. On 6/25/24 at10:42 a.m. Staff L, LPN U/M observed the bottles of medications removed from Resident #129's room. She stated she did not know the medications were in the room. She confirmed she worked this hall every morning and conducted room rounds throughout the day. She stated she would call the doctor to obtain orders for the medications at bedside. She confirmed the resident's medications should not be unsecured in the resident rooms. She stated nurses should supervise residents during medication administration. Review of a facility policy titled, Medication and Medication Supply Storage and Disposal, dated 11/30/14, showed central storage of medications is required for prescription, prescribed over the counter medications and CAM (Complementary and Alternative Medicine), will be kept in a locked area in their original labeled container, and may not be removed more than two hours prior to the scheduled administration time. Medications will be kept in a medication cart that locks, and keys are only accessible to the licensed personnel distributing medications. Only current medication for individuals living in the residence will be kept in the residence. 37999 3. Observation of the 300 High medication cart was conducted on 6/28/24 at 4:34 p.m. with Staff D, Registered Nurse (RN). The observation revealed a medication cup containing crushed medications mixed with applesauce located in a plastic tray in a drawer of the cart. The observation revealed three undated vials of Novolog insulin, 1 undated vial of Lantus insulin, 1 undated vial of Fiasp insulin, 1 undated Novolin 70/30 Flexpen, and an undated vial of Latanoprost Ophthalmic 0.005% solution. (Photographic Evidence Obtained) Observation of the 200 Low medication cart was conducted 6/28/24 at 5:03 p.m. with Staff F, RN. The observation revealed an unopened bottle of Insulin Glargine stored with other opened insulin containers. The bag holding the unopened vial showed the vial was opened on 6/25/24. An opened undated vial of Insulin Glargine and an opened undated vial of Insulin Aspart were observed in the medication cart. (Photographic Evidence Obtained) Review of the manufacturer website, https://www.novomedlink.com/, showed the medication Fiasp, once opened can be stored for a maximum of 4 weeks (28 days). The manufacturer website, novomedlink.com, showed Novolog should be disposed of 28 days after opening. The website, lantus.com, revealed opened vials of Lantus should be thrown away after 28 days, even if it still has insulin left in it. The Mayo Clinic, www.mayoclinic.org, showed Latanoprost Ophthalmic solution can be stored in the refrigerator or at room temperature for up to 6 weeks. An interview was conducted on 6/28/24 at 5:07 p.m. with the Director of Nursing (DON). The DON stated insulin should be dated on the tag attached to the vial, Lantus (unopened) should be refrigerated, and crushed medications should have been destroyed. Review of the policy titled, Medication and Medication Supply Storage and Disposal, effective 11/30/2014, document ALF-935, showed medications would be kept in a locked area, in their original labeled container, and may not be removed more than 2 hours prior to the scheduled administration. Meds will be kept in a medication cart that locks and keys are only accessible to the licensed personnel distributing medications. Medication will be stored in a(n) organized manner under proper conditions and in accordance with manufacturer's instructions.

Based on observation, interview, and facility policy review, the facility did not ensure the confidentiality of Protected Health Information (PHI) was maintained for one resident (#395) of 42 residents on the 200 Unit. Findings included: During a facility tour on 06/25/24 at 10:03 a.m. an observation was made of an IV (intravenous) label thrown into a trash can by Resident #395's bed. The IV label included PHI for the resident to include Resident #395's name, name of the medication, prescription number and the medication administration schedule. Review of the Admission Record showed Resident #395 was admitted to the facility on [DATE] with a diagnosis of sepsis. On 06/25/24 at 10:12 a.m. an interview was conducted with Staff F, Registered Nurse (RN). She stated resident's PHI should not be disposed of in the trash. She stated they should maintain the resident's confidentiality and HIPAA (Health Insurance Portability and Accountability Act) per their policy. An interview was conducted on 06/25/24 at 10:28 a.m. with Staff I, Licensed Practical Nurse (LPN). She observed the resident's information inside the trash can. She said, It's his IV information. It should not be in the trash. I believe the nurse who removed it was probably in a hurry. I'll remove the information from the trash can. On 06/25/24 at 10:31 a.m. an observation was made of Staff Q, Certified Nursing Assistant (CNA) removing trash from Resident #395's room. The trash bag was all tied up as she was observed leaving the room. Staff I, LPN stopped her in the hallway and proceeded to retrieve the IV information from the bagged trash. She stated she would dispose of it accordingly. Review of a facility policy titled, Confidentiality and Privacy, dated 11/30/2014, showed the confidentiality and privacy policy is implemented for the purpose of complying with the privacy/security regulations promulgated under the Health Insurance Portability and Accountability Act of 1996 (HIPPA or the Privacy/Security Rule). It is the policy of The Company, LLC to protect the confidentiality of Protected Health Information of its residents. The Procedure showed to never throw sensitive information in the trash. Shredding documents is the only acceptable method of destruction for health or financial information.

Based on interview and record review the facility failed to act upon a resident's grievance for one (#394) resident out of 42 residents on the 200 Unit. Findings included: During a facility tour on [DATE] at 10:13 a.m. Resident #394 was observed in bed. He stated he was constantly hot because the air conditioning (A/C) wall unit in this room did not work. He said, I have provided my own fan. The batteries died . They told my [family member] I can't have a fan that plugs in the wall because there was nowhere to plug it. He stated the family member brought another desk fan and the batteries were dead again. He stated he had notified facility staff. He said, The CNAs [certified nursing assistants] and the nurses know. I have requested a fan if they can't move me. The A/C wall unit was observed to be turned off. The resident stated his roommate turns it off. Review of the Admission Record showed Resident #394 was admitted to the facility on [DATE] with a primary diagnosis of wedge compression fracture of the fourth lumbar vertebra, sequela. Review of the facility's Grievance Log, dated [DATE] to [DATE], showed there was no documented grievance for Resident #394. An interview was conducted on [DATE] at 1:36 p.m. with the Director of Maintenance (DOM). He stated the A/C unit worked, but Resident #394's roommate did not want the AC turned on. He stated he notified the staff of the conflict between the two residents. He said, I don't know if there is anything we can do. On [DATE] at 1:40 p.m. an interview was conducted with Staff I, Licensed Practical Nurse (LPN). She stated she worked in this hall (200) on a regular basis and was familiar with the two residents. She stated Resident #394's roommate did not want the A/C turned on. She said, I know, he turns it off immediately after you turn it on. She stated to the DOM, What are we going to do. Maybe I can speak to the Social Services Director (SSD) for advice. Staff I, LPN confirmed Resident #394's roommate had this problem with every roommate he had. On [DATE] at 3:07 p.m. an interview was conducted with Staff R, Certified Nursing Assistant (CNA). She stated Resident #394's roommate did not like the A/C unit turned on. She stated he turned it off. She stated Resident #394 had been complaining because his roommate would not let him turn on the A/C unit. Staff R said, This morning [Resident #394] said again he was unhappy because it was too hot. She stated a family member brought a fan but there was nowhere to plug it in. Staff R stated the resident had complained to everyone. An interview was conducted with Staff L, LPN/Unit Manager on [DATE] at 3:12 p.m. She confirmed Resident #394's roommate would not let them turn it on. Staff L said, It (the A/C) works. We have spoken to him multiple times. He won't agree. [Resident #394] has requested a room change. I told him I do not have a room right now. Staff L stated she spoke to Admissions regarding roommate compatibility. She stated the owner wanted beds to be filled. She said, I have to wait until we find a place for him. During an interview on [DATE] at 3:32 p.m. Staff S, Assistant SSD stated on [DATE] nursing submitted a grievance related to ADLs (activities of daily living), but not about the room being hot or the request for a room change. She stated their procedure was a resident, family member or staff could initiate a grievance. She stated if the resident notified staff of the room concern, a grievance should be initiated as soon as possible. She stated nursing had not notified the Social Services department. She said, If the roommate did not want the A/C on; then we would initiate a room change. On [DATE] at 4:03 p.m. an interview was conducted with the Director of Nursing (DON). She stated the staff should have initiated a grievance for this resident. She said, Somebody should have documented his concerns. The DON confirmed the expectation was to initiate a grievance to document the resident's concern. On [DATE] at 4:18 p.m. an interview was conducted with the SSD. She stated she had not received any grievances related to this resident's A/C unit or a request for a room change. She stated if the resident had expressed an issue, it should be documented. Review of a facility policy titled, Complaint/Grievance, dated [DATE], showed the intent of this guideline is to support each resident's right to voice grievances and to assure that after receiving a complaint/grievance, the center actively seeks a resolution and keeps the resident appropriately appraised of its progress towards resolution. Prompt efforts by the center to resolve grievances the resident may have, including those with respect to the behavior of other residents. Under Process, the policy showed an employee receiving a complaint/grievance from a resident, family member, and/or visitor shall initiate a complaint/grievance form or electronic equivalent.

Based on observation, record review, and interview the facility failed to develop and/or implement an effective care plan for three (#57, #75, and #114) out of 53 sampled residents. Findings included: 1. On 6/25/24 at 10:44 a.m. Resident #57 was observed with matted hair on the front left side of her head. The resident reported not allowing staff to comb hair because she does it by herself. On 6/28/24 at 11:57 a.m. Resident #57 reported combing her own hair. The observation of the resident showed her hair was matted to the front of her head. At this time, Staff U, Certified Nursing Assistant (CNA) stated the family doesn't want to cut it. Review of Resident #57's Admission Record showed the resident was admitted on [DATE] and readmitted on [DATE]. The record revealed diagnoses not limited to unspecified encephalopathy, mood disorder due to known physiological condition with mixed features, and dementia in other diseases classified elsewhere severe without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. Review of Resident #57's June 2024 Medication Administration Record (MAR) showed the staff documented the resident was combative 6 out of 54 shifts and did not have any other behaviors. Review of Resident #57's care plan revealed the following: - Has an Activities of Daily Living (ADL) self-care performance deficit r/t (related to) decreased mobility, morbid obesity, Diabetes Mellitus (DM), hx (history) of falls, (and) right leg pain. The interventions revealed the resident required supervision for personal hygiene. - Has behaviors r/t refusal of personal care from males, refusal of UA C&S (Urinalysis Culture & Sensitivity), non-compliant with skin sweeps, she speaks not so nice to staff who enter her room, tells staff she doesn't like them or to get out of her room, fabricates stories, 2 staff to go into room when providing care, refusal of meds, refusal to go to ER (emergency room ), refusal to be straight cathed, yelling at staff, refusal of incontinence care, (and) refusal of med (medication) neb (nebulizer) treatments. During an interview on 6/28/24 at 5:14 p.m. the Director of Nursing (DON) stated Resident #57 does refuse staff to comb her hair and the facility has asked the spouse to cut her hair, which is refused. Review of the care plan for Resident #57 did not reveal the facility had developed a care plan or interventions related to the resident's matted hair and the resident/family refusal to assist with the resident's hair. 46234 2. An interview was conducted on 6/25/24 at 10:18 a.m. with Resident #75. He said he received glasses, but they do not work. He said he cannot see very well, can't read menus, and people are just shadows. Review of the Admission Record showed Resident #75 was admitted on [DATE] with diagnoses including malignant neoplasm of the brain, hemiplegia and hemiparesis following cerebral infarction, and chronic migraine. Review of Resident #75's Annual Minimum Data Set (MDS), dated [DATE], Section C - Cognitive Patterns, showed he had a BIMS score of 13, indicating he is cognitively intact. Section B - Hearing, Speech, and Vision showed he had highly impaired vision. Review of Resident #75's care plan did not show any focus areas or interventions related to vision loss. An interview was conducted on 6/28/24 at 9:47 a.m. with Staff FF, Certified Nursing Assistant (CNA). She said she frequently cares for Resident #75. She said he can see about 50% of things and can see if they are close to him. She said she sometimes reads his mail to him when he asks for help. Staff FF said sometimes activities brings the resident crossword puzzles, but he can't see to do them. An interview was conducted on 6/28/24 at 9:57 a.m. with Staff EE, Licensed Practical Nurse (LPN). She said Resident #75 had vision issues and wears glasses, but she doesn't know how much he can see. She said sometimes he will ask staff to read things to him and will ask for the room light to be off so he can try to see the TV better. An interview was conducted on 6/28/24 at 10:17 a.m. with the MDS Coordinator. She said normally when the MDS is done for a resident, the care plan is revised by the person doing the MDS. She said the care plan is updated with current information from the new assessment. She said she does not know Resident #75, but if someone had vision issues the system would trigger to do a care plan. She reviewed Resident #75's Annual MDS and confirmed it noted highly impaired vision. She confirmed he had no care plan in place and said his needs are not being accommodated if he can't read or see things. 3. Review of the Admission Record showed Resident #114 was admitted on [DATE] with diagnoses to include bipolar disorder, unspecified intellectual disabilities, anxiety disorder, major depressive disorder, post-traumatic stress disorder (PTSD), and autistic disorder. Review of Resident #114's care plan did not show any focus area or interventions in place related to autistic disorder. An interview was conducted on 6/28/24 at 10:17 a.m. with the MDS Coordinator. She said she had only been in the facility a couple of months and did not know all the residents, including Resident #114. She reviewed Resident #114's diagnoses and care plan. She stated that every diagnosis does not require a care plan, but anything that would be psychological and/or effect behavior should have one. She said autism effects everything and should be care planned. Review of a facility policy titled Plans of Care, revised 9/25/17, showed the following: Policy: An individualized person-centered plan of care will be established by the interdisciplinary team (IDT) with the resident and/or resident representative(s) to the extent practicable and updated in accordance with state and federal regulatory requirements. Plan of care is to be maintained as part of the final medical record. Procedure: -Develop a comprehensive plan of care for each resident that includes measurable objectives and timetables to meet the resident's medical, nursing, mental, and psychosocial needs that are identified in the comprehensive assessment . -The Individualized Person-Centered plan of care may include but is not limited to the following: . Resident's strengths and weaknesses. . Services to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required by state and federal regulatory requirements. . Other state and federal services, which are not being provided due to respecting a resident's right to refuse care. . Resident's goals for admission and desired outcomes, as well as preferences and potential for future discharge. . Individualized interventions that honor the resident's preferences and promote achievement of the resident's goals. . Interdisciplinary approaches that maintain and/or build upon resident abilities, strengths, and desired outcomes. . Alternative treatments as applicable.

Based on observation, record review and interview the facility failed to implement an effective discharge planning process to assist one resident (#72) with a discharge to another facility out of eight residents sampled. Findings included: During an observation made on 06/25/24 at 9:30 a.m., Resident #72 was observed lying down in bed dressed in her night clothes. Resident #72 was not able to verbally answer interview questions. She pulled out her phone to write her responses down. She wrote the staff at the facility was not treating her good. Staff will not assist her with her ADLs (activities of daily living). She said she was supposed to be up right now for her therapy, but she was not able to go because the aide from the 11:00 p.m. to 7:00 a.m. shift did not get her up. She said her and her [family member] requested that she be transferred to another facility but the person in social services will not assist them. Review of the Admission Record showed Resident #72 was admitted originally on 2/16/24 and readmitted on [DATE] with diagnoses to include acute embolism and thrombosis of left femoral vein, bipolar II disorder, major depressive disorder recurrent, unspecified, anxiety, adjustment disorder with mixed anxiety and depressed mood. Review of a Minimum Data Set (MDS), dated [DATE]. Section C - Cognitive Patterns showed a Brief Interview for Mental Status (BIMS) score of 15, which indicated Resident #72 was cognitively intact. Review of a care plan, initiated 2/20/24, showed a focus of: [Resident #72] wished to return/be discharged home. Review of the care plan goal showed [Resident #72] will verbalize/communicate an understanding of the discharge plan and describe the desired outcome by the review date. The interventions showed: established a pre-discharge plan with the resident/resident's representative/ caregivers and evaluate progress and revise plan; make arrangements with required community resources to support independence post-discharge homes [sic], PT (physical therapy), OT (occupational therapy), MD (medical doctor), wound nurse. During an interview on 6/26/24 at 2:00 pm. with Resident #72's family member, she stated she spoke with the Social Services Director (SSD) at the facility to see if they could assist them with trying to move [Resident #72] to another facility. She said the SSD told her that another facility will not take [Resident #72] at this time because she is Medicaid pending. She said [Resident #72] has been Medicaid pending since March. During an interview on 06/27/24 at 5:00 pm. with the SSD, she stated when a resident wants to transfer to another facility, she would help them by providing a list of facilities they could choose from. Sometimes the resident or their representatives may have a facility that they have already selected. Then she would reach out to the facility of their choice to coordinate the discharge between the resident and the facility. Some facilities may not take residents based on their payor source, for example if a resident is Medicaid pending then some facilities may not want to take the resident until their Medicaid is fully processed. She said the resident and her family member came to her to tell her that the resident wanted to go home but then they changed their mind and wanted her to transfer to another facility. [Resident #72's family member] reached out to her about wanting [Resident #72] to be transferred to another facility. I told her that [Resident #72] is Medicaid pending and most facilities will not take her until her Medicaid has been processed. The SSD said she did not assist the resident with looking for another facility because she knows, based on her own experience, that another facility would not take the resident because she is Medicaid pending. An interview was conducted with the Business Office Manager (BOM) following the interview with the SSD. The BOM stated the facility has a Medicaid specialist who does the Medicaid applications. The BOM stated 0n 6/18/2024 they reviewed Resident #72's file and saw the resident's application was not pulled from the system, meaning no one has pulled her application to work on it. The facility did not provide a policy related to discharge planning by the last day of the survey on 6/28/24.

Based on observation, interview and record review the facility did not ensure a functional communication system implemented for two (#393 and #97) of three residents sampled. Findings included: 1. On 06/25/24 at 10:19 a.m., and on 06/25/24 at 12:47 p.m. observations were made of Resident #393 laying on her bed. The resident did not respond to the interview attempts. During the observations, it was noted there were no alternate communication tools to enable this resident to interact with anyone. On 06/25/24 at 1:02 p.m. an interview was conducted with Staff I, Licensed Practical Nurse (LPN). She stated this resident was non-verbal following a stroke. She stated she observes her body to know what she needed. She stated it was hard to know what she really needed. Review of the Admission Record showed Resident #393 was admitted to the facility on [DATE] with diagnoses of traumatic hemorrhage of cerebrum, unspecified without loss of consciousness, subsequent encounter, acute respiratory failure, aphasia, hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting right dominant side. Review of a document titled, Baseline Care Plan and Summary, showed Resident #393 will be able to communicate desires/needs. The section titled Other, was noted blank. On 06/26/24 at 2:30 p.m. an interview was conducted with Staff R, Certified Nursing Assistant (CNA). She stated she does not speak with the resident. She said, The resident cannot speak. I go in and take care of her . I let the nurse know if I don't know what is going on. On 06/28/24 at 11:50 a.m. an interview was conducted with Staff L, LPN/Unit Manager. She stated this resident was non-verbal. She communicates through text messaging. She stated the resident could squeeze your hand to answer to yes and no questions. On 06/28/24 at 11:58 a.m. an interview was conducted with Staff Q, CNA and Staff Z, CNA. They stated they communicate with this resident by observing her face to see if she was happy or if she was sad. They confirmed they did not know this resident's preferred method of communication. On 06/28/24 at 12:31 p.m. an interview was conducted with the Director of the Nursing (DON). She stated if a resident was non-verbal, there should be a communication board in their room. She stated the resident was able to text using her phone. She stated the Unit Manager should share the unit cell phone with Resident #393 so she can communicate with them. She stated this should be documented in the care plan so all staff know how the resident communicated. The DON stated in the resident's care plan under the section Other, the MDS (Minimum Data Set) nurse should have entered alternate measures; such as use of a cell phone or a communication board. She stated all staff should be informed on how to interact with this resident. On 06/28/24 at 1:00 p.m., an interview was conducted with the MDS Coordinator/Registered Nurse (RN). She stated Resident #393 communicated via text message. She stated she had not spoken to the resident, but she created the baseline care plan after reviewing her admission paperwork. She said, Regarding the care plan, it should say the resident was non-verbal and include this resident's appropriate communication style. The MDS Coordinator/RN confirmed the baseline care plan showed the resident's non-verbal status was not identified. An interview was conducted with Staff AA, Speech Therapist (ST) on 06/28/24 at 2:01 p.m. She stated Resident #393 was non-verbal and they were working on hand squeezes. She stated the resident nodded yes and no, responded to eyebrow raises, blinking and visual picture boards. She stated they were working on pointing. Staff AA stated the most effective method of communication was to use her left hand and left eyebrow. Staff AA, ST stated they should have put this information in a place where everyone knew how to interact with Resident #393. She confirmed the care plan should be updated to include the appropriate communication methods. Review of a facility policy titled, Plans of Care, dated 11/30/14, showed an individualized person-centered plan of care will be established by the interdisciplinary team (IDT) with the resident and or resident representative to the extent practicable and updated in accordance with state and federal regulatory requirements. Under procedure the policy showed to develop and implement an individualized person-centered baseline plan of care within 48 hours of admission that includes but not limited to initial goals on the admission orders physician orders ., if applicable the other areas needed to provide effective care of the resident that meets professional standards of care to ensure that the resident's needs are met appropriately until the comprehensive plan of care is completed. 46498 2. During an observation made on 06/26/24 at 9:22 a.m. Resident #97 was observed lying down in bed dressed in her night clothes. She was not able to verbally communicate. She was observed pointing at different things and hitting on herself trying to communicate. During an observation made on 06/26/24 at 3:00 p.m. Resident #97 was observed lying down in bed dressed in a night gown. The resident was not able to communicate her needs. Resident #97 was observed trying to express herself with moving her hands around. Review of the Admission Record showed Resident #97 was admitted to the facility on [DATE] with diagnoses to included but not limited to hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, and depression unspecified. Review of Resident #97's medical record showed she did not have a communication care plan in place to assist her with her communication needs. During an interview on 06/27/24 at 6:00 p.m. Staff Y, CNA stated he can communicate with Resident #97. He stated when he enters her room, he calls her mom and asks her what she wants. Staff Y called out mom to Resident #97 and he was not able to understand what Resident #97 was trying to tell him. He stated she has a board that she can write on if she wanted to tell him something. During an interview on 06/28/24 at 9:55 a.m. the MDS Coordinator/RN stated care plans are created by the information triggered from the MDS. For a resident that is nonverbal, Section B on the MDS for hearing communication would be checked as rarely or never understood. This would then trigger for a communication care plan to be created. Resident #97's care plan was done in April (2024). She was coded as usually understood, which may have been coded wrong. She stated she was not here at the facility when the resident care plan was done. This was her first time even seeing the resident. No one told her about this resident's communication needs. She stated what she can see is that Resident #97 should have a communication care plan in place. She stated she will get therapy to see what she can do as far as getting the resident assessed and she will create a communication care plan with the appropriate intervention for the resident. The Director of MDS asked Resident #97 if she can write on the board that is next to her. Resident #97 was not able to write on the board that was given to her.

Based on observation, record review and interview the facility did not ensure activities of daily living (ADLs) were completed and maintained for two (#126 and #97) out of two residents sampled. Findings included: 1. During an observation and interview on 06/25/2024 at 10:15 a.m. Resident #126 was in bed, dressed for the day. Resident #126's hair was matted and unkept, she stated that she is not able to brush her hair on her own, so she gets knots in her hair. Resident #126 stated she really would like to go outside and get some sun, but she is always in bed, which causes her neck and back to hurt. She stated she does not ask the CNAs (certified nursing assistants) for help because they are short staffed and there is no point. During an interview on 06/27/2024 at 4:50 p.m. Resident #126 was lying in bed crying, and her hair was noted to be visibly unkept and matted. She stated no one has offered to help her out of bed, or to brush her hair. Resident #126 stated, I would just like to go outside for a little while, so I can see something other than these walls. Review of Resident #126's Admission Record revealed she was admitted to the facility on [DATE] with medical diagnoses of pain in left shoulder, muscle wasting and atrophy, weakness, unspecified abnormalities of gait and mobility, and unsteadiness on feet. Review of Resident #126's Quarterly Minimum Data Set (MDS), dated [DATE], Section C - Cognitive Patterns revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15. Shows resident cognitive level is intact. Functional Abilities and Goals, Section GG revealed Resident #126 has an impairment to her upper and lower extremity on one side and requires substantial/maximal assistance for Toileting hygiene, and Shower/bathe care, upper body dressing, lower body dressing, and putting on/taking off footwear. Resident #126 requires Partial/Moderate assistance for personal hygiene. According to the Self-Care Coding Substantial/maximal means the helper does more than half the effort. The helper lifts or holds trunk or limbs and provides more than half the effort and Partial/Moderate assistance means helper does less than half the effort. A helper lifts or holds trunk or limbs and provides less than half the effort. During an interview on 06/28/2024 at 5:00 p.m. Staff BB, CAN stated she needed a translator to answer questions and at this time another CNA on the floor translated for her. She stated she was not familiar with Resident #126 since this was the first time she has worked with her. She stated she typically provides residents with showers, diaper changes, and provides water and ice. She stated she had not offered to help Resident #126 to brush her hair or to get out of bed since being assigned to her. During an interview on 06/28/2024 at 5:00 p.m. Staff CC, CNA stated he is typically assigned to the other end of the hall and was not familiar with Resident #126's care. He stated part of his job as a CNA is to help residents with showers, diaper changes and provide them with water and ice. He stated he has not offered Resident #126 help with getting out of bed because it is too difficult for him to do. During an interview on 06/28/2024 at 8:55 a.m. Staff L, Licensed Practical Nurse/Unit Manager (LPN/UM) stated Resident #126 can be confused at times. She stated that she has a lot of new CNAs and she has to remind them they should be offering personal hygiene care to include brushing hair and shaving the residents. She stated she used to get a lot of care concerns with her 3:00 p.m. to 11:00 p.m. shift nurses, but it has really turned around. She stated she noticed residents, who do not speak Spanish, are not getting as good of care as residents who do speak Spanish. 46498 2. During an observation made on 06/26/24 at 9:22 a.m. Resident #97 was observed lying down in bed dressed in her night clothes. She was not able to verbally communicate. She was observed pointing at different things and hitting on herself trying to communicate. During an observation made on 06/26/2024 at 3:00 p.m Resident #97 was observed lying down in bed dressed in the same night gown all day. The resident was not able to communicate her needs. Resident #97 was observed trying to express herself with moving her hands around. Observations were made multiple times during the survey on 06/26/2024, 06/27/2024, and 6/28/2024 during multiple times and revealed Resident #97 in bed dressed in her night gown all day and evening. Review of a Admission Recordshowed Resident #97 was admitted to the facility on [DATE] with diagnoses to included but not limited to hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, diabetes mellitus due to underlying condition with diabetic autonomic (Poly) neuropathy, depression unspecified, and other lack of coordination. Review of a Quarterly Minimum Data Set (MDS), dated [DATE], showed a Brief Interview for Mental Status, (BIMS) score of 03, which indicated Resident #97 is severely cognitively impaired. Reivew of a care plan, dated 4/17/2024, showed a care plan Focus of Resident #97 has an ADL self- care performance deficit related to decreased mobility, cerebral vascular accident with hemiparesis/aphasia, liver injury, chronic obstructive pulmonary disease, hypertension, Diabetes Mellitus, paroxysmal atrial fibrillation. Date initiated 10/30/2023 and revised on 10/30/2023. Review of the care plan goal showed Resident #97 will improve current level of function in through the review date. Review of the care plan interventions showed Resident #97 requires substantial assist for upper body dressing and dependent for lower body dressing. Further review of the care plan interventions showed the resident requires substantial assist x1 for bathing/ showering. Date initiated 10/30/2023 and revised on 11/06/23. During an interview on 6/27/24 at 2:00 pm. Staff H, Certified Nursing Assistant (CNA) stated some residents are still in bed dressed in their gowns because they have not requested to get up out of bed. She said if her residents ask her to get up then she will assist them. During an interview on 6/27/24 at 2:30 p.m. with Staff J, License Practical Nurse/Unit Manager (LPN/UM) she stated her expectations are that staff dress and get their residents up out of bed. If residents refuse care, then the aides should make sure they report it to their nurse, so that we can address the situation. During an interview on 6/28/24 at 6:00 p.m. the Director of Nursing (DON) stated that her expectation is that staff assist their residents with ADL care. She said she was told by her staff that residents are in their beds and dressed in gowns because the residents refused staff assistance. She stated some residents don't have wheelchairs to get up in, but staff should assist with their care, dressing and get them up if they can.

Based on observation, interview, and record review the facility did not ensure trauma informed care was provided for one (#114) out of three residents with post-traumatic stress disorder (PTSD). Findings included: Review of Admission Record showed Resident #114 was admitted on [DATE] with diagnoses including bipolar disorder, unspecified intellectual disabilities, anxiety disorder, major depressive disorder, post-traumatic stress disorder (PTSD), and autistic disorder. Review of Resident #114's Quarterly Minimum Data Set (MDS), dated [DATE], Section I, Active Diagnosis, noted yes for post-traumatic stress disorder. Section C, Cognitive Patterns, was not able to be completed due to resident rarely/never being understood. Review of Resident #114's care plan did not show a focus area or interventions in place related to post-traumatic stress disorder. An observation was conducted on 10/25/24 at 10:40 a.m. of Resident #114 lying in bed and yelling out repeatedly. Staff EE, Licensed Practical Nurse (LPN) was in the hall and said, is she still crying? An interview was conducted on 6/28/24 at 10:17 a.m. with the MDS Coordinator. She said she had only worked in the facility a couple of months and did not know all the residents, including Resident #114. She said if a resident had a PTSD diagnosis there isn't a specific PTSD care plan, but there is a trauma informed care focus area. She reviewed Resident #114's diagnoses and care plan. She said the resident should have a care plan for trauma informed care. An interview was conducted on 6/28/24 with the Nursing Home Administrator (NHA). She reviewed Resident #114's medical record and said the resident is not being followed by psychiatry or psychology. She said Resident #114's primary care nurse practitioner has mental health training and managed the resident's medications. Review of the policy - Trauma Informed Care, document N-1580 and effective 10/24/22, showed Residents will be evaluated to identify a history of trauma, triggers and cultural preferences. Resident- centered interventions are initiated based on the resident triggers and preferences to decrease the risk of re- traumatization. The procedure included: -1. Residents are evaluated for trauma, triggers and cultural preferences on admission/re- admission, quarterly, and annually. -2. Develop resident- centered interventions based on trauma triggers and resident cultural preferences. -3. Develop a care plan and add interventions to the nurse aide Kardex. -4. Review and update care plan and interventions quarterly and as needed.

Based on record review and interview, the facility failed to ensure medications were administered as ordered for one resident (#393) of 42 residents on the 200 Unit. Findings included. Review of the Admission Record showed Resident #393 was admitted to the facility on [DATE] with diagnoses of traumatic hemorrhage of cerebrum, unspecified without loss of consciousness, subsequent encounter, acute respiratory failure, aphasia, hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting right dominant side. Review of the June 2024 Medication Administration Record (MAR) for Resident #393 revealed on 06/06/24 the resident was ordered Cephalexin Oral Tablet 500 mg (milligram), Give 500 mg enterally four times a day for infection (urinary tract infection) for 7 days. Review of the MAR showed Resident #393 received the Cephalexin antibiotic as follows: * On 06/07/24 at 2:50 p.m., Cephalexin 250 mg, 2 tablets were administered. Record review showed no other doses were administered on 06/07/24. * On 06/08/24 at 5:34 a.m., Cephalexin 250 mg, 2 tablets were administered. On 06/08/24 at 9:54 a.m., Cephalexin 250mg, 2 tablets were administered. Record review showed no other doses were administered on 06/08/24. * On 06/09/24 at 6:44 a.m., Cephalexin 250 mg, 2 tablets were administered. On 06/09/24 at 8:22 a.m., Cephalexin 250 mg, 2 tablets were administered. On 06/09/24 at 12:47 p.m., Cephalexin 250 mg, 2 tablets were administered. Record review showed no other doses were administered on 06/09/24. Review of the MAR for Resident #393 showed the resident did not receive the Cephalexin antibiotic as ordered from 06/10/24 to 06/13/24, which was the end of the 7 days. On 06/27/24 at 2:15 p.m. an interview was conducted with Staff L, Licensed Practical Nurse (LPN)/Unit Manager and the Director of Nursing (DON). The DON reviewed the resident's record and confirmed they had pulled the medication from the EDK (Emergency Drug kit). She stated they ran out of the Cephalexin that was in the EDK kit. The DON stated the nurse should have called the pharmacy to follow-up on the delivery of Resident #393's medications. She confirmed the missed doses. The DON said, She should not have missed her antibiotics. The expectation was for the nurse to contact the doctor and to notify the unit manager and DON if they did not have the antibiotics. During an interview with the Regional Nurse Consultant (RNC) on 06/27/24 at 2:35 p.m., the RNC stated the nurse should have followed up on the original order and called pharmacy. She said, Yes, the EDK should be used for an emergency; not on an on-going basis. She confirmed the nurse should have contacted the pharmacy to obtain the antibiotics. An interview was conducted on 06/27/24 at 9:24 a.m. with the Advanced Registered Nurse Practitioner (ARNP). She reviewed Resident #393's MAR and stated it looked like they did not follow-up regarding the antibiotics. She said, They should have called the pharmacy. It seems to be a timeliness issue. They may have pulled from their EDK stock. The nurse should have notified someone if the resident did not have medications. Antibiotics are critical meds. The resident already had critical labs. It did not help her situation. Review of a facility policy titled, Physician Orders, dated 11/30/24, showed the center will ensure physician orders are appropriately and timely documented in the medical record. The procedure showed: information received from the referring facility or agency to be reviewed, verified with the physician and transcribed to the electronic medical record. The attending physician will review and confirm orders.

Based on record review and interview, the facility failed to ensure critical labs were reported to the ordering physician in a timely manner for one resident (#393) of 53 residents sampled. Findings included: Review of the Admission Record showed Resident #393 was admitted to the facility on [DATE] with diagnoses of traumatic hemorrhage of cerebrum, unspecified without loss of consciousness, subsequent encounter, acute respiratory failure, aphasia, hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting right dominant side. Review of laboratory results for Resident #393 showed: On 6/10/24 at 6:15 a.m. labs were collected. On 6/10/24 at 8:55 a.m. labs were received. On 6/10/24 at 1:44 p.m. lab results were reported to the facility. Review of the lab results showed the following high readings that were flagged. Glucose serum 193; Reference range 70-105; Flagged high results. BUN (Blood Urea Nitrogen) 59; Reference range 7-25 Flagged high results. Sodium Serum 155; Reference range 135-145; Flagged high results. Chloride 113; Reference range 98-108; Flagged high results. Osmolarity Calculated 343.9; Reference range 275.0-295; Flagged high results. Review of Resident #393 progress notes and assessments showed there were no progress notes documented on this day to confirm the resident's physician was notified. Review of a hospital document titled, History and Physicals, Final Report, dated 06/13/24, showed the patient presented to the emergency room (ER) with abnormal labs. The resident was previously discharged to a facility. She returned to the ER secondary to having abnormal labs. Upon evaluation the patient was lethargic. When her labs were drawn, she had an increase in her white count of 18,000. Her BMP (Basic Metabolic Panel) showed her sodium was 160 and Potassium was 6. Her BUN was 134 and creatine was 2.76, which were previously normal. Patient received IV fluid per Sepsis protocol and broad- spectrum antibiotics. Patient was admitted to the Intensive Care Unit (ICU) for further evaluation and work up. On 06/27/24 at 09:09 a.m., an interview was conducted with the facility's ARNP (Advanced Registered Nurse Practitioner). She stated she had to send the resident out due to critical labs on June 13th. She stated the resident's sodium level was 155 and her BUN (kidney function) was 59. The ARNP stated she had re-ordered labs on the 13th because she had critical labs that were not addressed on the 10th. The ARNP said, I don't know why the physician was not notified. I don't know that they notified anyone. The ARNP stated if the lab results were critical, they should be reviewed STAT, meaning without delay. She said, Typically when I come in, I review the labs myself because most of the time they do not call. They also don't answer the phone. The ARNP stated the facility nurse should call with any critical labs. She stated a delay of 24 hours can make a significant difference for a resident. The ARNP said, I have told the administration they can call me. It is a problem that they don't call when the resident has a change in condition. The ARNP stated communication was a problem at this facility. On 06/27/24 at 11:16 a.m. an interview was conducted with the Director of Nursing (DON). The DON said, She [Resident #393] had critical labs. The nurse should notify the physician, put in orders and notes as soon as they receive the labs. The DON stated there should be a progress note if the physician was notified. The DON stated the laboratory provider called the facility, but it was a hit or miss process. The DON stated the laboratory provider sent a fax too. The DON confirmed the facility had access to the laboratory results. She said, We can log in and look. The DON stated the expectation was for the nurse to call the doctor as soon as the results were received, obtain orders, and document. She said, That is Nursing 101. The DON stated the resident should not have waited 24 hours for a response to critical labs. On 06/27/24 at 11:34 a.m. an interview was conducted with Staff L, Licensed Practical Nurse (LPN). She stated the nurses should notify the doctor of any critical labs and immediately put it in a progress note. She stated the physician should be called as soon as they review the labs. Review of a facility policy titled, Laboratory, Diagnostic and X-ray, dated 11/30/2014, showed an expectation to provide guidance on ordering, obtaining, documenting and reporting laboratory, diagnostic and X-ray results. Under procedure: *Critical values to be called to the center. * The center to notify the ordering practitioner (or the covering physician if after hours) of values outside the reference range or per physician order. * Document any new orders. * Document notification of the practitioner and resident/resident representative of lab work results, diagnostic testing and X-rays to be filed in the electronic medical record.

Based on observation, record review, and interview the facility failed to promptly provide dental services for one (#79) out of one sampled resident complaining of chewing difficulties related to tooth pain. Findings included: On 6/25/24 at 10:53 a.m. Resident #79 was observed lying in bed. The resident reported having no teeth, having a problem chewing, and had told everybody about the chewing problem. Review of Resident #79's Admission Record revealed the resident was originally admitted on [DATE] and readmitted on [DATE] and 11/29/22. The record included diagnoses not limited to unspecified Type 2 diabetes mellitus with unspecified complications, mild protein-calorie malnutrition, and gastro-esophageal reflux disease without esophagitis. The Admission Record revealed the primary payer source for the resident was Medicaid (MCD) Long Term Care (LTC) [provider name]. Review of Resident #79's Quarterly Minimum Data Set (MDS), dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 7 out of 15, indicating a severe cognitive impairment. The assessment revealed the resident was not edentulous, did not have any abnormal mouth tissues (ulcers, masses, oral lesions), no obvious or likely cavity or broken natural teeth, no inflamed or bleeding gums, or any mouth or facial pain, discomfort or difficulty with chewing. Review of Resident #79's medical record revealed a note, dated 5/28/24, showing the resident reported pain in a tooth, the Nurse Practitioner was notified, and an order was obtained for a dental consult and Acetaminophen. Review of Resident #79's progress notes showed the resident received two tablets of 325 mg (milligram) Acetaminophen on 6/4/24 at 11:18 p.m., 6/21/24 at 9:07 a.m., and 6/27/24 at 7:20 a.m., per an order for every 6 hours as needed for pain. The note did not reveal the location of the resident's pain. An interview was conducted with the Social Service Assistant (SSA) on 6/26/24 at 5:13 p.m The SSA reported having to check if dental had been in. The SSA stated the dentist comes in once a month, and the hygienist comes in once a month. The SSA stated she would have to check if dental had been in the facility twice during the month of June. The SSA stated dental services are supposed to write a note if the resident refuses and it gets uploaded (into the resident's clinical record). The SSA reviewed records and stated the dentist was at the facility on 5/29/24 (the day after Resident #79 had reported tooth pain) and the facility had to request an appointment. A request was made for any dental notes and information if Resident #79 had been seen on 5/29/24. On the morning of 6/27/24 the Director of Nursing was asked for the dental information requested of the SSA on 6/26/24. On 6/27/24 at approximately 5:00 p.m. a request was made to the Regional Nurse Consultant (RNC) for the previously requested dental information related to Resident #79. The RNC stated they were trying to get a dental appointment for the resident. On 6/27/24 at 5:28 p.m. another request was made to the DON regarding Resident #79's dental information (notes, appointments) and she stated the hygienist had been in the facility. On 6/27/24 at 6:15 p.m. a request was made to the DON asking if Resident #79 had been seen by dental services. Review of Resident #79's progress notes revealed a note written by the DON, dated 6/27/24 at 6:36 p.m., showing the resident had a 10 a.m. dentist appointment at an outside dental vendor. The note did not reveal a date of the appointment. Review of Resident #79's progress note, dated 6/27/24 at 7:09 p.m., showed the resident refers [sic] to continue with dental pain, the physician was notified with orders for Acetaminophen and labs obtained. The note revealed the resident had a dental consult appointment scheduled. An interview was conducted on 6/28/24 at 8:35 a.m. with the DON. The DON stated they attempted to reach out to the dental vendor yesterday but it had been after 5:00 p.m., so they were closed; and the hygienist should have given a list (of residents seen) to Medical Records but did not know what happened. On 6/28/24 at 9:10 a.m. Resident #79 was observed dressed, sitting in a wheelchair, and waiting to leave the facility for a dentist appointment. The resident reported not having any teeth, opening mouth and revealing 4-5 blackened broken teeth on the bottom. The resident stated her mouth continued to hurt. The facility did not provide supporting documentation to show Resident #79 had been seen by dental services during the month of May or June. The facility did provide documentation that the resident had been seen at an outside the facility dental vendor on 6/28/24, 32 days after the resident complained of tooth pain on 5/28/24. Review of the Policy and Procedure titled, Dentist Services, revised 11/27/17, showed The center will contract with a dentist licensed by the board of dentistry to provide routine and 24- hour emergency dental services. The procedures instructed: - Obtain order for dental consult. - The nurse or designee will if necessary or if requested assist the patient/ resident in making the appointment and arranging for transportation to and from the dentist's office. - Residents with lost or damaged dentures will be referred promptly within three days to the dentist. - If a referral does not occur within three days the nurse will evaluate and document changes inability to eat and drink. Review ability with physician and obtain orders as indicated. - Medicare and private pay residents may be charged for the services. The facility will provide Medicaid resident services in routine services covered under the state plan at no charge. If any resident of the facility is unable to pay for needed dental services, the facility will attempt to find alternative funding sources or alternative service delivery systems to ensure the resident maintains his/ her highest practicable level of well- being.

