Every finding on record at Avir at Temple West

Based on observation, interview and record review, the facility failed to store, prepare, distribute, serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen sanitation.The facility failed to ensure hair restraints were used by all Kitchen staff when entering the kitchen.The facility failed to ensure foods were properly distributed with professional standards for food service safety.This failure could place residents who ate food served by the kitchen at risk of cross contamination and food-borne illness. Findings include:Observation of the facility kitchen on 12/16/25 at 9:14 AM, revealed the DM was not wearing a hair restraint while testing the dishwasher temperature. Observation of the facility kitchen on 12/17/2025at 1:35 PM, revealed the DM was not wearing a hair restraint while in the kitchen, obtaining policy and logbooks.Interview on 12/17/2025 at 8:07 AM the DM stated her expectation was employees follow the company wide sanitation policy. She stated if hair restraints were not worn, hair could contaminate the food.Interview 12/17/25 at 12:34 PM, the [NAME] stated, everyone was required to wear a hair net that completely covers the hair on their heads. She stated this will prevent cross contamination and food borne illness.Interview on 12/18/2025 at 5:52 PM, the ADM stated kitchen staff and anyone who enters the kitchen should wear a hair net whenever they are in the kitchen. ADM stated all the kitchen staff have been trained by the DM about the expectations for food safety and kitchen sanitation.Findings include: During an observation of the dining room meal service on 12/16/25 at 11:29 AM, 4 staff members (CNA A, CNA B, LVN D, RN C) failed to perform hand sanitation prior to beginning drink and food service to 11 residents putting 11 residents at risk of cross contamination and food-borne illness During an observation of the dining room meal service on 12/17/25 at 11:39 AM, 3 staff members (RN C, LVN D, CNA F) failed to perform hand sanitation prior to beginning drink and food service to 13 residents putting 11 residents at risk of cross contamination and food-borne illness.During an observation of the dining room meal service on 12/18/25 at 7:30 AM, 5 staff members (ADM, LVN D, CNA H, CNA G, RN C) failed to perform hand sanitation prior to beginning drink and food service to 11 residents.During an interview on 12/17/2025 at 8:07 AM, DM stated that she has an expectation that all staff will sanitize hands before they begin food service. She stated, staff should use proper personal hand hygiene between serving every drink and every plate to a resident. DM stated that residents could get food born illnesses from improper personal hand hygiene.During an interview on 12/17/25 at 12:34 PM, the [NAME] stated, everyone is supposed to practice hand hygiene. She stated, staff are to wash hands anytime they touch their hair or their body. [NAME] stated a possible negative outcome for not using hand sanitizer could be food born illness. During an interview on 12/18/25 at 07:46 AM, CNA G stated she has been trained in proper hand hygiene. CNA G stated, you are supposed to wash your hands before walking into the dining room and you are to use hand sanitizer when leaving the dining room. CNA G stated, I have been taught that we are supposed to wash hands between tasks, so we don't pass germs.During an interview on 12/18/2025 at 2:30 PM, CNA H stated that she has been trained in proper hand hygiene. She stated, it was the facility expectation that before we start serving the residents we are to sanitize our hands. She stated, I sanitize my hands between serving drinks and serving plates to residents. During an interview on 12/18/25 at 8:07 AM, LVN D stated, Service staff are to practice hand hygiene before and between servicing food or drinks to a resident. He stated residents could get a bacterial infection if staff do not practice proper hand hygiene. LVN D did not know why service staff did not use proper hand hygiene when serving drinks and meals to their residents.During an interview with ADON on 12/18/2025 at 2:14 PM, ADON stated she was the facilities Infection Preventionist and that her expectation was that all staff members will practice hand hygiene. She stated staff are expected to sanitize hands between passing each drink and each plate to a resident. She stated that hand hygiene training was mandatory during new employee on boarding and that in- services on hand hygiene was done on12/01/2025. During an interview with ADM on 12/18/2025 at 5:52 PM, the ADM stated it was his expectation that all staff will use proper hand hygiene before, during and after staff serve food to residents. Record review of dietary Orientation and Competency Checklist confirms all 8 kitchen staff members have been trained in Handwashing techniques