Based on observations, interviews with the nursing staff, Nursing Home Administrator, the Director of Nursing, the resident's primary care physician, and review of the resident's medical record and facility policies, the facility failed to protect the resident's right to be free from neglect by not ensuring one resident (#1) of 10 residents at risk for elopement, was provided with supervision and services related to the resident's cognitive deficits and history of dementia, epilepsy, and confusion before admission to the facility. In addition, the facility failed to provide meals, shelter and ordered medical treatment during Resident #1's absence. The facility staff failed to ensure the medical care and safety of Resident #1; on 12/31/2023 at approximately 2:30 PM, Resident #1 ambulated from the second floor of the facility, entered the facility elevator, and rode the elevator down to the first floor of the facility. Resident #1 exited the facility through the front door, which was equipped with an electromagnetic locking device (a magnetic lock that is unlocked when de-energized and requires power to remain locked) and was opened by reception staff who thought Resident #1 was a visitor at the facility. Resident #1 was able to walk out the front door of the facility, travel approximately 0.2 miles, along a 4-lane road and was found more than 24 hours later at a nearby apartment complex in a vacant apartment by a member of the community. Resident #1 was discovered by a member of the community on 1/1/2024 at approximately 7:00 PM in a vacant apartment and was returned by facility staff at approximately 7:30 PM. The facility failed to take action to prevent the resident from exiting the facility by not determining and providing the necessary level of supervision, and not distinguishing the resident from visitors of the facility. The resident was not located for approximately 28 hours and 30 minutes. The failure created a situation that resulted in a likelihood for serious injury and/or death to Resident #1 and resulted in the determination of Immediate Jeopardy on 12/31/2023. The findings of Immediate Jeopardy were determined to be removed on 1/12/2024 and the severity and scope was reduced to a D. Findings included: A review of the facility policy titled Abuse, Neglect, Exploitation, & Misappropriation, last revised on 11/16/2022 revealed under the section titled Policy it is inherent in the nature and dignity of each resident at the center that he/she be afforded basic human rights, including the right to be free from abuse, neglect, mistreatment, exploitation, and/or misappropriation of property. The policy defines neglect as the failure of the center, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. The policy also revealed examples of neglect including failure to take precautionary measures to protect the health and safety of the resident and failure to adequately supervise a resident known to wander from the facility without the staff knowledge. A review of the facility policy titled Missing Patient/Resident, last revised on 8/1/2020, revealed under the section titled Overview, staff will investigate cases of missing patient/resident and possible elopement. An elopement occurs when a patient/resident leaves the premises or a safe area without authorization and/or any necessary supervision to do so, placing the patient/resident at risk for harm or injury. The policy also revealed the following facility procedure under the section titled Procedure: - Check the Leave of Absence (LOA) book and medical record to ensure the patient/resident is not on an authorized leave or medical appointment. - Announce (resident name) please return to your room, over the public announcement (PA) system. Repeat three times to alert staff of a missing patient/resident. - Assign staff to search the Center and grounds. - If the patient/resident is not located after an initial search, the point person will notify the Nursing Home Administrator (NHA), the Director of Nursing (DON), the resident representative, and the Primary Care Physician (PCP). The NHA and/or DON or designee will notify local law enforcement. A review of Resident #1's hospital history and physical (H&P), dated 12/13/2023 revealed Resident #1 arrived at the emergency department with a critically high blood pressure of 233/151, a heart rate of 101, and was unresponsive with active convulsions. Resident #1 was determined to be in critical condition with a risk of worsening seizures, stroke, or death. A review of Resident #1's preadmission Medical Certification for Medicaid Long Term Care Services and Patient Transfer Form, with a Physician Certification date of 12/29/2023 revealed under Section C: Decision Making Capacity (Patient) Resident #1 required a surrogate for medical decision making. The transfer form also revealed under Section S: Physical Function, Resident #1 ambulated with standby assistance and required no assistive devices to ambulate. The transfer form revealed under Section U: Mental/Cognitive Status at Transfer, Resident #1 was alert and disoriented but could follow simple instructions. A review of Resident #1's medical record revealed Resident #1 was admitted to the facility on [DATE] with diagnoses of epilepsy, unspecified, intractable, with status epilepticus, difficulty walking, essential hypertension, other symptoms and signs involving cognitive functions and awareness, diabetes mellitus, occlusion and stenosis of the right carotid artery, non-ST elevation (NSTEMI) myocardial infarction, dementia in other diseases classified elsewhere, severe, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, and history of falling. A review of Resident #1's Admission/Readmission Data Collection assessment dated [DATE] and completed by Staff B, Registered Nurse (RN), revealed under Section B: Cognition, Resident #1 was alert and oriented to person, place, and time. The assessment also revealed under Section N2: Elopement Risk Evaluation, Resident #1 was not cognitively impaired, was not independently mobile (either ambulatory or in a wheelchair), did not have poor decision-making skills, did not have the ability to exit the facility, and was not at risk for elopement. A review of the facility policy titled Admission Assessment, last revised on 8/22/2017 revealed at the time of admission or readmission, the nurse shall initiate the Admission Data Collection Form or its electronic equivalent. Pertinent information shall be collected by physical review, interview with resident and family, and review of the resident's available medical records. A telephone interview was conducted on 1/10/2024 at 12:02 PM with Resident #1's Primary Care Physician (PCP). The PCP stated he evaluated Resident #1 on 12/30/2023 and the resident appeared stable but was confused, disoriented to time, and did not give appropriate responses to questions. Resident #1 had a history of stroke and new onset seizures. The PCP stated he was notified of Resident #1's elopement from the facility on 12/31/2023 and of the resident's return on 1/1/2024. The PCP ordered lab work for Resident #1 upon his return to the facility and no abnormalities were found. The PCP stated Resident #1 was in danger during his elopement from the facility because he does not know what's fully going on and the resident had a possibility of increased seizure risk without his seizure medications. A review of Resident #1's physician's orders showed the resident missed evening and morning doses of his two medications for seizures and missed his three morning medications for hypertension: - An order dated 12/30/2023 for Lacosamide 100 milligrams (mg) by mouth in the morning and at bedtime for a diagnosis of seizures. - An order dated 12/30/2023 for Levetiracetam 1000 mg by mouth in the morning and at bedtime for a diagnosis of seizures. - An order dated 12/30/2023 for Lisinopril 5 mg by mouth once daily for a diagnosis of hypertension. - An order dated 12/30/2023 for Hydralazine Hydrochloride (HCl) 25 mg by mouth once daily for a diagnosis of hypertension. - An order dated 12/30/2023 for Amlodipine Besylate 10 mg by mouth once daily for a diagnosis of hypertension. - An order dated 1/1/2024 for an electronic elopement device to the right lower extremity. - An order dated 1/1/2024 to verify placement of the electronic elopement device to the resident's right lower extremity every shift. - An order dated 1/1/2024 to verify functioning of the electronic elopement device to the resident's right ankle every shift for safety. A review of Resident #1's Change in Condition Situation, Background, Assessment, and Recommendation (SBAR) Communication and Progress Note dated 12/31/2023 at 7:41 PM and authored by Staff A, Licensed Practical Nurse (LPN) and Unit Manager (UM), revealed under the section titled Situation Resident #1 could not be located in the facility. The note also revealed under the section titled Appearance Staff A, LPN UM looked for Resident #1 on the first floor of the facility after the resident did not return to the unit for the dinner meal. Staff A, LPN UM was not able to locate Resident #1 and the facility's elopement protocol was initiated. Resident #1's Primary Care Physician (PCP) was also notified of Resident #1's elopement at 9:00 PM and a recommendation was made to call 911. A review of Resident #1's care plan revealed a problem, dated 1/1/2024, indicating Resident #1 was a risk for elopement/wanderer related to a history of attempts to leave the facility unattended and impaired safety awareness. Listed interventions included the following: distract the resident from wandering by offering pleasant diversion, structured activities, food, conversation, television, or a book; applying an electronic elopement device to the resident's right lower extremity; monitor the resident's location frequently; and identify patterns of wandering. A review of Resident #1's Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 1/2/2024 revealed under Section C - Cognitive Patterns, a Brief Interview for Mental Status (BIMS) score of 3, which indicated severely impaired cognition. The assessment also revealed under Section E - Behavior, Resident #1 displayed behaviors of wandering 1 to 3 days of the assessment period, which placed Resident #1 at significant risk of getting to a potentially dangerous place. According to the National Institutes of Health, wandering behavior is one of the most important and challenging management aspects in persons with dementia. Wandering behavior in people with dementia (PwD) is associated with an increased risk of falls, injuries, and fractures, as well as going missing or being lost from a facility. This causes increased distress in caregivers at home and in healthcare facilities. The approach to the comprehensive evaluation of the risk assessment, prevention, and treatment needs more strengthening and effective measures as the prevalence of wandering remains high in the community. Both the caregiver and clinicians need a clear understanding and responsibility of ethical and legal issues while managing and restraining the PwD. The consequences of the wandering can vary from minor injury on the body to severe injury and death. The persistent wandering behavior and weak gait and balance have been shown to increase the risk of falls, fractures, and accidents in PwD. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8543604/#:~:text=Outcome%20of%20Wandering%20in%20Dementia,to%20severe%20injury%20and%20death.&text=The%20persistent%20wandering%20behavior%20and,fractures%2C%20and%20accidents%20in%20PwD. An interview was conducted on 1/9/2024 at 12:59 PM with Staff A, LPN UM, who was Resident #1's assigned nurse on 12/31/2023 for the 3:00 PM to 11:00 PM shift. Staff A, LPN UM stated she was called in to work the 3:00 PM to 11:00 PM shift on 12/31/2023 due to a call off and arrived at the facility around 4:00 PM. Staff A, LPN UM usually worked as the Unit Manager on Resident #1's floor but she was not familiar with Resident #1 because she was off at the time Resident #1 was admitted to the facility. When she arrived to the unit, Staff A, LPN UM did a shift-to-shift report with Staff B, RN, who told her Resident #1 was participating in an activity in the downstairs dining room. Neither staff member verified Resident #1 was at the activity at the time of the report. Staff A, LPN UM stated around 6:00 PM, she noticed Resident #1 did not return to the unit for dinner and his dinner tray in his room was untouched. Staff A, LPN UM went downstairs to the dining room to check on Resident #1 and he was not at the activity. Staff A, LPN UM stated she also checked the smoking porch off of the downstairs dining room and Resident #1 was not found. Staff A, LPN UM asked Staff C, Receptionist, if she had seen Resident #1 because she did not know what the resident looked like and Staff C, Receptionist responded, no. Staff A, LPN UM also checked with the other floor staff in the facility but was not able to locate Resident #1 on any floor. Staff A, LPN UM stated around 7:00 PM, she went to the reception desk and called the DON and told her Resident #1 could not be located in the building. During her telephone conversation with the DON, Staff A, LPN UM heard Staff C, Receptionist tell her she saw a group of people leaving the facility earlier in the day and was not able to state a time, but she was not certain Resident #1 was part of the group because she did not know what the resident looked like. Staff A, LPN UM stated after speaking with the DON, she initiated a code silver and notified Resident #1's representative. Staff A, LPN UM also stated the DON called her around 7:30 PM and told her to call 911. Staff A, LPN UM was connected to local law enforcement and informed them Resident #1 was missing from the facility. Staff A, LPN UM stated she went outside and searched the surrounding area for the resident, but no other staff members assisted her with the search on the outside perimeter of the facility. Staff A, LPN UM also stated local law enforcement arrived at the building around 10:00 PM and she provided Resident #1's information to them. After speaking with local law enforcement, Staff A, LPN UM completed some paperwork and documentation and left the faciity on [DATE] around 12:15 AM. Staff A, LPN UM arrived back at the facility on 1/1/2024 around 7:30 AM and assisted with staff in-services for the 7:00 AM to 3:00 PM staff, related to Resident #1's elopement. Around 2:00 PM, Staff A, LPN UM went to a local gas station Resident #1 frequently visited prior to his admission to the facility and spoke with members of the community in an attempt to locate Resident #1, but the resident was not found at that time. Staff A, LPN UM stated she received a phone call from the NHA around 6:00 PM on 1/1/2024, stating Resident #1 was found and was being returned to the facility. An interview was conducted on 1/9/2024 at 1:38 PM with Staff B, RN, who was Resident #1's assigned nurse on 12/31/2023 for the 7:00 AM to 3:00 PM shift. Staff B, RN stated she was familiar with Resident #1, and she was his nurse when he arrived at the facility on 12/29/2023. Staff B, RN also stated she completed Resident #1's admission assessment on 12/29/2023 and the resident was alert, but a little bit confused. Staff B, RN stated Resident #1 was able to appropriately answer questions, had knowledge of his surroundings, able to state where he was, and was able to state his name. Staff B, RN also stated at the time of his admission assessment, Resident #1 did not seem cognitively impaired and did not have any diagnoses to indicate cognitive impairment. Staff B, RN addressed Resident #1 did have a diagnosis of dementia and was independently mobile but was not able to state why Resident #1's admission assessment revealed the resident was cognitively intact, was not independently mobile, and did not have the ability to leave the facility. Staff B, LPN UM stated she observed Resident #1 on 12/31/2023 around 2:45 PM go onto the facility elevator wearing a jacket and Resident #1 stated to her he was going downstairs to participate in an activity. Staff B, LPN UM also stated around 3:00 PM, she did a shift-to-shift report with Staff A, LPN UM and told her Resident #1 was downstairs participating in an activity, but neither staff member verified Resident #1 was downstairs. After giving the shift-to-shift report, Staff B, RN left the facility. Staff B, RN stated she returned to the facility on [DATE] and was told by Staff A, LPN UM Resident #1 was missing from the facility. Staff B, RN also stated Resident #1 was returned to the facility by local law enforcement on 1/1/2024 around 7:00 PM. Staff B, RN completed a skin assessment for Resident #1 and the resident had no injuries. Staff B, RN stated Resident #1 appeared more confused upon his arrival and was wearing different clothing than the previous day. An interview was conducted on 1/9/2024 at 11:06 AM with Resident #1 in the resident's room. Resident #1 was observed sitting on the side of the bed in his room and was able to get up from the bed and walk to the door without difficulty and without the use of assistive devices. Resident #1 spoke clearly during the interview but was not able to appropriately answer questions. Resident #1 was not able to state where he was, what day it was, or why he was at the facility but was able to state his name, which he repeated several times during the interview. Resident #1 was not able to recall his elopement from the facility on 12/31/2023. An interview was conducted on 1/9/2024 at 2:02 PM with Staff F, Certified Nurse Aide (CNA). Staff F, CNA stated he was familiar with Resident #1 during previous interactions with the resident on 12/30/2023 and stated the resident was in and out when describing the resident's cognition. Staff F, CNA also stated the resident was able to hold a conversation, but only some things made sense, and Resident #1 was not aware of his surroundings. Staff F, CNA stated he worked on Resident #1's floor on 12/31/2023 during the 7:00 AM to 3:00 PM shift and saw the resident dressed to leave around 2:10 PM, but he did not see Resident #1 get onto the elevator or go downstairs during the shift. Staff F, CNA also stated he did not see the resident again before his shift ended at 3:00 PM because he was not assigned to the resident during the shift. Staff F, CNA stated he did not see Resident #1 until 1/2/2024 during the 7:00 AM to 3:00 PM shift. Staff F, CNA also stated he asked Resident #1 about his elopement from the facility but Resident #1 was not able to respond appropriately. An interview was conducted on 1/9/2024 at 2:23 PM with Staff D, Activity Coordinator (AC). Staff D, AC stated she worked at the facility on 12/31/2023 and she set up a football party activity in the first-floor dining area. Staff D, AC also stated she was not familiar with the resident and did not know what the resident looked like prior to his elopement on 12/31/2023. Staff D, AC stated she was assisting residents with a smoke break around 2:15 PM on 12/31/2023 and went to the reception desk to retrieve the smoking supplies when she saw a group of about 3 or 4 people leaving the facility through the front entrance. Staff D, AC was not able to state if Resident #1 was with the group of people exiting the facility because she was not familiar with the resident at the time. Staff D, AC left the facility around 3:15 PM and was told upon her return to the facility on [DATE] Resident #1 was missing from the facility. Staff D, AC stated she assisted several other facility staff members in looking for the resident in the community on 1/1/2024 around 8 or 9 AM, but they were not able to find the resident. A telephone interview was conducted on 1/10/2024 at 10:27 AM with Staff C, Receptionist. Staff C, Receptionist stated she worked at the facility from 8 AM to 8 PM on 12/31/2023 and works mostly weekends. Staff C, Receptionist also stated she was not familiar with Resident #1 prior to the elopement and had never seen the resident before. Staff C, Receptionist stated on 12/31/2023 around 1:30 PM or 2:00 PM, she observed a group of people exiting the facility through the front entrance. Staff C, Receptionist stated she just clicked the buzzer to open the door and let the group out because she assumed it was just a group of visitors leaving the facility and did not think a resident was with them. Staff C, Receptionist stated on 12/31/2023 around 7:00 PM, she noticed Staff A, LPN UM downstairs looking for the resident. Staff C, Receptionist told Staff A, LPN UM she saw a group of people leaving the facility around 1:30 PM or 2:00 PM but she was not sure if the resident was with the group because she did not know what the resident looked like. Staff C, Receptionist stated a code silver was initiated and she assisted Staff A, LPN UM with calling Resident #1's family members in an attempt to notify and locate the resident. Staff C, Receptionist also stated she assisted in searching for Resident #1 outside of the facility for about 10 or 15 minutes but had to leave the facility at 8:00 PM. Staff C, Receptionist returned to the facility at 10:00 PM to assist staff in trying to locate Resident #1 and left the facility around 11:00 PM. Staff C, Receptionist stated she returned to the facility on [DATE] around 8:00 AM and joined several other facility staff for a good hour in trying to find Resident #1 out in the community, but Resident #1 was not found. A telephone interview was attempted on 1/10/2024 at 11:46 AM with Staff E, CNA, who was Resident #1's assigned CNA on 12/31/2023 during the 7:00 AM to 3:00 PM shift. Staff E, CNA did not answer the phone call and a message was left for call back by Staff H, Social Services Aide (SSA), who assisted with translation. The phone call was not returned by Staff E, CNA. A telephone interview was conducted on 1/10/2024 at 11:50 AM with Staff G, CNA, who was Resident #1's assigned CNA on 12/31/2023 during the 3:00 PM to 11:00 PM shift. Staff G, CNA stated she was not familiar with Resident #1 and had not seen the resident before his return on 1/1/2024. Staff G, CNA also stated she arrived at the unit on 12/31/2023 around 3:00 PM and conducted shift-to-shift rounds with Staff E, CNA. Staff G, CNA stated she only did a verbal shift-to-shift report with Staff G, CNA and neither staff member verified where Resident #1 was at the time of the shift change. Staff G, CNA assisted another CNA with resident care at the beginning of the shift and noticed Resident #1 was not in his room when she brought his dinner tray to the room. Staff G, CNA stated she reported to Staff A, LPN UM Resident #1 was missing from the unit and a code silver was initiated. Staff G, CNA also stated she assisted in searching the facility for Resident #1 for about 15 to 20 minutes before returning to the unit to provide care for the other residents, but Resident #1 was not found. Staff G, CNA left the facility around 11:00 PM and returned on 1/1/2024 around 3:00 PM. Staff G, CNA stated Resident #1 returned to the facility 1/1/2024 and she provided a dinner tray for the resident upon his return. A review of a law enforcement report dated 12/31/2023 at 10:48 PM revealed Resident #1 eloped from the facility at approximately 2:00 PM and local law enforcement dispatched several units in the community to locate Resident #1. Local law enforcement spoke with Resident #1's representative, who told law enforcement Resident #1 recently suffered a seizure due to not taking his seizure medications and staff feared for the resident's safety. The local law enforcement report dated 12/31/2023 at 10:34 PM also revealed an interview with the NHA, who stated Resident #1 walked out of the facility at approximately 2:00 PM due to staff assuming the resident was a visitor at the facility. Local law enforcement obtained a description of Resident #1 and were told by the NHA Resident #1 had confusion and was unable to care for himself. A Local law enforcement interview with Resident #1's representative (RR) on 12/31/2023 at 10:43 PM revealed the following: - [Local law enforcement] spoke to the [RR] via phone The [RR] stated she is the [RR] of the missing party [Resident #1] and that he suffered a stroke [approximately] 5 [years] ago. [Resident #1] recently suffered a severe seizure which resulted in brain injury and was recently transferred from the hospital to the [facility] on Friday. [RR] stated that [Resident #1] cannot speak and his English [is] garbled and that he is easily confused and cannot take care of himself. [RR] stated that it is likely that [Resident #1] has no former knowledge of the area and would not attempt to go back to local address or friends' home (as he cannot recall them). [RR] stated that [Resident #1] can move with a crowd of people if they were crossing a cross walk but would have difficulty on his own. [RR] stated [Resident #1] has no money and no cellphone and no means of contacting family or friends. [RR] is concerned for [Resident #1's] safety. [RR] stated that the [Resident #1] suffered from the earlier seizure due to his not taking his meds and fears that without said medication he could have further incidents. A local law enforcement report dated 1/1/2024 at 7:22 PM revealed local law enforcement responded to an apartment complex at approximately 6:40 PM after a member of the community reported possibly seeing the resident through the window of an abandoned apartment. The report also revealed Resident #1 was standing near a stairway outside and identified himself to local law enforcement. Resident #1 was incoherent and was not able to answer any questions, but appeared in good physical condition and did not require medical attention. Resident #1 was returned to the facility by local law enforcement. A review of Resident #1's psychiatry evaluation dated 1/5/2024 revealed Resident #1 was alert and oriented only to self and was not able to answer questions appropriately. The evaluation also revealed Resident #1 was independently mobile, had disjointed thought process, and had poor short- and long-term memory. An interview was conducted on 1/8/2024 at 3:00 PM with the facility's NHA and DON. The NHA stated on 12/31/2023, Resident #1 eloped from the facility. During the investigation into Resident #1's elopement, the facility developed the following timeline of events through staff interviews: - On 12/31/2023 around 2:00 PM, Staff F, Certified Nursing Assistant (CNA) and Staff B, RN observed Resident #1 standing next to his room door, which was located across the hallway from the unit elevator, wearing a jacket, hat, and shoes. - On 12/31/2023 around 2:30 PM, Staff F, CNA and Staff B, RN observed Resident #1 getting onto the unit elevator and both staff assumed Resident #1 was going to the downstairs dining room to participate in an activity. - On 12/31/2023 at 3:00 PM, Staff G, CNA arrived to the unit for the 3:00 PM to 11:00 PM shift and did shift-to shift rounding with Staff F, CNA. Staff F, CNA informed Staff G, CNA Resident #1 was downstairs participating in an activity. Neither staff member verified Resident #1 was downstairs in the activity at the time of the shift-to-shift report. - On 12/31/2023 around 5:30 PM, food trays arrived for the dinner meal and Staff G, CNA dropped off a dinner tray to Resident #1's room. Resident #1 was not in the room, and it was assumed by staff he was downstairs participating in an activity in the downstairs dining room. - On 12/31/2023 around 6:00 PM, Staff A, LPN UM observed Resident #1's dinner tray was untouched, and Resident #1 did not return to his room for the dinner meal. Staff A, LPN UM went downstairs to the dining area to check if Resident #1 was participating in the activity. Staff A, LPN UM was not able to find Resident #1 in the first-floor dining room or on the first floor of the facility. Staff A, LPN UM initiated the facility's code silver protocol and facility staff began searching other floors in the facility for Resident #1 as well as outside of the facility. Staff A, LPN UM notified the DON, NHA, PCP, and resident representative of Resident #1's elopement. The facility staff conducted a 100% head count of every other resident in the facility and all other residents were accounted for at the time. - On 12/31/2023 around 7:40 PM, Staff A, LPN UM notified local law enforcement of Resident #1's elopement from the facility and contacted nearby hospitals to attempt to locate Resident #1. Resident #1 was not found. - On 12/31/2023 around 8:40 PM, The NHA drove to Resident #1's previous residence to see if Resident #1 was there and spoke to Resident #1's family member around 9:00 PM. Resident #1 was not at his previous address. - On 12/31/2023 around 10:00 PM, local law enforcement arrived at the facility and gathered information from the facility about Resident #1 to assist in finding the resident. Local law enforcement advised the facility a search in the local community would be conducted to find Resident #1. - On 1/1/2024 around 8:16 AM, Staff A, LPN UM contacted local hospitals in an attempt to locate Resident #1. Several facility staff conducted searches throughout the community in an attempt to locate Resident #1. Resident #1 was not located at any surrounding hospital and was not found in the community. - On 1/1/2024 at 6:28 PM, the NHA was notified by facility staff a member of the community may have located Resident #1 at a nearby apartment complex approximately 0.2 miles from the facility in a vacant apartment. Local law enforcement was notified, and facility staff went to the apartment complex. Resident #1 was discovered inside of the vacant apartment and was brought back to the facility around 7:00 PM. The NHA stated following Resident #1's return to the facility, a skin assessment was performed, and Resident #1 had no injuries from the elopement. Nursing staff also applied an electronic elopement device to Resident #1's right ankle following the elopement, in preparation for the installation of the system the next day. During the facility's investigation, interviews were conducted with Staff C, Receptionist and Staff D, AC, who stated they observed a group of four or so people exiting the facility on 12/31/2023 around 1:30 PM to 2:00 PM and they thought Resident #1 may have been in the group of people without staff knowledge at the time. The facility conducted a root cause analysis of the elopement and determined Resident #1 left with the group of visitors without staff knowledge due to not being recognized as a resident of the facility, facility staff not conducting proper shift-to-shift rounding to verify Resident #1's whereabouts at shift change, staff failing to recognize signs of elopement as evidence by Resident #1 getting on the facility elevator with his hat and jacket on, and Resident #1's elopement assessment not being properly completed upon his admission to the facility on [DATE]. The NHA said on 1/1/2024, a third-party vendor was contacted to install an elopement management system for the facility's front door and the unit was installed on 1/2/2024. The elopement management system works with the resident's electronic elopement device to prevent elopement by locking the door as the resident approaches it and sounding an audible alarm. The DON stated the facility now has a staff member in place on the first floor on a 24 hour basis by the facility elevator to ensure no residents at risk for elopement attempt to leave the facility. The DON also stated all facility staff had in-service education related to elopement and the elopement policy, abuse, neglect, and exploitation, the leave of absence (LOA) policy, and identification of wandering/elopement behaviors, which was completed on 1/4/2024. The DON also stated all nursing staff have been educated on the admission assessment process in order to properly identify elopement risks upon admission to the facility. The DON stated CNA staff have been educated on shift-to-shift reports and ensuring residents are[TRUNCATED]

Based on observations, interviews with the nursing staff, Nursing Home Administrator, the Director of Nursing, the resident's primary care physician, and review of the resident's medical record and facility policies, the facility failed to ensure one resident (#1) of 10 residents at risk for elopement, was provided with supervision and services related to the resident's cognitive deficits and history of dementia, epilepsy, and confusion before admission to the facility. The facility staff failed to ensure the safety of Resident #1; on 12/31/2023 at approximately 2:30 PM, Resident #1 ambulated from the second floor of the facility, entered the facility elevator, and rode the elevator down to the first floor of the facility. Resident #1 exited the facility through the front door, which was equipped with an electromagnetic locking device (a magnetic lock that is unlocked when de-energized and requires power to remain locked) and was opened by reception staff who thought Resident #1 was a visitor at the facility. Resident #1 was able to walk out the front door of the facility, travel approximately 0.2 miles along a 4-lane road and was found more than 24 hours later at a nearby apartment complex in a vacant apartment by a member of the community. Resident #1 was discovered by a member of the community on 1/1/2024 at approximately 7:00 PM in a vacant apartment and was returned by facility staff at approximately 7:30 PM. The facility failed to take action to prevent the resident from exiting the facility by not determining and providing the necessary level of supervision, and not distinguishing the resident from visitors of the facility. The resident was not located for approximately 28 hours and 30 minutes. The failure created a situation that resulted in a likelihood for serious injury and/or death to Resident #1 and resulted in the determination of Immediate Jeopardy on 12/31/2023. The findings of Immediate Jeopardy were determined to be removed on 1/12/2024 and the severity and scope was reduced to a D. Findings included: A review of Resident #1's Change in Condition Situation, Background, Assessment, and Recommendation (SBAR) Communication and Progress Note dated 12/31/2023 at 7:41 PM and authored by Staff A, Licensed Practical Nurse (LPN) and Unit Manager (UM), revealed under the section titled Situation Resident #1 could not be located in the facility. The note also revealed under the section titled Appearance Staff A, LPN UM looked for Resident #1 on the first floor of the facility after the resident did not return to the unit for the dinner meal. Staff A, LPN UM was not able to locate Resident #1 and the facility's elopement protocol was initiated. Resident #1's primary care physician (PCP) was also notified of Resident #1's elopement at 9:00 PM and a recommendation was made to call 911. A review of the facility policy titled Missing Patient/Resident, last revised on 8/1/2020, revealed under the section titled Overview, staff will investigate cases of missing patient/resident and possible elopement. An elopement occurs when a patient/resident leaves the premises or a safe area without authorization and/or any necessary supervision to do so, placing the patient/resident at risk for harm or injury. The policy also revealed the following facility procedure under the section titled Procedure: - Check the Leave of Absence (LOA) book and medical record to ensure the patient/resident is not on an authorized leave or medical appointment. - Announce (resident name) please return to your room, over the public announcement (PA) system. Repeat three times to alert staff of a missing patient/resident. - Assign staff to search the Center and grounds. - If the patient/resident is not located after an initial search, the point person will notify the Nursing Home Administrator (NHA), the Director of Nursing (DON), the resident representative, and the Primary Care Physician (PCP). The NHA and/or DON or designee will notify local law enforcement. A review of Resident #1's hospital history and physical (H&P), dated 12/13/2023 revealed Resident #1 arrived at the emergency department with a critically high blood pressure of 233/151, a heart rate of 101, and was unresponsive with active convulsions. Resident #1 was determined to be in critical condition with a risk of worsening seizures, stroke, or death. A review of Resident #1's preadmission Medical Certification for Medicaid Long Term Care Services and Patient Transfer Form, with a Physician Certification date of 12/29/2023 revealed under Section C: Decision Making Capacity (Patient) Resident #1 required a surrogate for medical decision making. The transfer form also revealed under Section S: Physical Function, Resident #1 ambulated with standby assistance and required no assistive devices to ambulate. The transfer form revealed under Section U: Mental/Cognitive Status at Transfer, Resident #1 was alert and disoriented but could follow simple instructions. A review of Resident #1's medical record revealed Resident #1 was admitted to the facility on [DATE] with diagnoses of epilepsy, unspecified, intractable, with status epilepticus, difficulty walking, essential hypertension, other symptoms and signs involving cognitive functions and awareness, diabetes mellitus, occlusion and stenosis of the right carotid artery, non-ST elevation (NSTEMI) myocardial infarction, dementia in other diseases classified elsewhere, severe, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, and history of falling. A review of Resident #1's Admission/Readmission Data Collection assessment dated [DATE] and completed by Staff B, Registered Nurse (RN) revealed under Section B: Cognition, Resident #1 was alert and oriented to person, place, and time. The assessment also revealed under Section N2: Elopement Risk Evaluation, Resident #1 was not cognitively impaired, was not independently mobile (either ambulatory or in a wheelchair), did not have poor decision-making skills, did not have the ability to exit the facility, and was not at risk for elopement. A review of the facility policy titled Admission Assessment, last revised on 8/22/2017 revealed at the time of admission or readmission, the nurse shall initiate the Admission Data Collection Form or its electronic equivalent. Pertinent information shall be collected by physical review, interview with resident and family, and review of the resident's available medical records. A review of Resident #1's physician's orders revealed the following: - An order dated 1/1/2024 for an electronic elopement device to the right lower extremity. - An order dated 1/1/2024 to verify placement of the electronic elopement device to the resident's right lower extremity every shift. - An order dated 1/1/2024 to verify functioning of the electronic elopement device to the resident's right ankle every shift for safety. - An order dated 12/30/2023 for Lacosamide 100 milligrams (mg) by mouth in the morning and at bedtime for a diagnosis of seizures. - An order dated 12/30/2023 for Levetiracetam 1000 mg by mouth in the morning and at bedtime for a diagnosis of seizures. - An order dated 12/30/2023 for Lisinopril 5 mg by mouth once daily for a diagnosis of hypertension. - An order dated 12/30/2023 for Hydralazine Hydrochloride (HCl) 25 mg by mouth once daily for a diagnosis of hypertension. - An order dated 12/30/2023 for Amlodipine Besylate 10 mg by mouth once daily for a diagnosis of hypertension. A review of Resident #1's care plan revealed a problem, dated 1/1/2024, that Resident #1 was a risk for elopement/wanderer related to a history of attempts to leave the facility unattended and impaired safety awareness. Interventions included to distract the resident from wandering by offering pleasant diversion, structured activities, food, conversation, television, or a book, applying an electronic elopement device to the resident's right lower extremity, monitor the resident's location frequently, and identify patterns of wandering. A review of Resident #1's Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 1/2/2024 revealed under Section C - Cognitive Patterns, a Brief Interview for Mental Status (BIMS) score of 3, which indicated severely impaired cognition. The assessment also revealed under Section E - Behavior, Resident #1 displayed behaviors of wandering 1 to 3 days of the assessment period, which placed Resident #1 at significant risk of getting to a potentially dangerous place. According to the National Institutes of Health, wandering behavior is one of the most important and challenging management aspects in persons with dementia. Wandering behavior in people with dementia (PwD) is associated with an increased risk of falls, injuries, and fractures, as well as going missing or being lost from a facility. This causes increased distress in caregivers at home and in healthcare facilities. The approach to the comprehensive evaluation of the risk assessment, prevention, and treatment needs more strengthening and effective measures as the prevalence of wandering remains high in the community. Both the caregiver and clinicians need a clear understanding and responsibility of ethical and legal issues while managing and restraining the PwD. The consequences of the wandering can vary from minor injury on the body to severe injury and death. The persistent wandering behavior and weak gait and balance have been shown to increase the risk of falls, fractures, and accidents in PwD. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8543604/#:~:text=Outcome%20of%20Wandering%20in%20Dementia,to%20severe%20injury%20and%20death.&text=The%20persistent%20wandering%20behavior%20and,fractures%2C%20and%20accidents%20in%20PwD. An interview was conducted on 1/9/2024 at 12:59 PM with Staff A, LPN UM, who was Resident #1's assigned nurse on 12/31/2023 for the 3:00 PM to 11:00 PM shift. Staff A, LPN UM stated she was called into work the 3:00 PM to 11:00 PM shift on 12/31/2023 due to a call off and arrived at the facility around 4:00 PM. Staff A, LPN UM usually worked as the Unit Manager on Resident #1's floor but she was not familiar with Resident #1 because she was off at the time Resident #1 was admitted to the facility. When she arrived to the unit, Staff A, LPN UM did a shift-to-shift report with Staff B, RN, who told her Resident #1 was participating in an activity in the downstairs dining room. Neither staff member verified Resident #1 was at the activity at the time of the report. Staff A, LPN UM stated around 6:00 PM, she noticed Resident #1 did not return to the unit for dinner and his dinner tray in his room was untouched. Staff A, LPN UM went downstairs to the dining room to check on Resident #1 and he was not at the activity. Staff A, LPN UM stated she also checked the smoking porch off of the downstairs dining room and Resident #1 was not found. Staff A, LPN asked Staff C, Receptionist if she had seen Resident #1 because she did not know what the resident looked like and Staff C, Receptionist responded no. Staff A, LPN UM also checked with the other floor staff in the facility but was not able to locate Resident #1 on any floor. Staff A, LPN UM stated around 7:00 PM, she went to the reception desk and called the DON and told her Resident #1 could not be located in the building. During her telephone conversation with the DON Staff A, LPN UM heard Staff C, Receptionist tell her she saw a group of people leaving the facility earlier in the day and was not able to state a time, but she was not certain Resident #1 was part of the group because she did not know what the resident looked like. Staff A, LPN UM stated after speaking with the DON, she initiated a code silver and notified Resident #1's representative. Staff A, LPN UM also stated the DON called her around 7:30 PM and told her to call 911. Staff A, LPN UM was connected to local law enforcement and informed them Resident #1 was missing from the facility. Staff A, LPN UM stated she went outside and searched the surrounding area for the resident, but no other staff members assisted her with the search on the outside perimeter of the facility. Staff A, LPN UM also stated local law enforcement arrived at the building around 10:00 PM and she provided Resident #1's information to them. After speaking with local law enforcement, Staff A, LPN UM completed some paperwork and documentation and left the faciity on [DATE] around 12:15 AM. Staff A, LPN UM arrived back at the facility on 1/1/2024 around 7:30 AM and assisted with staff in-services for the 7:00 AM to 3:00 PM staff, related to Resident #1's elopement. Around 2:00 PM, Staff A, LPN UM went to a local gas station Resident #1 frequently visited prior to his admission to the facility and spoke with members of the community in an attempt to locate Resident #1, but the resident was not found at that time. Staff A, LPN UM stated she received a phone call from the NHA around 6:00 PM on 1/1/2024, stating Resident #1 was found and was being returned to the facility. An interview was conducted on 1/9/2024 at 1:38 PM with Staff B, RN, who was Resident #1's assigned nurse on 12/31/2023 for the 7:00 AM to 3:00 PM shift. Staff B, RN stated she was familiar with Resident #1, and she was his nurse when he arrived at the facility on 12/29/2023. Staff B, RN also stated she completed Resident #1's admission assessment on 12/29/2023 and the resident was alert, but a little bit confused. Staff B, RN stated Resident #1 was able to appropriately answer questions, had knowledge of his surroundings, able to state where he was, and was able to state his name. Staff B, RN also stated at the time of his admission assessment, Resident #1 did not seem cognitively impaired and did not have any diagnoses to indicate cognitive impairment. Staff B, RN addressed Resident #1 did have a diagnoses of dementia and was independently mobile but was not able to state why Resident #1's admission assessment revealed the resident was cognitively intact, was not independently mobile, and did not have the ability to leave the facility. Staff B, LPN UM stated she observed Resident #1 on 12/31/2023 around 2:45 PM go onto the facility elevator wearing a jacket and Resident #1 stated to her he was going downstairs to participate in an activity. Staff B, LPN UM also stated around 3:00 PM, she did a shift-to-shift report with Staff A, LPN UM and told her Resident #1 was downstairs participating in an activity, but neither staff member verified Resident #1 was downstairs. After giving the shift-to-shift report, Staff B, RN left the facility. Staff B, RN stated she returned to the facility on [DATE] and was told by Staff A, LPN UM Resident #1 was missing from the facility. Staff B, RN also stated Resident #1 was returned to the facility by local law enforcement on 1/1/2024 around 7:00 PM. Staff B, RN completed a skin assessment for Resident #1 and the resident had no injuries. Staff B, RN stated Resident #1 appeared more confused upon his arrival and was wearing different clothing than the previous day. An interview was conducted on 1/9/2024 at 11:06 AM with Resident #1 in the resident's room. Resident #1 was observed sitting on the side of the bed in his room and was able to get up from the bed and walk to the door without difficulty and without the use of assistive devices. Resident #1 spoke clearly during the interview but was not able to appropriately answer questions. Resident #1 was not able to state where he was, what day it was, or why he was at the facility but was able to state his name, which he repeated several times during the interview. Resident #1 was not able to recall his elopement from the facility on 12/31/2023. An interview was conducted on 1/9/2024 at 2:02 PM with Staff F, CNA. Staff F, CNA stated he was familiar with Resident #1 during previous interactions with the resident on 12/30/2023 and stated the resident was in and out when describing the resident's cognition. Staff F, CNA also stated the resident was able to hold a conversation but only some things made sense and Resident #1 was not aware of his surroundings. Staff F, CNA stated he worked on Resident #1's floor on 12/31/2023 during the 7:00 AM to 3:00 PM shift and saw the resident dressed to leave around 2:10 PM, but he did not see Resident #1 get onto the elevator or go downstairs during the shift. Staff F, CNA also stated he did not see the resident again before his shift ended at 3:00 PM because he was not assigned to the resident during the shift. Staff F, CNA stated he did not see Resident #1 until 1/2/2024 during the 7:00 AM to 3:00 PM shift. Staff F, CNA also stated he asked Resident #1 about his elopement from the facility but Resident #1 was not able to respond appropriately. An interview was conducted on 1/9/2024 at 2:23 PM with Staff D, Activity Coordinator (AC). Staff D, AC stated she worked at the facility on 12/31/2023 and she set up a football party activity in the first floor dining area. Staff D, AC also stated she was not familiar with the resident and did not know what the resident looked like prior to his elopement on 12/31/2023. Staff D, AC stated she was assisting residents with a smoke break around 2:15 PM on 12/31/2023 and went to the reception desk to retrieve the smoking supplies when she saw a group of about 3 or 4 people leaving the facility through the front entrance. Staff D, AC was not able to state if Resident #1 was with the group of people exiting the facility because she was not familiar with the resident at the time. Staff D, AC left the facility around 3:15 PM and was told upon her return to the facility on [DATE] Resident #1 was missing from the facility. Staff D, AC stated she assisted several other facility staff members in looking for the resident in the community on 1/1/2024 around 8 or 9 AM, but they were not able to find the resident. A telephone interview was conducted on 1/10/2024 at 10:27 AM with Staff C, Receptionist. Staff C, Receptionist stated she worked at the facility from 8 AM to 8 PM on 12/31/2023 and works mostly weekends. Staff C, Receptionist also stated she was not familiar with Resident #1 prior to the elopement and had never seen the resident before. Staff C, Receptionist stated on 12/31/2023 around 1:30 PM or 2:00 PM, she observed a group of people exiting the facility through the front entrance. Staff C, Receptionist stated she just clicked the buzzer to open the door and let the group out because she assumed it was just a group of visitors leaving the facility and did not think a resident was with them. Staff C, Receptionist stated on 12/31/2023 around 7:00 PM, she noticed Staff A, LPN UM downstairs looking for the resident. Staff C, Receptionist told Staff A, LPN UM she saw a group of people leaving the facility around 1:30 PM or 2:00 PM but she was not sure if the resident was with the group because she did not know what the resident looked like. Staff C, Receptionist stated a code silver was initiated and she assisted Staff A, LPN UM with calling Resident #1's family members in an attempt to notify and locate the resident. Staff C, Receptionist also stated she assisted in searching for Resident #1 outside of the facility for about 10 or 15 minutes but had to leave the facility at 8:00 PM. Staff C, Receptionist returned to the facility at 10:00 PM to assist staff in trying to locate Resident #1 and left the facility around 11:00 PM. Staff C, Receptionist stated she returned to the facility on [DATE] around 8:00 AM and joined several other facility staff for a good hour in trying to find Resident #1 out in the community, but Resident #1 was not found. A telephone interview was attempted on 1/10/2024 at 11:46 AM with Staff E, Certified Nurse Aide (CNA), who was Resident #1's assigned CNA on 12/31/2023 during the 7:00 AM to 3:00 PM shift. Staff E, CNA did not answer the phone call and a message was left for call back by Staff H, Social Services Aide (SSA), who assisted with translation. The phone call was not returned by Staff E, CNA. A telephone interview was conducted on 1/10/2024 at 11:50 AM with Staff G, CNA, who was Resident #1's assigned CNA on 12/31/2023 during the 3:00 PM to 11:00 PM shift. Staff G, CNA stated she was not familiar with Resident #1 and had not seen the resident before his return on 1/1/2024. Staff G, CNA also stated she arrived at the unit on 12/31/2023 around 3:00 PM and conducted shift-to-shift rounds with Staff E, CNA. Staff G, CNA stated she only did a verbal shift-to-shift report with Staff G, CNA and neither staff member verified where Resident #1 was at the time of the shift change. Staff G, CNA assisted another CNA with resident care at the beginning of the shift and noticed Resident #1 was not in his room when she brought his dinner tray to the room. Staff G, CNA stated she reported to Staff A, LPN UM Resident #1 was missing from the unit and a code silver was initiated. Staff G, CNA also stated she assisted in searching the facility for Resident #1 for about 15 to 20 minutes before returning to the unit to provide care for the other residents, but Resident #1 was not found. Staff G, CNA left the facility around 11:00 PM and returned on 1/1/2024 around 3:00 PM. Staff G, CNA stated Resident #1 returned to the facility 1/1/2024 and she provided a dinner tray for the resident upon his return. A telephone interview was conducted on 1/10/2024 at 12:02 PM with Resident #1's PCP. The PCP stated he evaluated Resident #1 on 12/30/2023 and the resident appeared stable but was confused, disoriented to time, and did not give appropriate responses to questions. Resident #1 had a history of stroke and new onset seizures. The PCP stated he was notified of Resident #1's elopement from the facility on 12/31/2023 and of the resident's return on 1/1/2024. The PCP ordered lab work for Resident #1 upon his return to the facility and no abnormalities were found. The PCP stated Resident #1 was in danger during his elopement from the facility because he does not know what's fully going on and the resident had a possibility of increased seizure risk without his seizure medications. A review of a law enforcement report dated 12/31/2023 at 10:48 PM revealed Resident #1 eloped from the facility at approximately 2:00 PM and local law enforcement dispatched several units in the community to locate Resident #1. Local law enforcement spoke with Resident #1's representative, who told law enforcement Resident #1 recently suffered a seizure due to not taking his seizure medications and staff feared for the resident's safety. The local law enforcement report dated 12/31/2023 at 10:34 PM also revealed an interview with the NHA, who stated Resident #1 walked out of the facility at approximately 2:00 PM due to staff assuming the resident was a visitor at the facility. Local law enforcement obtained a description of Resident #1 and were told by the NHA Resident #1 had confusion and was unable to care for himself. A Local law enforcement interview with Resident #1's representative (RR) on 12/31/2023 at 10:43 PM revealed the following: - [Local law enforcement] spoke to the [RR] via phone The [RR] stated she is the [RR] of the missing party [Resident #1] and that he suffered a stroke [approximately] 5 [years] ago. [Resident #1] recently suffered a severe seizure which resulted in brain injury and was recently transferred from the hospital to the [facility] on Friday. [RR] stated that [Resident #1] cannot speak and his English [is] garbled and that he is easily confused and cannot take care of himself. [RR] stated that it is likely that [Resident #1] has no former knowledge of the area and would not attempt to go back to local address or friends' home (as he cannot recall them). [RR] stated that [Resident #1] can move with a crowd of people if they were crossing a cross walk but would have difficulty on his own. [RR] stated [Resident #1] has no money and no cellphone and no means of contacting family or friends. [RR] is concerned for [Resident #1's] safety. [RR] stated that the [Resident #1] suffered from the earlier seizure due to his not taking his meds and fears that without said medication he could have further incidents. A local law enforcement report dated 1/1/2024 at 7:22 PM revealed local law enforcement responded to an apartment complex at approximately 6:40 PM after a member of the community reported possibly seeing the resident through the window of an abandoned apartment. The report also revealed Resident #1 was standing near a stairway outside and identified himself to local law enforcement. Resident #1 was incoherent and was not able to answer any questions, but appeared in good physical condition and did not require medical attention. Resident #1 was returned to the facility by local law enforcement. A review of Resident #1's psychiatry evaluation dated 1/5/2024 revealed Resident #1 was alert and oriented only to self and was not able to answer questions appropriately. The evaluation also revealed Resident #1 was independently mobile, had disjointed thought process, and had poor short- and long-term memory. An interview was conducted on 1/8/2024 at 3:00 PM with the facility's NHA and DON. The NHA stated on 12/31/2023, Resident #1 eloped from the facility. During the investigation into Resident #1's elopement, the facility developed the following timeline of events through staff interviews: - On 12/31/2023 around 2:00 PM, Staff F, Certified Nursing Assistant (CNA) and Staff B, RN observed Resident #1 standing next to his room door, which was located across the hallway from the unit elevator, wearing a jacket, hat, and shoes. - On 12/31/2023 around 2:30 PM, Staff F, CNA and Staff B, RN observed Resident #1 getting onto the unit elevator and both staff assumed Resident #1 was going to the downstairs dining room to participate in an activity. - On 12/31/2023 at 3:00 PM, Staff G, CNA arrived to the unit for the 3:00 PM to 11:00 PM shift and did shift-to shift rounding with Staff F, CNA. Staff F, CNA informed Staff G, CNA Resident #1 was downstairs participating in an activity. Neither staff member verified Resident #1 was downstairs in the activity at the time of the shift-to-shift report. - On 12/31/2023 around 5:30 PM, food trays arrived for the dinner meal and Staff G, CNA dropped off a dinner tray to Resident #1's room. Resident #1 was not in the room, and it was assumed by staff he was downstairs participating in an activity in the downstairs dining room. - On 12/31/2023 around 6:00 PM, Staff A, LPN UM observed Resident #1's dinner tray was untouched, and Resident #1 did not return to his room for the dinner meal. Staff A, LPN UM went downstairs to the dining area to check if Resident #1 was participating in the activity. Staff A, LPN UM was not able to find Resident #1 in the first-floor dining room or on the first floor of the facility. Staff A, LPN UM initiated the facility's code silver protocol and facility staff began searching other floors in the facility for Resident #1 as well as outside of the facility. Staff A, LPN UM notified the DON, NHA, PCP, and resident representative of Resident #1's elopement. The facility staff conducted a 100% head count of every other resident in the facility and all other residents were accounted for at the time. - On 12/31/2023 around 7:40 PM, Staff A, LPN UM notified local law enforcement of Resident #1's elopement from the facility and contacted nearby hospitals to attempt to locate Resident #1. Resident #1 was not found. - On 12/31/2023 around 8:40 PM, The NHA drove to Resident #1's previous residence to see if Resident #1 was there and spoke to Resident #1's family member around 9:00 PM. Resident #1 was not at his previous address. - On 12/31/2023 around 10:00 PM, local law enforcement arrived at the facility and gathered information from the facility about Resident #1 to assist in finding the resident. Local law enforcement advised the facility a search in the local community would be conducted to find Resident #1. - On 1/1/2024 around 8:16 AM, Staff A, LPN UM contacted local hospitals in an attempt to locate Resident #1. Several facility staff conducted searches throughout the community in an attempt to locate Resident #1. Resident #1 was not located at any surrounding hospital and was not found in the community. - On 1/1/2024 at 6:28 PM, the NHA was notified by facility staff a member of the community may have located Resident #1 at a nearby apartment complex approximately 0.2 miles from the facility in a vacant apartment. Local law enforcement was notified, and facility staff went to the apartment complex. Resident #1 was discovered inside of the vacant apartment and was brought back to the facility around 7:00 PM. The NHA stated following Resident #1's return to the facility, a skin assessment was performed, and Resident #1 had no injuries from the elopement. Nursing staff also applied an electronic elopement device to Resident #1's right ankle following the elopement, in preparation for the installation of the system the next day. During the facility's investigation, interviews were conducted with Staff C, Receptionist and Staff D, AC, who stated they observed a group of four or so people exiting the facility on 12/31/2023 around 1:30 PM to 2:00 PM and they thought Resident #1 may have been in the group of people without staff knowledge at the time. The facility conducted a root cause analysis of the elopement and determined Resident #1 left with the group of visitors without staff knowledge due to not being recognized as a resident of the facility, facility staff not conducting proper shift-to-shift rounding to verify Resident #1's whereabouts at shift change, staff failing to recognize signs of elopement as evidence by Resident #1 getting on the facility elevator with his hat and jacket on, and Resident #1's elopement assessment not being properly completed upon his admission to the facility on [DATE]. The NHA said on 1/1/2024, a third-party vendor was contacted to install an elopement management system for the facility's front door and the unit was installed on 1/2/2024. The elopement management system works with the resident's electronic elopement device to prevent elopement by locking the door as the resident approaches it and sounding an audible alarm. The DON stated the facility now has a staff member in place on the first floor on a 24 hour basis by the facility elevator to ensure no residents at risk for elopement attempt to leave the facility. The DON also stated all facility staff had in-service education related to elopement and the elopement policy, abuse, neglect, and exploitation, the leave of absence (LOA) policy, and identification of wandering/elopement behaviors, which was completed on 1/4/2024. The DON also stated all nursing staff have been educated on the admission assessment process in order to properly identify elopement risks upon admission to the facility. The DON stated CNA staff have been educated on shift-to-shift reports and ensuring residents are physically accounted for at the beginning of each shift. Facility's immediate actions to remove the Immediate Jeopardy included: - On 1/1/2024, Resident #1 was returned to the facility and a body audit was completed with no findings. The PCP was notified and ordered lab work for Resident #1. No new orders after lab results reviewed by the PCP. - On 1/1/2024, an updated elopement risk evaluation was completed for Resident #1 by the DON. - On 1/1/2024, an electronic elopement device was placed on Resident #1. - On 1/5/2024, Resident #1 was seen by psychiatric services and was showing no signs of depression. - On 1/2/2024, the facility conducted a 100% audit of all residents with completion of the elopement risk evaluations. Residents identified at risk for elopement had an electronic elopement device placed. - On 1/2/2024, a staff member was placed at the elevator on the first floor to ensure any resident identified as an elopement risk does not exit through the door for 24 hours a day until all secure care systems/elopement management systems are installed and fully functioning. - On 1/2/2024, a third party vendor installed an elopement management system to the front door and ordered additional electronic elopemen[TRUNCATED]

Based on record review and interviews, the facility failed to ensure that it permitted a resident to return after a transfer to the hospital for one (Resident #328) of three residents reviewed for discharge rights. Findings included: A review of the Admission Record for Resident #328 revealed he was originally admitted into the facility in 2003 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Continued review of the Admission Record revealed the resident was discharged to an acute care hospital on 11/03/21, and his payer source was Medicaid. A Progress Note dated 11/03/21 at 10:52 a.m. revealed the resident was in a vegetative stage with [CONDITION(S)] under treatment. Resident noted with sweating and labored breathing. Resident #328 was sent out to the hospital per the medical doctor. Review of the Nursing Home Transfer and Discharge Notice with an effective date of 11/03/21 revealed Resident #328 was transferred to a local acute care hospital because his needs could not be met. The resident was noted sweating, labored breathing, in a vegetative stage with [CONDITION(S)] under treatment. A copy of the form was requested but not provided. On 04/01/22 at 2:12 p.m., the Risk Manager (RM) reported Resident #328 was a very difficult patient. He had a [CONDITION(S)] ([CONDITION(S)]), oxygen, needed to be suctioned, had a catheter, an ostomy, a tube feeding, and had stage 4 wounds on his bottom. The RM stated the wounds were a two-hour process for dressing changes. She stated they had a lot of issues with Resident #328's family. His mother had attempted to do wound care, knocked his [CONDITION(S)] out, was messing with the tube feeding machine and air mattress, and tried to reposition the resident. The RM stated there was a discussion with the Interdisciplinary Team (IDT) about Resident #328 not coming back after he was discharged to the hospital on 11/03/21. The IDT team was questioning if they could meet his needs related to his respiratory issues because they only had someone coming to do respiratory care in the facility once per month and he needed daily respiratory care because he had a lot of [MEDICATION(S)]. The RM reported Resident #328 was in a vegetative state. He had been in an accident fifteen years ago and had been a resident in the facility for fifteen years. The RM stated, It was not they we didn't want him back, but we could not meet his need. He needed a higher level of care stated the RM. The RM confirmed that no discharge notice was issued to the resident after he was transferred to the hospital. On 04/01/22 at 2:56 p.m., the RM stated she did not know the date the hospital attempted to bring Resident #328 back to the facility, but admissions would know. The RM reported the decision to not accept the resident back was a discussion with the IDT Team, but the Regional Team had the final say. The Regional Team agreed they could not readmit Resident #328 stated the RM. Due to the [CONDITION(S)], he was on high flow oxygen and that was something that they did not do in the facility. The RM reported the decision to discharge the resident had been discussed roughly four months prior to the discharge to the hospital. Resident #328 needed to be suctioned hourly and the facility did not have daily respiratory care. Respiratory was outsourced and only came to the facility on ce a week. The RM reported she did not know if the IDT team tried to find another place for Resident #328 to go. He needed a lot of care, and it took a lot of time to take care of him stated the RM. Taking care of him took away from the other residents stated the RM. On 04/01/22 at 4:27 p.m., the RM reported there had been conversations for months about Resident #328 declining. On 04/01/22 at 03:13 p.m., the Admissions Director reported the hospital attempted to bring Resident #328 back. She stated she was told he could not be readmitted . The Admissions Director reported the Director of Nursing (DON) said she didn't want to bring him back because he required too much time and that took away from the other patients. The Admission Director stated she reported to the family the DON did not want to readmit the resident and told them to reach out to higher management. The Admission Director reported the family was upset because Resident #328 had been a resident in the facility for [AGE] years. She reported the family came to the facility about a month later to get his belongings and reported he was still in the hospital because they could not find placement for him. The Admission Director reported she was only following the orders from upper management. On 04/01/22 at 4:04 p.m., the DON reported she would want to make sure that they could provide him with the correct level of care. If they could, they would accept him back. If not, he would need to go to an alternate level of care. A review of the Progress Notes dated 08/22/21 to 11/03/21 did not reflect any documentation related to planning a discharge for Resident #328. Additionally, the medical record did not contain any documentation to indicate that the resident's needs had been assessed post discharge to determine that the facility could no longer meet his needs. A care plan initiated 08/24/20 revealed the following: -Focus: Resident #328 wishes to stay at this facility under long term care. -Goal: Resident #328 will be here for long term care. A review of Resident #328's hospital discharge summary for the 11/3/21 admission revealed the initial discharge summary was done on 11/7/21 but patient remained in the hospital until 11/22/21 as the facility where he had spent an extended number of years decided he was not appropriate to return back. An exhaustive search of possible placements of facilities was done and eventually a facility was obtained in the Bradenton area [this new facility was approximately 50 miles away from the facility he had resided in for well over [AGE] years]. A review of the hospital case management notes revealed the following: · 11/4/21 at 3:02 p.m. - Patient admitted with respiratory distress, increased drainage from sacral wound. History [CONDITION(S)] brain injury, [CONDITION(S)], supra pubic cath, [CONDITION(S)], peg. Patient is a long term care (LTC) resident at [NAME] Health Care with recent multiple admissions. Accepted back to [NAME]. Long term acute care (LTAC) referrals also sent due to complex care required. [NAME] does not like to accept patient back on the weekend. Anticipated date of discharge 11/8/21. · 11/7/21 at 10:47 a.m. - Phone call placed to [NAME] Health Care to find out if patient can return today to the facility due to discharge (d/c) orders, voice message left awaiting call back. · 11/7/21 at 11:10 a.m. - Spoke to representative with [NAME] Health Care, states patient is not able to return today due to staffing. Patient will be d/c tomorrow morning. · 11/8/21 at 10:11 a.m. - Spoke to representative with [NAME] Health Care. Patient is able to return pending COVID results. Anticipate d/c today. · 11/8/21 1:23 p.m. - Spoke to DON for [NAME] Health Care who states per their Medical Director and Regional Leadership, it was decided that patient is too medically unstable for skilled nursing facility (SNF) at this time. They are requesting patient transition to LTACH (long term acute care hospital). Explained patient is on humidified [CONDITION(S)] collar at FiO2 28% which is an improvement from patient's baseline at the SNF, however DON states this is a directive from her Medical Director and Regional Leadership, decision stands that patient is unable to return to [NAME] SNF at this time. Updated referrals to SNF and LTACH. · 11/8/21 at 3:14 p.m. - Call to DON. DON states that patient may be able to return after LTACH, once patient respiratory status improved. Inquired about how long they will hold patient's bed. DON states SNF is no longer able to hold beds for patients. · 11/9/21 at 8:25 a.m. - Awaiting response back from a representative from a LTACH regarding (re:) possible acceptance. Left VM for DON at [NAME] Health Care. Spoke to patient's mother and updated on current d/c status. Mother is agreeable for patient to d/c to another location, however, does not want to travel far, as she is physically unable to travel longer distances. The writer explained the limited options at this time. Mother verbalized [NAME] Health Care has been speaking to her almost every day about patient's code status and she Will not make him a DNR [do not resuscitate]. · 11/9/21 at 12:42 p.m. - Received call from LTACH representative. They have denied due to not enough medical necessity for LTACH. Extended long term SNF referrals to Pinellas and Hillsborough counties. · 11/10/21 at 1:27 p.m. - Social Worker (SW) emailed management to see if they feel it would help for them to call the upper management at [NAME] who is declining to see about accepting the patient back. It may help to see what level they would like the patient to be at prior to accepting him back. Especially, since the LTACH is saying that he doesn't have enough medical necessity to accept. SW called additional SNFs in an effort to secure placement for the patient. · 11/15/21 at 8:00 a.m. - Extended long term SNF referrals within 50 mile radius. · 11/15/21 at 4:00 p.m. - Re-opened referral to [NAME] Health Care and left voicemail for DON to see if they will re-consider accepting patient back. · 11/17/21 at 12:58 p.m. - Family meeting with patient's mother. Discussed extensive long term SNF search to multiple counties with a facility in Bradenton who has agreed to accept the patient. The mother verbalized a concern with facility location and fear of diving on the Skyway Bridge. This writer explained that every SNF in Hillsborough and surrounding counties was referred and this is the only accepting facility at this time. Discharge plan to SNF in Bradenton once family tours tomorrow. · 11/19/21 at 8:30 a.m. - Call to Patient's mother. Mother concerned for the distance to the SNF in Bradenton. Discussed patient has had a discharge date of [DATE] and no longer has medical necessity to remain at the acute care level. Mother verbalized concerns with patient transferring to a facility far away. Awaiting patient's mother's arrival to hospital to discuss transfer and provide Notice of Financial Responsibility. · 11/19/21 at 1:36 p.m. - Face to face meeting with patient's mother. Mother is requesting additional time to personally search for a closer facility. Explained that referrals have been sent to every SNF in multiple counties and all have denied with exception of the SNF in Bradenton. Received call from SNF in Bradenton who states they must have a 10 liter oxygen concentrator in patient's room for safety and they will not be able to obtain one until sometime this weekend. Discharge plan to SNF in Bradenton on Monday, 11/22/21. · 11/19/21 at 2:54 p.m. - Spoke with DON at [NAME] Health Care. DON states they will not accept patient back. Discussed patient was at baseline, actually improved from baseline, however DON states she cannot take patient back due to his medical needs. · 11/22/21 at 2:31 p.m. - Patient to d/c to SNF in Bradenton. Transportation scheduled for 4:30 p.m. Spoke with mother who is agreeable. Review of the facility policy and procedure titled Transfer/Discharge Notification & Right to Appeal with an effective date of 09/23/2017 and a revision date of 3/26/18 revealed the following: Policy: Transfer and discharges of residents, initiated by the center (facility initiated) will be conducted according to Federal and/or State regulatory requirements.

Based on observations, record review, and interviews the facility failed to ensure weight loss was monitored and assessed timely, as evidenced by lack of weekly weights and lack of food consumption documentation, which resulted in a significant weight loss for one (Resident #67) out of seven residents sampled for nutrition. Findings included: On 3/29/22 at 1:02 p.m., Resident #67 was observed sitting in the bed in his room. He was alert and able to answer questions related to his care. He stated he really dislikes the pureed food he is getting and cannot eat it. He stated he has had no upper teeth for a long time, and he can eat regular food just fine. He stated he just wants regular food so he can eat. He stated he has to rely on what he can get to eat from the outside, and it is not enough. A review of the medical record revealed Resident #67 was admitted to the facility on [DATE] with a diagnoses, including [CONDITION(S)] ([CONDITION(S)]), opioid dependence, [CONDITION(S)] (CHF), dysphagia, underweight, and [CONDITION(S)]. A review of the Order Summary Report on 3/30/22 for Resident #67 indicated the following orders were active: -Regular diet dysphagia mechanical soft texture, regular/thin liquids consistency. Add fortified foods (started on 11/11/21). -Med Pass put amount ordered oral in add directions three times a day for supplements 240 milliliters (ml) (started on 11/10/21). -Speech Therapy (ST) evaluate and treat as indicated (started on 11/09/21). A review of the Quarterly Minimum Data Set (MDS) dated [DATE] for Resident #67 revealed in Section C-Cognitive Function, a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. The assessment revealed in Section G-Functional Status the resident was independent for eating with assistance for set up only. The assessment revealed in Section K-Swallowing/Nutritional Status, the resident had no swallowing disorder, a weight loss of more than 5% in a month or 10% in the last six months and not on a prescribed weight loss regimen. A review of the Weight Summary for Resident #67 revealed the following: Height 65 inches BMI (Basal Metabolic Index) 17.6 11/9/21 106.0 lbs. (pounds)Standing 12/3/21 105.2 lbs. Wheelchair 1/14/22 107.8 lbs. (no indication of method) 1/26/22 100.2 lbs. Wheelchair 2/2/22 86.9 lbs. Standing 3/3/22 99.4 lbs. (no indication of method) Resident #67 had a 13.3% weight loss in one month from 1/26/22 to 2/2/22. Resident #67 had a 6.23% weight loss in less than three months from 11/19/21 to 3/3/22. Review of the Comprehensive Care Plan for Resident #67 revealed the following: Focus: The resident has an activities of daily living self-care performance deficit related to disease processes. (initiated 3/1/22) Goal: Resident will maintain current level of function through review date. Interventions included but not limited to: The resident is able to feed self with setup. Focus: Resident #67 has a nutritional problem related to significant weight loss. (initiated 2/8/22) Goal: Resident will maintain adequate nutritional status as evidenced by maintaining at least 76-100% meal portions and supplements consumed ongoing through next review as well as weight stability/increase. Interventions: Provide and serve diet as ordered; Provide, serve diet as ordered. Monitor intake and record each meal. RD to evaluate and make diet change recommendations as needed. A review of the Nutrition Evaluation Initial, Annual and Significant Change record dated 11/12/21 indicated Resident #67 was on a dysphagia mechanical soft solid diet with thin liquids, had missing teeth, and no chewing or swallowing concerns. The document indicated Resident #67 had an Ideal Body Weight (IBW) of 142 lbs. and a current weight of 104.6 lbs. No history of weights was available. The meal intake level was reported as 76-100%. The document indicated the resident was at risk for malnutrition as evidenced by need for continued strong oral intake, limited oral intake documentation thus far, limited oral intake available, and a goal for the resident to continue to consume at least 76-100% meal portions daily. A review of the Nutrition Evaluation Initial, Annual and Significant Change record dated 2/8/22 indicated Resident #67 was on a dysphagia mechanical soft solid diet with thin liquids, had missing teeth, and no chewing or swallowing concerns. The document indicated Resident #67 had an IBW of 136 lbs. and a current weight of 100.2 lbs. The evaluation indicated a significant weight change of -5% since 1/14/22 with a BMI of 16.7. The meal intake level was reported as 76-100%. The document indicated the resident was at risk for malnutrition as evidenced by inadequate calorie and protein intake, inadequate food and beverage intake, significant weight loss with a goal to consume at least 51-100% meal portions daily as well as supplements provided, fortified foods, med pass 240 ml three times a day, weekly weights. On 3/30/22 at 1:00 p.m., Resident #67 was observed in the hallway on the second floor of the facility walking with his meal tray and yelling I can't eat this [expletive], as he brought the tray to staff members who were in the hallway. On 3/31/22 at 12:30 p.m., Resident #67 was observed seated in his room with his lunch tray on the overbed table. The resident stated he cannot eat that pureed [expletive]. He had finely chopped meatloaf, brown gravy, pureed seasoned green peas, mashed au gratin potatoes, sliced peaches, pureed dinner roll/bread, and margarine on his tray. The resident had only eaten the fruit. He was picking at the meat. The rest of the tray had been untouched. He stated there was no reason he could not get normal food, and he cannot get anyone to listen to him so he can eat. He stated he has had no teeth for a long time and has never eaten pureed food. He stated he has no problems eating and drinking. A review of the eating percentages documented in the tasks section of the medical record revealed only one day (3/18/22) of meal percentages had been recorded for Resident #67 between 3/16/22 and 3/31/22. On 4/1/22 at 10:25 a.m., an interview was conducted with the Director of Rehabilitation (DOR). The DOR stated an evaluation was completed for Resident #67 by speech therapy for swallowing due to weight loss. He stated at the time the resident had no concerns with the diet. On 4/1/22 at 11:09 a.m., an interview was conducted with the Registered Dietician (RD) and the Risk Manager, RN (RM). The RD stated he had been working at the facility for a year doing all the assessments. He stated he is physically in the facility three times a week. He stated he has one remote dietician who assists with quarterly assessments. He stated the nursing staff are responsible for the weekly weights and nursing is responsible for making sure all recommendations are carried out. The RD stated there is a weekly meeting on Fridays to discuss weights and determine gains or losses for the residents. The RD stated he was not aware the weekly weights were not completed as planned for Resident #67. The RD stated he was not aware Resident #67 had not been consuming his diet. The RD stated he was not aware the diet percentages had not been recorded as planned for Resident #67. The RD stated he noticed a significant weight loss for Resident #67 when he did his evaluation on 2/8/22 and he put in recommendations at that time. He stated all likes and dislikes for a resident are to be reported and the Certified Dietary Manager can make changes as needed. The RD confirmed meal percentages and weekly weights had not been completed for the resident or reported to him and stated he would evaluate the residents needs right away. The RM had nothing to add related to a lack of follow up by the RD. A policy was requested for Nutritional Assessment/Management for residents, and it was not supplied by the facility.

Based on observation, staff and resident interviews and review of facility records, the facility failed to provide sufficient staffing to meet the physical, and supervision needs and to assure the safety of 114 vulnerable residents located on 3 of 3 floors. On 8/1/2021 the facility's CNAs (Certified Nursing Assistants) and licensed nurses scheduled to provide care and services to the 114 residents were observed to be in the facility lobby protesting low facility staffing levels and refusing to work unless the management called in more staff. This left each floor of the facility, during a one hour and forty-five-minute period in the care of one or two staff members. The nursing floors were observed to be staffed with one nurse alone or one nurse plus an ancillary staff member providing for the needs of 25 residents on the 2nd floor, 45 residents on the 3rd floor and 42 residents on the 4th floor which included 6 bedfast residents (#5, #4, #6, #7, #8, #9) sampled of the 114 residents in the facility. Survey findings also showed a pattern of lack of sufficient staffing to care for the residents according to their assessed needs and as described in their care plans which led to harm for two (#6, #1) of six residents reviewed in the form of continued weight loss (#6) and pain (#1). For Resident #6, who lost 22.6 lbs. (pounds)from 06/01/2021 until 07/27/2021, which was a 21% loss in 8 weeks. The documentation showed a lack of monitoring of weights, even with a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #1 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . He stated that his hand cra.m.ps and hurts when the splint is not put on and that the splint had not been applied for several days. The restorative CNA who was assigned to provide splint and range of motion (ROM) care had been taken away from that duty to provide regular CNA care and the facility did not have a backup system to provide splint and ROM care. Findings included: 1. Resident #6 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . In an interview with the resident's nurse Staff P, Registered Nurse (RN P) on 08/02/2021 beginning at 12:20 p.m., she confirmed that she usually cared for Resident #6. She confirmed that the resident had been declining and had lost weight. A review was conducted of the resident's MDS (Minimum Data Set) quarterly assessment dated [DATE]. The assessment indicated the resident's cognition was severely impaired (Brief Interview for Mental Status score of 6). The resident was assessed as needing limited assistance at meals by one staff member. Her weight was documented as 110 lbs. and it was documented that she had lost a significant amount of weight without being on a physician ordered weight loss plan. Review of the MDS dated [DATE] revealed the resident had weighed 148 lbs. This was a weight loss of 38 lbs. in six months or 26%. Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the resident's weight revealed: the resident was 64 tall and after a readmission on 02/22/2021, she weighed 117.8 lbs. (on 02/24/2021). On 03/10/2021 the resident weighed 108.8, on 03/23/21 the resident weighed 109.6 lbs., on 03/30/21 the resident weighed 111.8 lbs., and on 04/06/21 the resident weighed 112. The resident maintained her weight between 110 lbs. and 112 lbs. from 03/30/21 until 06/01/2021 when she weighed 110 lbs. However, there was no weights documented from 06/01/2021 until 07/27/2021. On 7/27/2021 the resident weighed 87.4 lbs. There was no re-weigh. On 08/03/2021 the resident weighed 88.2 lbs. For a female who was 64 tall, an ideal body weight range is defined as between 108 - 138 lbs., according to Food and Medication Interactions, 10th edition, Geriatric Standards female. Resident #6 lost 22.6 lbs. from 06/01/2021 until 07/27/2021, which was a 21% loss in 8 weeks. This was more than a significant weight loss, which is identified as a loss of 5% in one month, 7.5 % in 3 months or 10% in a sixth month period. Review of the documented weights in the facility's electronic medical record revealed there hadn't been weekly weights taken to follow the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] A Policy for Weighing the Resident was obtained from the facility which included a Policy statement of: Residents of the facility shall be weighed upon admission and monthly and as needed unless ordered otherwise by the physician. Under Procedure, the ninth bullet point read: When there is a significant variance from the previous recorded weight the scale should be re-balanced and the resident re-weighed and a licensed nurse to validate. The facility policy for weighing the resident was not followed for both weighing the resident monthly and for not re-weighing the resident until one week later when there was a significant variance. In an interview with the Director of Nursing (DON) on 08/03/2021 at approximately 1:00 p.m., missing weights were discussed. The DON reported that restorative aides that had been taking the monthly and weekly weights were pulled to work the floor as they needed aides to provide resident care. She said the dietitian had been reviewing the weights and was supposed to be discussing them with the DON, but he hadn't been, and they are just now putting a plan into place to ensure the weights are being taken. In an interview with the Registered Dietitian on 08/03/2021 beginning at 1:45 p.m. he confirmed that weekly weights had been ordered but they stopped being obtained. The RD reported that there had been a restorative aide that was able to weigh residents both weekly and monthly, but that aide was working as an aide providing direct care to residents rather than providing restorative care. 2. An interview was conducted with Resident #1 on 8/1/21 at 1:10 p.m. He stated he is supposed to have a splint put on his left hand in the mornings. He stated the last couple of days he has not had it on. He stated his hand cra.m.ps and hurts when it is not on. He stated it had not been applied this morning. An observation was conducted of Resident #1, on 8/2/21 at 8:30 a.m. He was observed in his electric wheelchair outside of the facility. There was no splint observed on his left hand. A subsequent interview was conducted with Resident # 1, on 8/2/21 at 1:31 p.m. He stated that no one had offered to put his left-hand splint on today and he stated it is usually Staff H, Restorative CNA who applied his splint and the CNAs don't know how to do it. He confirmed his left-hand cra.m.ps when the splint is not put on. Review of the admission record for Resident #1 revealed he was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS showed functional Limitation in Range of Motion indicated impairment on one side for both upper and lower extremity. Review of a Therapy Communication to Restorative Nursing Program. form, dated 4/8/20, revealed Occupational Therapy recommendations/approaches, #2. Apply splint to left hand in A.M. and remove after lunch. Review of current physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the July 2021 Treatment Administration Record (TAR) revealed no order related to the splint. Review of the Restorative Aide documentation from 7/1/21 to 7/31/21 revealed that Apply splint on left hand in a.m. and remove after lunch. As resident tolerated was not documented as completed on 7/1/21, 7/2/21, 7/5,21, 7/9/21, 7/10/21, 7/11/21, 7/14 through 7/21/21, 7/23/21, 7/24/21, 7/25/21, 7/27/21, 7/28/21, 7/29/21, 7/30/31 and 7/31/21. There were no refusals of the splint documented. An interview was conducted with Staff H, a Restorative CNA, on 8/1/21 at 12:06 p.m. She stated she is supposed to provide restorative services to residents including applying splints and doing range of motion. She stated But I haven't been doing the restorative for the last three weeks or more as I have been pulled to the floor and given an assignment. She stated she provides restorative services to 15 residents. She stated the last time she was able to provide restorative services was one day last week or the week before. She stated on 7/31/21 she worked from 6:50 a.m. to 6:00 p.m. and had worked the previous three days. She stated last week it was back-to-back days with only three CNAs for over 46 patients and the patients are heavy, my back hurts. Staff H stated, We need to do something, they don't want to give us a raise, every time we say something they say there is no problem. She stated this morning when she came in, she checked her residents, and passed trays on the low number side of the 4th floor, Then everyone started to go down to the lobby, so we all went down. She stated when she came back up from the lobby at 9:20 a.m., she washed faces, bottoms and changed her residents; after I came back up is when I did this. She said regarding gathering in the lobby, If we didn't do this, there will be no change. I a.m. sorry it had to happen but it's not fair to us. On 8/1/21 at 1:29 p.m. she stated she thought she was in the lobby for approximately thirty minutes. She stated that Staff E and Staff M (CNAS) were supposed to be off on 8/1/21 but We called them to come in. Staff H, Restorative CNA provided na.m.es of residents who required restorative services for splinting. 3. The facility was observed to be a four-story building. The first floor of the building includes the main entrance and lobby, administrative offices, dietary, dining room, activities room, rehab therapy room, maintenance, laundry, and central supply. There are no resident rooms located on the first floor. Resident rooms are located on the second, third and fourth floors of the building and are accessible by two elevators in the middle of the building and two staircases on each end of the building. Upon arrival at the facility on 8/1/21 at 9:03 a.m., observation revealed a group of more than 10 Staff Members gathered in the front lobby on the first floor of the facility. At approximately 9:06 a.m. the group, with the exclusion of the receptionist, numbered 11. The employees were observed to be speaking over each other to the surveyor to explain their presence in the lobby. A CNA who wished to remain anonymous (Staff H) stated that there were only three staff working on the resident floors at the time of entrance. She stated that everyone else on the schedule was in the lobby. An RN (Registered Nurse), who wished to remain anonymous, (Staff C) stated that there were only the two nurses on the floor and no CNAs. On 8/1/21 at 9:07 a.m. the Medical Records Coordinator, when asked who the staff were in the lobby, stated Those were the staff who are supposed to be on the floor working. She stated the staff don't want to work with three people. She stated she doesn't work on weekends, but was called in as the staff were not working on the floors had walked off the floors and were in the lobby. She stated she came in to help feed the residents. Fourth Floor Observations: On 8/1/21 at 9:09 a.m., on the 4th floor, no CNAs were observed on the entire floor. There was one RN (Staff S) who confirmed she was the only staff member on the floor; all other staff were in the lobby. Residents were noted to be in their rooms, the majority in bed. The resident census for the 4th floor was 42 at the time of the observation at 9:09 a.m. Three call lights were observed on and the RN was observed heading towards them. The RN was noticeably teary eyed and visibly sweating and stated It's just me, everyone else is in the lobby. I a.m. trying to pass meds, feed residents provide care, answer call lights. I can't abandon the patients. She indicated that the staff had gone down to the lobby at approximately 7:45 a.m. A review of a census and condition form for the fourth floor, provided by the DON revealed that of the 42 residents on the floor, 3 were bedfast, 17 were dependent on at least 2 staff for transfers, 19 required 1-2 staff for assistance with transferring, 15 were dependent and required at least 2 staff for toilet use, 6 were dependent on staff for eating, 13 required assistance with eating, and 12 residents required use of a mechanical lift to be transferred from the bed to a chair. The three bed fast residents on the fourth floor were: Resident #7, a resident whose diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's 4/25/2021 MDS assessment showed she was totally dependent on staff for all ADL (Activities of Daily Living) care. On 8/3/21 at 3:50 p.m. Resident #7 stated she was able to use her call light to call for assistance if needed. Resident #8, a resident whose diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's 5/22/2021 MDS assessment showed that he required 2 staff and a mechanical lift for all transfers and was totally dependent on staff for all ADL care. Staff BB, CNA on 8/3/21 at 4:00 p.m. confirmed he was unable to call, or use his call light, to obtain assistance if needed. Resident #9, a resident whose diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's 6/29/2021 MDS assessment showed he required 2 staff and a mechanical lift for all transfers and was totally dependent on staff for all ADL care. Staff AA, RN on 8/3/21 at 4:05 p.m. confirmed he was unable to call, or use his call light, to obtain assistance if needed. Third Floor Observations: On 8/1/21 at 9:16 a.m. on the 3rd floor there were no CNAs observed. There was 1 RN (Staff J) on the floor who confirmed she was the only staff member on the floor; all other staff were in the lobby. The RN J stated she was trying to take care of the residents by herself. She appeared visibly distraught and teary eyed. She pointed to the schedule board on the wall (Photographic Evidence Obtained) which indicated that one RN and one CNA (Staff N) were assigned for a census of 45 residents. She pointed downward with her finger when asked where the CNA was and said that the CNA was downstairs in the lobby. Review of the census and condition form for the 3rd floor provided by the DON revealed a census of 45 residents. Two were bedfast, 17 were dependent on at least 2 staff for transfers, 28 required 1-2 staff for assistance with transferring, 12 were dependent and required at least 2 staff for toilet use, 3 were dependent on staff for eating, 13 required assistance with eating, and 11 residents required use of a mechanical lift to be transferred from the bed to a chair. The two bedfast residents on the third floor were: Resident #4, whose diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An interview with Staff EE, RN, confirmed he was unable to call, or use his call light, to obtain assistance if needed. Resident #6, whose diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . according to the Admission Record. Review of the resident's 5/29/21 MDS assessment showed she was totally dependent on staff for all ADL care. An interview with Staff EE, RN, confirmed Resident #6 was unable to use a call light but could call out to obtain assistance if needed. Second Floor Observations: Observation of the second floor at 9:20 a.m. revealed no CNAs. The Weekend Nursing Supervisor, and the Medical Records Coordinator were observed going in and out of rooms with breakfast trays. They were interviewed and confirmed they were the only staff on the floor and the other staff were in the lobby. The elevator doors opened at 9:22 a.m. and several staff were observed exiting onto the second floor. The second floor Resident census was 25, one call light was on, and the RN was heading towards it. Of the 25 residents on the floor, based on 2nd floor the census and condition document provided by the DON: 1 was bedfast, 4 were dependent on at least 2 staff for transfers, 16 required 1-2 staff for assistance with transferring, 5 were dependent and required at least 2 staff for toilet use, and 3 were dependent for eating, 3 required assistance with eating, 2 residents required use of a mechanical lift to be transferred from the bed to a chair and one resident had a [CONDITION(S)] (#5). The bedfast resident on the second floor was: Resident #5, whose diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's 6/5/2021 MDS assessment showed he was totally dependent on staff for all ADL care. Review of current physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's care plan revealed a focus of advanced directives FULL CODE, date initiated 8/4/2020 with a goal of Resident will have advanced directive followed. The Resident was observed on 8/3/21 and found lying on his left side on an air mattress on the bed, receiving oxygen at 2.5 L/M via a [CONDITION(S)] collar with tube feeding running at 75ml/Hr. 4. Staff Interviews were conducted with the staff who were in the lobby on 8/1/2021, including a nurse who remained on the nursing floor, the Weekend Supervisor, the Medical Records Coordinator, the DON, the Director of Human Resources, and the Activity Coordinator: An interview was conducted with the Weekend Nursing Supervisor at 2:40 p.m. on 8/1/21. She stated, We had previous warning this was going to occur, we have been short staffed for a while She stated when she arrived at 6:45 a.m. she noticed the CNA staff were outside and had not punched in. She stated they were waiting for me and said the schedule was not correct. She stated she looked at the schedule and there was a call out, CNA staffing was: 1 on 2nd floor, 3 on 3rd floor and 3 on 4th floor. She stated, I moved one to 3rd floor because they needed four. She stated it was almost the same situation as the day before, We have been working like this too much, the same people are working and burned out. She stated some are doing 12 -16 hours every day and, We have been voicing complaints to management, voicing complaints for a while and falling on deaf ears. She stated the staff were upset, they've been working a lot of days and they did not want to go back upstairs until they got extra help. The Weekend Nursing Supervisor stated all but two staff clocked in and went to the floors first. Two of the CNAs did not clock in, one of them stated it was not safe with no help. Both CNAs drove away and came back at 7:15 a.m. after she called them and asked them to please come back. She stated they did not go up on the floor when they came back, that they stayed in the lobby until all the staff went back upstairs at 9:20 a.m. She stated by 7:30 a.m., almost everyone was downstairs in the lobby except the ones who stayed behind on the floor, they all came down together. She stated she asked them what was going on and they told her that We warned you and you knew this day was coming. She stated Myself, Activity Coordinator and Medical Records Coordinator went to the fourth floor first. They went to the third floor and then the second floor, she stated We passed trays and fed people on each floor. She stated on the third floor, Staff J, (RN) and Staff N (CNA) were on the third and then Staff N, the only CNA, asked if she could go down to see what was going on. She stated staff N went down to the lobby, but she does not know how long Staff N stayed down there as she, the Weekend Nursing Supervisor, did not stay on the third floor long and she went with the other two to pass trays on the 2nd floor and she took the medication cart on the 2nd floor. She confirmed Staff C, the nurse on second floor, went to the lobby. The Weekend Nursing Supervisor stated the staff have been voicing complaints about short staffing for a while and the complaints were falling on deaf ears. She stated that at 9:20 a.m. the staff started to come upstairs to the floor. During an interview with the Director of Human Resources, on 8/1/21 at 10:04 a.m., she stated staffing has been a challenge, that the facility lost a lot of staff; 10 CNAs quit in one day, the week of July 19. She stated we have one 1 p.m. to 7 a.m. nurse and the 3 p.m. to 11 p.m. nurses have been picking up 11p.m. to 7a.m. shifts, But they've told me they are burnt. She stated the staff quit when the current Administrator started, she had been here before and they disliked her, and they do not want to work for her. She stated, In three weeks we have been taken all the way down. A subsequent interview was conducted with the Director of Human Resources, on 8/1/21 at 3:38 p.m. She stated, Today, everything that happened today, they are tired, and it's been coming. They keep asking for help. She confirmed that on the third floor it was Staff N, the second floor CNA who left the floor and went to the lobby with the other staff, she believed it was at 8:00 a.m. She confirmed that Staff K and R were supposed to be on the 2nd floor, and they were the two CNAs who did not clock in until 9:05 a.m. She stated that Staff M, a CNA, was called in on her day off and clocked in at 7:24 a.m. The Director of Human Resources stated that the Medical Records Coordinator is not a current CNA and not a PCA. An interview was conducted with Staff D, a CNA. She confirmed she was one of the staff who was in the lobby. She stated, I come every day. I work more than 40 hours overtime. We need people, the staff is tired. She stated there were only three CNAs yesterday on the 4th floor with 46 patients. Showers, feeding, seven need fed, showers, we want to do everything for them, it's impossible. She stated now there are 31 patients and 2 CNAS on the 2nd floor, and we have to run to take care of the residents. Staff D stated the staffing has been running short since the Administrator came She stated there is too much overtime, overtime every shift and she is working two shifts a day. She stated when state (state surveyors) is in the building more staff are brought in. She stated that at the Friday town hall when meeting there were no solutions given and we have to do it regarding protesting the staffing. She stated, We don't care about raises, we need bodies. An interview was conducted with Staff A, a CNA who wished to remain anonymous, (with the assistance of Staff D, CNA) on 8/1/21 at 11: 06 a.m. S/He stated, The situation, the leader/administrator, she here before, she leaves, everyone not happy, she came back she doesn't help for anyone, she say I don't care about them quitting, I'm going to get more. As soon as everyone heard she was coming back nine people left in same week. S/He stated that s/he went downstairs after s/he clocked in and checked on her/ his residents. S/He did not provide a time s/he went to the lobby or how long s/he was there. S/He stated Too much overtime, we can't do the numbers. We can't do showers, feed, change, answer lights, we need more people, we are tired. An interview was conducted with Staff F, an RN, (with the assistance of Staff D, CNA) on 8/1/21, at 11:22 a.m. She stated she came in between 6:30 and 6:45 a.m. and she saw that All the CNAs were sad. She stated the main complaint is that we are short CNAs, not just today. She stated we try to help as a nurse, but we have our own jobs-medication skin issues, falls etc. She stated today we have two CNAs on our floor and the restorative aide was sent to help. She stated patients are not getting the care they deserve, they need showered, changed every two to three hours. She stated 46 residents on her floor, and she has 25 of them. She stated the nurses are expected to work overtime also, but she cannot due to health issues. She stated, We went down to the lobby at 8:00 a.m. and everyone was complaining. She stated that there are heavy care residents on the fourth floor. She stated she administered some of the residents' medications before she went to the lobby and then administered the rest of the medications after she returned to the floor. An interview was conducted with Staff G, a RN, on 8/1/21 at 11:40 a.m. She stated she came today at 6:45 a.m. She stated, it's the same every day, I arrived and there were two nurses and one CNA on my floor. She stated, if only going to be the three, we do not want to work, it was like this yesterday. She stated, I called the hotline last month, I told them the same thing - not enough staff, patients are heavy care, not enough help. She stated patient care is difficult with only three of us, we don't have time to change them maybe one time, they want water, they want food, they want to go outside . We are supposed to give showers but with only three we can't . She stated she had 21 patients on her side and there were 24 on the other nurse's side. She stated that sometimes she works 11 p.m. to 7 a.m. and she has been the only nurse two times, last Tuesday was the latest time. Staff G stated there are so many staff working 16 hours a day and when the CNAs are finished with their shift the supervisor begs them to stay and work another shift. She stated Friday they (administration) say no agency, today they say agency is on the way. Regarding leaving the residents and going to the lobby, she stated We did not have intention to leave patients alone, wanted to have then bring agency to help us. Needed them to do something. We left one (staff member) on each floor. An interview was conducted with Staff R, CNA, who wished to remain anonymous, on 8/4/21 at 4:46 p.m. Staff R stated that on Saturday, 7/31/21, I talked to the supervisor, I talked to everyone, I told them tomorrow if there are three people working on the floor, I a.m. not working. Too many residents for three. If you complain they tell you lie. Staff R stated on Saturday 7/31 s/he told the Weekend Supervisor and the 3 p.m. to 11 p.m. supervisor that if there were not four people on the third-floor s/he was not clocking in. S/He stated when s/he got to work on the morning of 8/1/21, s/he checked and saw one CNA on the third floor, s/he stated s/he checked every floor and there was only one nurse and one CNA and that is why s/he did not clock in. S/He stated s/he told the supervisor to call the Administrator and tell her the situation. S/He stated I don't clock in; I wait for Administrator. Administrator told me if I don't clock in and go to the floor then I a.m. No Call, No Show. Staff R stated s/he talked to the DON on the phone, and she said she was coming in, and that is why everyone in the lobby went back upstairs. An interview was conducted with the Activity Coordinator on 8/1/21 at 1:20 p.m. She stated that she noticed between 7 a.m. and 8 a.m., the floor staff went down to the lobby. She stated that after the floor staff went down to the lobby, she and the Medical Records Coordinator went to the fourth floor and passed trays and then they worked their way down to third floor and second floor to pass trays. An interview was conducted with an RN who wished to remain anonymous, at 2:20 p.m. on 8/4/21 (with an interpreter at his/her request). They have been asked to do the work of 6 people and can't give the care the residents need. Stated the CNAs can't give 100% care of what the resident really needs. Can't take breaks and can't finish shifts on time and that the Nursing Home Administrator (NHA) is discriminating against them as she only cares about the time and numbers and not about the residents. S/he stated lot of people left because they don't pay them enough. When this NHA was here before she did not do anything, another came in and gave them a raise, he left, he was there 3 months, he at least heard them. They feel that she did not care that the CNAs were working short. CNAs asked for agency and only get agency CNAs since state (state surveyors) came into building. S/he confirmed s/he was one of the staff who left the floor and went to the lobby. An interview was conducted with Staff K, CNA , on 8/4/21 at 2:28 p.m. with an interpreter at her request. She stated for a few weeks they have been trying to resolve the problem with not enough employees. Worked with three CNAs on the floor on Saturday and when they came on Sunday (8/1/2021) it was the same situation. She did not clock in on Sunday and waited downstairs for others. It is too many residents to work with only 3 on the floor (3rd floor). There was always a nurse and a CNA on the floor, and they were taking turns to come downstairs. Doesn't remember who had the idea and they all agreed that the floors had to have someone on there at all times. Brought it up at the Town Hall meeting and the administrator already knew the problem. Said it's not healthy for them to work this much and it's hard for her to meet the needs of her residents - on her floor she has 6 residents who need feeding. The CNAs try to do as much care as they can when they are short. Staff K stated it's not all about the money, but its more about having staff for the residents and the staff are tired. She stated she was unaware of the extra shift bonus as she only works weekends. She stated that there was a town hall meeting on Friday and a few CNAs and nurses spoke about not enough staff at the meeting, but administration already knew there was a problem. A second interview was conducted with the Medical Records Coordinator on 8/4/21 at approximately 10:00 a.m. She stated on 8/1/21 she was passing trays on all three floors. She stated she didn't keep track of who was on the floor and who wasn't on the floor as far as CNAs. She stated they, the CNAs, are supposed to tell their nurse when they leave the floor, so she wasn't paying attention to who was on the floor or not. She stated that she, the Weekend Nursing Supervisor, and the Activity Coordinator passed the breakfast trays on the floors. She stated she is not a CNA or a PCA (personal care assistant), but she does pass trays and answer lights. An interview with Staff L, a CNA who wished to remain anonymous, was conducted on 8/4/21 at 10: 55 a.m. S/he stated a lot of staff quit because another building pays more money. S/he stated that the staff talked to the Administrator, however the Administrator stated no agency, that corporate would not let them use agency staff. S/he stated They say they can do nothing about it. They offer bonuses but we are so tired. No one says thank you, no one says we appreciate you. S/he stated that on 8/1/21, day shift, s/he was the only CNA on the floor, another CNA came to help but not until at about 10:00 a.m. Staff L stated there was only one nurse on the schedule for the floor, later in the morning, the weekend supervisor took the other cart. S/he stated that she and the nurse passed the breakfast trays that morning. S/he stated my nurse said she was going downstairs to the lob [TRUNCATED]