and food safety.Record Review of In- Service Training Reports on Infection control, Food Safety completed 12/01/2025.Facility provided Policy & Procedure Manual, not dated: Employee Hygiene for Food Safety.Policy: All food and nutrition services employees will practice good personal hygiene and safe food handling procedures.All employees will1. Wear hair restraints (hairnet, hat, and/ or beard restraint) to prevent hair from contacting exposed food. 2. All Employees: Hair restraints are required and should cover all hair on the head.4. All staff will be in good health, will practice good personal hygiene and will use safe food handling practices.Facility provided policy, titled, Handwashing/Hand Hygiene, dated 2001 revealed the following: Policy StatementThis facility considers hand hygiene the primary means to prevent the spread of healthcare-associated infections.Policy Interpretation and ImplementationAdministrative Practices to Promote Hand Hygiene1. All personnel are trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections.2. All personnel are expected to adhere to hand hygiene policies and practices to help prevent the spread of infections to other personnel, residents, and visitors.Indications for Hand Hygiened. after touching a resident.e. after touching the residents' environment. Applying Alcohol-Based Hand Rubs1. Apply generous amount of product to palm of hand and rub hands together.Facility provided Policy & Procedure Manual: Employee Hygiene for Food Safety.Policy: All food and nutrition services employees will practice good personal hygiene and safe food handling procedures.All employees will1. Wash hands before handling food, using posted handwashing procedures. 2. All staff will be in good health, will practice good personal hygiene and will use safe food handling practices.

Based on observation, interview, and record review, the facility failed to ensure the residents had the right to be free from psychosocial abuse and neglect for one (Resident #1) of four residents reviewed for abuse and neglect. The facility failed to ensure staff were not willfully abusing and neglecting Resident #1 as they did not assist her out of bed at a reasonable time which caused her to miss breakfast and lunch and remain in a soiled brief for long periods of time on a regular basis (no specific time frame), causing her to feel hungry and neglected. Resident #1 was consistently neglected and left in her bed for most of the day. An IJ was identified on 04/30/25. The IJ template was provided to the facility on [DATE] at 4:19 PM. While the IJ was removed on 05/01/25, the facility remained out of compliance at a scope of pattern and a severity level of no actual harm with the potential for more than minimal harm that is not immediate jeopardy. This failure placed residents at risk of abuse, neglect, trauma, and psychosocial harm. Findings included: Review of Resident #1's face sheet reflected an [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses of rheumatoid arthritis (condition that causes inflammation in the joints), dysphagia (difficulty swallowing), acquired deformity of neck, and adult failure to thrive. Review of Resident #1's quarterly MDS assessment, dated 01/27/25, reflected a BIMS score of 15, indicating she had no cognitive impairment. Section GG (Functional Abilities) reflected she was dependent on transferring and needed partial/moderate assistance with eating. Review of Resident #1's quarterly care plan, dated 02/13/25, reflected a problem of staff guidelines with an intervention of getting her out of bed and into her wheelchair between 6:00 AM and 7:30 AM daily and to remain up to eat breakfast, lunch, and dinner. It further reflected she was at risk for aspiration pneumonia with an intervention of having her in her motorized wheelchair for all meals. It further reflected she had an ADL self-care performance deficit with an intervention of her requesting to feed herself and refusing to be fed by staff. Furthermore, it reflected she had a swallowing problem related to a diagnosis of dysphagia with an intervention of being up in her motorized wheelchair for all meals. Review of Resident #1's quarterly IDT Care Conference notes, dated 02/12/25, reflected Resident #1, FM A, FM B, the DON, the ADON, the ADM, the SW, the DOR, the SW, the OMB and the MDSC were in attendance. The daily plan for Resident #1 reflected the following: Day staff: Staff to provide ADL care and get [Resident #1] up out of bed and into motorized W/C between 6:00 AM and 7:30 AM daily. Breakfast: Staff to have [Resident #1] remain up in MWC to eat breakfast Lunch: Staff to have [Resident #1] remain up in MWC to eat lunch Dinner: Staff to have [Resident #1] remain up in MWC to eat dinner Bedtime: [Resident #1] to be placed in bed around 8:00 PM nightly Review of Resident #1's progress notes, dated 