Based on observation, interview, and record review, the facility failed to provide restorative nursing services to 3 of 3 (#1, #2, #3 ) residents reviewed as evidenced by not donning and doffing hand splints which resulted in one resident (#1) experiencing pain and cramping on multiple days due to staff not applying the splint to the resident's left hand. Findings included: 1. An interview was conducted with Resident # 1 on 8/1/21 at 1:10 pm. He stated he is supposed to have a splint put on his left hand in the mornings. He stated the last couple of days he has not had it on. He stated his hand cramps and hurts when it is not on. He stated it had not been applied this morning. An observation was conducted of Resident # 1, on 8/2/21 at 8: 30 a.m. He was observed in his electric wheelchair outside of the facility. There was no splint observed on his left hand. A subsequent interview was conducted with Resident # 1, on 8/2/21 at 1:31 p.m. He stated that no one had offered to put his left hand splint on today and he stated it us usually Staff H (Restorative CNA) that applies his splint and the CNAs don't know how to do it. He confirmed his left hand cramps when the splint is not put on. Review of the record for Resident # 1 revealed he was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of an annual Minimum Data Set (MDS) assessment, dated 6/10/21 revealed a score of 15 (Cognitively Intact) on the Brief Interview for Mental Status (BIMS). Functional Limitation in Range of Motion indicated impairment on one side for both upper and lower extremity. A Therapy Communication to Restorative Nursing Program form, dated 4/8/20, revealed Occupational Therapy recommendations/ approaches of 1. Perform Bilateral UE (Upper Extremity ) A/AA(active assistive) PROM (passive range of motion) to all joints /planes 12 reps (repetitions) x 3 sets left hand, 2. Apply splint to left hand in AM and remove after lunch, 3. Perform Right UE AROM (active range of motion) to all joints/planes 12 reps x 3 sets. Review of Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the July 2021 Treatment Administration Record (TAR) revealed no order related to the splint. Review of the Restorative Aide documentation from 7/1/21 to 7/31/21 revealed that Apply splint on left hand in am and remove after lunch. As resident tolerated was not documented as completed on 7/1/21, 7/2/21, 7/5,21, 7/9/21, 7/10/21, 7/11/21, 7/14 through 7/21/21, 7/23/21, 7/24/21, 7/25/21, 7/27/21, 7/28/21, 7/29/21, 7/30/31 and 7/31/21. There were no refusals of the splint documented. 2. Review of the record for Resident # 2 revealed he was originally admitted to the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a quarterly MDS assessment, dated 6/30/21 for Resident # 2 revealed a score of 3 (severe cognitive impairment) on the BIMS assessment. Review of the activities of daily living section indicated that Resident # 2 required extensive assist of 2 persons for bed mobility and transfer, total dependence of two for toilet use and personal hygiene. There was no upper extremity impairment documented. Review of care plans for Resident # 2 revealed a care plan with focus of Has ADL self care performance deficit reference to Alzheimer's, Limited Mobility, Musculoskeletal impairment. The care plan focus was initiated 9/28/18 with a revision date of 12/26/18. The goal was listed as the resident will maintain current level of function in ADLs through next review date with a revision date of 4/8/21. Interventions included: Apply left hand splint On in the AM, Off in PM, resident does remove himself at times, Initiation date 12/26/18, revision date 5/6/19 Contractures: The resident has contractures, provide skin care to keep clean and prevent skin breakdown. (initiated 9/28/18 and revised 9/28/18) Review of a Therapy Communication to Restorative Nursing Program form, dated 4/15/20, revealed Current functional Status: He can hold objects in L (Left) hand that are thin and not heavy (washcloth, toothpaste) He is able to slightly open and close left fingers. Problems/Needs Pain in left fingers. Recommendations /Approaches 3. Pt to wear left hand splint: on in AM and off PM. Review of physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Restorative Aide documentation for July 2021 revealed Restorative: Apply left hand splint on in AM, Off in PM as tolerated. There was no documentation that the resident refused the splint. Documentation revealed the Splint was applied on 7/6/21, 7/7/21, 7/8/21, 7/13/21, 7/15/21, 7/22/21 and 7/26/21. There was no documentation that the splint was applied on 7/1/21, 7/2/21 , 7/5/21, 7/9/21, 7/19/21, 7/20/21, 7/21/21 , 7/23/21, 7/28/21 and 7/30/21. For the dates of 7/12/21, 7/14/21, 7/16/21, 7/26/31, 7/37/21 and 7/29/21 not applicable was documented for the splint. For the dates of 7/3/21, 7/4/21, 7/10/21, 7/11/21, 7/17/21, 7/18/21 7/24/21, 7/25/21 and 7/31/21 there is an X marked. Review of the legend for restorative documentation revealed no X as an option. An interview with the Regional MDS Coordinator was conducted on 8/5/21 at approximately 1: 30 pm. She reviewed the restorative documentation and stated she did not know why not applicable was documented. Observations were conducted of Resident # 2: On 8/1/21 at 1:18 p.m., Observed in bed, left hand visibly contracted, no splint observed on left hand On 8/2/21 at 10:35 a.m., Observed in bed with no splint observed on left hand On 8/2/21 at 1:29 p.m., Observed in bed with no splint on left hand. 3. On 08/02/2021 at 9:20 a.m. Resident #3 was observed laying in bed. The Resident's left arm/hand was observed with no splint in place and resting on the mattress. An interview was attempted with the resident; however, she was not interviewable. A review of the clinical record for Resident #3 revealed an admitted [DATE] and a readmitted [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the Care Plan showed a focus ADL [activities of daily living] deficit initiated 10/03/2018; interventions dated 10/18/2018 included- Restorative: Left hand splint apply after breakfast and removed after lunch. Place left hand on pillow. A review of the Restorative Aide documentation for the previous 30 days revealed: Apply left hand splint, with documentation that it was completed on 07/04/2021, 07/06/2021, 07/07/2021, 07/08/2021, 07/11/2021, 07/13/2021, 07/22/2021, 07/25/2021, and 07/26/2021; no additional documentation was present in the clinical record to indicate the splint was applied on other dates. A review of the Progress Notes showed an entry dated 07/15/2021 by the Assistant Director of Nursing (ADON) Resident continues on restorative program for splint. No skin concerns. No discomfort. Will continue to monitor. The record did not contain any entries to demonstrate the splint was applied on 07/15/2021. A review of the annual Minimum Data Set (MDS) dated [DATE] revealed under Section C: Brief Interview for Mental Status (BIMS) score 04, indicating severe cognitive impairment; Section G: Total dependence for all ADLs; and Section O: Restorative Nursing Program - splint/brace assistance [0]. A review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 08/02/2021 at 9:50 a.m. an interview was conducted with Staff U, Registered Nurse (RN). She stated the Restorative Aide is responsible for applying splints to residents in the Restorative Nursing Program, and said when there is no Restorative Aide, the Resident's Certified Nursing Assistant (CNA) will do it. She confirmed there was no order/action on the TAR for Resident #3 to place a splint on her left hand. On 08/02/2021 at 10:15 a.m. an interview was conducted with Staff V, CNA. She confirmed she was the CNA assigned to Resident #3. The CNA stated she was not aware Resident #3 required a splint to be placed on her left hand On 8/1/21 at 12: 06 pm. an interview was conducted with Staff H, Restorative Aide. She stated she is supposed to provide restorative services to residents including applying splints and doing range of motion. She stated but I haven't been doing the restorative for the last three weeks or more as I have been pulled to the floor and given an assignment. She stated she provides restorative services to 15 residents. She stated the last time she was able to provide restorative services was one day last week or the week before. She said on 7/31/21 she worked from 6:50 am to 6 pm and had worked the previous three days. She stated last week it was back-to-back days with only three CNAs for over 46 patients and the patients are heavy, my back hurts. Staff H said, we need to do something, they don't want to give us a raise, every time we say something they say there is no problem. She stated this morning when she came in, she checked her residents, and passed trays on the low number side of the 4th floor, then everyone started to go down to the lobby, so we all went down. She said when she came back up from the lobby at 9:20 am, she washed faces, bottoms and changed her residents. After I came back up is when I did this. She said regarding gathering in the lobby If we didn't do this, there will be no change. I am sorry it had to happen but it's not fair to us. An interview conducted on 08/02/2021 at 12:15 p.m. with the Director of Nursing (DON) revealed when there is no restorative aide assigned, it is the responsibility of the assigned CNA to complete splinting restorative duties and document. She stated there had been an issue with CNAs not documenting restorative duties and she informed the Nursing Home Administrator (NHA) who would do an AdHoc. During the interview with the DON on 8/2/21 at 12: 15 p.m., the staff schedule for 8/2/21 was reviewed with the DON. There were no staff names listed on the staff schedule for Restorative Aide. She stated yes that is correct when asked if that meant there was no one assigned to the restorative duties if they are not listed on the schedule as a restorative aide. An interview conducted on 08/02/2021 at 1:15 p.m. with the NHA revealed an AdHoc will be done (not done yet) for CNAs to complete restorative services and documentation when no restorative aide is assigned. She further stated that Agency CNAs will now be included. A review of a facility-provided policy titled Restorative Nursing Services, dated 02/01/2016, revised 08/24/2017 showed: Restorative Nursing will be provided to residents as indicated upon evaluation to assist in achieving the highest practicable level of physical functioning as possible. -Restorative programs provided by the Restorative Nursing Assistants will be documented each time the program is provided on the Restorative Tracking Form. On 08/03/2021 at 10:49 a.m. an interview was conducted with Staff W, ADON. The Regional Director of Nursing (RDON) was also present during the interview. The ADON confirmed she was the Restorative Nurse and had held this role since December 2020. The ADON outlined the Restorative Nursing Program stating the resident is evaluated by therapy and upon discharge from therapy she received the actions for the Restorative Nursing Program. She stated the restorative instructions are placed in the Electronic Medical Record (EMR) as a task for the Restorative Aide to complete. She explained in the absence of the Restorative Aide, CNAs are responsible for the ROM and the nurse is responsible for the splinting. She stated for splints there should be a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The ADON said there are approximately 40 residents in the Restorative Nursing Program for services that include but not limited to splinting, range of motion, weights, and gait training. Upon completion of the interview, the ADON and RDON reviewed the EMR for Residents #1, Resident #2 and Resident #3 and verified documentation was missing for splint application and removal, and an order was not present on the TAR for the nurse to complete the task in the absence of the Restorative Aide.

Based on observation of residents at meals, interview with facility staff and review of residents' medical records and facility documents, the facility failed to ensure nutritional interventions were in place, failed to follow physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . For Resident #6, who lost 22.6 lbs from 06/01/2021 until 07/27/2021, which was a 21% loss in 8 weeks the documentation showed a lack of monitoring of weights, even with a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Opportunities were missed to provide care and interventions to prevent the further worsening of Resident #6's condition. Findings included: 1- Resident #6 was a long term resident of the facility, admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation of the resident on 08/02/2021 beginning at 12:10 p.m. revealed a thin woman, lying on her right side with her knees pulled up, covered by a sheet. A pillow could be seen under the sheets having been placed between her knees. The resident had a nasal cannula under her nostrils with oxygen flowing at 2 liters/minute. Certified Nursing Aide (CNA) O walked into the room with personal hygiene supplies and confirmed she was going to provide care prior to lunch. She reported that she frequently cared for the resident and the resident had declined as she used to be more active and would get out of bed every day. She encouraged me to speak with the resident's nurse about the resident, saying she would know more. At 12:20 p.m. the resident's nurse (RN P) confirmed she usually cared for Resident #6 and confirmed the aide's report that she had been declining. The RN P reported that the resident had lost weight and the doctor had been made aware. She said that a Dietitian consult had been ordered as well as labs. She reported that the resident was blind, but knew staff and family voices and would interact if you spoke with her. RN P said Resident #6 wasn't eating much, but she would drink and she preferred anything sweet, such as milk shakes, yogurt or ice cream. At 12:45 p.m. the resident's aide went into the resident's room and was heard to ask the resident if she was ready for lunch. The resident said that she wasn't ready for lunch. The aide exited the room and while she spoke to the surveyor about the resident and her poor intake at meals, a second aide (CNA O) was observed to take the resident's lunch tray into the room. CNA O was heard telling the resident what she had received for lunch, and the resident could be heard saying that maybe later she would eat. The lunch tray remained at bedside. At 2:30 p.m. on 08/02/2021, the resident's aide reported that the resident had not eaten the lunch meal and drank less than half of the medpass that the nurse had brought in for her. On 08/03/2021 at 8:40 a.m., LPN T approached the resident and spoke with her about her breakfast. He sat down next to the bed and asked Resident #6 if she was ready for breakfast. The resident had received morning care and the head of the bed was up with the resident half sitting up, in a position to eat breakfast. The resident answered the LPN loudly with a 'NO'. He repeated her NO and added - you don't want your breakfast? Again Resident #6 responded 'NO'. He offered her the juice, letting her know it was orange juice and she agreed to drink some juice. Using a straw, the resident drank about half of the 4 ounce cup of juice. Nurse P entered the room and spoke with the resident, letting her know she had her chocolate shake. She asked Resident #6 if she would like some and Resident #6 very politely said No thank you. Nurse P commented about the bowl of yogurt, asking Resident #6 if she wanted some yogurt. Nurse P put the spoon with some yogurt to Resident #6's lips, but Resident #6 did not open her mouth. LPN T offered the juice again and the resident was agreeable to drinking some juice. Nurse P left the room and reported to the surveyor that usually the resident drank some of the med pass, never the whole cup (4 ounces), but usually some of it. Later that morning the resident's aide confirmed the resident had not eaten any of the breakfast. A medical record review was conducted for Resident #6 which revealed the resident had a diet order for a Dysphagia Mechanical Soft texture diet with thin liquids, fortified foods and chocolate pudding three times a day. Multiple supplements had also been ordered for the resident, reflecting the nurse's comment that the resident had lost weight. Supplement orders included the house supplement (without amount to administer) four times a day for lack of appetite (ordered 08/02/21); initially a house supplement (without amount to administer) twice a day for supplement ordered on 03/31/2021; magic cup three times a day for No Sugar Added Shake 90 ml chocolate, ordered on 07/28/2021; and Prostat AWC sugar free, give 30 ml orally three times a day for supplement. A review of the Medication Administration Records for the supplement intake revealed the nurses were only checking that the supplement had been provided to the resident rather than documenting the percent consumed. Labs were ordered on 06/15/2021 which included a request for pre [MEDICATION(S)]. Review of the lab results obtained on 06/17/2021 did not include the pre [MEDICATION(S)]. The lab results included a value for [MEDICATION(S)] of 2.9 which compared to the the reference range of 3.5-5.7 was low. A telephone order dated 06/18/2021was noted requesting a dietitian consult due to low [MEDICATION(S)]. There was no dietitian consult related to the order. Labs were ordered on 07/27/2021 which included pre [MEDICATION(S)]. The results again did not include the pre [MEDICATION(S)]. [MEDICATION(S)] and pre [MEDICATION(S)] are reviewed for residents with weight loss as they are a marker of malnutrition and malabsorption. Pre [MEDICATION(S)] is a better indicator of dietary change than [MEDICATION(S)] as its half life is short (2-3 days) compared to [MEDICATION(S)]. A low pre [MEDICATION(S)] would reflect poor intake, including protein. (Food Medication Interactions, 10th edition) On 08/04/2021 at 12:15 p.m., Nurse P was asked about the labs ordered on 06/15/2021 and 07/27/2021. Nurse P confirmed the pre [MEDICATION(S)] ordered with the other lab values was not obtained. She reported that she was not aware that there was a special request form to submit for pre [MEDICATION(S)] and didn't know why the pre [MEDICATION(S)] had not been obtained. Additional orders were noted: continue with weekly weights for weight loss ordered on 06/15/2021; weekly weights every Tuesday (weight loss) one time a day every Tuesday to begin on 08/03/2021; and weekly weights x 4 then monthly unless otherwise indicated, ordered on 02/23/2021. [MEDICATION(S)] Tablet (Mirtazapine) give 7.5 mg by mouth at bedtime for bedtime had been ordered on 07/19/2021 (as an appetite stimulant). A new order dated 08/03/2021 for wound care (coccyx: cleanse with Dakin's solution ¼ half, pat dry, apply santyl ointment and calcium ag plain and cover with dry dressing QD (every day) and PRN (as needed) for wound care. A review was conducted of the Minimum Data Set (MDS) quarterly assessment dated [DATE] which revealed the resident had a stage III pressure sore. On the prior quarterly MDS assessment dated [DATE] the pressure sore was noted as a stage II. A review of the resident's weight was conducted and noted that the resident was 64 tall and after a readmission on 02/22/2021, she weighed 117.8 lbs (on 02/24/2021). On 03/10/2021 the resident weighed 108.8, on 03/23/21 the resident weighed 109.6 lbs, on 03/30/21 the resident weighed 111.8 lbs, and on 04/06/21 the resident weighed 112. The resident maintained her weight between 110 lbs and 112 lbs from 03/30/21 until 06/01/2021 (when she weighed 110 lbs). There was no weight documented until 07/27/2021 when documentation indicated the resident weighed 87.4 lbs. There was no re-weight until 08/03/2021 when it was reported that the resident weighed 88.2 lbs. For a female who was 64 tall, an ideal body weight range is defined as between 108 - 138 lbs, according to Food and Medication Interactions, 10 th edition, Geriatric Standards female. Resident #6 lost 22.6 lbs from 06/01/2021 until 07/27/2021, which was a 21% loss in 8 weeks. This was more than a significant weight loss, which is identified as a loss of 5% in one month, 7.5 % in 3 months or 10% in a six month period. Review of the documented weights in the facility's electronic medical record revealed there hadn't been weekly weights taken to follow the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] A Policy for Weighing the Resident was obtained from the facility which included a Policy statement of : Residents of the facility shall be weighed upon admission and monthly and as needed unless ordered otherwise by the physician. Under Procedure, the ninth bullet point read: When there is a significant variance from the previous recorded weight the scale should be re-balanced and the resident re-weighed and a licensed nurse to validate. The facility policy for weighing the resident was not followed for both weighing the resident monthly and for not re-weighing the resident until one week later when there was a significant variance. A review was conducted of the resident's MDS (Minimum Data Set) quarterly assessment dated [DATE]. The assessment indicated the resident's cognition was severely impaired (Brief Interview for Mental Status score of 6). The resident was assessed as needing limited assistance at meals by one staff member. Her weight was documented as 110 lbs and it was documented that she had lost a significant amount of weight without being on a physician ordered weight loss plan. Review of the MDS dated [DATE] revealed the resident had weighed 148 lbs. This was a weight loss of 38 lbs in six months or 26%. The resident had a care plan developed for her self care performance deficit related to eating with the intervention to assist the resident with one staff at meals. The resident had a care plan for the Focus of a nutritional problem or potential nutritional problem related to her history of [CONDITION(S)], and hypertension. The Focus also included the resident's significant weight loss with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Interventions included monitoring signs and symptoms of dysphagia, monitoring and recording signs and symptoms of malnutrition, obtaining and monitor lab values, providing the ordered diet and supplements and monitoring intake and RD to evaluate and make recommendations for changes in the diet order. A review was conducted of the Registered Dietitian's assessments and progress notes of Resident #6's weight loss and dietary intake. On 04/08/2021 the Registered Dietitian (RD) documented the resident had weight loss of 13.8% in the last 90 days. The note documented that the resident was receiving a Regular diet with prostat 30 ml once a day and medpass three times a day as well as a multi-vitamin. He noted that the resident was eating 75% of meals and the diet was appropriate for the resident with strong intake. He planned to follow the resident's weekly weights for trends and provide additional recommendations as indicated. On 04/28/21 the RD documented weight loss and the resident's diet and supplements with the comment that her intake was adequate. On 05/12/2021 the RD documented weight loss with the resident receiving an appropriate diet with supplements. On 06/01/2021 the RD documented a weight loss trend with weights ranging from 108 - 130 lbs down from 145 lbs in September 2020. The RD documented scattered intake of 26-100% with an average of 50% at meals. He documented the food and multivitamin supplements with the possibility of recommending an appetite stimulant and weekly weights. On 07/27/2021 the RD conducted a comprehensive nutritional assessment which documented the resident's weight for height appearance indicated she was underweight. Her estimated daily needs were based on her actual weight with the diet assessed as appropriate. The Nutrition diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Summary and Prognosis included the statement that the RD spoke with the resident who told him her appetite was good and agreed with the addition of a chocolate magic cup three times a day. The summary referred to the 06/01/2021 evaluation but contradicted the information documented in the prior evaluation (weight was stable and approximately 65% average meal portions consumed.) The summary referred to the unstageable pressure ulcer on the coccyx. Meal intakes were documented as having decreased to 0 - 25% with total dependence on staff for assistance with meals and supplements. There were no references to lab values, pending labs or the ordered and missed lab request for prealbumin. There was no indication that the resident was observed during meals to ensure the documented meal percentages were accurate. There was no reference to how much of the various supplements ordered for the resident were consumed. There was no comparison between the estimated calorie and protein needs of the resident to what she was actually consuming. In an interview with the Registered Dietitian on 08/03/2021 beginning at 1:45 p.m. he confirmed that weekly weights had been ordered but they stopped being obtained. The RD reported that there had been a Restorative Aide that was able to weigh residents both weekly and monthly, but that aide was working as an aide providing direct care to residents rather than providing restorative care. The RD confirmed he had not spoken with the physician or physician extender about the resident's weight loss. He reported that at a July Standards of Care meeting Resident #6 and her weight loss had been discussed. The resident's advanced directives were also discussed and he confirmed he would not speak with her about a feeding tube. But he didn't think the physician had documented that she should be receiving end of life care. He confirmed he was trying to cover her with supplements for her weight loss but reported he did not know where to find documentation that would show how much of each supplement she was taking. He also confirmed that he was relying on the nursing aides documentation of how much she ate at meals as he had not observed her at any meals. He was not aware of her labs and that there had been several orders for pre [MEDICATION(S)]. He reported that he received text messages from the nurses when there was a nutrition consult ordered. After reviewing the documentation on the resident's continued weight loss, lack of monitoring of weights, even with a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] #6. 2- Resident #10 was initially admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the quarterly Minimum Data Set (MDS) assessment completed on 06/19/2021 revealed a Brief Interview for Mental Status (BIMS) score of 3, indicating severe cognitive impairment. The MDS included a functional status assessment identifying the resident as needing extensive assistance with one person for bed mobility, transferring, walking, moving in a wheelchair, toilet use and personal hygiene needs. The resident was able to enjoy his meals with the assistance of one staff with set up and supervision only. On 08/02/2021 beginning at 10:00 a.m., Resident #10 was observed lying in his bed with the bed low to the floor and the head of the bed up at approximately a 45 degree angle. The television was on with the room lights low. The resident did not respond to the surveyor's greetings, but when asked if he ate meals by mouth or did he have a feeding tube, he answered that he ate by mouth. At 1:00 p.m. on 08/02/2021, the resident was served his lunch, while he was in bed, with the over bed table located across his waist and the aide assisting with set up of the items on the tray. He was observed to use a spoon and eat very slowly, but appropriately. Review of the tray slip listing the resident's diet order and any special instructions indicated the resident's diet was Regular, Dysphagia advanced, fortified foods, large cup with all drinks, food in bowls. Observation of the resident's meal revealed his hot dog and baked beans had been served on a dinner plate, not bowls as the tray slip indicated. The resident had received milk which was noted to be served in the 8 ounce carton with a straw stuck into the spout of the carton, not a large cup. The vegetable was a cold mixed vegetable salad (green beans and peas) which was served in a bowl. By 1:30 p.m. the resident nodded yes when the aide asked if he was done. The resident had eaten about 50% of the meal. A review of the resident's medical record revealed [MEDICAL RECORD OR PHYSICIAN ORDER] . The lunch meal that was provided to the resident did not include nectar thick liquids, as the milk that was served to the resident was thin consistency. A review of the nursing aides Kardex, with the admitted [DATE], did not include the thickened nectar consistency under the Eating/Nutrition or Fluids subject area. On 08/02/2021 at 3:00 p.m. the Certified Dietary Manager (CDM) reported that he was familiar with the resident, commenting, Yeah, we send him his food in bowls. During a review of the tray slip with the CDM, when it was reported that the entrée was not in bowls he said staff must have missed that. He reported that mashed potatoes were planned as the fortified foods and he said they must not have been made. When asked about the large cup for the beverages the CDM reported that he frequently doesn't receive the adaptive equipment back with the meal trays so has trouble sending it back to the resident at the next meal. He said he didn't know about the nectar thick liquids and said the diet orders come from the nursing staff. The Diet Order & Communication Form was located in the resident's medical record. It was dated 07/05/2021 and noted to identify the resident's diet order as Regular, Mechanical Soft, Nectar Thickened Liquids. (photo evidence obtained) An interview was conducted with the Speech Therapist (ST) on 08/04/2021 beginning at 10:05 a.m. The ST reported that she conducted a screening with the resident at breakfast that morning and observed that the resident took multiple swallows with thin liquids which indicated to her that he might be aspirating the thin liquid. She reported that when he swallowed the nectar thick liquid he had no multiple swallows, indicating he was having no problem swallowing the thicker liquid. She reported that she felt more comfortable with the resident receiving thickened liquids. During the interview with the ST, the Occupational Therapist was present. He reported that he was familiar with the resident and felt that the order to receive all food in bowls was still appropriate for the resident, as he needed that direction to ensure he would finish his meal. He confirmed that it was appropriate for the resident to receive supervision at meals as he was able to eat independently, but staff should look in on him and encourage him if necessary. The resident's weight record was reviewed and noted for documented weights from initial admission until the weight documented on 06/03/2021. On 03/15/2021 the resident's weight was 148.6 lbs, with weight gain to 151.2 lbs documented on 03/24/21 and again on 03/31 with a weight of 154.2 lbs. On 04/07/21 the resident remained stable at 154.2 lbs and on 04/21/21 the resident's weight dropped two pounds to 152 lbs. The next weight was taken on 06/03/2021 which was 161.2 lbs. There was no monthly weight in May and there were no other weights documented until the review date of 08/02/2021. In an interview with the Director of Nurses (DON) on 08/03/2021 at approximately 1:00 p.m., missing weights were discussed. The DON reported that restorative aides that had been taking the monthly and weekly weights were pulled to work the floor as they needed aides to provide resident care. She said the dietitian had been reviewing the weights and was supposed to be discussing them with the DON but he hadn't been and they are just now putting a plan into place to ensure the weights are being taken. The Nutrition Assessments conducted by the Registered Dietitian (RD) were reviewed. On 04/21/2021 the RD documented that the resident's weight for height appearance indicated an acceptable weight. Estimated calorie, protein and fluid needs were documented. The assessment did not include what the weight and height were for either evaluation, only to say that it was the resident's actual weight that the estimated needs were based on. The diet was indicated as appropriate without documenting what the diet was. The resident was assessed as being at risk for compromised nutrition integrity related to dysphagia and a CVA (cerebral vascular accident). The Summary read: new resident assessment. Receiving a dysphagia diet w (with)/mechsoft (mechanical soft) solids and nectar thick liquids w/fortified foods. Diet appropriate. PO (by mouth) intake strong thus far w/75-100% meal portions consumed. BMI wnl (within normal limits) (Body mass index within normal limits) and will continue to monitor weight trends. Will follow as per protocol. No additional recommendations at this time. A Nutritional Review had been conducted on 06/22/2021 by the RD. The resident's height was documented as 69 with the usual body weight of 150 lbs and the most recent weight of 161.2 lbs documented on 06/02/2021. The BMI was 23.8 with a weight trend documented as 8.48% gain in 90 days. The diet order was listed as Regular diet, Dysphagia Advanced texture, Nectar Thickened Fluid consistency, fortified foods. The resident had no trouble chewing or swallowing. Intake of food and fluids was documented at 75%. The resident was independent at meals and assistive devices at meals included food in bowls and large drink cups. Current lab data was identified as waiting on current labs. A summary of the review indicated: current weight is 161.2 lbs, BMI 23.8, weight gain is beneficial for resident, po intakes are good. Continue with current plan of care. A review of physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . In an interview conducted with the Registered Dietitian (RD) on 08/03/2021 beginning at 1:45 p.m., the RD confirmed that he doesn't conduct meal rounds to observe residents at meals. He confirmed even when he is evaluating a resident's nutritional status he doesn't observe them at a meal. He said he didn't know that the resident's diet slip did not include the nectar thick liquid order. He confirmed he was not aware that the resident was not consistently receiving his ordered diet that included fortified foods, food in bowls and big drink cups. The RD reported that he usually developed the resident care plan. A review of the care plan (revised on 04/21/2021) revealed the focus was identified as a nutritional problem or potential nutritional problem related to the subarachnoid hemorrhage and dysphagia. Interventions included Provide and serve diet as ordered; obtain and monitor lab /diagnostic work as ordered; and Monitor/document/report as necessary (prn) s/sx (signs/symptoms) of dysphagia including choking, coughing, several attempts at swallowing. Resident #10 had gained significant weight (12.6 lbs or 7.8%) in just under 90 days from his initial admission in March 2021 until June, bringing him up to an ideal body weight for his height. The nutritional review in April and June documented the resident's diet order as including nectar thick liquids, but the dietary department did not include that on the resident's diet slip and the resident was served thin liquids on his diet tray. Labs were obtained in May but not reviewed in the June assessment. 3- Resident # 28 was identified by the facility as having lost weight and when spoken with on 08/02/2021 beginning at 12:25 p.m. she confirmed she was waiting for lunch, she was sort of hungry, but she didn't think she had lost weight. Within the hour, the resident was observed in the day room with another resident and a nurse sitting at a table. Both residents had their lunches in front of them and Resident #28 seemed to be enjoying her meal. Nurse X, who was sitting with the two residents, confirmed that the residents seem to eat more if someone sits with them, encourages and talks with them. A review was conducted of the resident's Minimum Data Set Assessment conducted on 07/02/2021. The resident was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Brief Interview for Mental Status was conducted and the resident scored a 3 indicating severe cognitive impairment. The resident needed extensive assistance of two staff for bed mobility and to transfer, but once in her wheelchair she was independent with supervision of one staff only. She needed assistance by one staff for toileting and personal hygiene. She was independent at meals. A review of the resident's medical record revealed [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #28 had frequent weights - both weekly and monthly - documented which were stable (April MDS weight = 158 lbs and July MDS weight = 154). Beginning in May weekly weights had become infrequent. On 05/10/21 the resident weighed 164 lbs; the next weight was on 06/03/21 which was 155 lbs. Resident #28's weights remained in the 150's until her weight dropped from 152 lbs on 07/05/21 to 140 lbs on 07/07/2021. The weight after 07/07/21 was taken on 07/12/2021 when the weight was 139 lbs. Weekly weights were documented on 07/19/21 and 07/26/2021 (138 lbs and 136 lbs respectively.) There was no re-weight after the loss of 9 lbs in four weeks until 25 days later when the weight was down two pounds and then two days later the weight was down 12 lbs. A review of the facility's policy on Weighing the Resident included under Procedure: when there is a significant variance from the previous recorded weight the scale should be re-balanced and the resident re-weighed and a licensed nurse to validate. This point under Procedure had not been followed. Further record review revealed on 07/26/2021 the Nurse Practitioner (NP) had assessed the resident and current labs and had ordered a dietitian consult. Review of the labs obtained on 07/26/21 revealed the [MEDICATION(S)] was 3.3 and the prealbumin was 14.9 with both values identified as low. Review of the progress notes and assessment tab in the medical record did not reveal that the Registered Dietitian (RD) had responded to the NP's order for a consult. A Weight warning by the RD dated 07/26/2021 revealed the resident's weight was 136 lbs on 07/26/21. The RD noted that there had been weight loss but the BMI remained within normal limits and the resident's intake at meals was between 51 - 100%. The RD noted that the resident was on weekly weights and received a mighty shake twice a day and multivitamins. The resident had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no reference to the request for the consult or that a renal supplement had been ordered for the resident's chronic kidney disease on 07/22/2021. An interview was conducted on 08/04/2021 beginning at 1:20 p.m. with the RD who reported that when a dietary consult is ordered he is made aware by a text that the nurses send.

Based on resident and facility record review, policy review, staff and administrative interviews, and observations, it was determined that the facility failed to be administered in a manner that enabled it to use its resources effectively to maintain the highest practicable physical well-being for twelve out of twenty residents reviewed (#19,#30,#32,#58,#178,#101,#193,#20,#79,#137,#210,#63). The facility failed to demonstrate corrective action following the survey of 4/6/12, as well as the follow-up survey of 5/4/2012, which resulted in an increase in the severity and scope of findings to Immediate Jeopardy during the survey ending 6/15/2012. The facility failed to demonstrate an effective system to implement plans of action to correct identified quality deficiencies including [MEDICAL CONDITION] care. The facility failed to provide the appropriate respiratory supplies, equipment and services to achieve the current minimum standards for respiratory care and the prevention of infection. Resident #32 was observed to receive improper care of the [MEDICAL CONDITION] that enabled her to breathe through a direct portal into her respiratory tract, and was treated for [REDACTED]. The facility's policy and procedure related to exchanging [MEDICAL CONDITION] stated, "[MEDICAL CONDITION] are changed regularly to decrease the possibility of infection and maintain a patent airway," but there was no documentation that this policy was implemented, and interviews with staff and physicians confirmed that this was not done. Resident #58's clinical record revealed that a physician ordered procedure for "capping trials" of the [MEDICAL CONDITION], in preparation for its removal so that the resident may breathe through her nose and mouth again, was not allowed to begin for twenty nine days due to an administrative decision and the physician was not notified of the delay. The facility terminated the position of respiratory therapist in August 2011, and then failed to ensure that adequate training in respiratory care was provided for the nursing staff. Resident #101, #193, #20, #79, #137, #210, and #63 were observed to have respiratory support equipment and supplies at their bedside that were not cleaned, disinfected, stored, and/or maintained properly according to the facility ' s policy and procedure and the current standards of infection control. Failure of the Administrator, the facility and staff to provide the advanced respiratory care required according to policy, procedure and the current standards of care and ensure that care concerns, including that of previously identified [MEDICAL CONDITION] problems for which the facility has been noncompliant since 03/20/12, resulted in findings of Immediate Jeopardy on 06/07/12, which was removed on 6/15/12 and reduced to the scope and severity of a "E". Findings include: 1. An entrance conference was conducted with Administrator and Administrator in Training (AIT) on 06/05/12 at 9:18 a.m. The Administrator stated that he was an interim administrator. The sign in sheets for the last 12 Quality Assurance (QA) Meetings were among documents that were requested. In an interview with the AIT 06/09/12 at 3:08 p.m. further documentation was offered which consisted of two one page spreadsheets outlining QA meetings. The AIT stated that the March 2012 meeting was for February concerns and the April meeting was for March concerns. There was no May meeting spreadsheet for April concerns, and the scheduled June meeting would be for May concerns. There was a section for the Medical Director which stated no recommendations for changes in policies or procedures and another section without any recommendations for plan of correction or plan of care implementation changes. A review of the Plan of Correction for the previous deficient practice related to [MEDICAL CONDITION] care dated 5/4/12 included, "Residents receive [MEDICAL CONDITION] care services utilizing sterile technique" and "Licensed staff re-educated related to [MEDICAL CONDITION] care" and "DCS/Designee to conduct random Quality Monitoring of resident [MEDICAL CONDITION] care to ensure sterile technique utilized." 2. On 6/12/12 at approximately 1:10 p.m. an interview was conducted with the administrator and the administrative assistant/administrator in training. The administrator stated that he is the interim administrator, and had been employed at this facility for approximately 14 days. The administrative in training confirmed that the facility did have a respiratory therapist on staff, but the position was terminated last year, and she did not know the reason. The administrator also stated that he did not know why the respiratory therapy position was deleted, but that it was the administrator's right to delete a position. He stated that a contract will go into effect July 1, 2012 between the facility and Respiratory Company A. He stated that he did not know what specific services, equipment or education that this company have been providing or will provide. He attributed the delay in contracting Respiratory Company A as a result of a "data submission problem" with the prior administrator. He stated that this had to be reviewed by the legal department at the management company and it was out of his hands. When asked if he was aware of the citations involving deficient practice related to [MEDICAL CONDITION] care 3/20/12 and the re-visit that did not result in correction, he stated, "As far as I'm concerned, the facility is in compliance." He did confirm that he was aware of "a few complaints and a few re-visits that were due." He confirmed that it was a component of his administrative duties to be in compliance with CMS. He stated that he was aware of a plan of correction and that a "four point plan" had been developed, but there had been no discussion regarding resuming respiratory therapy services. He acknowledged the problems with the contract that impeded the facility's procurement of respiratory related supplies which included the inability to obtain the Lukens trap containers that were required to obtain a physician-ordered culture and sensitivity to properly identify and treat Resident #32's respiratory infection. He stated that he was not aware of any recommendations that had been made to the facility regarding respiratory equipment and supplies by Respiratory Company A for a contact that was never signed. The administrative assistant stated that she attended a Quality Assurance meeting a few months back, and the Medical Director was present, but she could not recall [MEDICAL CONDITION] care or suctioning techniques being discussed. 3. review of the facility's documented "HR Job Descriptions/Administrator With HIPPA Language" dated 1/2001, revealed under position summary, "The primary purpose of the Administrator is to oversee, manage, and direct the day-to-day functions and overall operations of the facility in accordance with the current federal, state, and local government regulations that govern long-term care facilities and the Operators requirements. The Administrator's focus is on maintaining the highest degree of quality care for the resident/patient while achieving the facility's business objectives. " Further review revealed that " Essential Duties and Responsibilities" included the following specific administrative functions: "Ensure that all employees, residents, visitors and the general public follows established policies and procedures." "Make routine inspections of the facility to assure that established policies and procedures are being implemented and followed." "Review and develop a plan of correction for deficiencies noted during survey inspections." "Assist department directors in the planning, conducting, and scheduling of in-service training classes, on-the-job training and orientation programs to assure that current material and programs are continuously provided." "Ensure that the facility is maintained in a clean and safe manner for resident comfort and convenience by assuring that necessary equipment and supplies are maintained to perform such duties/services." "Ensure that adequate supplies and equipment are on hand to meet the day-to-day operational needs of the facility and residents." Further review revealed that the current administrator signed an attached acknowledgment of the job description on 6/6/12. 4. "Performance Improvement Q/I Monitor Forms" were offered by the facility for the months of March, April and May, 2012. There was no data relevant to the specific deficient practice regarding [MEDICAL CONDITION] care and suctioning according to policy and procedure, including the regular exchanging of [MEDICAL CONDITION] to maintain an open airway and prevent infection as stated on the policy and procedure dated 3/12. There was no specific reference on the form to following infection control measures as they related to residents with a [MEDICAL CONDITION] and no specific information captured related to those residents. 5. Observations and record review of 5 (#30, 32, 19, 58 and 178) of 5 [MEDICAL CONDITION] residents revealed that none of the five had had the [MEDICAL CONDITION] changed according to facility policy, procedure and current standards of care. (Lippincott 2012). Inadequate care of residents with [MEDICAL CONDITION] that enables them to breathe is directly related to respiratory infection, [MEDICAL CONDITION], and death. Two of these residents #30 and # 58 (#'s 4 and 6 on the 3/20/12 Investigation and #'s 2 and 4 on the 4/6/12 investigation) were found to have inadequate care with breaks in infection control on the initial investigations. These issues were revisited on 05/04/12 and the issues were found to be uncorrected with new observations of inadequate care and issues with infection control. This survey ending 06/15/12, with two second re-visits in conjunction, found these residents and the expanded sample of five out of five current [MEDICAL CONDITION] residents with continued inadequate [MEDICAL CONDITION] care and ineffective infection control. 6. On 6/9/12 at approximately 9:42 a.m., an interview was conducted with the Medical Director who stated that he was not aware of the continued non-compliance regarding [MEDICAL CONDITION] care since 3/20/12. He stated that he did attend a Quality Assurance meeting a few months back, but did not recall discussing advanced respiratory care for the residents. He confirmed that [MEDICAL CONDITION] have not been routinely changed for the residents at the facility. He stated that "sometimes the least that is done invasively is better" for the residents. He pointed out that Resident #32 had a poor prognosis and was at risk for infection related to her co-morbidities. He confirmed that [MEDICAL CONDITION] should be changed periodically because maintaining an open airway and infection control should always be a priority regardless of the individual's prognosis. He also confirmed that the equipment such as the Lukens trap containers should be present and available in the facility. 7. On 6/12/12, an observation was conducted of all respiratory equipment listed as in use for residents based on a facility list or respiratory residents. The observation began at 11:00am and revealed the following: At 11:15 a.m. on 06/12/12 Resident #1001 was observed to have an oxygen concentrator with a maintenance sticker that documented maintenance was completed in 10/05 and was due to be done again on 10/10. There was a large hole observed in the side of the concentrator where the plastic had been broken. At 11:20 a.m. on 06/12/12 Resident #193 was observed to have a nebulizer machine that was dusty and dirty; the mouth piece was not in a plastic bag but was placed into a compartment in the machine that was dusty. There was a plastic bag attached to the machine dated 4/25/12. There was no maintenance tag on the nebulizer machine indicating when it had last been serviced or when the next service was due. At 01:50 p.m. on 06/12/12 Resident #20 was observed to have nebulizer machine that had no maintenance tag on the machine indicating when it was last serviced or when it was due to be serviced. At 12:10 p.m. on 06/12/12 Resident #79 was observed to have an oxygen concentrator with a maintenance sticker which documented it was last services on 1/28/09 and was due for service 1/10. The concentrator filter was observed to be full of dust and appeared to not have been changed. At 01:35 p.m. on 06/12/12 Resident #137 was observed to have and oxygen concentrator with tubing that had no date and was in a plastic bag dated 5/14/12. The maintenance sticker on the oxygen concentrator documented the unit was last serviced 10/9/8 and was due to be serviced 10/09. The concentrator filter was observed to be coated with dust. At 01:40 p.m. on 06/12/12 Resident #210 was observed to have a nebulizer machine at his bedside that had no maintenance sticker to indicate when the machine was last serviced and when it was next due for service. At 01:45 p.m. on 06/12/12 Resident #63 was observed to have an oxygen concentrator that had no filter in the filter compartment of the machine. Air being pulled through the concentrator was not being filtered. At 11:50 a.m. on 06/12/12 Resident #178 was observed to have an oxygen concentrator with a humidifier. There was no date on the oxygen tubing or the humidifier as to when it was last changed. At 11:58 a.m. on 06/12/12 Resident #58 was observed to have a nebulizer machine at the bed side that did not have a maintenance sticker indicating when maintenance was last done or was next due. 8. At 1:35 p.m. on 06/12/12 an interview and tour was conducted with the DON to show him the respiratory equipment found out dated and in disrepair. He confirmed that there would be no maintenance tags found on any of the nebulizer machines and he confirmed the findings on the remaining respiratory equipment. 9. In an interview with the consulting Pulmonologist physician on 6/8/12 at 3:30 p.m., he stated that he had been consulting on [MEDICAL CONDITION] residents, and this included residents with tracheostomies, at this facility for approximately one month. He stated that he is strictly a consultant and was not paid by the facility. He stated that he became involved with the facility when he noted nursing home residents having frequent readmissions to the hospital, and he thought if they were to receive appropriate care in the nursing homes, then readmissions could be reduced. He stated that he was under the impression that the facility was going to have the services of a respiratory therapy company beginning 6/1/12, as this is what he was told by management, but added that he discovered this had been delayed. He stated that he has had some concerns regarding the respiratory care that has been provided at the facility. He stated that he employed a respiratory therapist who provided the facility's nursing staff with an in-service regarding appropriate [MEDICAL CONDITION] care and suctioning a few weeks ago. He stated that Resident #32, one of the five residents that had a [MEDICAL CONDITION], had a large amount of secretions from her lungs, and required a cuffed [MEDICAL CONDITION] to control her extensive secretions in order to prevent her from acquiring aspiration pneumonia. He stated that this type of [MEDICAL CONDITION] was not what was in place. He stated that he verbally requested a cuffed [MEDICAL CONDITION] (Shiley#8) on May 30 when he made rounds, and had planned to change the [MEDICAL CONDITION] on 6/6/12, but when he arrived at the facility, they had not ordered the proper [MEDICAL CONDITION] that had a cuff. He stated that he re-requested the cuffed [MEDICAL CONDITION] again on 6/6/12 that would have a cuff to aid in the control of the resident's secretions. He stated that he felt that the resident did have an underlying infection, but the sputum specimens that were sent were "contaminated." He confirmed that he did not know that the facility did not have the proper Lukens trap containers that is required to collect a proper sputum specimen, and was unaware that the sputum specimens had been collected improperly by not using sterile technique, due to not having the appropriate container available. He confirmed that sputum specimens from a [MEDICAL CONDITION] should be collected using this type of container, so that a specimen could be obtained for an accurate culture and sensitivity, and the proper antibiotic could then be prescribed for the best chance at complete eradication of the infection. He denied giving a verbal order to discontinue the sputum culture and sensitivity on 6/6/12. He stated that [MEDICAL CONDITION] should be changed periodically to keep an open airway, and for infection control and he suggested the change should be done every one to three months. He confirmed that improper suctioning and [MEDICAL CONDITION] care by not using the appropriate aseptic and sterile technique is related to infection including pneumonia. 10. The Administrator did not ensure that timely and effective resource management and the appropriate action was taken by the facility to ensure speech therapy. A delay of twenty-nine days from 5/2/12 to 5/31/12, was found for a speech therapy evaluation for resident #58. A physician order [REDACTED].#58, to assess if she was a candidate to have her [MEDICAL CONDITION] removed. The order was written, and then came to administration for approval because Resident #58's pay source was Medicaid. The speech therapy evaluation was authorized by the interim administrator on 5/31/12 and the resident began to have the physician ordered therapy. In an interview at 4:09 p.m. 6/9/12 with the Director of Nursing (DON), it was stated the capping trials were not done because they were waiting for authorization from the prior Administrator because the resident was a Medicaid patient. Capping trials required prior approval because Medicaid did not cover speech therapy. The DON stated that the current Administrator authorized the treatment on the first day he was here. The DON further stated this would only be an issue with the Medicaid residents, and the consulting pulmonologist's goal was "to get the [MEDICAL CONDITION] residents off their tracheostomies" and it required speech therapy to accomplish this. 11. The Administrator did not ensure that timely and effective resource management and action was taken by the facility to resolve an issue with lack of trained staff for [MEDICAL CONDITION] care since the investigation of 03/20/12, which began the current noncompliance Inadequate care of residents with [MEDICAL CONDITION] that enables them to breathe is directly related to respiratory infection, [MEDICAL CONDITION], and death. On 6/7/12 at 5:50 p.m., [MEDICAL CONDITION] care was observed for Resident #32. Employee P, the licensed practical nurse (LPN) that was assigned to Resident #32 for the 3:00 p.m. to 11:00 p.m. shift was observed washing her hands and assembling supplies that included: mask, gown, clean gloves, sterile gloves, paper towels, hand sanitizer and a [MEDICAL CONDITION] care kit. Employee B also entered the room and stated that she would assist Employee P as per the instructions from the DON. Employee B also washed her hands and put on clean gloves. The resident continued to be on oxygen per concentrator at 3 liters per minute. They positioned the resident into a semi-fowlers position by raising the head of the bed. Employee P washed her hands again and placed the paper towels on the over bed table. She applied a pulse oximeter to Resident #32's finger to obtain a reading for the resident's oxygen saturation. She stated that the saturation was low at 88%. Employee B stated that she had to put the oximeter on the residents thumb in order to get better contact. The oximeter was repositioned as directed by Employee B. The saturation then increased to an acceptable 94%. Employee P sanitized her hands and put on sterile gloves. She picked up the [MEDICAL CONDITION] kit (the outside being non-sterile and thus breaking sterile technique) and opened the kit and dumped the sterile contents out onto the unsterile paper towels. She then stated, "I should have done this first," and removed and discarded the sterile gloves and then put on another pair of sterile gloves. She then pulled open the drawer on the nightstand, again breaking sterile technique, and removed a container of solution. She was asked to identify what was in the container, and she said, "It's the saline." Employee B interjected and stated, "We are supposed to use the saline that's in [MEDICAL CONDITION]." The container that was removed from the drawer was inspected and labeled as normal saline, expiration date 1/14,and had been previously opened with approximately 25% of the liquid still present. There was no resident's name or date that it had been opened recorded on the container. Employee B confirmed that sterile normal saline is used to cleanse the inner cannula of the [MEDICAL CONDITION]. (The policy and procedure for [MEDICAL CONDITION] care dated 5/12 under step # 12 stated, "Separate 4x4 gauze and pour sterile water or saline over gauze into one container, and step 13# stated "Pour normal saline into second sterile container for rinsing.") Employee B confirmed that using the previously opened, undated and unlabeled container of saline would not have been consistent with sterile technique for cleansing the non-disposable inner cannula which is inserted directly into the Resident #32's trachea, had Employee P been allowed to continue. Employee P stated that she needed more supplies, and she discarded the opened [MEDICAL CONDITION] kit, removed her gloves, and both nurses left the room. They returned at approximately 6:00 p.m., and Employee P stated that she had reviewed the policy for [MEDICAL CONDITION] care. She washed her hands again and opened the [MEDICAL CONDITION] kit by peeling back the top lid, and setting the tray on the over bed table. She placed a sterile barrier on the over-bed table next to the tray, and then picked up the tray and dumped the sterile contents onto the sterile barrier. Then she placed the tray on the sterile barrier that had been resting on the over-bed table, thus contaminating the sterile field. She opened sterile gloves and put them on, and then placed the paper that the sterile gloves were packaged in underneath the resident's [MEDICAL CONDITION] on her chest. She poured the saline solution and the package of peroxide into the tray. She removed the gauze sponge that was placed around t-piece from the [MEDICAL CONDITION] and with some difficulty attempted to remove the inner cannula. The resident coughed, and approximately two tablespoons of thick, yellow sputum spilled out of the [MEDICAL CONDITION]. Employee P stated that the resident needed to be suctioned first. She used the closed suction catheter technique and placed saline from a small unit dose container of saline into the resident's [MEDICAL CONDITION] using the port on the closed suction catheter. She suctioned the resident by advancing the closed catheter into the [MEDICAL CONDITION], and then applied intermittent suction while withdrawing the catheter. The resident coughed continuously during the suctioning, and the gurgling and sounds of fluid in the resident's lungs were audible in the room. Employee P confirmed that there was sputum moving in the suction catheter, and she stated that the suction appeared to be working. She removed the sterile gloves and re-sanitized her hands. She applied new sterile gloves again, and removed the inner cannula with some difficulty. The resident again coughed and approximately two tablespoons of thick, yellow sputum was expelled out of her [MEDICAL CONDITION] onto the paper that the sterile gloves came in. Employee P placed the inner cannula which appeared to be stained a deep yellow, into the tray that contained the peroxide and normal saline. She was observed to cleanse the inside and outside of the cannula utilizing the cleansing tool included in the sterile kit. She replaced the inner cannula into the [MEDICAL CONDITION] while the resident continued to cough violently and spewed thick creamy yellow sputum from her [MEDICAL CONDITION]. She replaced the t-piece that hooked onto the [MEDICAL CONDITION] into the tubing that the oxygen was connected to which appeared moist with condensation or mucous, and reattached the t-piece to the [MEDICAL CONDITION]. She cleansed the residents' skin that surrounded the [MEDICAL CONDITION] by using a saline soaked gauze sponge that she picked up from on top of the sterile barrier, and dipped into the saline solution in the tray. She did not apply another dressing around the [MEDICAL CONDITION], and left the area bare. (A review of the policy and procedure for [MEDICAL CONDITION] care dated 5/12 lists step #24: "Place 4x4 gauze dressing between the [MEDICAL CONDITION] and resident/patient's skin.") She discarded the remains of the [MEDICAL CONDITION] kit, and removed her gloves and washed her hands. Employee P stated that the [MEDICAL CONDITION] ties were recently changed and did not require changing. The [MEDICAL CONDITION] ties were observed to be in place without the presence of secretions on the ties. During an interview at approximately 6:30 p.m. Employee P confirmed that she had omitted placing the dressing around the [MEDICAL CONDITION] site and also confirmed that this was a part of [MEDICAL CONDITION] care, but that she intended to apply the dressing "later." She also confirmed that sterile technique was difficult to follow for her. She also stated that Resident #32 had pneumonia. 12. A review of Resident #32's clinical record revealed portable chest x-ray results dated 5/5/12 that stated "perihilar pneumonia" (an atypical pneumonia located at the top of the respiratory tract) as the impression. The physician's orders [REDACTED].[REDACTED]. She continued to receive the [MEDICATION NAME] through 6/8/12. A review of the vital signs that included temperatures revealed that there were no abnormal temperatures documented and it appeared that Resident #32 was not having fevers as a symptom of her pneumonia. However, further review revealed physician's progress notes dated 5/20/12 that revealed Resident #32 had an axillary temperature of 102.5, and had continued respiratory congestion and rubs on auscultation. Another physician's progress note dated 5/22/12 revealed that Resident #32 had a fever of 100.0 axillary, as reported by the nurse, had a pending culture and sensitivity for the thick greenish yellow mucus that was noted in the resident's [MEDICAL CONDITION], and continued on the [MEDICATION NAME] for the respiratory infection. Another physician's progress note dated 5/26/12 stated that the resident was doing better with her upper respiratory infection, but the cough continued that was productive of greenish mucus, and the sputum culture and sensitivity was to be re-collected. A review of the physician's orders [REDACTED]. The results for all three specimens sent stated in the final report that the results suggested contamination, and therefore identification could not be made of the causative bacteria or the antibiotic that would be most effective against it. A review of the facility's infection control log stated that Resident #32 had infections requiring antibiotic therapy listed as "pneumonia" on 5/7/12 and "respiratory" on 5/20/12. 13. On 6/8/12 at approximately 11:45 a.m., an interview was conducted with the Unit Manager of the 3rd floor, and Employee Q, who had stated that she was assigned as Resident #32's nurse, and had frequently cared for her. She confirmed that the resident was diagnosed with [REDACTED]. She confirmed that the three sputum specimens that had been sent to the laboratory and were noted to be contaminated specimens. She pointed out the note at the bottom of the laboratory result form dated 5/3/12 that stated, "No further workup unless requested by physician." She stated that she interpreted this to mean no further specimens needed to be sent. Employee Q stated that she had sent at least one of the sputum specimens. She stated that she did not know how to collect a sputum specimen from a [MEDICAL CONDITION], and she had asked the DON and the ADON. She stated that a "lady doctor" that was present in the facility told her that a "Luky-tube" was required, and that she needed to get a "deep suction" and that the laboratory could provide the "Luky-tube." She stated that she called the laboratory, but was told that they did not supply the container. She stated that she told management of the need for the specialized container, but no one had been successful in obtaining the proper container required for the specimen. She stated that she had collected, and sent to the lab, the sputum that had been coughed up around the Resident #32's [MEDICAL CONDITION], since the laboratory would not deliver the proper container and there seemed to be no way to get them. She stated that when she spoke with the physician who was the consulting pulmonologist on 6/6/12, he gave a verbal order to discontinue the sputum specimen and stated he would collect it when he returned to change the [MEDICAL CONDITION]. 14. On 6/8/12 at approximately 3:50 p.m. an interview was conducted with the DON. He confirmed that a consulting pulmonologist was making rounds on the residents with advanced respiratory care needs including residents with tracheostomies. He stated that he was aware that this physician had ordered a [MEDICAL CONDITION] with a cuff for Resident #32, and also that the facility did not stock them. He stated that the [MEDICAL CONDITION] with a cuff had been ordered. He also confirmed that [MEDICAL CONDITION] should be changed regularly. He provided a policy and procedure, dated 03/12, that revealed under policy: "[MEDICAL CONDITION] are changed regularly to decrease the possibility of infection and to maintain a patent airway." He confirmed that there were no respiratory therapy (RT) services currently in the facility, but there was a contact pending with Company A for additional supplies, education and possible labor. He stated that the contract was supposed to have been effective June 1, 2012, but there was a delay, and he did not know the reason for the delay. He stated that in the past the facility had a part time RT on staff, but that position was deleted in November of 2011. He stated that the nursing staff had been solely responsible for advanced respiratory care including [MEDICAL CONDITION] care, suctioning and collection of sputum specimens. He confirmed that he was aware that there were no Lukens sputum collection devices in the facility, and he understood that this was necessary to be able to collect a proper specimen for a sputum culture and sensitivity. He stated that he called the respiratory company that the contract was going to be with, but they could not supply the Lukens containers because the contract had not yet been signed. He stated that he also called the laboratory, and they could not provide them either. He stated that he was working with another supplier currently to get the containers. He stated that the consulting pulmonologist had allowed the facility to " use his RT" to provide as a resource for the nursing staff when providing care to residents with tracheostomies. He stated that this RT was in the facility once a few weeks ago, and gave an in-service on tracheal suctioning and care. He stated that the facility does not keep competency skills checklists for the nurses to determine what additional training that they may need to deliver care to the residents. A list of all currently employed nurses that would be considered able to care for residents with [MEDICAL CONDITION] in place was requested. The ADON provided the list, and 39 nurses were identified. He was aware of the problems involving Employee B and Employee P during the observations of Resident #32 on 6/7/12 and stated that these two employees would not be providing care for residents with tracheostomies until they had been sufficiently re-trained. 15. On 6/12/12 at approximately 11:35 a.m. an interview was cond

Based on resident and facility record review, policy review, staff interviews, and observations, it was determined that the facility failed to be administered in a manner that enabled it to use its resources effectively to maintain the highest practicable physical well-being for thirteen out of twenty residents reviewed (#19,#30,#32,#58,#178,#101,#193,#20,#79,#137,#210,#63 and #106). The facility failed to demonstrate corrective action which resulted in on-going deficient practice and continued non-compliance related to infection control regarding respiratory care and wound care. The facility failed to provide the appropriate respiratory supplies, equipment and services to achieve the current minimum standards for respiratory care and the prevention of infection. Resident #32 was observed to receive improper care of the [MEDICAL CONDITION] that enabled her to breathe through a direct portal into her respiratory tract, and was treated for [REDACTED]. The facility ' s policy and procedure related to exchanging [MEDICAL CONDITION] stated, " [MEDICAL CONDITION] are changed regularly to decrease the possibility of infection and maintain a patent airway, " but there was no documentation that this policy was implemented, and interviews with staff and physicians confirmed that this was not done. Resident #58 ' s clinical record revealed that a physician ordered procedure for " capping trials " of the [MEDICAL CONDITION], in preparation for its removal so that the resident may breathe through her nose and mouth again, was not authorized by the facility to begin for twenty nine days. The facility terminated the position of respiratory therapist in August 2011, and then failed to ensure that adequate training in respiratory care was provided for the nursing staff. Resident #106 was observed to receive improper wound care that was not within the policy and procedure related to aseptic technique. Resident #101, #193, #20, #79, #137, #210, and #63 were observed to have respiratory support equipment and supplies at their bedside that were not cleaned, disinfected, stored, and/or maintained properly according to the facility ' s policy and procedure and the current standards of infection control. This occurred even after observations and deficiencies were issued for continued non-compliance related to infection control, which dated back to 4/6/2012, and for improper technique related to [MEDICAL CONDITION] care which had infection control implications, which dated back to 3/20/2012. Failure of the facility and staff to ensure proper cleaning, disinfection and maintenance of respiratory equipment and the availability of supplies, as well as the failure to ensure proper aseptic technique during [MEDICAL CONDITION] care, [MEDICAL CONDITION] exchanges, suctioning, and wound care for a pressure ulcer according to policy and procedure, resulted in findings of Immediate Jeopardy on 6/7/12. The Immediate Jeopardy was removed on 6/15/12, and reduced to the scope and severity of an E. Relevant findings included: 1. A review of the facility ' s documented " HR Job Descriptions/Administrator With HIPPA Language " dated 1/2001, revealed under position summary, " The primary purpose of the Administrator is to oversee, manage, and direct the day-to-day functions and overall operations of the facility in accordance with the current federal, state, and local government regulations that govern long-term care facilities and the Operators requirements. The Administrator ' s focus is on maintaining the highest degree of quality care for the resident/patient while achieving the facility ' s business objectives. " Further review revealed that " Essential Duties and Responsibilities " included the following specific administrative functions: " Ensure that all employees, residents, visitors and the general public follows established policies and procedures. " " Make routine inspections of the facility to assure that established policies and procedures are being implemented and followed. " " Review and develop a plan of correction for deficiencies noted during survey inspections. " " Assist department directors in the planning, conducting, and scheduling of in-service training classes, on-the-job training and orientation programs to assure that current material and programs are continuously provided. " " Ensure that the facility is maintained in a clean and safe manner for resident comfort and convenience by assuring that necessary equipment and supplies are maintained to perform such duties/services. " " Ensure that adequate supplies and equipment are on hand to meet the day-to-day operational needs of the facility and residents. " Further review revealed that the current administrator signed an attached acknowledgment of the job description on 6/6/12. 2. On 6/12/12 at approximately 1:10 p.m. an interview was conducted with the administrator and the administrative assistant. The administrator stated that he is the interim administrator, and had been employed at this facility for approximately 14 days. The administrative assistant confirmed that the facility did have a respiratory therapist on staff, but the position was terminated last year, and she did not know the reason. The administrator also stated that he did not know why the respiratory therapy position was deleted, but that it was the administrator ' s right to delete a position. He stated that there is currently a contract with two companies to provide respiratory supplies and services. He stated that a contract will go into effect July 1, 2012 between the facility and Respiratory Company A. He stated that Respiratory Company B will continue to provide services until then to ensure a smooth transition. He stated that he did not know what specific services, equipment or education that either company have been providing or will provide. He attributed the delay in contracting Respiratory Company A as a result of a " data submission problem " with the prior administrator. He stated that this had to be reviewed by the legal department at the management company and it was out of his hands. When asked if he was aware of the citations involving deficient practice related to [MEDICAL CONDITION] care 3/20/12 and the re-visit that did not result in correction, he stated, " As far as I ' m concerned, the facility is in compliance. " He did confirm that he was aware of " a few complaints and a few re-visits that were due. " He confirmed that it was a component of his administrative duties to be in compliance with CMS. He stated that he was aware of a plan of correction and that a " four point plan " had been developed, but there had been no discussion regarding resuming respiratory therapy services. He acknowledged the problems with the contract that impeded the facility ' s procurement of respiratory related supplies which included the inability to obtain the Lukens trap containers. He stated that he was not aware of any recommendations that had been made to the facility regarding respiratory equipment and supplies by Respiratory Company A. The administrative assistant stated that she attended a Quality Assurance meeting a few months back, and the Medical Director was present, but she could not recall [MEDICAL CONDITION] care or suctioning techniques being discussed. 3. A review of the Plan of Correction for the previous deficient practice related to [MEDICAL CONDITION] care dated 5/4/12 included, " Residents receive [MEDICAL CONDITION] care services utilizing sterile technique " and " Licensed staff re-educated related to [MEDICAL CONDITION] care " and " DCS/Designee to conduct random Quality Monitoring of resident [MEDICAL CONDITION] care to ensure sterile technique utilized. " 4. In an interview with the consulting Pulmonologist physician on 6/8/12 at 3:30 p.m., he stated that he had been consulting on [MEDICAL CONDITION] residents, and this included residents with tracheostomies, at this facility for approximately one month. He stated that he is strictly a consultant and was not paid by the facility. He stated that he became involved with the facility when he noted nursing home residents having frequent readmissions to the hospital, and he thought if they were to receive appropriate care in the nursing homes, then readmissions could be reduced. He stated that he was under the impression that the facility was going to have the services of a respiratory therapy company beginning 6/1/12, as this is what he was told by management, but added that he discovered this had been delayed. He stated that he has had some concerns regarding the respiratory care that has been provided at the facility. He stated that he employed a respiratory therapist who provided the facility ' s nursing staff with an in-service regarding appropriate [MEDICAL CONDITION] care and suctioning a few weeks ago. He stated that Resident #32, one of the five residents that had a [MEDICAL CONDITION], had a large amount of secretions from her lungs, and required a cuffed [MEDICAL CONDITION] to control her extensive secretions in order to prevent her from acquiring aspiration pneumonia. He stated that this type of [MEDICAL CONDITION] was not what was in place. He stated that he verbally requested a cuffed [MEDICAL CONDITION] (Shiley#8) on May 30 when he made rounds, and had planned to change the [MEDICAL CONDITION] on 6/6/12, but when he arrived at the facility, they had not ordered the proper [MEDICAL CONDITION] that had a cuff. He stated that he re-requested the cuffed [MEDICAL CONDITION] again on 6/6/12 that would have a cuff to aid in the control of the resident ' s secretions. He stated that he felt that the resident did have an underlying infection, but the sputum specimens that were sent were " contaminated. " He confirmed that he did not know that the facility did not have the proper Lukens trap containers that is required to collect a proper sputum specimen, and was unaware that the sputum specimens had been collected improperly by not using sterile technique, due to not having the appropriate container available. He confirmed that sputum specimens from a [MEDICAL CONDITION] should be collected using this type of container, so that a specimen could be obtained for an accurate culture and sensitivity, and the proper antibiotic could then be prescribed for the best chance at complete eradication of the infection. He denied giving a verbal order to discontinue the sputum culture and sensitivity on 6/6/12. He stated that [MEDICAL CONDITION] should be changed periodically to keep an open airway, and for infection control and he suggested the change should be done every one to three months. He confirmed that improper suctioning and [MEDICAL CONDITION] care by not using the appropriate aseptic and sterile technique is related to infection including pneumonia. 5. On 6/8/12 at approximately 3:50 p.m. an interview was conducted with the Director of Nursing (DON). He confirmed that a consulting pulmonologist was making rounds on the residents with advanced respiratory care needs including residents with tracheostomies. He stated that he was aware that this physician had ordered a [MEDICAL CONDITION] with a cuff for Resident #32, and also that the facility did not stock them. He stated that the [MEDICAL CONDITION] with a cuff had been ordered. He also confirmed that [MEDICAL CONDITION] should be changed regularly. He provided a policy and procedure, dated 03/12, that revealed under policy: " [MEDICAL CONDITION] are changed regularly to decrease the possibility of infection and to maintain a patent airway. " He confirmed that there were no respiratory therapy (RT) services currently in the facility, but there was a contact pending with Company A for additional supplies, education and possible labor. He stated that the contract was supposed to have been effective June 1, 2012, but there was a delay, and he did not know the reason for the delay. He stated that in the past the facility had a part time RT on staff, but that position was deleted in November of 2011. He stated that the nursing staff had been solely responsible for advanced respiratory care including [MEDICAL CONDITION] care, suctioning and collection of sputum specimens. He confirmed that he was aware that there were no Lukens sputum collection devices in the facility, and he understood that this was necessary to be able to collect a proper specimen for a sputum culture and sensitivity. He stated that he called the respiratory company that the contract was going to be with, but they could not supply the Lukens containers because the contract had not yet been signed. He stated that he also called the laboratory, and they could not provide them either. He stated that he was working with another supplier currently to get the containers. He stated that the consulting pulmonologist had allowed the facility to " use his RT " to provide as a resource for the nursing staff when providing care to residents with tracheostomies. He stated that this RT was in the facility once a few weeks ago, and gave an in-service on tracheal suctioning and care. He stated that the facility does not keep competency skills checklists for the nurses to determine what additional training that they may need to deliver care to the residents. A list of all currently employed nurses that would be considered able to care for residents with [MEDICAL CONDITION] in place was requested. The ADON provided the list, and 39 nurses were identified. 1. On 6/12/12 at 2:00 p.m. an interview was conducted with the district manager for Respiratory Company A. She stated that she received a call on 6/11/12 stating that the contract with Company A would be expedited, and would be effective that day (6/12/12), instead of 7/1/12. She stated that she was currently in the facility to make decisions on recommendations regarding respiratory supplies, equipment, and labor. She stated that she would provide the facility with her assessment, and it would then be subject to approval by the facility ' s management corporation. She stated that a prior assessment had been done a few months ago, but those recommendations were not contracted by the facility at that time, and she no longer had them. She stated that the facility had an agreement with a separate medical equipment company, Company C, which then partnered with Company A to provide respiratory supplies and equipment. 2. On 6/13/12 the facility provided a document titled " Respiratory Care Services Agreement " in response to the request made to the administrator for the current contract for respiratory supplies and services. The agreement document was reviewed, and revealed that it is a proposed agreement between Company A, a respiratory care and supplies company, and Company C, a general medical supplies company, stating that if the facility requested respiratory equipment and supplies, then Company C may sub-contract with Company A for specific requests made by the facility. " Schedule A " on the last page of the agreement document had a listing of specific respiratory services that were available. At the bottom of the page there was a place for Company C to initial and date, and a place for the facility to initial and date. Both of these were blank, indicating that the facility did not have a completed contract for specific respiratory supplies, care and services until sub-standard quality of care was identified when the partial extended survey took place on 6/11/12. 3. On 6/12/12, an observation was conducted of all respiratory equipment listed as in-use for residents based on the facility CMS Form #802. The observation began at 11:00a.m. and revealed the following: At 11:15a.m., Resident # 101 was observed to have an oxygen concentrator with a maintenance sticker that documented maintenance was completed in 10/05 and was due to be done again on 10/10. There was a large hole observed in the side of the concentrator where the plastic had been broken. At 11:20a.m., Resident # 193 was observed to have a nebulizer machine that was dusty and dirty, and the mouth piece was not in a plastic bag but was placed into a compartment in the machine that was dusty. There was a plastic bag attached to the machine dated 4/25/12. There was no maintenance tag on the nebulizer machine indicating when it had last been serviced, or when the next service was due. Resident #20 was observed to have a nebulizer machine beside his bed that had no maintenance tag on the machine indicating when it was last serviced, or when it was due to be serviced. At 12:10 p.m., resident # 79 was observed to have an oxygen concentrator with a maintenance sticker which documented the last service as being on 1/28/09, and was due for service 1/10. The concentrator filter appeared to be thick with dust. Resident # 137 was observed to have an oxygen concentrator with tubing that had no date, and was in a plastic bag dated 5/14/12. The maintenance sticker on the oxygen concentrator documented the unit was last serviced on 10/9/08, and was due to be serviced 10/09. The concentrator filter was observed to be coated with dust. Resident # 210 was observed to have a nebulizer machine at his bedside that had no maintenance sticker to indicate when the machine was last serviced and when it was next due for service. Resident # 63 was observed to have a oxygen concentrator that had no filter in the filter compartment of the machine. Air being pulled through the concentrator was not being filtered. Resident # 178 was observed to have an oxygen concentrator with a humidifier. There was no date on the oxygen tubing or the humidifier as to when it was last changed. Resident # 58 was observed to have a nebulizer machine at the bed side that did not have a maintenance sticker indicating when maintenance was last done or was next due. At 1:35 p.m., an interview and tour was conducted with the DON to show him the respiratory equipment that was found to be out-dated and in disrepair. He confirmed that there would be no maintenance tags found on any of the nebulizer machines, and he confirmed the findings on the remaining respiratory equipment. A review of the facility ' s policy and procedure titled " Equipment Rounds " and dated 3/12 stated under step #1, " At least once per shift, personnel shall verify oxygen equipment, which is in use, and check accuracy of FIO2 and/or liter flow. Verification of use shall be documented in the resident ' s record. Inlet filters on oxygen concentrators shall be visually inspected and cleaned/replaced as necessary. " Step #2 stated, " At least once per day, personnel shall visually inspect air compressors, suction machines, and treatment compressors for inlet filter status, operational verification, and general cleanliness. Inlet filters, suction canisters, and suction tubing will be cleaned/replaced if soiled. " There was no documentation provided by the facility regarding the implementation of the " Equipment Rounds " policy. 4. On 6/7/12 at 10:10 a.m. The DON stated that there was no log that he was aware of that documented checking the function and maintenance of the respiratory and suction equipment. He stated that the central supply coordinator was responsible for the " Equipment Rounds " and was identified as Employee R. 5. On 6/7/12 at approximately 10:35 a.m. an observation was made of the suction equipment in Resident #32 ' s room. The suction machine was resting on the bedside table. It had a thick, dusty coating on the base, and was stained on the right side with yellowish-white dried drainage. There was no tag, label or sticker that listed when the machine was last inspected or serviced. 6. On 6/7/12 at approximately 10:50 a.m., an interview was conducted with Employee R. She stated that she is a certified nurse assistant, but works as the facility ' s central supply coordinator. She confirmed that she makes rounds every day on the equipment and supplies that are located within the resident ' s rooms. She stated that she checked Resident #32 ' s room that morning, and the suction set up was functional. She also stated that she is responsible for cleaning and disinfecting the equipment every day. She stated, " I maintain them, and I clean them. " When asked what she does if a machine is not working properly, she stated that if she cannot fix the problem herself, then " they get tossed, and I get a new one. " There was no equipment rounds log that was produced by the facility for review. 7. On 6/7/12 at 5:50 p.m., [MEDICAL CONDITION] care was observed for Resident #32, which was the resident that the consulting pulmonologist identified as requiring a new [MEDICAL CONDITION] that had not yet been provided by the facility, and sputum specimens that had been ordered for culture and sensitivity that could not be processed due to possible inappropriate collection of the specimen. The resident was lying supine with her eyes slightly open but not focused. She did not respond to a verbal greeting. Her movements were spastic. She was breathing through a [MEDICAL CONDITION], or opening in her neck into which a tube was inserted. There were approximately two to three teaspoons of yellowish green, thick drainage that surrounded the opening of the tube and spilled out onto her neck. Her respirations gurgled with each breath. Employee P, the licensed practical nurse (LPN) that was assigned to Resident #32 for the 3:00 p.m. to 11:00 p.m. shift was observed washing her hands and assembling supplies that included: mask, gown, clean gloves, sterile gloves, paper towels, hand sanitizer and a [MEDICAL CONDITION] care kit. Employee B also entered the room and stated that she would assist Employee P as per the instructions from the DON. Employee B also washed her hands and put on clean gloves. The resident continued to be on oxygen per concentrator at 3 liters per minute. They positioned the resident into a semi-fowlers position by raising the head of the bed. Employee P washed her hands again and placed the paper towels on the over bed table. She applied a pulse oximeter to Resident #32 ' s finger to obtain a reading for the resident ' s oxygen saturation. She stated that the saturation was low at 88%. Employee B stated that she had to put the oximeter on the residents thumb in order to get better contact. The oximeter was repositioned as directed by Employee B. The saturation then increased to an acceptable 94%. Employee P sanitized her hands and put on sterile gloves. She picked up the [MEDICAL CONDITION] kit (the outside being non-sterile and thus breaking sterile technique) and opened the kit and dumped the sterile contents out onto the unsterile paper towels. She then stated, "I should have done this first," and removed and discarded the sterile gloves and then put on another pair of sterile gloves. She then pulled open the drawer on the nightstand, again breaking sterile technique, and removed a container of solution. She was asked to identify what was in the container, and she said, " It ' s the saline. " Employee B interjected and stated, "We are supposed to use the saline that's in [MEDICAL CONDITION]." The container that was removed from the drawer was inspected and labeled as normal saline, expiration date 1/14,and had been previously opened with approximately 25% of the liquid still present. There was no resident ' s name or date that it had been opened that was recorded on the container. Employee B confirmed that sterile normal saline is used to cleanse the inner cannula of the [MEDICAL CONDITION]. (The policy and procedure for [MEDICAL CONDITION] care dated 5/12 under step # 12 stated, " Separate 4x4 gauze and pour sterile water or saline over gauze into one container, and step 13# stated " Pour normal saline into second sterile container for rinsing. " ) Employee B confirmed that using the previously opened, undated and unlabeled container of saline would not have been consistent with sterile technique for cleansing the non-disposable inner cannula which is inserted directly into the Resident #32 ' s trachea, had Employee P been allowed to continue. Employee P stated that she needed more supplies, and she discarded the opened [MEDICAL CONDITION] kit, removed her gloves, and both nurses left the room. They returned at approximately 6:00 p.m., and Employee P stated that she had reviewed the policy for [MEDICAL CONDITION] care. She washed her hands again and opened the [MEDICAL CONDITION] kit by peeling back the top lid, and setting the tray on the over bed table. She placed a sterile barrier on the over-bed table next to the tray, and then picked up the tray and dumped the sterile contents onto the sterile barrier. Then she placed the tray on the sterile barrier that had been resting on the over-bed table, thus contaminating the sterile field. She opened sterile gloves and put them on, and then placed the paper that the sterile gloves were packaged in underneath the resident's [MEDICAL CONDITION] on her chest. She poured the saline solution and the package of peroxide into the tray. She removed the gauze sponge that was placed around t-piece from the [MEDICAL CONDITION] and with some difficulty attempted to remove the inner cannula. The resident coughed, and approximately two tablespoons of thick, yellow sputum spilled out of the [MEDICAL CONDITION]. Employee P stated that the resident needed to be suctioned first. She used the closed suction catheter technique and placed saline from a small unit dose container of saline into the resident's [MEDICAL CONDITION] using the port on the closed suction catheter. She suctioned the resident by advancing the closed catheter into the [MEDICAL CONDITION], and then applied intermittent suction while withdrawing the catheter. The resident coughed continuously during the suctioning, and the gurgling and sounds of fluid in the resident ' s lungs were audible in the room. Employee P confirmed that there was sputum moving in the suction catheter, and she stated that the suction appeared to be working. She removed the sterile gloves and re-sanitized her hands. She applied new sterile gloves again, and removed the inner cannula with some difficulty. The resident again coughed and approximately two tablespoons of thick, yellow sputum was expelled out of her [MEDICAL CONDITION] onto the paper that the sterile gloves came in. Employee P placed the inner cannula which appeared to be stained a deep yellow, into the tray that contained the peroxide and normal saline. She was observed to cleanse the inside and outside of the cannula utilizing the cleansing tool included in the sterile kit. She replaced the inner cannula into the [MEDICAL CONDITION] while the resident continued to cough violently and spewed thick creamy yellow sputum from her [MEDICAL CONDITION]. She replaced the t-piece that hooked onto the [MEDICAL CONDITION] into the tubing that the oxygen was connected to which appeared moist with condensation or mucous, and reattached the t-piece to the [MEDICAL CONDITION]. She cleansed the residents' skin that surrounded the [MEDICAL CONDITION] by using a saline soaked gauze sponge that she picked up from on top of the sterile barrier, and dipped into the saline solution in the tray. She did not apply another dressing around the [MEDICAL CONDITION], and left the area bare. (A review of the policy and procedure for [MEDICAL CONDITION] care dated 5/12 lists step #24: " Place 4x4 gauze dressing between the [MEDICAL CONDITION] and resident/patient ' s skin. " ) She discarded the remains of the [MEDICAL CONDITION] kit, and removed her gloves and washed her hands. Employee P stated that the [MEDICAL CONDITION] ties were recently changed and did not require changing. The [MEDICAL CONDITION] ties were observed to be in place without the presence of secretions on the ties. During an interview at approximately 6:30 p.m. Employee P confirmed that she had omitted placing the dressing around the [MEDICAL CONDITION] site and also confirmed that this was a part of [MEDICAL CONDITION] care, but that she intended to apply the dressing " later. " She also confirmed that sterile technique was difficult to follow for her. She also stated that Resident #32 had pneumonia. 8. A review of Resident #32 ' s medical record revealed that she was a fifty three year old woman that was originally admitted to the facility on [DATE]. Her medical [DIAGNOSES REDACTED]. A review of the last Minimum Data Set comprehensive quarterly assessment dated [DATE] revealed under Section O that she was receiving oxygen, suctioning and tracheal care. Further review of Resident #32 ' s record revealed a care plan dated 5/24/12 that listed a problem that stated, " Potential Complication: [MEDICAL CONDITION]/Infection secondary to [MEDICAL CONDITION]. Goals included that Resident #32 will maintain a patent [MEDICAL CONDITION] daily and the [MEDICAL CONDITION] will be free of infection through the next review. Interventions included: Regularly inspect and cleanse the [MEDICAL CONDITION], provide humidification of inspired air, monitor for signs and symptoms of respiratory distress, monitor for signs and symptoms of infection, ie. foul smelling sputum, discolored sputum, fever, bloody sputum, etc. and notify MD, oxygen at three liters [MEDICAL CONDITIONS] every six hours and as needed, and suction [MEDICAL CONDITION] every shift and as needed for respiratory distress. 9. Further review of Resident #32 ' s clinical record revealed portable chest x-ray results dated 5/5/12 that stated " perihilar pneumonia " (an atypical pneumonia located at the top of the respiratory tract) as the impression. The physician's order [REDACTED].[REDACTED]. She continued to receive the [MEDICATION NAME] through 6/8/12. A review of the vital signs that included temperatures revealed that there were no abnormal temperatures documented and it appeared that Resident #32 was not having fevers as a symptom of her pneumonia. However, further review revealed physician ' s progress notes dated 5/20/12 that revealed Resident #32 had an axillary temperature of 102.5, and had continued respiratory congestion and rubs on auscultation. Another physician ' s progress note dated 5/22/12 revealed that Resident #32 had a fever of 100.0 axillary, as reported by the nurse, had a pending culture and sensitivity for the thick greenish yellow mucus that was noted in the resident ' s [MEDICAL CONDITION], and continued on the [MEDICATION NAME] for the respiratory infection. Another physician ' s progress note dated 5/26/12 stated that the resident was doing better with her upper respiratory infection, but the cough continued that was productive of greenish mucus, and the sputum culture and sensitivity was to be re-collected. A review of the physician's order [REDACTED]. The results for all three specimens sent stated in the final report that the results suggested contamination, and therefore identification could not be made of the causative bacteria or the antibiotic that would be most effective against it. A review of the facility ' s infection control log stated that Resident #32 had infections requiring antibiotic therapy listed as " pneumonia " on 5/7/12 and " respiratory on 5/20/12. 10. On 6/8/12 at approximately 11:45 a.m., an interview was conducted with the Unit Manager of the 3rd floor, and Employee Q, who had stated that she was assigned as Resident #32 ' s nurse, and had frequently cared for her. The unit manager stated that the resident had not been running fevers, and this was confirmed on the vital signs flow sheet that she produced from the clinical record that listed the resident as having normal temperatures recorded. She could not give an explanation for the fevers that were documented on the physician ' s progress notes. She confirmed that the resident was diagnosed with [REDACTED]. She confirmed that the three sputum specimens that had been sent to the laboratory and were noted to be contaminated specimens. She pointed out the note at the bottom of the laboratory result form dated 5/3/12 that stated, " No further workup unless requested by physician. " She stated that she interpreted this

Based on interviews with administrative staff, review of administrative records, and facility policies, it was determined that; the Quality Assurance Committee failed to discuss areas of concern at the facility, review policies and procedures, and address the concerns or citations given following the 03/20/12 and 04/06/12 Agency for Health Care Administration Investigations or the 05/04/12 revisit to the surveys. The facility failed to implement resident care policies, and ensure coordination of medical care in the facility, for 5 (#30, 32, 19, 58 and 178) of 5 [MEDICAL CONDITION] residents reviewed which put the vulnerable residents at risk for physical complications and poor outcomes. The facility did not ensure Quality Assurance measures were effective and that [MEDICAL CONDITION] care was performed on residents #30 and #58 from the survey of 03/20/12, the same residents (#30 and #58) identified during the 5/4/12 Revisit conducted, nor the current survey beginning 6/5/12, reflecting a pattern of non-compliant practice for oversight and physical management of these vulnerable adults. The Quality Assurance Committee did not ensure that current [MEDICAL CONDITION] residents, #32, #19 and #178, as well as #30 and #58, had the equipment, supplies and/or trained staff to meet their needs. Failure of the Quality Assurance Committee to ensure that care concerns, including that of previously identified [MEDICAL CONDITION] problems, were consistently brought to the committee for review and resolution, resulted in findings of immediate jeopardy on 06/07/12, which was removed on 6/15/12 and reduced to the scope and severity of a " E. " Findings include: 1. During surveys of 3/20/2012 and 5/4/2012, the facility was cited at F 328 related to care of residents with tracheostomies. Review of the Facility's plan of correction for the Agency for Health Care Administration's report of 3/20/2012 for F 328 regarding concerns [MEDICAL CONDITION] included: "2. Resident's with tracheostomies receive MD [MEDICAL CONDITION] and docummentation. 3. Licensed staff re-educated on obtaining MD orders for [MEDICAL CONDITION] care and inputting of physician orders [REDACTED]. Quality monitoring tools will be reviewed with RM/QI committee monthly." During a follow-up visit conducted on 5/4/2012, the Agency determined that the facility was not in compliance with F 328, again for care of [MEDICAL CONDITION] residents. The facility plan of correction for that visit included: "2. Residents receive [MEDICAL CONDITION] services using sterile technique. Unit managers inform nurses when resident tube feeding is stopped for patient care. 3. Licensed staff re-educated on sterile technique related to [MEDICAL CONDITION] care and communication related to tube feeding. 4. DCS/Designee to conduct random Quality monitoring of resident [MEDICAL CONDITION] care to ensure sterile technique and residents with tube feeding to ensure proper run time. Quality monitoring tools to be reviewed by RM/QI committee monthly." 2. Review of "Quality Improvement Data Form" submitted by the facility and covering the period form 3/20/2012 to 5/2/12 included at least two varieties. The "Quality Improvement Data Form" for F 328 included the criteria of: Patient has physician orders; MD orders confirmed; oxygen at appropriate level;[MEDICAL CONDITION] as ordered;[MEDICAL CONDITION] provided as ordered; oxygen sats within normal limits; and absent signs/symptoms of infection." The "Performance Improvement Q/I Monitor form" included criteria such as:[MEDICAL CONDITION] MD order;[MEDICAL CONDITION] TAR;[MEDICAL CONDITION] on MD order;[MEDICAL CONDITION] on TAR; foleys on MD order; foleys on Tar; MD notified of change in condition; and Bed mobility, bathing, and care documented on ADL Flowsheet." 3. An entrance conference was conducted with the Administrator and Administrator in Training (AIT) on 06/05/12 at 9:18 a.m. The sign in sheets for the last year of Quality Assurance (QA) Meeting were requested. In an interview with the Administrator 06/07/12 at 2:15 p.m., the facility was informed that the documentation provided was not clear as to determining if the required meetings had been conducted. Later on 6/7/2012, the Administrator in Training brought the minutes of the QA meeting for 2011 in a large binder with tabs for each month. In the presence of the AIT, the tabs starting with 6/11 were reviewed. The typed list of attendees was reviewed for Administrator, Director of Nursing and Medical Director and at least three other attendees. Attendees list and other documentation indicated that a QA meeting had been held 6/11, 7/11, 8/11 and 9/11. The tabs for 10/11, 11/11 and 12/11, however, were empty. 4. In an interview with the Medical Director by phone 06/09/12 at 9:42 a.m., he stated that he attended the QA meeting quarterly and that he had attended one such meeting 2 months ago (April 2012). When questioned about the continued noncompliance by the facility since 03/20/12 on aspects of [MEDICAL CONDITION] care that was identified during an AHCA survey of that date, he stated he was not aware of the noncompliance or any issues with [MEDICAL CONDITION] care. 5. In an interview with the Administrator 06/09/12 at 10:55 a.m., a further inquiry was made into proof or documentation of QA meetings for the last quarter of 2011 and the first 2 quarters of 2012. The administrator stated that the QA meetings were held the second Wednesday of each month and that the next meeting for the 2nd quarter was to be held 06/13/12, and that they would look for documentation of a first quarter meeting. The Administrator in Training later presented an announcement for the June meeting from the Administrator, with sign in sheets for the meetings from 1/12 through 4/12. 6. In an interview with the AIT 06/09/12 at 3:08 p.m. further documentation was offered which consisted of two one page spreadsheets outlining QA meetings. It was said that the March 2012 meeting was for February concerns and the April meeting was for March concerns. There was no May meeting spreadsheet for April concerns and the scheduled June meeting would be for May concerns. There was a section for the Medical Director on the two forms presented for (March 2012 and April 2010) which stated no recommendations for changes in policies or procedures and another section without any recommendations for plan of correction or plan of care implementation changes. 7. Observations and record review of 5 (#30, 32, 19, 58 and 178) of 5 [MEDICAL CONDITION] residents revealed that none of the five had had the [MEDICAL CONDITION] changed according to facility policy, procedure and current standards of care. (Lippincott 2012). Inadequate care of residents with [MEDICAL CONDITION] that enables them to breathe is directly related to respiratory infection, [MEDICAL CONDITION], and death. Two of these residents # 30 and # 58 (#'s 4 and 6 on the 3/20/12 Investigation and 3's 2 and 4 on the 4/6/12 investigation) were found to have inadequate care with breaks in infection control on the initial investigations. These issues were revisited on 05/04/12 and the issues were found to be uncorrected with new observations of care concerns and issues with infection control. This survey, ending 06/15/12, with second revisits in conjunction, found these residents and the expanded sample of all current [MEDICAL CONDITION] residents with on-going and heightened concerns in the delivery of care, staff training and competency issues and concerns with infection control. The facility has not been in compliance with the regulatory requirements at F 328 since 3/20/2012 as demonstrated by the following current findings of non-compliance: a. On 6/7/12 at approximately 9:05 a.m. the surveyor knocked and entered Resident #32's room. Audible gurgling and rattling sounds were heard, and a closer inspection revealed that the sounds were coming from Resident #32 s breathing through her [MEDICAL CONDITION]. There was thick, yellow mucous bubbling up from the [MEDICAL CONDITION] with each breath. Additionally, thick, yellow mucous was noted to have accumulated in the [MEDICAL CONDITION] oxygen mask. Humidified oxygen at 3 liters per minute was attached to an oxygen concentrator. Resident #32 coughed, and more mucous came up from the [MEDICAL CONDITION]. Employee #B who identified herself as being the nurse that was assigned to this resident, was present at the bedside. She stated that she had just suctioned the resident. She confirmed that the resident appeared to have a large amount of secretions that continued to be coughed out of her [MEDICAL CONDITION], and that there was gurgling present with her respiratory effort. She stated, "But, it stresses her to be suctioned," and indicated that she did not think that it would be appropriate to suction again. Approximately one minute later, the nurse did suction the resident again, after both the surveyor and the nurse observed the resident attempting to clear her own airway and coughing up approximately several tablespoons of sputum. The resident was able to clear some sputum from her [MEDICAL CONDITION] by coughing, but the remainder of the sputum was observed to have aspirated back into the resident's airway. Employee B used the closed catheter system, but it did not appear that the secretions were removed with each pass of the suction catheter. More secretions continued to be coughed up around the [MEDICAL CONDITION] site as the resident coughed violently with spastic movements while the apparently ineffective suction catheter was reintroduced into her airway again and again. Employee B stated that she thought the suction was functional, although the mucous was observed not to be moving in the suction catheter. At approximately 9:10 a.m., the Director of Nursing (DON) appeared in the room. He attempted to suction the resident immediately using the closed suction system, and agreed that the secretions did not appear to be clearing when suctioned. He turned the suction gauge to the maximum limit, and confirmed that there still continued to be no suction. He stated that he would change the catheter tubing. At 9:15 a.m. the DON stated that the suction hose had come loose from the canister lid and that is why there was no suction. He stated that he had detected the problem and it was now resolved. At 9:20 a.m. a repeat observation was done of the resident and she was lying supine in her bed with the head of the bed raised approximately 30 degrees. There was no further gurgling noted with her respirations and there were no further secretions noted coming from her [MEDICAL CONDITION]. b. A review of Resident #32's medical record revealed that she was a fifty three year old woman that was originally admitted to the facility on [DATE]. Her medical [DIAGNOSES REDACTED]. A review of the last Minimum Data Set comprehensive quarterly assessment dated [DATE] revealed under Section O that she is receiving oxygen, suctioning and tracheal care. Further review of Resident #32's record revealed a care plan dated 5/24/12 that listed a problem that stated, "Potential Complication: [MEDICAL CONDITION]/Infection secondary to [MEDICAL CONDITION]. Goals included that Resident #32 will maintain a patent [MEDICAL CONDITION] daily and the [MEDICAL CONDITION] will be free of infection through the next review. Interventions included: Regularly inspect and cleanse the [MEDICAL CONDITION], provide humidification of inspired air, monitor for signs and symptoms of respiratory distress, monitor for signs and symptoms of infection, ie. foul smelling sputum, discolored sputum, fever, bloody sputum, etc. and notify MD, oxygen at three liters [MEDICAL CONDITIONS] every six hours and as needed, and suction [MEDICAL CONDITION] every shift and as needed for respiratory distress. c. On 6/7/12 at 10:10 a.m. an interview was conducted with Employee B and the Director or Nursing (DON). Employee B was asked to describe how she knew when a resident required suctioning and she replied, "Usually they will have some gurgling, you can hear it most of time, and if there is gook around the trach, then I would suction per order and the protocol." She confirmed that Resident #32 had orders to suction her [MEDICAL CONDITION] as needed. She further stated that around 9:00 a.m. on 6/7/12, she went in to Resident #32's room to take down her breathing treatment, and noted that she did require suctioning. She stated, "I listened to her sounds, then I suctioned her. She had some white frothy secretions." She confirmed that the suction was not effective when she attempted to suction the resident when the surveyor was present. The DON stated that he had been told that he was needed in room [ROOM NUMBER], and immediately came to the room. He stated further, "When I got there I tried to suction her as well. I noticed that when I went in, I wasn't getting any suction. I thought that I was getting a small amount, but she was having some frothy sputum that continued to come up." He also stated that he after he looked at the suction set up, he noticed that one of the hoses was not connected to the suction canister's lid properly. When he reattached it, he was able to suction Resident #32's airway effectively. Employee B confirmed that she called the DON when the noticed there seemed to be a problem with the suction. Employee B was asked how the facility ensured that the suction machines and set-ups are functional, and she replied that the Central Supply Coordinator makes rounds every day to check the suction. The DON stated that there was no log that he was aware of that documented checking the function and maintenance of the respiratory and suction equipment. d. On 6/7/12 at approximately 10:35 a.m. an observation was made of the suction equipment in Resident #32's room. The suction machine was resting on the bedside table. It had a thick, dusty coating on the base, and was stained on the right side with yellowish-white dried drainage. There was no tag, label or sticker that listed when the machine was last inspected or serviced. e. On 6/7/12 at approximately 10:50 a.m., an interview was conducted with Employee R. She stated that she is a certified nurse assistant, but works as the facility's central supply coordinator. She confirmed that she makes rounds every day on the equipment and supplies that are located within the resident's rooms. She stated that when she checked Resident #32's room this morning, the suction set up was functional. She also stated that she is responsible for cleaning and disinfecting the equipment every day. She stated, "I maintain them, and I clean them." When asked what she does if a machine is not working properly, she stated that if she cannot fix the problem herself, then "they get tossed, and I get a new one." f. On 6/7/12 at 5:50 p.m., [MEDICAL CONDITION] care was observed for Resident #32. Employee P, the licensed practical nurse (LPN) that was assigned to Resident #32 for the 3:00 p.m. to 11:00 p.m. shift was observed washing her hands and assembling supplies that included: mask, gown, clean gloves, sterile gloves, paper towels, hand sanitizer and a [MEDICAL CONDITION] care kit. Employee B also entered the room and stated that she would assist Employee P as per the instructions from the DON. Employee B also washed her hands and put on clean gloves. The resident continued to be on oxygen per concentrator at 3 liters per minute. They positioned the resident into a semi-fowlers position by raising the head of the bed. Employee P washed her hands again and placed the paper towels on the over bed table. She applied a pulse oximeter to Resident #32's finger to obtain a reading for the resident's oxygen saturation. She stated that the saturation was low at 88%. Employee B stated that she had to put the oximeter on the residents thumb in order to get better contact. The oximeter was repositioned as directed by Employee B. The saturation then increased to an acceptable 94%. Employee P sanitized her hands and put on sterile gloves. She picked up the [MEDICAL CONDITION] kit (the outside being non-sterile and thus breaking sterile technique) and opened the kit and dumped the sterile contents out onto the unsterile paper towels. She then stated, "I should have done this first," and removed and discarded the sterile gloves and then put on another pair of sterile gloves. She then pulled open the drawer on the nightstand, again breaking sterile technique, and removed a container of solution. She was asked to identify what was in the container, and she said, "it's the saline." Employee B interjected and stated, "We are supposed to use the saline that's in [MEDICAL CONDITION]." The container that was removed from the drawer was inspected and labeled as normal saline, expiration date 1/14,and had been previously opened with approximately 25% of the liquid still present. There was no resident's name or date that it had been opened recorded on the container. Employee B confirmed that sterile normal saline is used to cleanse the inner cannula of the [MEDICAL CONDITION]. The policy and procedure for [MEDICAL CONDITION] care dated 5/12 under step #12 stated, "Separate 4x4 gauze and pour sterile water or saline over gauze into one container, and step 13# stated "Pour normal saline into second sterile container for rinsing." Employee B confirmed that using the previously opened, undated and unlabeled container of saline would not have been consistent with sterile technique for cleansing the non-disposable inner cannula which is inserted directly into the Resident #32's trachea, had Employee P been allowed to continue. Employee P stated that she needed more supplies, and she discarded the opened [MEDICAL CONDITION] kit, removed her gloves, and both nurses left the room. They returned at approximately 6:00 p.m., and Employee P stated that she had reviewed the policy for [MEDICAL CONDITION] care. She washed her hands again and opened the [MEDICAL CONDITION] kit by peeling back the top lid, and setting the tray on the over bed table. She placed a sterile barrier on the over-bed table next to the tray, and then picked up the tray and dumped the sterile contents onto the sterile barrier. Then she placed the tray on the sterile barrier that had been resting on the over-bed table, thus contaminating the sterile field. She opened sterile gloves and put them on, and then placed the paper that the sterile gloves were packaged in underneath the resident's [MEDICAL CONDITION] on her chest. She poured the saline solution and the package of peroxide into the tray. She removed the gauze sponge that was placed around t-piece from the [MEDICAL CONDITION] and with some difficulty attempted to remove the inner cannula. The resident coughed, and approximately two tablespoons of thick, yellow sputum spilled out of the [MEDICAL CONDITION]. Employee P stated that the resident needed to be suctioned first. She used the closed suction catheter technique and placed saline from a small unit dose container of saline into the resident's [MEDICAL CONDITION] using the port on the closed suction catheter. She suctioned the resident by advancing the closed catheter into the [MEDICAL CONDITION], and then applied intermittent suction while withdrawing the catheter. The resident coughed continuously during the suctioning, and the gurgling and sounds of fluid in the resident's lungs were audible in the room. Employee P confirmed that there was sputum moving in the suction catheter, and she stated that the suction appeared to be working. She removed the sterile gloves and re-sanitized her hands. She applied new sterile gloves again, and removed the inner cannula with some difficulty. The resident again coughed and approximately two tablespoons of thick, yellow sputum was expelled out of her [MEDICAL CONDITION] onto the paper that the sterile gloves came in. Employee P placed the inner cannula which appeared to be stained a deep yellow, into the tray that contained the peroxide and normal saline. She was observed to cleanse the inside and outside of the cannula utilizing the cleansing tool included in the sterile kit. She replaced the inner cannula into the [MEDICAL CONDITION] while the resident continued to cough violently and spewed thick creamy yellow sputum from her [MEDICAL CONDITION]. She replaced the t-piece that hooked onto the [MEDICAL CONDITION] into the tubing that the oxygen was connected to which appeared moist with condensation or mucous, and reattached the t-piece to the [MEDICAL CONDITION]. She cleansed the residents' skin that surrounded the [MEDICAL CONDITION] by using a saline soaked gauze sponge that she picked up from on top of the sterile barrier, and dipped into the saline solution in the tray. She did not apply another dressing around the [MEDICAL CONDITION], and left the area bare. A review of the policy and procedure for [MEDICAL CONDITION] care dated 5/12 lists step #24: "Place 4x4 gauze dressing between the [MEDICAL CONDITION] and resident/patient's skin." She discarded the remains of the [MEDICAL CONDITION] kit, and removed her gloves and washed her hands. Employee P stated that the [MEDICAL CONDITION] ties were recently changed and did not require changing. The [MEDICAL CONDITION] ties were observed to be in place without the presence of secretions on the ties. During an interview at approximately 6:30 p.m. Employee P confirmed that she had omitted placing the dressing around the [MEDICAL CONDITION] site and also confirmed that this was a part of [MEDICAL CONDITION] care, but that she intended to apply the dressing "later." She also confirmed that sterile technique was difficult to follow for her. She also stated that Resident #32 had pneumonia. Further review of Resident #32's clinical record revealed portable chest x-ray results dated 5/5/12 that stated "perihilar pneumonia" as the impression. The physician's orders [REDACTED].[REDACTED]. She continued to receive the [MEDICATION NAME] through 6/8/12. A review of the vital signs that included temperatures revealed that there were no abnormal temperatures documented and it appeared that Resident #32 was not having fevers as a symptom of her pneumonia. However, further review revealed physician's progress notes dated 5/20/12 that revealed Resident #32 had an axillary temperature of 102.5, and had continued respiratory congestion and rubs on auscultation. Another physician's progress note dated 5/22/12 revealed that Resident #32 had a fever of 100.0 axillary, as reported by the nurse, had a pending culture and sensitivity for the thick greenish yellow mucus that was noted in the resident ' s [MEDICAL CONDITION], and continued on the [MEDICATION NAME] for the respiratory infection. Another physician's progress note dated 5/26/12 stated that the resident was doing better with her upper respiratory infection, but the cough continued that was productive of greenish mucus, and the sputum culture and sensitivity was to be re-collected. A review of the physician's orders [REDACTED]. The results for all three specimens sent stated in the final report that the results suggested contamination, and therefore identification could not be made of the causative bacteria or the antibiotic that would be most effective against it. A review of the facility's infection control log stated that Resident #32 had infections requiring antibiotic therapy listed as "pneumonia" on 5/7/12, and "respiratory" on 5/20/12. g. On 6/8/12 at approximately 11:45 a.m., an interview was conducted with the Unit Manager of the 3rd floor, and Employee Q, who had stated that she was assigned as Resident #32's nurse, and had frequently cared for her. The unit manager stated that the resident had not been running fevers, and this was confirmed on the vital signs flow sheet that she produced from the clinical record that listed the resident as having normal temperatures recorded. She could not give an explanation for the fevers that were documented on the physician's progress notes. She confirmed that the resident was diagnosed with [REDACTED]. She confirmed that the three sputum specimens that had been sent to the laboratory and were noted to be contaminated specimens. She pointed out the note at the bottom of the laboratory result form, dated 5/3/12 that stated, "No further workup unless requested by physician." She stated that she interpreted this to mean no further specimens needed to be sent. Employee Q stated that she had sent at least one of the sputum specimens. She stated that she did not know how to collect a sputum specimen from a [MEDICAL CONDITION], and she had asked the DON and the ADON. She stated that a "lady doctor" that was present in the facility told her that a "Luky-tube" was required, and that she needed to get a "deep suction" and that the laboratory could provide the "Luky-tube." She stated that she called the laboratory, but was told that they did not supply the container. She stated that she told management of the need for the specialized container, but no one had been successful in obtaining the proper container required for the specimen. She stated that she had collected, and sent to the lab, the sputum that had been coughed up around the Resident #32's [MEDICAL CONDITION], since the laboratory would not deliver the proper container and there seemed to be no way to get them. She stated that when she spoke with the physician who was the consulting pulmonologist on 6/6/12, he gave a verbal order to discontinue the sputum specimen and stated he would collect it when he returned to change the [MEDICAL CONDITION]. h. In an interview with the consulting Pulmonologist on 6/8/12 at 3:30 p.m. he stated that he had been consulting on [MEDICAL CONDITION] residents at this facility for approximately one month. He stated that he is strictly a consultant and was not paid by the facility. He stated that he became involved with the facility when he noted nursing home residents having frequent readmissions to the hospital, and he thought if they were to receive appropriate care in the nursing homes, then readmissions could be reduced. He stated that he was under the impression that the facility was going to have the services of a respiratory therapy company beginning 6/1/12, as this is what he was told by management, but stated that he discovered this had been delayed. He stated that he has had some concerns regarding the respiratory care that has been provided at the facility. He stated that he has a respiratory therapist that has provided an in-service to the nursing staff on proper suctioning in the facility. He stated that Resident #32 had a large amount of secretions from her lungs, and required a cuffed [MEDICAL CONDITION] to control her extensive secretions in order to prevent her from acquiring aspiration pneumonia. He stated that this type of [MEDICAL CONDITION] was not what was in place. He stated that he verbally requested a Shiley cuffed [MEDICAL CONDITION] #8 on May 30 when he made rounds, and had planned to change the [MEDICAL CONDITION] on 6/6/12, but when he arrived to the facility, they had not ordered the proper [MEDICAL CONDITION] that had a cuff. He stated that he re-requested the cuffed [MEDICAL CONDITION] again on 6/6/12 that would have a cuff to aid in the control of the resident's secretions. He stated that he felt that the resident did have an underlying infection, but the sputum specimens that were sent were contaminated specimens. He confirmed that he did not know that the facility did not have the proper Lukens trap containers that is required to collect a proper specimen, and was unaware that the sputum specimens had been collected improperly by not using sterile technique. He confirmed that sputum specimens from a [MEDICAL CONDITION] should be collected using this type of container, so that a specimen could be obtained for an accurate culture and sensitivity, and the proper antibiotic could be prescribed for the best chance at complete eradication of the infection. He denied giving a verbal order to discontinue the sputum culture and sensitivity and that he would obtain one when he changed the tube. He stated that [MEDICAL CONDITION] should be changed frequently to keep an open airway, and for infection control, and he suggested the change should be done every one to three months. i. On 6/8/12 at approximately 3:50 p.m. an interview was conducted with the DON. He confirmed that a consulting pulmonologist was making rounds on the residents with advanced respiratory care needs including residents with tracheostomies. He stated that he was aware that this physician had ordered a [MEDICAL CONDITION] with a cuff for Resident #32, and also that the facility did not stock them. He stated that the [MEDICAL CONDITION] with a cuff had been ordered. He also confirmed that [MEDICAL CONDITION] should be changed regularly. He provided a policy and procedure dated 03/12 that revealed under policy: "[MEDICAL CONDITION] are changed regularly to decrease the possibility of infection and to maintain a patent airway." He confirmed that there were no respiratory therapy (RT) services currently in the facility, but there was a contact pending with Company A for additional supplies, education and possible labor. He stated that the contract was supposed to have been effective June 1, 2012, but there was a delay, and he did not know the reason for the delay. He stated that in the past the facility had a part time RT on staff, but that position was deleted in November of 2011. He stated that the nursing staff had been solely responsible for advanced respiratory care including [MEDICAL CONDITION] care, suctioning and collection of sputum specimens. He confirmed that he was aware that there were no Lukens sputum collection devices in the facility, and he understood that this was necessary to be able to collect a proper specimen for a sputum culture and sensitivity. He stated that he called the respiratory company that the contract was going to be with, but they could not supply the Lukens containers because the contract had not yet been signed. He stated that he also called the laboratory, and they could not provide them either. He stated that he was working with another supplier currently to get the containers. He stated that the consulting pulmonologist had allowed the facility to "use his RT" to provide as a resource for the nursing staff when providing care to residents with tracheostomies. He stated that this RT was in the facility once a few weeks ago, and gave an in-service on tracheal suctioning and care. He stated that the facility does not keep competency skills checklists for the nurses to determine what additional training that they may need to deliver care to the residents. A list of all currently employed nurses that would be considered able to care for residents with [MEDICAL CONDITION] in place was requested. The ADON provided the list, and 39 nurses were identified. He was aware of the problems involving Employee B and Employee P during the observations of Resident #32 on 6/7/12 and stated that these two employees would not be providing care for residents with tracheostomies until they had been sufficiently re-trained. j. On 6/9/12 at approximately 9:42 a.m., an interview was conducted with the Medical Director who stated that he was not aware of the continued non-compliance regarding [MEDICAL CONDITION] care since 3/20/12. He stated that he did attend a Quality Assurance meeting a few months back, but did not recall discussing advanced respiratory care for the residents. He confirmed that [MEDICAL CONDITION] have not been routinely changed for the residents at the facility. He stated that "sometimes the least that is done invasively is better" for the residents. He pointed out that Resident #32 has a poor prognosis and is at risk for infection related to her co-morbidities. He confirmed that [MEDICAL CONDITION] should be changed periodically because maintaining an open airway and infection control should always be a priority regardless of the individual's prognosis. He also confirmed that the equipment such as the Lukens trap containers should be present and available in the facility. k. On 6/1