04/22/25 at 1:31 PM and documented by the SW, reflected the following: [Resident #1]'s light on when SW entered room. [FM D] was standing at [Resident #1]'s bedside. SW asked what [Resident #1] needed since light was on. [FM D] stated that [Resident #1] has been lying in bed in feces since this morning and no one has come into room . [Resident #1] asked to speak with SW once they were done. [Resident #1] stated her light had been on all morning and no one came into her room. Review of an email, dated 04/30/25 at 11:40 AM from the OMB, reflected she had been advocating for Resident #1 for months. She stated they isolate her, refuse to service her, and tell her to leave. She stated she was fragile and missing breakfast and lunch on a regular basis. She stated she believed it had caused Resident #1 physical and psychosocial harm. Review of Resident #1's weights in her EMR, on 04/30/25, reflected a 5.4% weight loss for the last three months indicating a significant weight loss: 01/24/25 - 95.6 Lbs. 02/10/25 - 94.2 Lbs. 03/06/25 - 92.6 Lbs. 04/09/25 - 91.2 Lbs. 04/18/25 - 90.2 Lbs Review of video footage provided by Resident #1's FM A, on 04/30/25, reflected the following: - On 04/13/25, she was not assisted out of bed until 1:59 PM. - On 04/16/25, she was not assisted out of bed until 1:15 PM. - On 04/21/25, she was assisted to bed at 6:45 PM and not assisted out of bed on 04/22/25 until 2:03 PM. During an interview on 04/30/25 at 10:12 AM, the SW stated they had Resident #1's care plan meeting approximately three months ago. She stated Resident #1, her family members, the OMB, and facility leadership were there. She stated it was decided she needed to be gotten up before breakfast. She stated due to her arm/hand contractures, she was unable to eat in bed and needed to be in her wheelchair to feed herself. She stated Resident #1 refused to be fed by staff. She stated for the first couple weeks (getting her up before breakfast) it happened and then it stopped. She stated Resident #1 had been labeled as a difficult resident because Resident #1 was demanding and there were a lot of aides who refused to go into her room, including CNA C. She stated CNA C had been assigned her hall on 04/22/25. She stated she and the MDSC noticed her light had been on for a while around 1:30 PM and went to see what she needed. She stated Resident #1 had not had her brief changed or gotten up that entire day and did not eat breakfast or lunch. She stated Resident #1 was very upset and angry and felt like they (staff) did not take care of her. She stated Resident #1 did not want to move to another facility because she believed she deserved to be taken care of. SW stated she believed Resident #1 had lost weight but was unsure of how much. She stated this was an on-going problem. SW stated that day (04/30/25) they had gotten her up around 8:45 AM, so she had not eaten breakfast. She stated the ADM let the staff choose if they were going to give her care and she believed it was neglectful. During an interview on 04/30/25 at 10:30 AM, RN E stated she worked Resident #1's hall on 04/22/25 and had heard around 1:15 PM she had still not been assisted out of bed, which meant she did not have breakfast or lunch. She stated that was not typical, but sometimes they just fell behind. RN E stated she knew that there were some staff members that did not like to go in her room because she could be difficult. During a telephone interview on 04/30/25 at 10:41 AM, Resident #1's FM A stated she just wanted her (Resident #1) to be treated with dignity and respect. She stated on the videos she sent were just three instances of her being left in bed during the day, she stated it happened all the time. She stated around 12:10 PM on 04/22/25, Resident #1 called her and told her she was not doing too good and had been laying in her poop for quite some time. She stated FM D walked into her room around 1:06 PM and her call light was still on. She stated he went to go find someone for assistants and two aides came in at 1:17 PM, and she was not in her wheelchair until 2:03 PM. She stated a few months ago, they agreed in a care plan meeting that they would be getting her out of between 6:30 AM and 7:00 AM. She stated that lasted a whole two weeks. FM A stated she knew Resident #1 had a tongue on her, but she was in her right mind and deserved to be cared for. During an observation and interview on 04/30/25 at 11:01 AM, revealed Resident #1 in her wheelchair in her room watching television. She stated she did not get breakfast that day and never did because the staff would not get her up. She stated when she was in bed all day, she felt like she was starving and empty. She stated they (staff) knew she wanted to be out of bed no later than 8:00 AM. Resident #1 stated she was tired of being covered in poop, was tired of being neglected, and did