Based on interviews with administrative staff, review of administrative records, and facility policies, it was determined that the Quality Assurance Committee failed to demonstrate an effective system to implement plans of action to correct identified quality deficiencies following the survey of 4/6//12 as well as the follow-up survey of 5/4/2012, and which resulted in an increase in the severity and scope of findings to Immediate Jeopardy during the survey ending 6/15/2012. During the survey ending on 6/15/2012, the facility failed to ensure the prevention of infection for twelve (#19,#30,#32,#58,#178,#1001,#193,#20,#79,#137,#210,#63)out of twenty residents related to a failure to provide regular [MEDICAL CONDITION] exchanges, [MEDICAL CONDITION] care and suctioning using aseptic technique, wound care using aseptic technique, and the cleaning, disinfecting and maintaining of respiratory equipment according to policy and procedure. The lack of an effective Quality Assurance plan resulted in findings of immediate jeopardy, which placed vulnerable residents at continued risk and was removed on 6/15/12 and reduced to the scope and severity of a "E." Findings include: 1. During a survey on 4/6/2012, F 441 was identified related to care concerns with infection control. The facility prepared a plan of correction which included the following measures: " Residents ___ and ___ had dressing changes with appropriate infection control technique; Residents with wounds receive care with appropriate infection control technique; licensed staff re-educated infection control technique during wound care; and DNS/Designee to conduct random quality monitoring of infection control technique during wound care. Quality monitoring tools to be reviewed with RM/QI committee monthly." During a 5/4/2012 revisit, the facility was, again, not found in substantial compliance with the infection control requirement and prepared a plan of correction which included the following: "Residents # _________ and ___________ were assessed and had no adverse outcomes; Residents receive [MEDICAL CONDITION] services utilizing sterile technique; Licensed staff re-educated on sterile technique related to [MEDICAL CONDITION] care; and DCS/Designee to conduct random Quality Monitoring of resident [MEDICAL CONDITION] care to ensure sterile technique utilized. Qualtiy monitoring tools to be reviewed by RM/QI committee monthly." 2. Review of "Performance Improvement Q/I Monitor Form" offered by the facility for review, found that one such form which included a reference to "signs and symptoms of infection reported as change in condition." There was no specific reference on the form to following infection control measures as they related to residents with a [MEDICAL CONDITION] and no specific information captured related to those residents. 3. On 6/12/12 at approximately 1:10 p.m. an interview was conducted with the administrator and the administrative assistant. When asked if he was aware of the citations involving deficient practice related to [MEDICAL CONDITION] care 3/20/12 and the re-visit that did not result in correction, he stated, "As far as I'm concerned, the facility is in compliance." He did confirm that he was aware of "a few complaints and a few re-visits that were due." He confirmed that it was a component of his administrative duties to be in compliance with CMS. He stated that he was aware of a plan of correction and that a "four point plan" had been developed, but there had been no discussion regarding resuming respiratory therapy services. He acknowledged the problems with the delayed contract for respiratory equipment and supplies that impeded the facility's procurement of respiratory related supplies which included the inability to obtain the Lukens trap containers. He stated that he was not aware of any recommendations that had been made to the facility regarding respiratory equipment and supplies by Respiratory Company A. The administrative assistant stated that she attended a Quality Assurance meeting a few months back, and the Medical Director was present, but she could not recall [MEDICAL CONDITION] care or suctioning techniques being discussed. 4. In an interview with the Medical Director by phone 06/09/12 at 9:42 a.m., he stated that he attended the QA meeting quarterly and that he had attended one such meeting 2 months ago (April 2012). When questioned about the continued noncompliance by the facility since 03/20/12 on aspects of [MEDICAL CONDITION] care that was identified during an AHCA survey, he stated he was not aware of the noncompliance or any issues with [MEDICAL CONDITION] care. 5. As a result of the survey ending 6/15/2012, the facility was identified with on-going non-compliance with an increase in severity and scope as denoted by the current finding: a. A review of Resident #32's medical record revealed that she was a fifty three year old woman that was originally admitted to the facility on [DATE]. Her medical [DIAGNOSES REDACTED]. A review of the last Minimum Data Set comprehensive quarterly assessment dated [DATE] revealed under Section O that she was receiving oxygen, suctioning and tracheal care. Further review of Resident #32's record revealed a care plan dated 5/24/12 that listed a problem that stated, "Potential Complication: [MEDICAL CONDITION]/Infection secondary to [MEDICAL CONDITION]. Goals included that Resident #32 will maintain a patent [MEDICAL CONDITION] daily and the [MEDICAL CONDITION] will be free of infection through the next review. Interventions included: Regularly inspect and cleanse the [MEDICAL CONDITION], provide humidification of inspired air, monitor for signs and symptoms of respiratory distress, monitor for signs and symptoms of infection, ie. foul smelling sputum, discolored sputum, fever, bloody sputum, etc. and notify MD, oxygen at three liters [MEDICAL CONDITIONS] every six hours and as needed, and suction [MEDICAL CONDITION] every shift and as needed for respiratory distress. b. On 6/7/12 at approximately 10:35 a.m. an observation was made of the suction equipment in Resident #32's room. The suction machine was resting on the bedside table. It had a thick, dusty coating on the base, and was stained on the right side with yellowish-white dried drainage. There was no tag, label or sticker that listed when the machine was last inspected or serviced. c. On 6/7/12 at 5:50 p.m., [MEDICAL CONDITION] care was observed for Resident #32. Employee P, the licensed practical nurse (LPN) that was assigned to Resident #32 for the 3:00 p.m. to 11:00 p.m. shift was observed washing her hands and assembling supplies that included: mask, gown, clean gloves, sterile gloves, paper towels, hand sanitizer and a [MEDICAL CONDITION] care kit. Employee B also entered the room and stated that she would assist Employee P as per the instructions from the DON. Employee B also washed her hands and put on clean gloves. The resident continued to be on oxygen per concentrator at 3 liters per minute. They positioned the resident into a semi-fowlers position by raising the head of the bed. Employee P washed her hands again and placed the paper towels on the over bed table. She applied a pulse oximeter to Resident #32's finger to obtain a reading for the resident's oxygen saturation. She stated that the saturation was low at 88%. Employee B stated that she had to put the oximeter on the residents thumb in order to get better contact. The oximeter was repositioned as directed by Employee B. The saturation then increased to an acceptable 94%. Employee P sanitized her hands and put on sterile gloves. She picked up the [MEDICAL CONDITION] kit (the outside being non-sterile and thus breaking sterile technique) and opened the kit and dumped the sterile contents out onto the unsterile paper towels. She then stated, "I should have done this first," and removed and discarded the sterile gloves and then put on another pair of sterile gloves. She then pulled open the drawer on the nightstand, again breaking sterile technique, and removed a container of solution. She was asked to identify what was in the container, and she said, "It's the saline." Employee B interjected and stated, "We are supposed to use the saline that's in [MEDICAL CONDITION]." The container that was removed from the drawer was inspected and labeled as normal saline, expiration date 1/14,and had been previously opened with approximately 25% of the liquid still present. There was no resident's name or date that it had been opened that was recorded on the container. Employee B confirmed that sterile normal saline is used to cleanse the inner cannula of the [MEDICAL CONDITION]. (The policy and procedure for [MEDICAL CONDITION] care dated 5/12 under step # 12 stated, "Separate 4x4 gauze and pour sterile water or saline over gauze into one container, and step 13# stated "Pour normal saline into second sterile container for rinsing.") Employee B confirmed that using the previously opened, undated and unlabeled container of saline would not have been consistent with sterile technique for cleansing the non-disposable inner cannula which is inserted directly into the Resident #32's trachea, had Employee P been allowed to continue. Employee P stated that she needed more supplies, and she discarded the opened [MEDICAL CONDITION] kit, removed her gloves, and both nurses left the room. They returned at approximately 6:00 p.m., and Employee P stated that she had reviewed the policy for [MEDICAL CONDITION] care. She washed her hands again and opened the [MEDICAL CONDITION] kit by peeling back the top lid, and setting the tray on the over bed table. She placed a sterile barrier on the over-bed table next to the tray, and then picked up the tray and dumped the sterile contents onto the sterile barrier. Then she placed the tray on the sterile barrier that had been resting on the over-bed table, thus contaminating the sterile field. She opened sterile gloves and put them on, and then placed the paper that the sterile gloves were packaged in underneath the resident's [MEDICAL CONDITION] on her chest. She poured the saline solution and the package of peroxide into the tray. She removed the gauze sponge that was placed around t-piece from the [MEDICAL CONDITION] and with some difficulty attempted to remove the inner cannula. The resident coughed, and approximately two tablespoons of thick, yellow sputum spilled out of the [MEDICAL CONDITION]. Employee P stated that the resident needed to be suctioned first. She used the closed suction catheter technique and placed saline from a small unit dose container of saline into the resident's [MEDICAL CONDITION] using the port on the closed suction catheter. She suctioned the resident by advancing the closed catheter into the [MEDICAL CONDITION], and then applied intermittent suction while withdrawing the catheter. The resident coughed continuously during the suctioning, and the gurgling and sounds of fluid in the resident's lungs were audible in the room. Employee P confirmed that there was sputum moving in the suction catheter, and she stated that the suction appeared to be working. She removed the sterile gloves and re-sanitized her hands. She applied new sterile gloves again, and removed the inner cannula with some difficulty. The resident again coughed and approximately two tablespoons of thick, yellow sputum was expelled out of her [MEDICAL CONDITION] onto the paper that the sterile gloves came in. Employee P placed the inner cannula which appeared to be stained a deep yellow, into the tray that contained the peroxide and normal saline. She was observed to cleanse the inside and outside of the cannula utilizing the cleansing tool included in the sterile kit. She replaced the inner cannula into the [MEDICAL CONDITION] while the resident continued to cough violently and spewed thick creamy yellow sputum from her [MEDICAL CONDITION]. She replaced the t-piece that hooked onto the [MEDICAL CONDITION] into the tubing that the oxygen was connected to which appeared moist with condensation or mucous, and reattached the t-piece to the [MEDICAL CONDITION]. She cleansed the residents' skin that surrounded the [MEDICAL CONDITION] by using a saline soaked gauze sponge that she picked up from on top of the sterile barrier, and dipped into the saline solution in the tray. She did not apply another dressing around the [MEDICAL CONDITION], and left the area bare. (A review of the policy and procedure for [MEDICAL CONDITION] care dated 5/12 lists step #24: "Place 4x4 gauze dressing between the [MEDICAL CONDITION] and resident/patient's skin.") She discarded the remains of the [MEDICAL CONDITION] kit, and removed her gloves and washed her hands. Employee P stated that the [MEDICAL CONDITION] ties were recently changed and did not require changing. The [MEDICAL CONDITION] ties were observed to be in place without the presence of secretions on the ties. During an interview at approximately 6:30 p.m. Employee P confirmed that she had omitted placing the dressing around the [MEDICAL CONDITION] site and also confirmed that this was a part of [MEDICAL CONDITION] care, but that she intended to apply the dressing "later." She also confirmed that sterile technique was difficult to follow for her. She also stated that Resident #32 had pneumonia. d. Further review of Resident #32's clinical record revealed portable chest x-ray results dated 5/5/12 that stated "perihilar pneumonia" (an atypical pneumonia located at the top of the respiratory tract) as the impression. The physician's orders [REDACTED].[REDACTED]. She continued to receive the [MEDICATION NAME] through 6/8/12. A review of the vital signs that included temperatures revealed that there were no abnormal temperatures documented and it appeared that Resident #32 was not having fevers as a symptom of her pneumonia. However, further review revealed physician's progress notes dated 5/20/12 that revealed Resident #32 had an axillary temperature of 102.5, and had continued respiratory congestion and rubs on auscultation. Another physician's progress note dated 5/22/12 revealed that Resident #32 had a fever of 100.0 axillary, as reported by the nurse, had a pending culture and sensitivity for the thick greenish yellow mucus that was noted in the resident's [MEDICAL CONDITION], and continued on the [MEDICATION NAME] for the respiratory infection. Another physician's progress note dated 5/26/12 stated that the resident was doing better with her upper respiratory infection, but the cough continued that was productive of greenish mucus, and the sputum culture and sensitivity was to be re-collected. A review of the physician's orders [REDACTED]. The results for all three specimens sent stated in the final report that the results suggested contamination, and therefore identification could not be made of the causative bacteria or the antibiotic that would be most effective against it. A review of the facility's infection control log stated that Resident #32 had infections requiring antibiotic therapy listed as "pneumonia" on 5/7/12 and "respiratory" on 5/20/12. e. On 6/8/12 at approximately 11:45 a.m., an interview was conducted with the Unit Manager of the 3rd floor, and Employee Q, who had stated that she was assigned as Resident #32's nurse, and had frequently cared for her. The unit manager stated that the resident had not been running fevers, and this was confirmed on the vital signs flow sheet that she produced from the clinical record that listed the resident as having normal temperatures recorded. She could not give an explanation for the fevers that were documented on the physician's progress notes. She confirmed that the resident was diagnosed with [REDACTED]. She confirmed that the three sputum specimens that had been sent to the laboratory and were noted to be contaminated specimens. She pointed out the note at the bottom of the laboratory result form dated 5/3/12 that stated, "No further workup unless requested by physician." She stated that she interpreted this to mean no further specimens needed to be sent. Employee Q stated that she had sent at least one of the sputum specimens. She stated that she did not know how to collect a sputum specimen from a [MEDICAL CONDITION], and she had asked the DON and the ADON. She stated that a "lady doctor" that was present in the facility told her that a "Luky-tube" was required, and that she needed to get a "deep suction" and that the laboratory could provide the "Luky-tube." She stated that she called the laboratory, but was told that they did not supply the container. She stated that she told management of the need for the specialized container, but no one had been successful in obtaining the proper container required for the specimen. She stated that she had collected, and sent to the lab, the sputum that had been coughed up around the Resident #32's [MEDICAL CONDITION], since the laboratory would not deliver the proper container and there seemed to be no way to get them. She stated that when she spoke with the physician who was the consulting pulmonologist on 6/6/12, he gave a verbal order to discontinue the sputum specimen and stated he would collect it when he returned to change the [MEDICAL CONDITION]. f. In an interview with the consulting Pulmonologist on 6/8/12 at 3:30 p.m. he stated that he had been consulting on [MEDICAL CONDITION] residents at this facility for approximately one month. He stated that he is strictly a consultant and was not paid by the facility. He stated that he became involved with the facility when he noted nursing home residents having frequent readmissions to the hospital, and he thought if they were to receive appropriate care in the nursing homes, then readmissions could be reduced. He stated that he was under the impression that the facility was going to have the services of a respiratory therapy company beginning 6/1/12, as this is what he was told by management, but added that he discovered this had been delayed. He stated that he has had some concerns regarding the respiratory care that has been provided at the facility. He stated that he employed a respiratory therapist who provided the facility's nursing staff with an in-service regarding appropriate [MEDICAL CONDITION] care and suctioning. He stated that Resident #32 had a large amount of secretions from her lungs, and required a cuffed [MEDICAL CONDITION] to control her extensive secretions in order to prevent her from acquiring aspiration pneumonia. He stated that this type of [MEDICAL CONDITION] was not what was in place. He stated that he verbally requested a Shiley cuffed [MEDICAL CONDITION] #8 on May 30 when he made rounds, and had planned to change the [MEDICAL CONDITION] on 6/6/12, but when he arrived to the facility, they had not ordered the proper [MEDICAL CONDITION] that had a cuff. He stated that he re-requested the cuffed [MEDICAL CONDITION] again on 6/6/12 that would have a cuff to aid in the control of the resident's secretions. He stated that he felt that the resident did have an underlying infection, but the sputum specimens that were sent were contaminated. He confirmed that he did not know that the facility did not have the proper Lukens trap containers that is required to collect a proper specimen, and was unaware that the sputum specimens had been collected improperly by not using sterile technique. He confirmed that sputum specimens from a [MEDICAL CONDITION] should be collected using this type of container, so that a specimen could be obtained for an accurate culture and sensitivity, and the proper antibiotic could be prescribed for the best chance at complete eradication of the infection. He denied giving a verbal order to discontinue the sputum culture and sensitivity on 6/6/12. He stated that [MEDICAL CONDITION] should be changed frequently to keep an open airway, and for infection control and he suggested the change should be done every one to three months. He confirmed that improper suctioning and [MEDICAL CONDITION] care by not using the appropriate aseptic and sterile technique is related to infection including pneumonia. g. On 6/8/12 at approximately 3:50 p.m. an interview was conducted with the DON. He confirmed that a consulting pulmonologist was making rounds on the residents with advanced respiratory care needs including residents with tracheostomies. He stated that he was aware that this physician had ordered a [MEDICAL CONDITION] with a cuff for Resident #32, and also that the facility did not stock them. He stated that the [MEDICAL CONDITION] with a cuff had been ordered. He also confirmed that [MEDICAL CONDITION] should be changed regularly. He provided a policy and procedure, dated 03/12, that revealed under policy: "[MEDICAL CONDITION] are changed regularly to decrease the possibility of infection and to maintain a patent airway." He confirmed that there were no respiratory therapy (RT) services currently in the facility, but there was a contact pending with Company A for additional supplies, education and possible labor. He stated that the contract was supposed to have been effective June 1, 2012, but there was a delay, and he did not know the reason for the delay. He stated that in the past the facility had a part time RT on staff, but that position was deleted in November of 2011. He stated that the nursing staff had been solely responsible for advanced respiratory care including [MEDICAL CONDITION] care, suctioning and collection of sputum specimens. He confirmed that he was aware that there were no Lukens sputum collection devices in the facility, and he understood that this was necessary to be able to collect a proper specimen for a sputum culture and sensitivity. He stated that he called the respiratory company that the contract was going to be with, but they could not supply the Lukens containers because the contract had not yet been signed. He stated that he also called the laboratory, and they could not provide them either. He stated that he was working with another supplier currently to get the containers. He stated that the consulting pulmonologist had allowed the facility to "use his RT" to provide as a resource for the nursing staff when providing care to residents with tracheostomies. He stated that this RT was in the facility once a few weeks ago, and gave an in-service on tracheal suctioning and care. He stated that the facility does not keep competency skills checklists for the nurses to determine what additional training that they may need to deliver care to the residents. A list of all currently employed nurses that would be considered able to care for residents with [MEDICAL CONDITION] in place was requested. The ADON provided the list, and 39 nurses were identified. He was aware of the problems involving Employee B and Employee P during the observations of Resident #32 on 6/7/12 and stated that these two employees would not be providing care for residents with tracheostomies until they had been sufficiently re-trained. h. On 6/9/12 at approximately 9:42 a.m., an interview was conducted with the Medical Director who stated that he was not aware of the continued non-compliance regarding [MEDICAL CONDITION] care since 3/20/12. He stated that he did attend a Quality Assurance meeting a few months back, but did not recall discussing advanced respiratory care for the residents. He confirmed that [MEDICAL CONDITION] have not been routinely changed for the residents at the facility. He stated that "sometimes the least that is done invasively is better" for the residents. He pointed out that Resident #32 had a poor prognosis and was at risk for infection related to her co-morbidities. He confirmed that [MEDICAL CONDITION] should be changed periodically because maintaining an open airway and infection control should always be a priority regardless of the individual's prognosis. He also confirmed that the equipment such as the Lukens trap containers should be present and available in the facility. i. On 6/13/12 at approximately 1:00 p.m. a phone call was made to the laboratory that is listed on the heading of the laboratory results for Resident #32. An interview was conducted with the medical technologist in the microbiology department who identified herself as the manager, stated that when specimens grow out multiple organisms, then it is suspected to be contaminated, and this could be related to improper collection of the specimen. The exact identification of the pathogen or bacteria causing the infection cannot be properly identified, and therefore the proper antibiotic that would be most effective cannot be identified either. She stated that sputum specimens taken from tracheostomies should be collected using sputum trap, or a Lukens trap, and should be collected from deep within the respiratory tract using sterile technique. She stated that the statement that was listed on the bottom of Resident #32's report dated 5/3/12 that stated "No further workup unless requested by physician" does not mean that the specimen does not need to be recollected, it means that the laboratory cannot complete the work-up due to the quality of the specimen. j. On 6/9/12, a review of the facility's in-services that were provided regarding tracheal care and suctioning was reviewed. An in-service dated 5/27/12 with the printed title of "Intermittent Catheterization" which was struck out and re-titled, "Trach Suction Closed System," had a sign in sheet in which there were five out of thirty nine nurses that attended. Another in-service, which was undated and titled "Trach Suction-Aseptic Technique," which was given by a respiratory therapist that was employed by the consulting pulmonologist, and had two sign in sheets attached that revealed a total of ten out of thirty nine nurses attended. An in-service titled "Return Demonstration:[MEDICAL CONDITIONS]" which was also undated, revealed eighteen out of thirty nine nurses attended. A final in-service dated 6/1/12 and titled, "Suctioning,[MEDICAL CONDITION]," revealed seventeen out of thirty nine nurses attended. On 6/15/12 the ADON produced an updated list of 42 nurses that would be considered available and eligible to provide care for residents with tracheotomies. k. On 6/11/12 at 2:55 p.m. the staffing sheets were reviewed on the nurse's station where Resident # 32 and Resident #19 were located. Employee B and Employee P were both assigned to Resident #32 and Resident #19 for the 3:00 p.m. to 11:00 p.m. shift on 6/11/12. Both of these nurses were involved in the substandard quality of care observations of [MEDICAL CONDITION] care and suctioning on 6/7/12. At that time, the facility had stated that Employee B and Employee P would not be caring for residents with tracheostomies until they had been sufficiently re-trained. l. On 6/11/12 at approximately 3:05 p.m. an interview was conducted with Employee Q who stated that she was the assigned nurse for Resident #32 for 7:00 a.m. to 3:00 p.m. shift, and that she was preparing to give report to Employee P. She confirmed that Resident #32 was being transferred to the second floor, but they were still waiting for the family to be notified and for the social worker to complete her work that was involved in the transfer. She stated that she had not been told to give report to anyone else for Resident #32. m. On 6/11/12 at 3:15 p.m. an observation was made of Resident #32. She was lying supine, and the head of her bed was up approximately thirty degrees. Her [MEDICAL CONDITION] oxygen mask was present over her [MEDICAL CONDITION] and the humidified oxygen was adjusted to three liters. There was thick sputum at the opening of the [MEDICAL CONDITION], and gurgling was heard with every respiration. A closed suction device was in place and hooked up to suction at the bedside. There were no belongings that had been packed up that would suggest the resident was in the process of currently being transported to the second floor. n. On 6/12/12 at approximately 10:30 a.m., an interview was conducted with a respiratory therapist from Company B, who stated that she was sent to the facility on [DATE] to begin providing in-services to the nursing staff for [MEDICAL CONDITION] care and suctioning. She stated that Company B was not currently contracted with the facility for supplies or labor, and she was there only for educational purposes. She stated that she was under the assumption that the facility was contracted with another company to provide supplies. She stated that she would be going over a variety of topics regarding [MEDICAL CONDITION] care with the nurses that included [MEDICAL CONDITION] care, suctioning, oxygen systems, specimen collection, and emergency procedures. She stated that she thought that "some of the confusion" was coming from what needed to be sterile and what did not. She stated that changing a gauze dressing on the outside of the [MEDICAL CONDITION] is a clean procedure, and does not require sterile technique because it is not invasive. She confirmed that removing and cleaning an inner cannula on a [MEDICAL CONDITION] is a sterile procedure because it is an invasive procedure as it comes in contact with the inside of the resident's trachea, and therefore carries significant risk for infection. She stated that most of the facilities that she has seen use disposable inner cannulas that do not require removal, cleaning and reinsertion under sterile technique. She stated that the facility did not specify what type of [MEDICAL CONDITION] or inner cannulas that they have. She stated that Company B had recommended to the facility an oxygen system in which an air compressor is used with a concentrator to create humidified mist for the [MEDICAL CONDITION] collar since they do not have piped in oxygen in the facility. This allows condensation to be collected in a bag and prevents accumulation of moisture in the oxygen tubing. She stated that residents that are on aspiration precautions should have [MEDICAL CONDITION] that have cuffs on them to prevent fluid and secretions from seeping into the lungs around the [MEDICAL CONDITION]. She also confirmed that sputum specimens from tracheostomies are required to be collected using a Lukens trap and a suction catheter under sterile technique. o. On 6/12/12, an observation was conducted of all respiratory equipment listed as in use for residents based on the facility CMS Form #802. The observation began at 11:00a.m. and revealed the following: At 11:15a.m., Resident #101 was observed to have an oxygen concentrator with a maintenance sticker that documented maintenance was completed in 10/05 and was due to be done again on 10/10. There was a large hole observed in the side of the concentrator where the plastic had been broken. At 11:20 a.m., Resident #193 was observed to have a nebulizer machine that was dusty and dirty, and the mouth piece was not in a plastic bag but was placed into a compartment in the machine that was dusty. There was a plastic bag attached to the machine dated 4/25/12. There was no maintenance tag on the nebulizer machine indicating when it had last been serviced, or when the next service was due. Resident #20 was observed to have a nebulizer machine beside his bed that had no maintenance tag on the machine indicating when it was last serviced, or when it was due to be serviced. At 12:10 p.m., resident #79 was observed to have an oxygen concentrator with a maintenance sticker which documented the last service as being on 1/28/09, and was due for service 1/10. The concentrator filter appeared to be thick with dust. Resident #137 was observed to have an oxygen concentrator with tubing that had no date, and was in a plastic bag dated 5/14/12. The maintenance sticker on the oxygen concentrator documented the unit was last serviced on 10/9/08, and was due to be serviced 10/09. The concentrator filter was observed to be coated with dust. Resident #210 was observed to have a nebulizer machine at his bedside that had no maintenance sticker to indicate when the machine was last serviced and when it was next due for service. Resident #63 was observed to have a oxygen concentrator that had no filter in the filter compartment of the machine. Air being pulled through the concentrator was not being filter

Based on observation, interview and record review the facility failed to promote care for residents in a manner and in an environment that maintains or enhances each resident's dignity and respect in full recognition of his or her individuality for three (#'s 16, 103, 207) of forty-six stage II residents and 2 confidential interviews, related to dining activities on the third and fourth floor, a facility physician examining a resident in the dining room during his dinner meal (resident #207), the unnecessary use of a brief for one resident (resident #207) and incontinence care and supplies for all ninety incontinent residents. Failure to treat residents with dignity and respect affects their physical and psycho-social well-being. Findings include: 1. In a confidential interview that was conducted with an alert and oriented resident on 6/6/12 at 4:00 p.m., at the resident's request, he reported that the facility had a recent decline in services. He reported one of the most vexing problems was the limited supply of briefs. He reported he was provided with a limited amount of briefs and that if he went on leave on the weekend, when he returned he would be missing the clean briefs that had been stored in his room. He reported that Certified Nursing Assistants (CNAs) used them for other residents. The resident was visibly shaken during the interview. A record review of the May 2012 resident council minutes shows that in that meeting the facility administration told the residents they could only have "five briefs daily and blue chucks were used at night only. Pull ups will address with administration for better understanding." On 6/7/12 at 9:30 a.m. in an interview, the fourth floor unit manager and a fourth floor unit nurse reported that facility policy allowed 5 briefs per resident and three pads. They reported that this policy has resulted in shortages of brief supplies and also meant that often at nighttime the resident's bedding becomes soaked. On 6/8/12 at 9:20 a.m. in an interview, the central supply manager confirmed that five briefs per day were allotted for each incontinent resident as reported in the resident council minutes and by staff. The briefs were for daytime wear and then residents are not briefed at night. She confirmed they had not been ordering paper pads for the bed but rather had purchased cloth pads that did not withstand the laundering process and the use of the cloth pads resulted in the soaking of all the residents' bed sheets if they were incontinent at night. A record review of the facility's invoices for briefs shows that the facility ordered briefs in the past five weeks (May 2, 2012 order date through June 6, 2012 order date). On the facility 672, provided as part of the facility documentation for the annual survey, it was noted that 90 of the 140 census residents were incontinent. This calculates as briefs ordered for 90 residents times 35 days or 3150 patient days divided into briefs which means that the facility purchased 4.5 briefs per day and no pads for those incontinent residents in the month of May and the first week of June. On 6/9/12 at 3:00 p.m. in a confidential interview with a resident's family member, she reported that the current practice of leaving residents without briefs at night time was problematic. She reported that her husband's roommate urinates and defecates in the middle of the night and because of the brief less practice the resident is left soiled for the night in his excrement. 2. On 06/05/2012 at 3:07 PM an interview was conducted with a family member of resident #207. She stated that she had told the staff that placing a brief on the resident was unnecessary because he is able to use the bathroom with assistance. The family member said that the staff continued to place a brief on the resident. A review of the resident's record was done where the admission Care Plan dated 5/21/2012 stated all ADL's (Activity of Daily Living) shows assist of one. A nursing note dated 5/21/2012 stated the resident as being continent of bowel and bladder with periods of incontinence. Care Plan dated 06/07/2012 reflects the resident as being incontinent of bowel and bladder. Approaches include toileting every two hours or as needed and maintaining resident's privacy and dignity during care. Applying briefs is not listed as an approach in the care plan. The section for continence on the Resident Information Sheet used by the Certified Nursing Assistants does not have briefs/liners/pull-ups checked reflecting that they would not be used. At 11:40 a.m. on 06/07/2012 an interview was conducted with Certified Nursing Assistant (F). She stated that they do not put a brief on the resident when he is bed, only when he is up. She said that "sometimes he wets himself". An interview was conducted with Unit Manager (G) on 06/07/2012 at 11:55 a.m. She stated that she did not realize he was wearing briefs daily. She said that the resident was able to use the toilet with assistance and that she didn't think he needed to wear the briefs. She stated that she had helped him use the toilet this morning and that he was able to understand and stand steady on is feet. An interview was conducted with Certified Nursing Assistant (C.N.A.) (H) on 06/07/2012 at 11:55 a.m. She stated that the resident was wearing a brief this day. She said that only one brief was typically used on the resident per day because he stays dry when he is up out of bed. She said that he seldom wets the brief during the day and that she assists him with toileting every two hours. She said that he was alert sometimes only once wetting the brief. The C.N.A. showed that the resident had underwear in his drawer. On 06/07/2012 an interview was conducted with Registered Nurse (I) at 12:15 p.m.. She stated that if a resident is wearing a brief it would be documented on the Resident Information Sheet for the C.N.A.s. She acknowledged that the sheet was not marked to apply briefs on the resident. She also acknowledged that the resident is on a toileting schedule and didn't need to wear briefs. An interview was conducted with C.N.A. (H) at 10:55 a.m. on 06/08/2012. She stated that the resident was currently in therapy and that he did not have a brief on this day. She said that his bed was dry this morning, she had toileted him, and that he had not wet his clothes this morning. At 11:05 a.m. on 06/08/12 an interview was conducted with the resident. He stated that he had a brief on this day. He was asked if he felt he needed to wear the brief. He stated, "I don't think so". He was asked if the aid helps him use the toilet. He said yes. He was asked who had put the brief on him this day. he responded, "I don't know, I have it on". He was asked again if needed to wear a brief. He said "no". 3. In an interview on 6/9/12 at 9:21 a.m. resident #103, who had a right leg amputation, he explained that the facility stopped providing pull ups that he used. Fortunately some unidentified individuals were giving him the pull ups. He further explained that with the pull up briefs he can be independent in toileting. When he uses the pull ups he can pull them right up after using the toilet but with the regular briefs he has to have a CNA assist him as he cannot maintain his balance while fastening the briefs. 4. On 6/7/12 at 12:20 p.m. during a second dietary observation it was observed that there were seven residents seated at three tables in the third floor-dining/activity room waiting for lunch. They had not been served their beverages. The dietary cart with resident's trays arrived on the unit. Six unit staff proceeded up and down the hallway distributing the trays to the resident rooms. The staff did not distribute the lunch meal trays to the residents in the dining room At 12:38 p.m. the third floor unit manager started getting the beverages for the residents in the dining room as the other five staff members stood by. Resident #16 yelled out "I am hungry." When asked about the delay the UM said one tray for a resident who was seated at the first table was missing so the staff could not distribute to the other residents in the dining room. The UM said the facility procedure was to fill out slip for dietary requesting a substitute tray and send a certified nursing assistant to the kitchen for the missing tray. The resident whose tray was missing was escorted back to his room by a staff person and then the other residents were given their trays. It was observed that a tray intended for a 200 hall resident was on the dietary tray cart. When asked about that resident's tray, the third floor manager indicated the second floor unit manager would have to follow the same procedure she had just stated.