not know what to do anymore. During an interview on 04/30/25 at 11:44 AM, the MDSC stated she spoke with Resident #1 that morning (04/30/25) around 9:30 AM and she was out of bed but had missed breakfast due to being assisted out of bed late. She stated she was not able to eat laying down and must be in her wheelchair to feed herself. She stated she had heard of staff members refusing to go into her room because they had their own opinions of her. She stated Resident #1 could be difficult at times but that did not mean they could just neglect and not take care of her. She stated there had been occasions where she had witnessed her being in bed for long periods of time. She stated her expectation was that every resident would be up and out of bed by the time she got there each morning at 8:00A AM. MDSC's expectations were that every resident was checked on/changed every two hours and when they (Residents) asked for something they got it. During an interview on 04/30/25 at 11:53 AM, CNA C stated he was always assigned Resident #1's hall but he barely went into her room because she used to accuse him of stuff like poisoning her or stealing her stuff. He stated those were very serious allegations and he was not going to go through that. He stated other staff had to go into her room to take care of her. CNA C stated he knew she requested to get up early, but she usually was gotten out of bed around 1:00 PM. During an interview on 04/30/25 at 12:08 PM, the ADM stated Resident #1 was one of the toughest residents he had ever been part of caring for. He stated she threatens nurses and aides. He stated they have tried bending over backwards for her. He stated they did have a care plan and the OMB was present and they tried to get her up at the time she requested but she would sometimes refuse. He stated it was always a moving target with Resident #1. He stated she will keep staff in there for over an hour when there are other residents that need to be cared for. ADM stated she called staff names, berated them, and talked to them like dogs. During an interview on 04/30/25 at 12:48 PM, CNA F stated she was a floater, and floaters were not assigned a hall, but assigned to residents that were more high-demanding, such as Resident #1. She stated she knew of a few staff members that refused to go into her room. She stated she had no problems with Resident #1. She stated her shift was from 8:00 AM - 2:30 PM and when she got to work, she would go assist another resident who required assistance with feeding and then straight to Resident #1's room to get her up for the day. She stated it was after breakfast and often missed breakfast because no one would get her up. She stated she could not answer why no one got her up before she did around 9:00 AM on her days she worked. She stated she believed it was an issue. CNA F stated Resident #1 could be cranky, but it did not mean she should be neglected. During a telephone interview on 04/30/25 at 1:17 PM, Resident #1's NP stated it did not meet her expectations for residents to not get assisted out of bed until 1:00 PM unless they refused to. She stated it did not meet her expectations for residents to go without meals or to not provide care for more difficult residents. She stated that was absolutely not okay. NP stated that could lead to pressure wounds, skin breakdown, and weight loss. NP stated even though Resident #1 had her preferences and was able to voice them, that did not mean she should be neglected. During a telephone interview on 04/30/25 at 1:40 PM, Resident #1's FM D stated he went to visit her on 04/22/25 but could not remember the time. He stated he was so upset when he got there and saw the state she was in. He stated she had not eaten or been changed all day long. She stated she was starving and laying up in her own mess. He stated he went and asked CNA C to assist her, but he refused to go into her room. He stated that was straight-up neglect. He stated he then went and spoke to the ADM who told him, (Resident #1) just plays games. He stated he became so upset he had to walk out of the facility to calm down. FM D stated he would never in his life treat an elderly person the way they (staff) do. During an observation and interview on 04/30/25, this Surveyor along with the MDSC asked Resident #1 if it would be okay for her to get weighed, and she agreed. The MDSC went into the hall to find someone to assist them utilize the scale on the mechanical lift. CNA C was in the hall and the MDSC walked right by him. She was asked why she did not ask CNA C for assistance, and she stated that he did not like Resident #1 or going into her room. The MDSC, RN A, and CNA G utilized the mechanical lift and it reflected Resident #1's current weight was 89.6 pounds. During an interview on 04/30/25 at 4:01 PM, the ADM stated his expectations were that