Based on observation, interview, medical record and policy review, the facility did not ensure compliance with standards of infection control during dressing changes for two ( #2,#4) of three residents reviewed for infection control, as it related to glove changes, hand washing and cleaning of equipment. Findings include: 1. Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 4/5/12 9:10 a.m., a wound care observation was conducted while nurse A performed the resident's ordered wound care. After washing her hands, she donned gloves and placed a barrier on the over bed table and placed supplies on the barrier. These included sterile water, [MEDICATION NAME] and gauze. She then moved the resident's leg from underneath the covers and then removed her gloves and went to the med cart to retrieve a pair of scissors. She reapplied gloves and then cut the dressing open. She removed her gloves and washed her hands and applied new gloves. She then cleansed the wound with sterile water and gauze 4x4 using proper motion. With the same gloves on, she reached into a bag of clean gauze for another 4x4. She then opened the [MEDICATION NAME] and put the ointment on her gloved finger and wiped it into the wound with her finger. Wearing the same gloves she then applied clean gauze and reached back into the clean supply bag for a roll of gauze and wrapped the dressing. Wearing the same gloves she had on when she cleaned the wound and wiped the ointment into it with her finger, she then reached up and manipulated a roll of tape she had attached to the stethoscope around her neck and then taped the gauze dressing in place. She then removed her gloves (no hand washing or sanitizing was done) and placed the dressing change supplies back into the supply bag. She then labeled the dressing. She walked out of the resident's room and placed the contaminated scissors, on top of the medication cart without cleaning them and took the remaining supplies to the wound care cart, where she placed the sterile water and ointment into a drawer labeled for the resident. She threw a way the bag of gauze and the plastic bag used to transport the supplies She then went into the area behind the nurse's desk and washed her hands. In an interview with her immediately after the completion of this, she confirmed that she did not change her gloves and wash her hands after cleaning the wound and applying ointment into the wound with a gloved finger. She stated that she was going to clean the scissors, but did not prior to placing them on the medication cart. 2. A review of the medical record for resident #4 documented on the face sheet, that the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An observation of the resident's wound care was completed on 4/6/12 at 10:20 am, and was performed by nurse D. There were four different wounds observed. The nurse brought supplies to the room in plastic bag. She washed her hands and placed a barrier on over bed table and then placed her supplies on the barrier. She cleansed the left knee wound with saline and patted it dry. She removed the glove from her right hand and place new one. She did not change the glove on her left hand. She then placed her finger into the silvadine jar scooping out the cream with her finger and then wiping it on gauze 4x4. She then placed that gauze onto the wound. She then cleansed the right ankle wound without changing gloves. After cleansing, she then removed the gloves and put on new ones. She did not wash her hands or use sanitizer in between glove changes. She again put her gloved finger into ointment and scooped out the ointment and wiped it onto gauze 4x4 and placed the gauze onto the wound. She then removed her gloves and put on new ones without washing her hands and wrapped the ankle and the knee with ABD pads and kling and secured them with tape. She placed her scissors into her pocket without cleaning them and then took the gloves off and washed her hands. She then applied new gloves. She proceeded to the Left hip wound and removed the dressing. She then took a clean 4x4 and cleansed the wound with saline using proper circular motion. She then removed her right glove and put a new glove on. She did not change the left glove nor did she wash or sanitize her hands. She cut open the dressing package, with the scissors she had used to open the leg dressing and did not clean them prior to. She then placed her gloved finger into the jar of silvidene and scooped out the ointment and wiped it onto a gauze 4x4. She placed the gauze onto the wound and covered it with an island dressing. She removed her gloves and dated the dressing. The nurse then moved to the chest dressing. She cut open the dressing pack with same scissors she had been using and did not clean them between uses. She then washed her hands and gloved only the right hand and removed the chest dressing with her ungloved left hand. She then placed a glove onto her left hand. She cleansed the chest wound with saline using her right hand and then removed the glove from her right hand and put on a new one. She did not replace the glove on her left hand nor did she wash her hands or use hand sanitizer. Once the new glove was on she, again, put her gloved finger into the jar of silvidene ointment and scooped out the ointment, wiping it onto a gauze 4x4. She then placed the gauze onto the wound and removed her gloves and dated the dressing. In an interview with the nurse immediately following the dressing change, she confirmed she often changed only one glove and did not wash her hands in between glove changes. She also confirmed she placed her finger into the jar of ointment each time she used the ointment and that she did not clean the scissors. A review of the facility procedure titled Dressing Change (dated 9/11) documented: #6 Wash hands and apply gloves #7 Remove soiled dressing #9 place soiled dressing and gloves into plastic bag #10 Remove gloves and wash hands #11 Set up supplies #12 Apply gloves #14 Cleanse wound #15 Follow order for topical application of medication #17 Apply dressing #18 Label Dressing with date and time #19 Remove gloves and wash hands A review of the hand washing policy from the infection control manual, dated 2/9, documented that hand washing was to be completed after contact with a wound, and removal of gloves.

Based on observations, interviews and record review, the facility failed to ensure the prevention of infection for twelve (#19,#30,#32,#58,#178,#1001,#193,#20,#79,#137,#210,#63)out of twenty residents related to a failure to provide regular tracheostomy tube exchanges, tracheostomy care and suctioning using aseptic technique, wound care using aseptic technique, and the cleaning, disinfecting and maintaining of respiratory equipment according to policy and procedure. Resident #32 was observed to receive improper care of the tracheostomy tube that enabled her to breathe and provided a direct portal into her respiratory tract. Resident #32 was treated for [REDACTED]. During this time, the facility failed to provide the appropriate container for the proper method to obtain a physician ordered specimen to accurately identify the microorganism that caused the infection for the most effective treatment. The facility ' s policy and procedure related to exchanging tracheostomy tubes stated, " Tracheostomy tubes are changed regularly to decrease the possibility of infection and maintain a patent airway, " but the facility did not regularly change the tracheostomy tubes for Resident #19,#30,#32,#58 and #178. Resident # 106 was observed to receive improper wound care that was not within the policy and procedure related to aseptic technique. Resident #1001, #193, #20, #79, #137, #210, and #63 were observed to have respiratory support equipment and supplies at their bedside that were not cleaned, disinfected, stored, and/or maintained properly according to the facility ' s policy and procedure and the current standards of infection control. Failure of the facility and staff to ensure proper cleaning, disinfection and maintenance of respiratory equipment as well as the failure to ensure proper aseptic technique during tracheostomy care, suctioning, and wound care for a pressure ulcer according to policy and procedure, resulted in findings of Immediate Jeopardy on 6/7/12. The Immediate Jeopardy was removed on 6/15/12, and reduced to the scope and severity of an E. Relevant findings included: 1. A review of Resident #32 ' s medical record revealed that she was a fifty three year old woman that was originally admitted to the facility on [DATE]. Her medical [DIAGNOSES REDACTED]. A review of the last Minimum Data Set comprehensive quarterly assessment dated [DATE] revealed under Section O that she was receiving oxygen, suctioning and tracheal care. Further review of Resident #32 ' s record revealed a care plan dated 5/24/12 that listed a problem that stated, " Potential Complication: Hypoxia/Infection secondary to Tracheostomy. Goals included that Resident #32 will maintain a patent tracheostomy tube daily and the tracheostomy will be free of infection through the next review. Interventions included: Regularly inspect and cleanse the tracheostomy tube, provide humidification of inspired air, monitor for signs and symptoms of respiratory distress, monitor for signs and symptoms of infection, ie. foul smelling sputum, discolored sputum, fever, bloody sputum, etc. and notify MD, oxygen at three liters via trach collar, and trach care every six hours and as needed, and suction tracheostomy every shift and as needed for respiratory distress. 2. On 6/7/12 at approximately 10:35 a.m. an observation was made of the suction equipment in Resident #32 ' s room. The suction machine was resting on the bedside table. It had a thick, dusty coating on the base, and was stained on the right side with yellowish-white dried drainage. There was no tag, label or sticker that listed when the machine was last inspected or serviced. 3. On 6/7/12 at 5:50 p.m., tracheostomy care was observed for Resident #32. Employee P, the licensed practical nurse (LPN) that was assigned to Resident #32 for the 3:00 p.m. to 11:00 p.m. shift was observed washing her hands and assembling supplies that included: mask, gown, clean gloves, sterile gloves, paper towels, hand sanitizer and a tracheostomy care kit. Employee B also entered the room and stated that she would assist Employee P as per the instructions from the DON. Employee B also washed her hands and put on clean gloves. The resident continued to be on oxygen per concentrator at 3 liters per minute. They positioned the resident into a semi-fowlers position by raising the head of the bed. Employee P washed her hands again and placed the paper towels on the over bed table. She applied a pulse oximeter to Resident #32 ' s finger to obtain a reading for the resident ' s oxygen saturation. She stated that the saturation was low at 88%. Employee B stated that she had to put the oximeter on the residents thumb in order to get better contact. The oximeter was repositioned as directed by Employee B. The saturation then increased to an acceptable 94%. Employee P sanitized her hands and put on sterile gloves. She picked up the tracheostomy kit (the outside being non-sterile and thus breaking sterile technique) and opened the kit and dumped the sterile contents out onto the unsterile paper towels. She then stated, "I should have done this first," and removed and discarded the sterile gloves and then put on another pair of sterile gloves. She then pulled open the drawer on the nightstand, again breaking sterile technique, and removed a container of solution. She was asked to identify what was in the container, and she said, " It ' s the saline. " Employee B interjected and stated, "We are supposed to use the saline that's in the trach kit." The container that was removed from the drawer was inspected and labeled as normal saline, expiration date 1/14,and had been previously opened with approximately 25% of the liquid still present. There was no resident ' s name or date that it had been opened that was recorded on the container. Employee B confirmed that sterile normal saline is used to cleanse the inner cannula of the tracheostomy. (The policy and procedure for tracheostomy care dated 5/12 under step # 12 stated, " Separate 4x4 gauze and pour sterile water or saline over gauze into one container, and step 13# stated " Pour normal saline into second sterile container for rinsing. " ) Employee B confirmed that using the previously opened, undated and unlabeled container of saline would not have been consistent with sterile technique for cleansing the non-disposable inner cannula which is inserted directly into the Resident #32 ' s trachea, had Employee P been allowed to continue. Employee P stated that she needed more supplies, and she discarded the opened tracheostomy kit, removed her gloves, and both nurses left the room. They returned at approximately 6:00 p.m., and Employee P stated that she had reviewed the policy for tracheostomy care. She washed her hands again and opened the tracheostomy kit by peeling back the top lid, and setting the tray on the over bed table. She placed a sterile barrier on the over-bed table next to the tray, and then picked up the tray and dumped the sterile contents onto the sterile barrier. Then she placed the tray on the sterile barrier that had been resting on the over-bed table, thus contaminating the sterile field. She opened sterile gloves and put them on, and then placed the paper that the sterile gloves were packaged in underneath the resident's tracheostomy on her chest. She poured the saline solution and the package of peroxide into the tray. She removed the gauze sponge that was placed around t-piece from the tracheostomy and with some difficulty attempted to remove the inner cannula. The resident coughed, and approximately two tablespoons of thick, yellow sputum spilled out of the tracheostomy. Employee P stated that the resident needed to be suctioned first. She used the closed suction catheter technique and placed saline from a small unit dose container of saline into the resident's tracheostomy using the port on the closed suction catheter. She suctioned the resident by advancing the closed catheter into the tracheostomy, and then applied intermittent suction while withdrawing the catheter. The resident coughed continuously during the suctioning, and the gurgling and sounds of fluid in the resident ' s lungs were audible in the room. Employee P confirmed that there was sputum moving in the suction catheter, and she stated that the suction appeared to be working. She removed the sterile gloves and re-sanitized her hands. She applied new sterile gloves again, and removed the inner cannula with some difficulty. The resident again coughed and approximately two tablespoons of thick, yellow sputum was expelled out of her tracheostomy onto the paper that the sterile gloves came in. Employee P placed the inner cannula which appeared to be stained a deep yellow, into the tray that contained the peroxide and normal saline. She was observed to cleanse the inside and outside of the cannula utilizing the cleansing tool included in the sterile kit. She replaced the inner cannula into the tracheostomy while the resident continued to cough violently and spewed thick creamy yellow sputum from her tracheostomy. She replaced the t-piece that hooked onto the tracheostomy into the tubing that the oxygen was connected to which appeared moist with condensation or mucous, and reattached the t-piece to the tracheostomy. She cleansed the residents' skin that surrounded the tracheostomy by using a saline soaked gauze sponge that she picked up from on top of the sterile barrier, and dipped into the saline solution in the tray. She did not apply another dressing around the tracheostomy, and left the area bare. (A review of the policy and procedure for tracheostomy care dated 5/12 lists step #24: " Place 4x4 gauze dressing between the tracheostomy tube and resident/patient ' s skin. " ) She discarded the remains of the tracheostomy kit, and removed her gloves and washed her hands. Employee P stated that the tracheostomy ties were recently changed and did not require changing. The tracheostomy ties were observed to be in place without the presence of secretions on the ties. During an interview at approximately 6:30 p.m. Employee P confirmed that she had omitted placing the dressing around the tracheostomy site and also confirmed that this was a part of tracheostomy care, but that she intended to apply the dressing " later. " She also confirmed that sterile technique was difficult to follow for her. She also stated that Resident #32 had pneumonia. 4. Further review of Resident #32 ' s clinical record revealed portable chest x-ray results dated 5/5/12 that stated " perihilar pneumonia " (an atypical pneumonia located at the top of the respiratory tract) as the impression. The physician's order [REDACTED]. Further physician's order [REDACTED].#32 received a total of 7 injections until it was discontinued on 5/27/12. She continued to receive the [MEDICATION NAME] through 6/8/12. A review of the vital signs that included temperatures revealed that there were no abnormal temperatures documented and it appeared that Resident #32 was not having fevers as a symptom of her pneumonia. However, further review revealed physician ' s progress notes dated 5/20/12 that revealed Resident #32 had an axillary temperature of 102.5, and had continued respiratory congestion and rubs on auscultation. Another physician ' s progress note dated 5/22/12 revealed that Resident #32 had a fever of 100.0 axillary, as reported by the nurse, had a pending culture and sensitivity for the thick greenish yellow mucus that was noted in the resident ' s tracheostomy tube, and continued on the [MEDICATION NAME] for the respiratory infection. Another physician ' s progress note dated 5/26/12 stated that the resident was doing better with her upper respiratory infection, but the cough continued that was productive of greenish mucus, and the sputum culture and sensitivity was to be re-collected. A review of the physician's order [REDACTED]. The results for all three specimens sent stated in the final report that the results suggested contamination, and therefore identification could not be made of the causative bacteria or the antibiotic that would be most effective against it. A review of the facility ' s infection control log stated that Resident #32 had infections requiring antibiotic therapy listed as " pneumonia " on 5/7/12 and " respiratory on 5/20/12. 5. On 6/8/12 at approximately 11:45 a.m., an interview was conducted with the Unit Manager of the 3rd floor, and Employee Q, who had stated that she was assigned as Resident #32 ' s nurse, and had frequently cared for her. The unit manager stated that the resident had not been running fevers, and this was confirmed on the vital signs flow sheet that she produced from the clinical record that listed the resident as having normal temperatures recorded. She could not give an explanation for the fevers that were documented on the physician ' s progress notes. She confirmed that the resident was diagnosed with [REDACTED]. She confirmed that the three sputum specimens that had been sent to the laboratory and were noted to be contaminated specimens. She pointed out the note at the bottom of the laboratory result form, dated 5/3/12 that stated, " No further workup unless requested by physician. " She stated that she interpreted this to mean no further specimens needed to be sent. Employee Q stated that she had sent at least one of the sputum specimens. She stated that she did not know how to collect a sputum specimen from a tracheostomy, and she had asked the DON and the ADON. She stated that a " lady doctor " that was present in the facility told her that a " Luky-tube " was required, and that she needed to get a " deep suction " and that the laboratory could provide the " Luky-tube. " She stated that she called the laboratory, but was told that they did not supply the container. She stated that she told management of the need for the specialized container, but no one had been successful in obtaining the proper container required for the specimen. She stated that she had collected, and sent to the lab, the sputum that had been coughed up around the Resident #32 ' s tracheostomy, since the laboratory would not deliver the proper container and there seemed to be no way to get them. She stated that when she spoke with the physician who was the consulting pulmonologist on 6/6/12, he gave a verbal order to discontinue the sputum specimen and stated he would collect it when he returned to change the tracheostomy. 6. In an interview with the consulting Pulmonologist on 6/8/12 at 3:30 p.m. he stated that he had been consulting on pulmonary residents at this facility for approximately one month. He stated that he is strictly a consultant and was not paid by the facility. He stated that he became involved with the facility when he noted nursing home residents having frequent readmissions to the hospital, and he thought if they were to receive appropriate care in the nursing homes, then readmissions could be reduced. He stated that he was under the impression that the facility was going to have the services of a respiratory therapy company beginning 6/1/12, as this is what he was told by management, but added that he discovered this had been delayed. He stated that he has had some concerns regarding the respiratory care that has been provided at the facility. He stated that he employed a respiratory therapist who provided the facility ' s nursing staff with an in-service regarding appropriate tracheostomy care and suctioning. He stated that Resident #32 had a large amount of secretions from her lungs, and required a cuffed tracheostomy tube to control her extensive secretions in order to prevent her from acquiring aspiration pneumonia. He stated that this type of tracheostomy tube was not what was in place. He stated that he verbally requested a Shiley cuffed tracheostomy tube #8 on May 30 when he made rounds, and had planned to change the tracheostomy on 6/6/12, but when he arrived to the facility, they had not ordered the proper tracheostomy that had a cuff. He stated that he re-requested the cuffed tracheostomy tube again on 6/6/12 that would have a cuff to aid in the control of the resident ' s secretions. He stated that he felt that the resident did have an underlying infection, but the sputum specimens that were sent were contaminated. He confirmed that he did not know that the facility did not have the proper Lukens trap containers that is required to collect a proper specimen, and was unaware that the sputum specimens had been collected improperly by not using sterile technique. He confirmed that sputum specimens from a tracheostomy should be collected using this type of container, so that a specimen could be obtained for an accurate culture and sensitivity, and the proper antibiotic could be prescribed for the best chance at complete eradication of the infection. He denied giving a verbal order to discontinue the sputum culture and sensitivity on 6/6/12. He stated that tracheostomy tubes should be changed frequently to keep an open airway, and for infection control and he suggested the change should be done every one to three months. He confirmed that improper suctioning and tracheostomy care by not using the appropriate aseptic and sterile technique is related to infection including pneumonia. 7. On 6/8/12 at approximately 3:50 p.m. an interview was conducted with the DON. He confirmed that a consulting pulmonologist was making rounds on the residents with advanced respiratory care needs including residents with tracheostomies. He stated that he was aware that this physician had ordered a tracheostomy with a cuff for Resident #32, and also that the facility did not stock them. He stated that the tracheostomy tube with a cuff had been ordered. He also confirmed that tracheostomy tubes should be changed regularly. He provided a policy and procedure, dated 03/12, that revealed under policy: " Tracheostomy tubes are changed regularly to decrease the possibility of infection and to maintain a patent airway. " He confirmed that there were no respiratory therapy (RT) services currently in the facility, but there was a contact pending with Company A for additional supplies, education and possible labor. He stated that the contract was supposed to have been effective June 1, 2012, but there was a delay, and he did not know the reason for the delay. He stated that in the past the facility had a part time RT on staff, but that position was deleted in November of 2011. He stated that the nursing staff had been solely responsible for advanced respiratory care including tracheostomy care, suctioning and collection of sputum specimens. He confirmed that he was aware that there were no Lukens sputum collection devices in the facility, and he understood that this was necessary to be able to collect a proper specimen for a sputum culture and sensitivity. He stated that he called the respiratory company that the contract was going to be with, but they could not supply the Lukens containers because the contract had not yet been signed. He stated that he also called the laboratory, and they could not provide them either. He stated that he was working with another supplier currently to get the containers. He stated that the consulting pulmonologist had allowed the facility to " use his RT " to provide as a resource for the nursing staff when providing care to residents with tracheostomies. He stated that this RT was in the facility once a few weeks ago, and gave an in-service on tracheal suctioning and care. He stated that the facility does not keep competency skills checklists for the nurses to determine what additional training that they may need to deliver care to the residents. A list of all currently employed nurses that would be considered able to care for residents with tracheostomy tubes in place was requested. The ADON provided the list, and 39 nurses were identified. He was aware of the problems involving Employee B and Employee P during the observations of Resident #32 on 6/7/12 and stated that these two employees would not be providing care for residents with tracheostomies until they had been sufficiently re-trained. 8. On 6/9/12 at approximately 9:42 a.m., an interview was conducted with the Medical Director who stated that he was not aware of the continued non-compliance regarding tracheostomy care since 3/20/12. He stated that he did attend a Quality Assurance meeting a few months back, but did not recall discussing advanced respiratory care for the residents. He confirmed that tracheostomy tubes have not been routinely changed for the residents at the facility. He stated that " sometimes the least that is done invasively is better " for the residents. He pointed out that Resident #32 had a poor prognosis and was at risk for infection related to her co-morbidities. He confirmed that tracheostomy tubes should be changed periodically because maintaining an open airway and infection control should always be a priority regardless of the individual ' s prognosis. He also confirmed that the equipment such as the Lukens trap containers should be present and available in the facility. 9. On 6/13/12 at approximately 1:00 p.m. a phone call was made to the laboratory that is listed on the heading of the laboratory results for Resident #32. An interview was conducted with the medical technologist in the microbiology department who identified herself as the manager, stated that when specimens grow out multiple organisms, then it is suspected to be contaminated, and this could be related to improper collection of the specimen. The exact identification of the pathogen or bacteria causing the infection cannot be properly identified, and therefore the proper antibiotic that would be most effective cannot be identified either. She stated that sputum specimens taken from tracheostomies should be collected using sputum trap, or a Lukens trap, and should be collected from deep within the respiratory tract using sterile technique. She stated that the statement that was listed on the bottom of Resident #32 ' s report dated 5/3/12 that stated " No further workup unless requested by physician " does not mean that the specimen does not need to be recollected, it means that the laboratory cannot complete the work-up due to the quality of the specimen. j 10. On 6/9/12, a review of the facility ' s in-services that were provided regarding tracheal care and suctioning was reviewed. An in-service dated 5/27/12 with the printed title of " Intermittent Catheterization " which was struck out and re-titled, " Trach Suction Closed System, " had a sign in sheet in which there were five out of thirty nine nurses that attended. Another in-service, which was undated and titled " Trach Suction-Aseptic Technique, " which was given by a respiratory therapist that was employed by the consulting pulmonologist, and had two sign in sheets attached that revealed a total of ten out of thirty nine nurses attended. An in-service titled " Return Demonstration: Trach Care Closed Trach Suctioning " which was also undated, revealed eighteen out of thirty nine nurses attended. A final in-service dated 6/1/12 and titled, " Suctioning, Trach Care, " revealed seventeen out of thirty nine nurses attended. On 6/15/12 the ADON produced an updated list of 42 nurses that would be considered available and eligible to provide care for residents with tracheotomies. 11. On 6/11/12 at 2:55 p.m. the staffing sheets were reviewed on the nurse ' s station where Resident # 32 and Resident #19 were located. Employee B and Employee P were both assigned to Resident #32 and Resident #19 for the 3:00 p.m. to 11:00 p.m. shift on 6/11/12. Both of these nurses were involved in the substandard quality of care observations of tracheostomy care and suctioning on 6/7/12. At that time, the facility had stated that Employee B and Employee P would not be caring for residents with tracheostomies until they had been sufficiently re-trained. 12. On 6/11/12 at approximately 3:05p.m. an interview was conducted with Employee Q who stated that she was the assigned nurse for Resident #32 for 7:00 a.m. to 3:00 p.m. shift, and that she was preparing to give report to Employee P. She confirmed that Resident #32 was being transferred to the second floor, but they were still waiting for the family to be notified and for the social worker to complete her work that was involved in the transfer. She stated that she had not been told to give report to anyone else for Resident #32. 13. On 6/11/12 at 3:15 p.m. an observation was made of Resident #32. She was lying supine, and the head of her bed was up approximately thirty degrees. Her tracheostomy oxygen mask was present over her tracheostomy and the humidified oxygen was adjusted to three liters. There was thick sputum at the opening of the tracheostomy tube, and gurgling was heard with every respiration. A closed suction device was in place and hooked up to suction at the bedside. There were no belongings that had been packed up that would suggest the resident was in the process of currently being transported to the second floor. 14. On 6/12/12 at approximately 10:30 a.m., an interview was conducted with a respiratory therapist from Company B, who stated that she was sent to the facility on [DATE] to begin providing in-services to the nursing staff for tracheostomy care and suctioning. She stated that Company B was not currently contracted with the facility for supplies or labor, and she was there only for educational purposes. She stated that she was under the assumption that the facility was contracted with another company to provide supplies. She stated that she would be going over a variety of topics regarding tracheostomy care with the nurses that included tracheostomy care, suctioning, oxygen systems, specimen collection, and emergency procedures. She stated that she thought that " some of the confusion " was coming from what needed to be sterile and what did not. She stated that changing a gauze dressing on the outside of the tracheostomy is a clean procedure, and does not require sterile technique because it is not invasive. She confirmed that removing and cleaning an inner cannula on a tracheostomy is a sterile procedure because it is an invasive procedure as it comes in contact with the inside of the resident ' s trachea, and therefore carries significant risk for infection. She stated that most of the facilities that she has seen use disposable inner cannulas that do not require removal, cleaning and reinsertion under sterile technique. She stated that the facility did not specify what type of tracheostomy tubes or inner cannulas that they have. She stated that Company B had recommended to the facility an oxygen system in which an air compressor is used with a concentrator to create humidified mist for the tracheostomy collar since they do not have piped in oxygen in the facility. This allows condensation to be collected in a bag and prevents accumulation of moisture in the oxygen tubing. She stated that residents that are on aspiration precautions should have tracheostomy tubes that have cuffs on them to prevent fluid and secretions from seeping into the lungs around the tracheostomy tube. She also confirmed that sputum specimens from tracheostomies are required to be collected using a Lukens trap and a suction catheter under sterile technique. 15. On 6/12/12, an observation was conducted of all respiratory equipment listed as in use for residents based on the facility CMS Form #802. The observation began at 11:00a.m. and revealed the following: At 11:15a.m., Resident # 101 was observed to have an oxygen concentrator with a maintenance sticker that documented maintenance was completed in 10/05 and was due to be done again on 10/10. There was a large hole observed in the side of the concentrator where the plastic had been broken. At 11:20a.m., Resident # 193 was observed to have a nebulizer machine that was dusty and dirty, and the mouth piece was not in a plastic bag but was placed into a compartment in the machine that was dusty. There was a plastic bag attached to the machine dated 4/25/12. There was no maintenance tag on the nebulizer machine indicating when it had last been serviced, or when the next service was due. Resident #20 was observed to have a nebulizer machine beside his bed that had no maintenance tag on the machine indicating when it was last serviced, or when it was due to be serviced. At 12:10 p.m., resident # 79 was observed to have an oxygen concentrator with a maintenance sticker which documented the last service as being on 1/28/09, and was due for service 1/10. The concentrator filter appeared to be thick with dust. Resident # 137 was observed to have an oxygen concentrator with tubing that had no date, and was in a plastic bag dated 5/14/12. The maintenance sticker on the oxygen concentrator documented the unit was last serviced on 10/9/08, and was due to be serviced 10/09. The concentrator filter was observed to be coated with dust. Resident # 210 was observed to have a nebulizer machine at his bedside that had no maintenance sticker to indicate when the machine was last serviced and when it was next due for service. Resident # 63 was observed to have a oxygen concentrator that had no filter in the filter compartment of the machine. Air being pulled through the concentrator was not being filtered. Resident # 178 was observed to have an oxygen concentrator with a humidifier. There was no date on the oxygen tubing or the humidifier as to when it was last changed. Resident # 58 was observed to have a nebulizer machine at the bed side that did not have a maintenance sticker indicating when maintenance was last done or was next due. At 1:35 p.m., an interview and tour was conducted with the DON to show him the respiratory equipment that was found to be outdated and in disrepair. He confirmed that there would be no maintenance tags found on any of the nebulizer machines, and he confirmed the findings on the remaining respiratory equipment. A review of the facility ' s policy and procedure titled " Equipment Rounds " and dated 3/12 stated under step #1, " At least once per shift, personnel shall verify oxygen equipment, which is in use, and check accuracy of FIO2 and/or liter flow. Verification of use shall be documented in the resident ' s record. Inlet filters on oxygen concentrators shall be visually inspected and cleaned/replaced as necessary. " Step #2 stated, " At least once per day, personnel shall visually inspect air compressors, suction machines, and treatment compressors for inlet filter status, operational verification, and general cleanliness. Inlet filters, suction canisters, and suction tubing will be cleaned/replaced if soiled. " 16. On 6/12/12 Resident #19 ' s clinical record was reviewed and revealed that he is a forty three year old man that was originally admitted to the facility on [DATE]. His medical [DIAGNOSES REDACTED]. His last comprehensive assessment dated [DATE] revealed under Section O that he had a tracheostomy and required tracheostomy care, as well as suctioning and oxygen. His last quarterly assessment dated [DATE] revealed under Section O that he has continued to receive oxygen, suctioning and tracheal care. A Tracheostomy Care Plan last updated on 4/26/12 included that Resident #19 is at risk for secretions, swelling and infection. The goals included that he would be free of pneumonia and stoma site infection. Approaches included: Tracheostomy care and suction as ordered and as needed, and to clean the inner cannula per MD orders, and replace as ordered. There was no documentation in the clinical record of the

Based on medical record review , staff interview and facility policy review, the facility did not ensure that nursing care was provided appropriately for two (#3 #1) of three residents sampled, as it related to obtaining and following physicians orders, reporting a change in resident condition, and ensuring the provision of personal care for a comatose resident. The Florida Nurse Practice Act includes: 3) (a) "Practice of professional nursing" means the performance of those acts requiring substantial specialized knowledge, judgment, and nursing skill based upon applied principles of psychological, biological, physical, and social sciences which shall include, but not be limited to: 1. The observation, assessment, nursing diagnosis, planning, intervention, and evaluation of care; health teaching and counseling of the ill, injured, or infirm; and the promotion of wellness, maintenance of health, and prevention of illness of others. 2. The administration of medications and treatments as prescribed or authorized by a duly licensed practitioner authorized by the laws of this state to prescribe such medications and treatments. 3. The supervision and teaching of other personnel in the theory and performance of any of the above acts. (b) "Practice of practical nursing" means the performance of selected acts, including the administration of treatments and medications, in the care of the ill, injured, or infirm and the promotion of wellness, maintenance of health, and prevention of illness of others under the direction of a registered nurse, a licensed physician, a licensed osteopathic physician, a licensed podiatric physician, or a licensed dentist. The professional nurse and the practical nurse shall be responsible and accountable for making decisions that are based upon the individual's educational preparation and experience in nursing. Findings include: 1. Resident #3 was admitted to the facility on [DATE]. Admitting [DIAGNOSES REDACTED]. Hospital 3008 documented principal [DIAGNOSES REDACTED]. The nursing admission data collection and initial plan of care, dated 2/24/12 at 6:48 p.m., documented that the resident was admitted to the facility with a tracheotomy as his respiratory opening and a Foley catheter for urine drainage. A review of the medical record revealed no physicians orders for the care of the tracheotomy from admission on 2/24/12 until 2/27/12, three days after he was admitted . Further review of the medical record revealed there were no physician's orders for care of the Foley catheter from admission on 2/24/12 until 2/26/12, two days after the resident's admission to the facility. A review of the Treatment Administration Record (TAR) and Medication Administration Record (MAR) for February revealed that there the order for tracheotomy care was initiated on 2/27/12 and the order for Foley catheter care was initiated on 2/26/12. A review of the physician order summary for February also revealed that the orders for tracheotomy care were initiated on 2/17/12 and the orders for Foley catheter care were initiated on 2/26/12. There were no physician telephone orders in the medical record for Foley catheter care or tracheotomy care from 2/24/12 through 2/26 and 2/27/12. At 1:30 p.m., on 3/20/12, the Director of Nursing (DON) reviewed the resident's medical record, including the TAR and the MAR. He confirmed the orders for the Tracheotomy care were initiated on 2/27/12 and the orders for the Foley catheter care were initiated on 2/26/12. He stated he felt something was missing and went to review the MAR and the TAR on his lap top. He returned at 1:47 p.m. and stated he was unable to locate any additional information regarding the admission orders [REDACTED] An interview was conducted with the unit manager on 3/20/12 at 3:00 p.m. She stated that when a resident with a tracheotomy and or a Foley catheter was admitted to the facility without orders, it was her expectation that the nurse would call the physician and request orders based on the facilities policy for tracheotomy care and Foley catheter care. A review of the facility policy Admission and Readmitted d 8/10 documented that admission orders [REDACTED]. Under Procedure #2 the policy documents that the staff are to confirm transfer documentation arrives with the resident or has already been received. Documentation included but was not limited to physician orders, hospital discharge notes, transfer status, advanced directives, code status, allergies and state required documents. Under procedure #5 the policy documented to clarify the resident's medication and treatment orders with the physician. Procedure #6 documented the staff was to contact the attending physician immediately upon admission to review and confirm physician orders. Clarify questions or recommendations and obtain additional physician orders as indicated. 2. A review of the nursing care track note for resident #3 dated 2/25/12 documented that the resident had a temperature of 99F on the 11-7 shift. On the 7-2 shift the resident's temperature increased to 99.2F. On 2/26/12 on the 7-3 shift the resident's temperature was 99.5F and on 3-11 shift his temperature was 99.8F. On 2/27/12 on 11-7 the resident's temperature was 100.5. On 7-3 his temperature was 100F and on 3-11 shift the resident's temperature went to 101F. The nursing narrative written at 9:45 p.m. documented that the resident had a temperature of 101F with " a lot of mucous" from his tracheotomy. He was given Tylenol 650 mg for the temperature. There was no documentation that the resident's physician was notified of the elevation in temperatures or the excessive secretions from the resident's tracheotomy. On 3/20/12 at 1:30 p.m., the Director of Nursing (DON) reviewed the resident's medical record and confirmed there was no documentation of notification to the physician that the resident's temperature had gone to 100F and above and that he had increased secretions from his tracheotomy with the elevated temperatures. C. Further review resident #3s medical record, revealed there was no Activity of Daily Living (ADL) Flow sheet documenting that ADL care was provided. This was confirmed by Director of Nursing (DON) during a review of the medical record, at 1:30 p.m. on 3/20/12. The DON stated he was going have medical records look in the filing for the flow sheet. At 4:15 p.m. after having been asked for ADL sheet three times the DON brought an ADL sheet dated February 2012. It was documented that the resident received assistance with bed mobility four times on the day shift on 2/24/12. Per the nursing admission data collection form, the resident did not arrive at the facility until 6:48 p.m. on 2/24/12. This was brought to the DONs attention and he had no explanation. The back of the ADL flow sheet was blank and nowhere on the ADL sheet was it documented the resident received a bath or oral care. 3. A review of the medical record revealed that resident #1 was admitted to the facility on [DATE]. Per the face sheet the resident's admitting [DIAGNOSES REDACTED]. Per the admission data collection form dated 6/1/12, the resident arrived at the facility with a tracheotomy and a feeding tube. Further review of the physician's orders revealed a Physician order summary signed on 03/07/12, that documented the following tracheotomy related orders to be active. Oxygen at 2 liters/minute continuously via tracheotomy collar (humidified), suction three times a day at 6 a.m., 2 p.m., and 10 p.m.. Tracheotomy care to be done with deep suctioning, three times a day, after instilling three milliliters of sterile saline into the Tracheostoma. Use bedside humidifier as well as humidified oxygen, and [MEDICATION NAME] external ointment 2% three times a day at 6 a.m., 2 p.m., and 10 p.m.. Apply [MEDICATION NAME] three times daily to the 6 o'clock aspect of Tracheostoma. Further review of the Medication Administration Record ( MAR ) revealed that on 03/06/12 the order for Tracheostoma care every shift, Tracheostoma care with deep suctioning three times daily after instilling three milliliters of sterile saline in Tracheostoma, bedside humidifier as well as humidified oxygen had been discontinued. A review of the physician orders revealed no order had been written to discontinue the previous orders written on 3/7/12. A new order initiated 3/6/12 was present on the on the MAR, to suction the resident PRN (as needed) for increased secretions or shortness of breath. Every shift monitor stoma site for redness, pain, [MEDICAL CONDITION], odor and signs and symptoms of infection. Every shift cleanses the stoma site with normal saline, and every shift use humidifier. There was no physician's order present in the medical record, for the change in treatment. An interview was conducted, with the Director of Nursing (DON), on 3/20/12 at 12:05 p.m. He confirmed the orders on the MAR were different from the orders on the physician order summary. He also confirmed there was no order to stop the previous orders from 3/6/12 or make changes to the treatment. While further reviewing the physician orders in the medical record, a telephone order dated 01/19/12 documented to " see progress note and orders on it for Tracheostoma care. Have Charge nurse/nurse administrator review them also." The progress note written by the ear, nose and throat physician stated that the resident was " not receiving adequate stoma care" and listed humidified oxygen, bedside humidifier, deep suctioning with three milliliters of sterile saline and [MEDICATION NAME] ointment was needed for proper closure of the Tracheostoma. The physician also wrote in the progress note that the "patient will suffocate and die" if "[MEDICAL CONDITION] is not preformed properly." The physician stated that the stoma was not closing because the resident's stoma had a "clearly visible mucus plug in it" that he removed. During an Interview with the DON on 03/20/12 at 12:34 p.m., He acknowledged that he had not been notified of the order on 01/19/12 nor had he been made aware of the progress note that was written regarding the physician's concern regarding care.

Based on observation, record review and interview, the facility failed to ensure that respiratory care and wound care were provided in accordance with the professional standards of quality for six out of seven residents (#19,#30,#32,#58,#178, #106). Five of the six residents (#19,#30,#32,#58,#178) had tracheostomies present in their necks that allowed them to breathe, and they required [MEDICAL CONDITION] care and suctioning using the proper aseptic technique according to policy and procedure to prevent infection and potential severe complications. The facility failed to follow their own policy and procedure regarding [MEDICAL CONDITION] exchanges, [MEDICAL CONDITION] care and suctioning, and placed these already vulnerable residents at increased risk for infection and a compromised airway. The facility also failed to ensure that their nursing staff were competent and sufficiently skilled to provide [MEDICAL CONDITION] care and suctioning. ("Knowing How to Care For A Patient With A [MEDICAL CONDITION].. is vital because inappropriate care may lead to complications and even death." Nursing 2009, August 2009 Volume 39, Number 8, pages 34-39). One of the six residents (#106) received pressure ulcer wound care that was not administered according to the facility's own policy and procedure related to aseptic technique. According to the Nurse Practice Act, 3)(a) "Practice of professional nursing" means the performance of those acts requiring substantial specialized knowledge, judgment, and nursing skill based upon applied principles of psychological, biological, physical, and social sciences which shall include, but not be limited to: 1. The observation, assessment, nursing diagnosis, planning, intervention, and evaluation of care; health teaching and counseling of the ill, injured, or infirm; and the promotion of wellness, maintenance of health, and prevention of illness of others. 2. The administration of medications and treatments as prescribed or authorized by a duly licensed practitioner authorized by the laws of this state to prescribe such medications and treatments. 3. The supervision and teaching of other personnel in the theory and performance of any of the above acts. (b) "Practice of practical nursing" means the performance of selected acts, including the administration of treatments and medications, in the care of the ill, injured, or infirm and the promotion of wellness, maintenance of health, and prevention of illness of others under the direction of a registered nurse, a licensed physician, a licensed osteopathic physician, a licensed podiatric physician, or a licensed dentist. The professional nurse and the practical nurse shall be responsible and accountable for making decisions that are based upon the individual's educational preparation and experience in nursing. Failure of the facility and nursing staff to ensure that services provided met professional standards, resulted in findings of Immediate Jeopardy on 6/7/12. The Immediate Jeopardy was removed on 6/15/12, and reduced to the scope and severity of an E. Relevant findings included: 1. On 6/7/12 at approximately 9:05 a.m. the surveyor knocked and entered Resident #32's room. Audible gurgling and rattling sounds were heard. A closer inspection revealed that the sounds were coming from Resident #32's breathing through her [MEDICAL CONDITION]. There was thick, yellow mucous bubbling up from the [MEDICAL CONDITION] with each breath. Additionally, thick, yellow mucous was noted to have accumulated in the [MEDICAL CONDITION] oxygen mask. Humidified oxygen at 3 liters per minute was attached to an oxygen concentrator. Resident #32 coughed, and more mucous came up from the [MEDICAL CONDITION]. Employee #B who identified herself as being the nurse that was assigned to this resident, was present at the bedside. She stated that she had just suctioned the resident. She confirmed that the resident appeared to have a large amount of secretions that continued to be coughed out of her [MEDICAL CONDITION], and that there was gurgling present with her respiratory effort. She stated, "But, it stresses her to be suctioned," and indicated that she did not think that it would be appropriate to suction again. Approximately one minute later, the nurse did suction the resident again, after both the surveyor and the nurse observed the resident attempting to clear her own airway and coughing up approximately several tablespoons of sputum. The resident was able to clear some sputum from her [MEDICAL CONDITION] by coughing, but the remainder of the sputum was observed to have aspirated back into the resident's airway. Employee B used the closed catheter system, but it did not appear that the secretions were removed with each pass of the suction catheter. More secretions continued to be coughed up around the [MEDICAL CONDITION] site as the resident coughed violently with spastic movements while the apparently ineffective suction catheter was reintroduced into her airway again and again. Employee B stated that she thought the suction was functional, although the mucous was observed not to be moving in the suction catheter. At approximately 9:10 a.m., the Director of Nursing (DON) appeared in the room. He attempted to suction the resident immediately using the closed suction system, and agreed that the secretions did not appear to be clearing when suctioned. He turned the suction gauge to the maximum limit, and confirmed that there still continued to be no suction. He stated that he would change the catheter tubing. At 9:15 a.m. the DON stated that the suction hose had come loose from the canister lid and that is why there was no suction. He stated that he had detected the problem and it was now resolved. At 9:20 a.m. a repeat observation was done of the resident and she was lying supine in her bed with the head of the bed raised approximately 30 degrees. There was no further gurgling noted with her respirations and there were no further secretions noted coming from her [MEDICAL CONDITION]. 2. A review of Resident #32's medical record revealed that she was a fifty three year old woman that was originally admitted to the facility on [DATE]. Her medical [DIAGNOSES REDACTED]. A review of the last Minimum Data Set comprehensive quarterly assessment dated [DATE] revealed under Section O that she was receiving oxygen, suctioning and tracheal care. Further review of Resident #32's record revealed a care plan dated 5/24/12 that listed a problem that stated, "Potential Complication: [MEDICAL CONDITION]/Infection secondary to [MEDICAL CONDITION]. Goals included that Resident #32 will maintain a patent [MEDICAL CONDITION] daily and the [MEDICAL CONDITION] will be free of infection through the next review. Interventions included: Regularly inspect and cleanse the [MEDICAL CONDITION], provide humidification of inspired air, monitor for signs and symptoms of respiratory distress, monitor for signs and symptoms of infection, ie. foul smelling sputum, discolored sputum, fever, bloody sputum, etc. and notify MD, oxygen at three liters [MEDICAL CONDITIONS] every six hours and as needed, and suction [MEDICAL CONDITION] every shift and as needed for respiratory distress. 3. On 6/7/12 at 10:10 a.m. an interview was conducted with Employee B and the Director or Nursing (DON). Employee B was asked to describe how she knew when a resident required suctioning and she replied, "Usually they will have some gurgling, you can hear it most of time, and if there is gook around the trach, then I would suction per order and the protocol." She confirmed that Resident #32 had orders to suction her [MEDICAL CONDITION] as needed. She further stated that around 9:00 a.m. on 6/7/12, she went in to Resident #32's room to take down her breathing treatment, and noted that she did require suctioning. She stated, "I listened to her sounds, then I suctioned her. She had some white frothy secretions." She confirmed that the suction was not effective when she attempted to suction the resident when the surveyor was present. The DON stated that he had been told that he was needed in room [ROOM NUMBER], and immediately came to the room. He stated further, "When I got there I tried to suction her as well. I noticed that when I went in, I wasn't getting any suction. I thought that I was getting a small amount, but she was having some frothy sputum that continued to come up." He also stated that he after he looked at the suction set up, he noticed that one of the hoses was not connected to the suction canister's lid properly. When he reattached it, he was able to suction Resident #32's airway effectively. Employee B confirmed that she called the DON when the noticed there seemed to be a problem with the suction. Employee B was asked how the facility ensured that the suction machines and set-ups are functional, and she replied that the Central Supply Coordinator makes rounds every day to check the suction. The DON stated that there was no log that he was aware of that documented checking the function and maintenance of the respiratory and suction equipment. 4. On 6/7/12 at 5:50 p.m., [MEDICAL CONDITION] care was observed for Resident #32. Employee P, the licensed practical nurse (LPN) that was assigned to Resident #32 for the 3:00 p.m. to 11:00 p.m. shift was observed washing her hands and assembling supplies that included: mask, gown, clean gloves, sterile gloves, paper towels, hand sanitizer and a [MEDICAL CONDITION] care kit. Employee B also entered the room and stated that she would assist Employee P as per the instructions from the DON. Employee B also washed her hands and put on clean gloves. The resident continued to be on oxygen per concentrator at 3 liters per minute. They positioned the resident into a semi-fowlers position by raising the head of the bed. Employee P washed her hands again and placed the paper towels on the over bed table. She applied a pulse oximeter to Resident #32's finger to obtain a reading for the resident's oxygen saturation. She stated that the saturation was low at 88%. Employee B stated that she had to put the oximeter on the residents thumb in order to get better contact. The oximeter was repositioned as directed by Employee B. The saturation then increased to an acceptable 94%. Employee P sanitized her hands and put on sterile gloves. She picked up the [MEDICAL CONDITION] kit (the outside being non-sterile and thus breaking sterile technique) and opened the kit and dumped the sterile contents out onto the unsterile paper towels. She then stated, "I should have done this first," and removed and discarded the sterile gloves and then put on another pair of sterile gloves. She then pulled open the drawer on the nightstand, again breaking sterile technique, and removed a container of solution. She was asked to identify what was in the container, and she said, "It's the saline." Employee B interjected and stated, "We are supposed to use the saline that's in [MEDICAL CONDITION]." The container that was removed from the drawer was inspected and labeled as normal saline, expiration date 1/14,and had been previously opened with approximately 25% of the liquid still present. There was no resident's name or date that it had been opened recorded on the container. Employee B confirmed that sterile normal saline is used to cleanse the inner cannula of the [MEDICAL CONDITION]. (The policy and procedure for [MEDICAL CONDITION] care dated 5/12 under step #12 stated, "Separate 4x4 gauze and pour sterile water or saline over gauze into one container, and step 13# stated "Pour normal saline into second sterile container for rinsing.") Employee B confirmed that using the previously opened, undated and unlabeled container of saline would not have been consistent with sterile technique for cleansing the non-disposable inner cannula which is inserted directly into the Resident #32's trachea, had Employee P been allowed to continue. Employee P stated that she needed more supplies, and she discarded the opened [MEDICAL CONDITION] kit, removed her gloves, and both nurses left the room. They returned at approximately 6:00 p.m., and Employee P stated that she had reviewed the policy for [MEDICAL CONDITION] care. She washed her hands again and opened the [MEDICAL CONDITION] kit by peeling back the top lid, and setting the tray on the over bed table. She placed a sterile barrier on the over-bed table next to the tray, and then picked up the tray and dumped the sterile contents onto the sterile barrier. Then she placed the tray on the sterile barrier that had been resting on the over-bed table, thus contaminating the sterile field. She opened sterile gloves and put them on, and then placed the paper that the sterile gloves were packaged in underneath the resident's [MEDICAL CONDITION] on her chest. She poured the saline solution and the package of peroxide into the tray. She removed the gauze sponge that was placed around t-piece from the [MEDICAL CONDITION] and with some difficulty attempted to remove the inner cannula. The resident coughed, and approximately two tablespoons of thick, yellow sputum spilled out of the [MEDICAL CONDITION]. Employee P stated that the resident needed to be suctioned first. She used the closed suction catheter technique and placed saline from a small unit dose container of saline into the resident's [MEDICAL CONDITION] using the port on the closed suction catheter. She suctioned the resident by advancing the closed catheter into the [MEDICAL CONDITION], and then applied intermittent suction while withdrawing the catheter. The resident coughed continuously during the suctioning, and the gurgling and sounds of fluid in the resident's lungs were audible in the room. Employee P confirmed that there was sputum moving in the suction catheter, and she stated that the suction appeared to be working. She removed the sterile gloves and re-sanitized her hands. She applied new sterile gloves again, and removed the inner cannula with some difficulty. The resident again coughed and approximately two tablespoons of thick, yellow sputum was expelled out of her [MEDICAL CONDITION] onto the paper that the sterile gloves came in. Employee P placed the inner cannula which appeared to be stained a deep yellow, into the tray that contained the peroxide and normal saline. She was observed to cleanse the inside and outside of the cannula utilizing the cleansing tool included in the sterile kit. She replaced the inner cannula into the [MEDICAL CONDITION] while the resident continued to cough violently and spewed thick creamy yellow sputum from her [MEDICAL CONDITION]. She replaced the t-piece that hooked onto the [MEDICAL CONDITION] into the tubing that the oxygen was connected to which appeared moist with condensation or mucous, and reattached the t-piece to the [MEDICAL CONDITION]. She cleansed the residents' skin that surrounded the [MEDICAL CONDITION] by using a saline soaked gauze sponge that she picked up from on top of the sterile barrier, and dipped into the saline solution in the tray. She did not apply another dressing around the [MEDICAL CONDITION], and left the area bare. (A review of the policy and procedure for [MEDICAL CONDITION] care dated 5/12 lists step #24: "Place 4x4 gauze dressing between the [MEDICAL CONDITION] and resident/patient ' s skin.") She discarded the remains of the [MEDICAL CONDITION] kit, and removed her gloves and washed her hands. Employee P stated that the [MEDICAL CONDITION] ties were recently changed and did not require changing. The [MEDICAL CONDITION] ties were observed to be in place without the presence of secretions on the ties. During an interview at approximately 6:30 p.m. Employee P confirmed that she had omitted placing the dressing around the [MEDICAL CONDITION] site and also confirmed that this was a part of [MEDICAL CONDITION] care, but that she intended to apply the dressing "later." She also confirmed that sterile technique was difficult to follow for her during the observation. She also stated that Resident #32 had pneumonia. 5. Further review of Resident #32's clinical record revealed portable chest x-ray results dated 5/5/12 that stated "perihilar pneumonia" (an atypical pneumonia located at the top of the respiratory tract) as the impression. The physician's orders [REDACTED].[REDACTED]. She continued to receive the [MEDICATION NAME] through 6/8/12. A review of the vital signs that included temperatures revealed that there were no abnormal temperatures documented and it appeared that Resident #32 was not having fevers as a symptom of her pneumonia. However, further review revealed physician's progress notes dated 5/20/12 that revealed Resident #32 had an axillary temperature of 102.5, and had continued respiratory congestion and rubs on auscultation. Another physician's progress note dated 5/22/12 revealed that Resident #32 had a fever of 100.0 axillary, as reported by the nurse, had a pending culture and sensitivity for the thick greenish yellow mucus that was noted in the resident's [MEDICAL CONDITION], and continued on the [MEDICATION NAME] for the respiratory infection. Another physician's progress note dated 5/26/12 stated that the resident was doing better with her upper respiratory infection, but the cough continued that was productive of greenish mucus, and the sputum culture and sensitivity was to be re-collected. A review of the physician's orders [REDACTED]. The results for all three specimens sent stated in the final report that the results suggested contamination, and therefore identification could not be made of the causative bacteria or the antibiotic that would be most effective against it. A review of the facility's infection control log stated that Resident #32 had infections requiring antibiotic therapy listed as "pneumonia" on 5/7/12 and "respiratory" on 5/20/12. 6. On 6/8/12 at approximately 11:45 a.m., an interview was conducted with the Unit Manager of the 3rd floor, and Employee Q, who had stated that she was assigned as Resident #32's nurse, and had frequently cared for her. The unit manager stated that the resident had not been running fevers, and this was confirmed on the vital signs flow sheet that she produced from the clinical record that listed the resident as having normal temperatures recorded. She could not give an explanation for the fevers that were documented on the physician's progress notes. She confirmed that the resident was diagnosed with [REDACTED]. She confirmed that the three sputum specimens that had been sent to the laboratory and were noted to be contaminated specimens. She pointed out the note at the bottom of the laboratory result form dated 5/3/12 that stated, "No further workup unless requested by physician." She stated that she interpreted this to mean no further specimens needed to be sent. Employee Q stated that she had sent at least one of the sputum specimens. She stated that she did not know how to collect a sputum specimen from a [MEDICAL CONDITION], and she had asked the DON and the ADON. She stated that a "lady doctor" that was present in the facility told her that a "Luky-tube" was required, and that she needed to get a "deep suction" and that the laboratory could provide the "Luky-tube." She stated that she called the laboratory, but was told that they did not supply the container. She stated that she told management of the need for the specialized container, but no one had been successful in obtaining the proper container required for the specimen. She stated that she had collected, and sent to the lab, the sputum that had been coughed up around the Resident #32's [MEDICAL CONDITION], since the laboratory would not deliver the proper container and there seemed to be no way to get them. She stated that when she spoke with the physician who was the consulting pulmonologist on 6/6/12, he gave a verbal order to discontinue the sputum specimen and stated he would collect it when he returned to change the [MEDICAL CONDITION]. 7. In an interview with the consulting Pulmonologist on 6/8/12 at 3:30 p.m. he stated that he had been consulting on [MEDICAL CONDITION] residents at this facility for approximately one month. He stated that he became involved with the facility when he noted nursing home residents having frequent readmissions to the hospital, and he thought if they were to receive appropriate care in the nursing homes, then readmissions could be reduced. He stated that he has had some concerns regarding the respiratory care that has been provided at the facility. He stated that he has a respiratory therapist that has provided an in-service to the facility's nursing staff on proper suctioning using aseptic technique recently. He stated that Resident #32 had a large amount of secretions from her lungs, and required a cuffed [MEDICAL CONDITION] to control her extensive secretions in order to prevent her from acquiring aspiration pneumonia. He stated that this type of [MEDICAL CONDITION] was not what was in place. He stated that he verbally requested a Shiley cuffed [MEDICAL CONDITION] #8 on May 30 when he made rounds, and had planned to change the [MEDICAL CONDITION] on 6/6/12, but when he arrived to the facility, they had not ordered the proper [MEDICAL CONDITION] that had a cuff. He stated that he re-requested the cuffed [MEDICAL CONDITION] again on 6/6/12 that would have a cuff to aid in the control of the resident's secretions. He stated that he felt that the resident did have an underlying infection, but the sputum specimens that were sent were contaminated specimens. He confirmed that he did not know that the facility did not have the proper Lukens trap containers that is required to collect a proper specimen, and was unaware that the sputum specimens had been collected improperly by not using sterile technique. He confirmed that sputum specimens from a [MEDICAL CONDITION] should be collected using this type of container, so that a specimen could be obtained for an accurate culture and sensitivity, and the proper antibiotic could be prescribed for the best chance at complete eradication of the infection. He denied giving a verbal order to discontinue the sputum culture and sensitivity and that he would obtain one when he changed the tube. He stated that [MEDICAL CONDITION] should be changed frequently to keep an open airway, and for infection control and he suggested the change should be done every one to three months. He confirmed that improper suctioning and [MEDICAL CONDITION] care by not using the appropriate aseptic and sterile technique is related to infection including pneumonia. 8. On 6/8/12 at approximately 3:50 p.m. an interview was conducted with the DON. He confirmed that a consulting pulmonologist was making rounds on the residents with advanced respiratory care needs including residents with tracheostomies. He stated that he was aware that this physician had ordered a [MEDICAL CONDITION] with a cuff for Resident #32, and also that the facility did not stock them. He stated that the [MEDICAL CONDITION] with a cuff had been ordered, but had not yet been received. He also confirmed that [MEDICAL CONDITION] should be changed regularly. He provided a policy and procedure, dated 03/12, that revealed under policy: "[MEDICAL CONDITION] are changed regularly to decrease the possibility of infection and to maintain a patent airway. He confirmed that he was aware that there were no Lukens sputum collection devices in the facility, and he understood that this was necessary to be able to collect a proper specimen for a sputum culture and sensitivity. He stated that he called the respiratory company that the pending contract was going to be with, but they could not supply the Lukens containers because the contract had not yet been signed. He stated that he also called the laboratory, and they could not provide them either. He stated that he was working with another supplier currently to get the containers. He stated that the consulting pulmonologist had allowed the facility to "use his RT" to provide as a resource for the nursing staff when providing care to residents with tracheostomies. He stated that this RT was in the facility once a few weeks ago, and gave an in-service on tracheal suctioning and care. He stated that the facility does not keep competency skills checklists for the nurses to determine what additional training that they may need to deliver care to the residents. A list of all currently employed nurses that would be considered able to care for residents with [MEDICAL CONDITION] in place was requested. The ADON provided the list, and 39 nurses were identified. He was aware of the problems involving Employee B and Employee P during the observations of Resident #32 on 6/7/12 and stated that these two employees would not be providing care for residents with tracheostomies until they had been sufficiently re-trained. 9. On 6/13/12 at approximately 1:00 p.m. a phone call was made to the laboratory that is listed on the heading of the laboratory results for Resident #32. An interview was conducted with the medical technologist in the microbiology department who identified herself as the manager, stated that when specimens grow out multiple organisms, then it is suspected to be contaminated, and this could be related to improper collection of the specimen. The exact identification of the pathogen or bacteria causing the infection cannot be properly identified, and therefore the proper antibiotic that would be most effective cannot be identified either. She stated that sputum specimens taken from tracheostomies should be collected using sputum trap, or a Lukens trap, and should be collected from deep within the respiratory tract using sterile technique. She stated that the statement that was listed on the bottom of Resident #32's report dated 5/3/12 that stated "No further workup unless requested by physician" does not mean that the specimen does not need to be recollected, it means that the laboratory cannot complete the work-up due to the quality of the specimen. 10. On 6/9/12, a review of the facility's in-services that were provided regarding tracheal care and suctioning was reviewed. An in-service dated 5/27/12 with the printed title of "Intermittent Catheterization" which was struck out and re-titled, "Trach Suction Closed System," had a sign in sheet in which there were five out of thirty nine nurses that attended. Another in-service, which was undated and titled "Trach Suction-Aseptic Technique," which was given by a respiratory therapist that was employed by the consulting pulmonologist, and had two sign in sheets attached that revealed a total of ten out of thirty nine nurses attended. An in-service titled "Return Demonstration:[MEDICAL CONDITIONS]" which was also undated, revealed eighteen out of thirty nine nurses attended. A final in-service dated 6/1/12 and titled, "Suctioning,[MEDICAL CONDITION]," revealed seventeen out of thirty nine nurses attended. On 6/15/12 the ADON produced an updated list of 42 nurses that would be considered available and eligible to provide care for residents with tracheotomies. 11. On 6/11/12 at 2:55 p.m. the staffing sheets were reviewed on the nurse's station where Resident #32 and Resident #19 were located. Employee B and Employee P were both assigned to Resident #32 and Resident #19 for the 3:00 p.m. to 11:00 p.m. shift on 6/11/12. Both of these nurses were involved in the substandard quality of care observations of [MEDICAL CONDITION] care and suctioning on 6/7/12. At that time, the facility had stated that Employee B and Employee P would not be caring for residents with tracheostomies until they had been sufficiently re-trained. 12. On 6/11/12 at approximately 3:05 p.m. an interview was conducted with Employee Q who stated that she was the assigned nurse for Resident #32 for 7:00 a.m. to 3:00 p.m. shift, and that she was preparing to give report to Employee P. She confirmed that Resident #32 was being transferred to the second floor, but they were still waiting for the family to be notified and for the social worker to complete her work that was involved in the transfer. She stated that she had not been told to give report to anyone else for Resident #32. 13. On 6/11/12 at approximately 3:10 p.m. an interview was conducted with the DON. He confirmed that the resident #32 was being transferred to the second floor. He stated that there had been an in-service given that morning by Respiratory Company B regarding [MEDICAL CONDITION] care and suctioning. A review of the sign-in sheets revealed that 10 nurses had attended, and neither Employee B, nor Employee P had attended. The DON confirmed that both of these nurses had been identified as requiring additional training for [MEDICAL CONDITION] care prior to resuming care for these residents. He stated that more in-services would be held, and he also stated that Resident #32 would remain assigned to Employee Q until she was transferred to the second floor. 14. On 6/11/12 at 3:15 p.m. an observation was made of Resident #32. She was lying supine, and the head of her bed was up approximately thirty degrees. Her [MEDICAL CONDITION] oxygen mask was present over her [MEDICAL CONDITION] and the humidified oxygen was adjusted to three liters. There was thick sputum at the opening of the [MEDICAL CONDITION], and gurgling was heard with every respiration. A closed suction device was in place and hooked up to suction at the bedside. There were no belongings that had been packed up that would suggest the resident was in the process of currently being transported to the second floor. 15. On 6/12/12 at approximately 11:35 a.m. an interview was conducted with the Unit Manager on the second floor nursing station. She stated that Resident #32 had been transferred to an acute care hospital on [DATE] to have her [MEDICAL CONDITION] changed. A subsequent review of the hospital records revealed a History and Physical dated 6/11/12 that stated, "She presented with [MEDICAL CONDITION] malfunction and per nursing home notes, the patient's [MEDICAL CONDITION] needs to be replaced." Further review of the records dated 6/12/12 and titled, "Consultation" revealed that Resident #32 required an otolaryngology consultation because the [MEDICAL CONDITION] had been unable to be exchanged for a new one in the emergency room . The consultation stated that the [MEDICAL CONDITION]'s cuff had been cut and was unable to be removed in the emergency room . It was replaced with a smaller tube, and the recommendations were to change the tube every three months. A follow-up call was made on 6/20/12 at approximately 5:00 p.m. to the consulting otolaryngologist physician. He confirmed that he removed Resident #32's [MEDICAL CONDITION] on 6/12/12, and placed a new one. He stated that the "malfunction" was due to the [MEDICAL CONDITION]'s cuff had been cut, and why this had been done "was a mystery" to him. He confirmed that [MEDICAL CONDITION] that have functional cuffs are clinically indicated for a resident that neurologically was unable to handle their own secretions, such as Resident #32, because they cannot protect their own airway from vomitus or oral secretions. He stated that the new tube that he placed on 6/12/12 has a functional cuff that is necessary to assist in preventing aspiration pneumonia. He also confirmed that tracheotomy tubes should be changed at least every three months to maintain an open airway and prevent infection. He stated that he could not determine from the resident's records when the tube had last been changed. 16. On 6/12/12 at approximately 10:30 a.m., an interview was conducted with a respiratory therapist from Company B, who stated that she was sent to the facility on [DATE] to begin providing in-services to the nursing staff for [MEDICAL CONDITION] care and suctioning She also confirmed that sputum specimens from tracheostomies are required to be collected using a Lukens trap and a suction catheter under sterile technique. 17. On 6/12/12 at approximately 11:10 a.m. an observation was made of Resident #19. He was on a stretcher in the hall of the second floor nursing station accompanied by three paramedics waiting for the elevator. His mouth was wide open and his respirations were labo

Based on medical record review, staff interview and policy review, the facility did not ensure that orders were obtained for [MEDICAL CONDITION] care and did not provide [MEDICAL CONDITION] care according to physician orders once obtained for two ( #3 and #1) of three residents sampled. Finding Include: 1. Resident # 3 was a [AGE] year old resident admitted to the facility on [DATE]. Admitting [DIAGNOSES REDACTED]. Hospital 3008 documented principal [DIAGNOSES REDACTED]. The nursing admission data collection and initial plan of care, dated 2/24/12 at 6:48 pm, documented that the resident was admitted to the facility with a [MEDICAL CONDITION] as his respiratory opening. A review of the hospital discharge orders dated 2/24/12 revealed there were no orders for [MEDICAL CONDITION] care or [MEDICAL CONDITION] suctioning. A review of the facility physician order summary signed 2/27/12 documented that physician orders for [MEDICAL CONDITION] care every shift were initiated on 2/27/12, three days after the resident was admitted to the facility. A review of the February Medication Administration Record [REDACTED]. A review of the nursing care track notes from the medical record revealed that [MEDICAL CONDITION] care was performed two times from 2/24/12 to 2/26/12. This was performed without a physician ' s order. A review of the facility policy [MEDICAL CONDITION] Care, with a revision date of 9/8, documented the purpose of [MEDICAL CONDITION] care was to maintain and open airway and prevent infection in a resident with a [MEDICAL CONDITION]. The policy also documented under procedure #1. " Verify physician ' s order". An interview was conducted with the unit manager on 3/2012 at 3:00pm. She stated that when a resident with a [MEDICAL CONDITION] was admitted to the facility without orders, it was her expectation that the nurse would call the physician and request orders based on the facilities policy for [MEDICAL CONDITION] care. An interview was conducted with Director of Nursing on 3/20/12 at 1:30pm, at which time he reviewed the medical record and confirmed there were no physicians orders for [MEDICAL CONDITION] care until 2/27/12, three days after the resident was admitted . He also confirmed that [MEDICAL CONDITION] care for the resident was not documented as completed on the MAR until 2/27/12 and that care was documented in the nursing notes twice prior to having the physicians order. He Stated he felt something was missing and wanted to check his lap top to review the MAR. The DON returned at 1:47 pm and stated he was unable to locate any additional information. He stated he was sure the care was provided but was unable to produce documentation to support the care was rendered. 2. A review of the medical record revealed that resident #1 was admitted to the facility on [DATE]. Per the face sheet the resident ' s admitting [DIAGNOSES REDACTED]. Per the admission data collection form dated 6/1/12, the resident arrived at the facility with a [MEDICAL CONDITION] and a feeding tube. Further review of the physician ' s orders revealed a Physician order record signed on 03/07/12 that documented the following [MEDICAL CONDITION] related orders to be active. Oxygen at 2 liters/minute continuously via [MEDICAL CONDITION] collar (humidified), suction three times a day at 6am, 2pm, and 10 pm. Tracheostoma care to be done with deep suctioning, three times a day, after instilling three milliliters of sterile saline into the Tracheostoma. Use bedside humidifier as well as humidified oxygen, and [MEDICATION NAME] external ointment 2% three times a day at 6am, 2pm, and 10pm. Apply [MEDICATION NAME] three times daily to the 6 o ' clock aspect of Tracheostoma. Further review of the Medication Administration Record [REDACTED]. A review of the physician orders revealed no order had been written to discontinue the previous orders written on 3/7/12. A new order initiated 3/6/12 was present on the on the MAR, to suction the resident PRN (as needed) for increased secretions or shortness of breath. Every shift monitor stoma site for redness, pain, [MEDICAL CONDITION], odor and signs and symptoms of infection. Every shift cleanses the stoma site with normal saline, and every shift use humidifier. There was no physician's order present in the medical record, for the change in treatment. An interview was conducted, with the Director of Nursing (DON), on 3/20/12 at 12:05 p.m. He confirmed the orders on the MAR indicated [REDACTED]. He also confirmed there was no order to stop the previous orders from 3/6/12 or make changes to the treatment. While further reviewing the physician orders in the medical record, a telephone order dated 01/19/12 documented to " see progress note and orders on it for Tracheostoma care. Have Charge nurse/nurse administrator review them also " . The progress note written by the ear, nose and throat physician stated that the resident was " not receiving adequate stoma care " and listed humidified oxygen, bedside humidifier, deep suctioning with three milliliters of sterile saline and [MEDICATION NAME] ointment was needed for proper closure of the Tracheostoma. The physician also wrote in the progress note that the " patient will suffocate and die " if "[MEDICAL CONDITION] is not preformed properly " . The physician stated that the stoma was not closing because the resident ' s stoma had a " clearly visible mucus plug in it " that he removed. During an Interview with the DON on 03/20/12 at 12:34 p.m., He acknowledged that he had not been notified of the order on 01/19/12 nor had he been made aware of the progress note that was written regarding the physician ' s concern regarding care.

Based on observations, interviews and record review, the facility failed to ensure the safe and effective respiratory care which resulted in the compromised respiratory systems and the ability to breathe for five out of five (#19, #30, #32, #58, and #178) residents with tracheostomies. The facility failed to ensure that [MEDICAL CONDITION] exchanges, care, and suctioning were provided and performed according to facility policy, procedure and current standards of care Resident #32 required suction at the bedside to clear her airway of large amounts of thick mucus; the suction was observed to be ineffective, and routine [MEDICAL CONDITION] care was not provided according to policy and procedure related to the prevention of infection. The facility failed to provide physician ordered equipment that included a more appropriate [MEDICAL CONDITION] that was indicated for Resident #32 ' s due to large amounts of mucus and the proper laboratory containers that were required to obtain an accurate culture and sensitivity to identify the most effective antibiotic. Resident #32 was ultimately sent to an acute care hospital six days later to have the [MEDICAL CONDITION] changed, and the [MEDICAL CONDITION] was noted to have been malfunctioning per the hospital discharge summary dated 6/13/12. The facility failed to provide regular, systematic changes of [MEDICAL CONDITION] according to their own policy for all five residents (#19, #30, #32, #58, and #178) with tracheostomies which should have been done to prevent infection of the respiratory system, and ensure that an open airway was maintained. Resident #58 ' s clinical record revealed that a physician ordered procedure for capping trials of the [MEDICAL CONDITION], in preparation for its removal, was not authorized by the facility to begin for twenty nine days. The facility terminated the position of respiratory therapist in August 2011, and then failed to ensure that adequate training for the nursing staff was provided in advanced respiratory care was given. This occurred even after observations and deficiencies issued for continued non-compliance, related to [MEDICAL CONDITION] care, dating back to 3/20/12. Failure of the facility and staff to ensure safe and effective [MEDICAL CONDITION] care and suctioning according to policy and procedure resulted in findings of Immediate Jeopardy on 6/7/12, which was removed on 6/15/12, and reduced to the scope and severity of an E. Relevant findings included: 1. On 6/7/12 at approximately 9:05 a.m. the surveyor knocked and entered Resident #32 ' s room. Audible gurgling and rattling sounds were heard. A closer inspection revealed that the sounds were coming from Resident #32 ' s breathing through her [MEDICAL CONDITION]. There was thick, yellow mucous bubbling up from the [MEDICAL CONDITION] with each breath. Additionally, thick, yellow mucous was noted to have accumulated in the [MEDICAL CONDITION] oxygen mask. Humidified oxygen at 3 liters per minute was attached to an oxygen concentrator. Resident #32 coughed, and more mucous came up from the [MEDICAL CONDITION]. Employee # B who identified herself as being the nurse that was assigned to this resident, was present at the bedside. She stated that she had just suctioned the resident. She confirmed that the resident appeared to have a large amount of secretions that continued to be coughed out of her [MEDICAL CONDITION], and that there was gurgling present with her respiratory effort. She stated, "But, it stresses her to be suctioned," and indicated that she did not think that it would be appropriate to suction again. Approximately one minute later, the nurse did suction the resident again, after both the surveyor and the nurse observed the resident attempting to clear her own airway and coughing up approximately several tablespoons of sputum. The resident was able to clear some sputum from her [MEDICAL CONDITION] by coughing, but the remainder of the sputum was observed to have aspirated back into the resident ' s airway. Employee B used the closed catheter system, but it did not appear that the secretions were removed with each pass of the suction catheter. More secretions continued to be coughed up around the [MEDICAL CONDITION] site as the resident coughed violently with spastic movements while the apparently ineffective suction catheter was reintroduced into her airway again and again. Employee B stated that she thought the suction was functional, although the mucous was observed not to be moving in the suction catheter. At approximately 9:10 a.m., the Director of Nursing (DON) appeared in the room. He attempted to suction the resident immediately using the closed suction system, and agreed that the secretions did not appear to be clearing when suctioned. He turned the suction gauge to the maximum limit, and confirmed that there still continued to be no suction. He stated that he would change the catheter tubing. At 9:15 a.m. the DON stated that the suction hose had come loose from the canister lid and that is why there was no suction. He stated that he had detected the problem and it was now resolved. At 9:20 a.m. a repeat observation was done of the resident and she was lying supine in her bed with the head of the bed raised approximately 30 degrees. There was no further gurgling noted with her respirations and there were no further secretions noted coming from her [MEDICAL CONDITION]. 2. A review of Resident #32 ' s medical record revealed that she was a fifty three year old woman that was originally admitted to the facility on [DATE]. Her medical [DIAGNOSES REDACTED]. A review of the last Minimum Data Set comprehensive quarterly assessment dated [DATE] revealed under Section O that she was receiving oxygen, suctioning and tracheal care. Further review of Resident #32 ' s record revealed a care plan dated 5/24/12 that listed a problem that stated, " Potential Complication: [MEDICAL CONDITION]/Infection secondary to [MEDICAL CONDITION]. Goals included that Resident #32 will maintain a patent [MEDICAL CONDITION] daily and the [MEDICAL CONDITION] will be free of infection through the next review. Interventions included: Regularly inspect and cleanse the [MEDICAL CONDITION], provide humidification of inspired air, monitor for signs and symptoms of respiratory distress, monitor for signs and symptoms of infection, ie. foul smelling sputum, discolored sputum, fever, bloody sputum, etc. and notify MD, oxygen at three liters [MEDICAL CONDITIONS] every six hours and as needed, and suction [MEDICAL CONDITION] every shift and as needed for respiratory distress. 3. On 6/7/12 at 10:10 a.m. an interview was conducted with Employee B and the Director or Nursing (DON). Employee B was asked to describe how she knew when a resident required suctioning and she replied, " Usually they will have some gurgling, you can hear it most of time, and if there is gook around the trach, then I would suction per order and the protocol." She confirmed that Resident #32 had orders to suction her [MEDICAL CONDITION] as needed. She further stated that around 9:00 a.m. on 6/7/12, she went in to Resident #32 ' s room to take down her breathing treatment, and noted that she did require suctioning. She stated, " I listened to her sounds, then I suctioned her. She had some white frothy secretions." She confirmed that the suction was not effective when she attempted to suction the resident when the surveyor was present. The DON stated that he had been told that he was needed in room [ROOM NUMBER], and immediately came to the room. He stated further, " When I got there I tried to suction her as well. I noticed that when I went in, I wasn't getting any suction. I thought that I was getting a small amount, but she was having some frothy sputum that continued to come up. " He also stated that he after he looked at the suction set up, he noticed that one of the hoses was not connected to the suction canister ' s lid properly. When he reattached it, he was able to suction Resident #32 ' s airway effectively. Employee B confirmed that she called the DON when the noticed there seemed to be a problem with the suction. Employee B was asked how the facility ensured that the suction machines and set-ups are functional, and she replied that the Central Supply Coordinator makes rounds every day to check the suction. The DON stated that there was no log that he was aware of that documented checking the function and maintenance of the respiratory and suction equipment. 4. On 6/7/12 at approximately 10:35 a.m. an observation was made of the suction equipment in Resident #32 ' s room. The suction machine was resting on the bedside table. It had a thick, dusty coating on the base, and was stained on the right side with yellowish-white dried drainage. There was no tag, label or sticker that listed when the machine was last inspected or serviced. 5. On 6/7/12 at approximately 10:50 a.m., an interview was conducted with Employee R. She stated that she is a certified nurse assistant, but works as the facility ' s central supply coordinator. She confirmed that she makes rounds every day on the equipment and supplies that are located within the resident ' s rooms. She stated that when she checked Resident #32 ' s room this morning, the suction set up was functional. She also stated that she is responsible for cleaning and disinfecting the equipment every day. She stated, " I maintain them, and I clean them. " When asked what she does if a machine is not working properly, she stated that if she cannot fix the problem herself, then " they get tossed, and I get a new one. " 6. On 6/7/12 at 5:50 p.m., [MEDICAL CONDITION] care was observed for Resident #32. Employee P, the licensed practical nurse (LPN) that was assigned to Resident #32 for the 3:00 p.m. to 11:00 p.m. shift was observed washing her hands and assembling supplies that included: mask, gown, clean gloves, sterile gloves, paper towels, hand sanitizer and a [MEDICAL CONDITION] care kit. Employee B also entered the room and stated that she would assist Employee P as per the instructions from the DON. Employee B also washed her hands and put on clean gloves. The resident continued to be on oxygen per concentrator at 3 liters per minute. They positioned the resident into a semi-fowlers position by raising the head of the bed. Employee P washed her hands again and placed the paper towels on the over bed table. She applied a pulse oximeter to Resident #32 ' s finger to obtain a reading for the resident ' s oxygen saturation. She stated that the saturation was low at 88%. Employee B stated that she had to put the oximeter on the residents thumb in order to get better contact. The oximeter was repositioned as directed by Employee B. The saturation then increased to an acceptable 94%. Employee P sanitized her hands and put on sterile gloves. She picked up the [MEDICAL CONDITION] kit (the outside being non-sterile and thus breaking sterile technique) and opened the kit and dumped the sterile contents out onto the unsterile paper towels. She then stated, "I should have done this first," and removed and discarded the sterile gloves and then put on another pair of sterile gloves. She then pulled open the drawer on the nightstand, again breaking sterile technique, and removed a container of solution. She was asked to identify what was in the container, and she said, " It ' s the saline. " Employee B interjected and stated, "We are supposed to use the saline that's in [MEDICAL CONDITION]." The container that was removed from the drawer was inspected and labeled as normal saline, expiration date 1/14,and had been previously opened with approximately 25% of the liquid still present. There was no resident ' s name or date that it had been opened recorded on the container. Employee B confirmed that sterile normal saline is used to cleanse the inner cannula of the [MEDICAL CONDITION]. (The policy and procedure for [MEDICAL CONDITION] care dated 5/12 under step # 12 stated, " Separate 4x4 gauze and pour sterile water or saline over gauze into one container, and step 13# stated " Pour normal saline into second sterile container for rinsing. " ) Employee B confirmed that using the previously opened, undated and unlabeled container of saline would not have been consistent with sterile technique for cleansing the non-disposable inner cannula which is inserted directly into the Resident #32 ' s trachea, had Employee P been allowed to continue. Employee P stated that she needed more supplies, and she discarded the opened [MEDICAL CONDITION] kit, removed her gloves, and both nurses left the room. They returned at approximately 6:00 p.m., and Employee P stated that she had reviewed the policy for [MEDICAL CONDITION] care. She washed her hands again and opened the [MEDICAL CONDITION] kit by peeling back the top lid, and setting the tray on the over bed table. She placed a sterile barrier on the over-bed table next to the tray, and then picked up the tray and dumped the sterile contents onto the sterile barrier. Then she placed the tray on the sterile barrier that had been resting on the over-bed table, thus contaminating the sterile field. She opened sterile gloves and put them on, and then placed the paper that the sterile gloves were packaged in underneath the resident's [MEDICAL CONDITION] on her chest. She poured the saline solution and the package of peroxide into the tray. She removed the gauze sponge that was placed around t-piece from the [MEDICAL CONDITION] and with some difficulty attempted to remove the inner cannula. The resident coughed, and approximately two tablespoons of thick, yellow sputum spilled out of the [MEDICAL CONDITION]. Employee P stated that the resident needed to be suctioned first. She used the closed suction catheter technique and placed saline from a small unit dose container of saline into the resident's [MEDICAL CONDITION] using the port on the closed suction catheter. She suctioned the resident by advancing the closed catheter into the [MEDICAL CONDITION], and then applied intermittent suction while withdrawing the catheter. The resident coughed continuously during the suctioning, and the gurgling and sounds of fluid in the resident ' s lungs were audible in the room. Employee P confirmed that there was sputum moving in the suction catheter, and she stated that the suction appeared to be working. She removed the sterile gloves and re-sanitized her hands. She applied new sterile gloves again, and removed the inner cannula with some difficulty. The resident again coughed and approximately two tablespoons of thick, yellow sputum was expelled out of her [MEDICAL CONDITION] onto the paper that the sterile gloves came in. Employee P placed the inner cannula which appeared to be stained a deep yellow, into the tray that contained the peroxide and normal saline. She was observed to cleanse the inside and outside of the cannula utilizing the cleansing tool included in the sterile kit. She replaced the inner cannula into the [MEDICAL CONDITION] while the resident continued to cough violently and spewed thick creamy yellow sputum from her [MEDICAL CONDITION]. She replaced the t-piece that hooked onto the [MEDICAL CONDITION] into the tubing that the oxygen was connected to which appeared moist with condensation or mucous, and reattached the t-piece to the [MEDICAL CONDITION]. She cleansed the residents' skin that surrounded the [MEDICAL CONDITION] by using a saline soaked gauze sponge that she picked up from on top of the sterile barrier, and dipped into the saline solution in the tray. She did not apply another dressing around the [MEDICAL CONDITION], and left the area bare. (A review of the policy and procedure for [MEDICAL CONDITION] care dated 5/12 lists step #24: " Place 4x4 gauze dressing between the [MEDICAL CONDITION] and resident/patient ' s skin. " ) She discarded the remains of the [MEDICAL CONDITION] kit, and removed her gloves and washed her hands. Employee P stated that the [MEDICAL CONDITION] ties were recently changed and did not require changing. The [MEDICAL CONDITION] ties were observed to be in place without the presence of secretions on the ties. During an interview at approximately 6:30 p.m. Employee P confirmed that she had omitted placing the dressing around the [MEDICAL CONDITION] site and also confirmed that this was a part of [MEDICAL CONDITION] care, but that she intended to apply the dressing " later. " She also confirmed that sterile technique was difficult to follow for her. She also stated that Resident #32 had pneumonia. 7. Further review of Resident #32 ' s clinical record revealed portable chest x-ray results dated 5/5/12 that stated " perihilar pneumonia " (an atypical pneumonia located at the top of the respiratory tract) as the impression. The physician's order [REDACTED].[REDACTED]. She continued to receive the [MEDICATION NAME] through 6/8/12. A review of the vital signs that included temperatures revealed that there were no abnormal temperatures documented and it appeared that Resident #32 was not having fevers as a symptom of her pneumonia. However, further review revealed physician ' s progress notes dated 5/20/12 that revealed Resident #32 had an axillary temperature of 102.5, and had continued respiratory congestion and rubs on auscultation. Another physician ' s progress note dated 5/22/12 revealed that Resident #32 had a fever of 100.0 axillary, as reported by the nurse, had a pending culture and sensitivity for the thick greenish yellow mucus that was noted in the resident ' s [MEDICAL CONDITION], and continued on the [MEDICATION NAME] for the respiratory infection. Another physician ' s progress note dated 5/26/12 stated that the resident was doing better with her upper respiratory infection, but the cough continued that was productive of greenish mucus, and the sputum culture and sensitivity was to be re-collected. A review of the physician's order [REDACTED]. The results for all three specimens sent stated in the final report that the results suggested contamination, and therefore identification could not be made of the causative bacteria or the antibiotic that would be most effective against it. A review of the facility ' s infection control log stated that Resident #32 had infections requiring antibiotic therapy listed as " pneumonia " on 5/7/12 and " respiratory " on 5/20/12. 8.On 6/8/12 at approximately 11:45 a.m., an interview was conducted with the Unit Manager of the 3rd floor, and Employee Q, who had stated that she was assigned as Resident #32 ' s nurse, and had frequently cared for her. The unit manager stated that the resident had not been running fevers, and this was confirmed on the vital signs flow sheet that she produced from the clinical record that listed the resident as having normal temperatures recorded. She could not give an explanation for the fevers that were documented on the physician ' s progress notes. She confirmed that the resident was diagnosed with [REDACTED]. She confirmed that the three sputum specimens that had been sent to the laboratory and were noted to be contaminated specimens. She pointed out the note at the bottom of the laboratory result form dated 5/3/12 that stated, " No further workup unless requested by physician. " She stated that she interpreted this to mean no further specimens needed to be sent. Employee Q stated that she had sent at least one of the sputum specimens. She stated that she did not know how to collect a sputum specimen from a [MEDICAL CONDITION], and she had asked the DON and the ADON. She stated that a " lady doctor " that was present in the facility told her that a " Luky-tube " was required, and that she needed to get a " deep suction " and that the laboratory could provide the " Luky-tube. " She stated that she called the laboratory, but was told that they did not supply the container. She stated that she told management of the need for the specialized container, but no one had been successful in obtaining the proper container required for the specimen. She stated that she had collected, and sent to the lab, the sputum that had been coughed up around the Resident #32 ' s [MEDICAL CONDITION], since the laboratory would not deliver the proper container and there seemed to be no way to get them. She stated that when she spoke with the physician who was the consulting pulmonologist on 6/6/12, he gave a verbal order to discontinue the sputum specimen and stated he would collect it when he returned to change the [MEDICAL CONDITION]. 9.In an interview with the consulting Pulmonologist on 6/8/12 at 3:30 p.m. he stated that he had been consulting on [MEDICAL CONDITION] residents at this facility for approximately one month. He stated that he is strictly a consultant and was not paid by the facility. He stated that he became involved with the facility when he noted nursing home residents having frequent readmissions to the hospital, and he thought if they were to receive appropriate care in the nursing homes, then readmissions could be reduced. He stated that he was under the impression that the facility was going to have the services of a respiratory therapy company beginning 6/1/12, as this is what he was told by management, but stated that he discovered this had been delayed. He stated that he has had some concerns regarding the respiratory care that has been provided at the facility. He stated that he has a respiratory therapist that has provided an in-service to the nursing staff on proper suctioning in the facility. He stated that Resident #32 had a large amount of secretions from her lungs, and required a cuffed [MEDICAL CONDITION] to control her extensive secretions in order to prevent her from acquiring aspiration pneumonia. He stated that this type of [MEDICAL CONDITION] was not what was in place. He stated that he verbally requested a " cuffed [MEDICAL CONDITION] Shiley #8 " on May 30 when he made rounds, and had planned to change the [MEDICAL CONDITION] on 6/6/12, but when he arrived to the facility, they had not ordered the proper [MEDICAL CONDITION] that had a cuff. He stated that he re-requested the cuffed [MEDICAL CONDITION] again on 6/6/12 that would have a cuff to aid in the control of the resident ' s secretions. He stated that he felt that the resident did have an underlying infection, but the sputum specimens that were sent were contaminated specimens. He confirmed that he did not know that the facility did not have the proper Lukens trap containers that is required to collect a proper specimen, and was unaware that the sputum specimens had been collected improperly by not using sterile technique. He confirmed that sputum specimens from a [MEDICAL CONDITION] should be collected using this type of container, so that a specimen could be obtained for an accurate culture and sensitivity, and the proper antibiotic could be prescribed for the best chance at complete eradication of the infection. He denied giving a verbal order to discontinue the sputum culture and sensitivity and that he would obtain one when he changed the tube. He stated that [MEDICAL CONDITION] should be changed frequently to keep an open airway, and for infection control and he suggested the change should be done every one to three months. He confirmed that improper suctioning and [MEDICAL CONDITION] care by not using the appropriate aseptic and sterile technique is related to infection including pneumonia. 10. On 6/8/12 at approximately 3:50 p.m. an interview was conducted with the DON. He confirmed that a consulting pulmonologist was making rounds on the residents with advanced respiratory care needs including residents with tracheostomies. He stated that he was aware that this physician had ordered a [MEDICAL CONDITION] with a cuff for Resident #32, and also that the facility did not stock them. He stated that the [MEDICAL CONDITION] with a cuff had been ordered. He also confirmed that [MEDICAL CONDITION] should be changed regularly. He provided a policy and procedure, dated 03/12, that revealed under policy: " [MEDICAL CONDITION] are changed regularly to decrease the possibility of infection and to maintain a patent airway. " He confirmed that there were no respiratory therapy (RT) services currently in the facility, but there was a contact pending with Company A for additional supplies, education and possible labor. He stated that the contract was supposed to have been effective June 1, 2012, but there was a delay, and he did not know the reason for the delay. He stated that in the past the facility had a part time RT on staff, but that position was deleted in November of 2011. He stated that the nursing staff had been solely responsible for advanced respiratory care including [MEDICAL CONDITION] care, suctioning and collection of sputum specimens. He confirmed that he was aware that there were no Lukens sputum collection devices in the facility, and he understood that this was necessary to be able to collect a proper specimen for a sputum culture and sensitivity. He stated that he called the respiratory company that the contract was going to be with, but they could not supply the Lukens containers because the contract had not yet been signed. He stated that he also called the laboratory, and they could not provide them either. He stated that he was working with another supplier currently to get the containers. He stated that the consulting pulmonologist had allowed the facility to " use his RT " to provide as a resource for the nursing staff when providing care to residents with tracheostomies. He stated that this RT was in the facility once a few weeks ago, and gave an in-service on tracheal suctioning and care. He stated that the facility does not keep competency skills checklists for the nurses to determine what additional training that they may need to deliver care to the residents. A list of all currently employed nurses that would be considered able to care for residents with [MEDICAL CONDITION] in place was requested. The ADON provided the list, and 39 nurses were identified. He was aware of the problems involving Employee B and Employee P during the observations of Resident #32 on 6/7/12 and stated that these two employees would not be providing care for residents with tracheostomies until they had been sufficiently re-trained. 11. On 6/9/12 at approximately 9:42 a.m., an interview was conducted with the Medical Director who stated that he was not aware of the continued non-compliance regarding [MEDICAL CONDITION] care since 3/20/12. He stated that he did attend a Quality Assurance meeting a few months back, but did not recall discussing advanced respiratory care for the residents. He confirmed that [MEDICAL CONDITION] have not been routinely changed for the residents at the facility. He stated that " sometimes the least that is done invasively is better " for the residents. He pointed out that Resident #32 had a poor prognosis and was at risk for infection related to her co-morbidities. He confirmed that [MEDICAL CONDITION] should be changed periodically because maintaining an open airway and infection control should always be a priority regardless of the individual ' s prognosis. He also confirmed that the equipment such as the Lukens trap containers should be present and available in the facility. 12. On 6/13/12 at approximately 1:00 p.m. a phone call was made to the laboratory that is listed on the heading of the laboratory results for Resident #32. An interview was conducted with the medical technologist in the microbiology department who identified herself as the manager, stated that when specimens grow out multiple organisms, then it is suspected to be contaminated, and this could be related to improper collection of the specimen. The exact identification of the pathogen or bacteria causing the infection cannot be properly identified, and therefore the proper antibiotic that would be most effective cannot be identified either. She stated that sputum specimens taken from tracheostomies should be collected using sputum trap, or a Lukens trap, and should be collected from deep within the respiratory tract using sterile technique. She stated that the statement that was listed on the bottom of Resident #32 ' s report dated 5/3/12 that stated " No further workup unless requested by physician " does not mean that the specimen does not need to be recollected, it means that the laboratory cannot complete the work-up due to the quality of the specimen. 13.In an interview conducted on 6/9/12 at approximately 12:05 p.m., the DON stated that he had been successful at obtaining a Shiley #8 cuffed [MEDICAL CONDITION] for Resident #32 as per the physician ' s request. He stated that he was able to obtain this along with a sterile [MEDICAL CONDITION] changing kit from an acute care hospital located nearby, and it would be available when the physician returned to the facility the following week. 14.On 6/9/12, a review of the facility ' s in-services that were provided regarding tracheal care and suctioning was reviewed. An in-service dated 5/27/12 with the printed title of " Intermittent Catheterization " which was struck out and re-titled, "[MEDICAL CONDITION] Closed System, " had a sign in sheet in which there were five out of thirty nine nurses that attended. Another in-service, which was undated and titled "[MEDICAL CONDITION]-Aseptic Technique, " which was given by a respiratory therapist that was employed by the consulting pulmonologist, and had two sign in sheets attached that revealed a total of ten out of thirty nine nurses attended. An in-service titled " Return Demonstration:[MEDICAL CONDITIONS] " which was also undated, revealed eighteen out of thirty nine nurses attended. A final in-service dated 6/1/12 and titled, " Suctioning,[MEDICAL CONDITION], " revealed seventeen out of thirty nine nurses attended. On 6/15/12 the ADON produced an updated list of 42 nurses that would be considered available and eligible to provide care for residents with tracheotomies. 15. On 6/11/12 at 2:55 p.m. the staffing sheets were reviewed on the nurse ' s station where Resident # 32 and Resident #19 were located. Employee B and Employee P were both assigned to Resident #32 and Resident #19 for the 3:00 p.m. to 11:00 p.m. shift on 6/11/12. Both of these nurses were involved in the substandard quality of care observations of [MEDICAL CONDITION] care and suctioning on 6/7/12. At that time, the facility had stated that Employee B and Employee P would not be caring for residents with tracheostomies until they had been sufficiently re-trained. 16. On 6/11/12 at approximately 3:05p.m. an interview was conducted with Employee Q who stated that she was the assigned nurse for Resident #32 for 7:00 a.m. to 3:00 p.m. shift, and that she was preparing to give report to Employee P. She confirmed that Resident #32 was being transferred to the second floor, but they were still waiting for the family to be notified and for the social worker to complete her work that was involved in the transfer. She stated that she had not been told to give report to anyone else for Resident #32. 17. On 6/11/12 at approximately 3:10 p.m. an interview was conducted with the DON. He confirmed that the resident #32 was being transferred to the second floor. He stated that there had been an in-service given that morning by Respiratory Company B regarding [MEDICAL CONDITION] care and suctioning. A review of the sign-in sheets revealed that 10 nurses had attended, and neither Employee B, nor Employee P had attended. The DON confirmed that both of these nurses had been identified as requiring additional training for [MEDICAL CONDITION] care prior to resuming care for these residents. He stated that more in-services would be held, and he also stated that Resident #32 would remain assigned to Employee Q until she was transferred to the second floor. 18. On 6/11/12 at 3:15 p.m. an observation was made of Resident #32. She was lying supine, and the head of her bed was up approximately thirty degrees. Her [MEDICAL CONDITION] oxygen mask was present over her [MEDICAL CONDITION] and the humidified oxygen was adjusted to three liters. There was thick sputum at the opening of the trache