residents received every meal to get the full intake they needed. He stated he did not see why Resident #1 could not eat in her bed like other residents did. He stated he had never heard she had to be out of bed to eat due to a physical disability or that she had been missing meals. He stated he was aware there had been days she had been gotten up late but there could be a variety of reasons, such as her sending them away, or since they needed two people for transferring, a staff member could be waiting for someone else to be available. He stated she had threatened staff with their lively hood, and it was bullying on her part. He stated he was aware there were staff that did not like to go into Resident #1's room but he would tell them they still had to go in there and care for her. He stated they have been instructed to always have someone with them, so they had a witness. He stated floaters were assigned differently. He stated they were normally assigned to Resident #1 because she took up so much of their time. He stated missing meals and not getting out of bed could cause weight loss or skin breakdown. Review of the facility's CNA Job Description, dated 02/11/20, reflected the following: JOB SUMMARY: Responsible for assisting resident with activities of daily living in order to promote resident independence and dignity. Review of the facility's Abuse, Neglect, and Exploitation Policy, revised April 2021, reflected the following: Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. Establish and maintain a culture of compassion and caring for all residents and particularly those with behavioral, cognitive or emotional problems. The ADM and ADON were notified on 04/30/25 at 4:19 PM that an IJ had been identified and an IJ template was provided. The following POR was approved on 05/01/25 at 11:01 AM: Corrective Action 1. Facility team members were immediately in serviced on Abuse/Neglect and prior to next shift worked for those team members who are new hires, PRN, vacation, Agency and Leave of Absence. Education will be provided through verbal in servicing and post- test will be given to ensure retention of education. DON/ADON were provided training on Abuse/Neglect on 4/30/25 by RDO/RDCS. Responsible Party: DON/ADON Target Date: 4/30/25 and ongoing Follow-up: Team member roster will printed to ensure all team members on assignment sheet have been in-serviced each shift. Provide ongoing education to all new hires, agency, prn, leave of absence prior to first shift worked. Corrective Action 2. Skin assessment was completed on Resident #1. Skilled Wound Care Physician will conduct an onsite visit 05/01/25. Responsible Party: DON/ADON Target Date: 4/30/25 and ongoing Corrective Action 3. Interviewable residents were interviewed by IDT team to inquire if residents had any concerns with any basic care not being met. No concerns identified. Responsible Party: IDT Team Target Date: 4/30/25 Corrective Action 4. April weight loss summary report was reviewed for all significant weight losses for those residents who are not able to be interviewed to validate that residents who need assistance with meals did not sustain weight loss due to lack of required assistance with meal service and review meal intake documentation. No concerns noted. Responsible Party: IDT Team Target Date: 4/30/25 and ongoing Follow-up: Significant weight losses will be reviewed in (EMR) weekly by IDT Corrective Action 5. In serviced clinical team on importance of Q2 hour rounding on residents requiring assistance to ensure their needs are being met. Responsible Party: DON/ADON Target Date: 4/30/25 Follow-up: Follow the morning meeting process to ensure compliance. Corrective Action 6. One on one education completed with CNA C regarding assisting residents or finding assistance to provide care for residents in need. In serviced all staff assigned to resident hall that they cannot refuse to go into resident room as assigned. Administrator trained by Regional Director of Operations. Responsible Party: Administrator Target Date: 4/30/25 Corrective Action 7. Daily rounding will be conducted by the IDT team for all assigned residents to address any concerns and identify any issues for those residents unable to communicate. Responsible Party: IDT Team Target Date: 4/30/25 Follow-up: Follow morning meeting process to ensure compliance Corrective Action 8. Ad HOC QAPI meeting with MD conducted to discuss the plan of correction for compliance. Responsible Party: IDT Team Target Date: 4/30/25 and ongoing Follow-up: Review any compliance issues in QAPI meeting for 3 months The Surveyor monitored the POR on 05/01/25 as followed: During an observation and interview on 05/01/25 at 3:28 PM revealed Resident #1 in her wheelchair in her room. She stated she was gotten up before breakfast and was able to eat breakfast and lunch that day. During an observation and interview on 05/01/25 at 4:19 PM revealed a resident who required a mechanical lift transfer laying in her bed. She stated she opted to stay in bed yesterday and today because she had been tired. She stated the staff had offered to get her up before each meal. During interviews on 05/01/25 from 1:39 PM - 4:30 PM, one MA, two CNAs, and two RNs stated they were in-serviced before their shifts on abuse and neglect, checking on residents every two hours, getting all residents out of bed before all meals (if they desired), notifying the charge nurse of refusals, and they could not refuse to go in any resident rooms. They all knew who their abuse and neglect coordinator was and could name several types of abuse such as sexual, emotional, and psychosocial. During an interview on 05/01/25 at 2:20 PM, the ADM stated he was in-serviced on abuse and neglect on 04/30/25 and residents should always be free from any abuse or neglect while in the facility. Review of the facility's Ad HOC QAPI meeting agenda, dated 04/30/25, reflected the ADM, the MD, the RDO, and RDCS were in attendance. Review of Resident #1's skin assessment, dated 04/30/25, reflected she had no new skin issues. Review of an in-service dated 04/30/25 and conducted by the RDO, reflected the ADM and ADON were in-serviced on their Abuse and Neglect Policy. Review of an in-service, dated 04/30/25 and conducted by the RDO, reflected all staff were in-serviced on how they were not allowed to refuse care or refuse going into a resident room they were assigned to. Review of an in-service, dated 04/30/25 and conducted by the ADON, reflected all staff were in-serviced on rounding on residents every two hours to ensure their needs were being met. Review of an in-service, dated 04/30/25 and conducted by the ADON, reflected al staff were in-serviced on their Abuse and Neglect Policy. Review of Abuse and Neglect Prohibition Quizzes, dated 04/30/25, reflected staff completed the quizzes with no concerns. Review of Resident Surveys, dated 04/30/25 and conducted by the ADON, reflected all residents were interviewed (resulting in no concerns) the following questions: Do you get the care you need? Do you get out of bed when you need or want to? Do you receive 3 meals daily at the appropriate time of day? Review of documentation, dated 05/01/25 and documented by the ADM, reflected the following: Our ADON scheduled an in-person in-service for nurses and CNA's the evening of 4/30/25. There were multiple topics in the in-service, including a resident's right to refuse care. Within that context, she stated that employees cannot refuse to provide care for any resident in this building. This administrator was present throughout the in-service and reiterated that point. The ADM, RDO, and RDCS were notified on 05/01/25 at 5:58 PM that the IJ had been removed. While the IJ was removed, the facility remained at a level of no actual harm at a scope of pattern that was not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems.

Based on observation, interview, and record review, the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently to maintain the highest practicable well-being of each resident for one (Resident #1) of four residents reviewed for administration. The facility Administrator failed to ensure staff were not willfully abusing and neglecting Resident #1 as they did not assist her out of bed at a reasonable time which caused her to miss breakfast and lunch on a regular basis (no specific time frame). She was consistently neglected and left in her bed for most of the day. An IJ was identified on 04/30/25. The IJ template was provided to the facility on [DATE] at 4:19 PM. While the IJ was removed on 05/01/25, the facility remained out of compliance at a scope of pattern and a severity level of no actual harm with the potential for more than minimal harm that is not immediate jeopardy. This deficient practice could place residents at risk for abuse, neglect, injury, harm, serious impairment, and death. Findings included: Review of Resident #1's face sheet reflected an [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses of rheumatoid arthritis (condition that causes inflammation in the joints), dysphagia (difficulty swallowing), acquired deformity of neck, and adult failure to thrive. Review of Resident #1's quarterly MDS assessment, dated 01/27/25, reflected a BIMS score of 15, indicating she had no cognitive impairment. Section GG (Functional Abilities) reflected she was dependent on transferring and needed partial/moderate assistance with eating. Review of Resident #1's quarterly care plan, dated 02/13/25, reflected a problem of staff guidelines with an intervention of getting her out of bed and into her wheelchair between 6:00 AM and 7:30 AM daily and to remain up to eat breakfast, lunch, and dinner. It further reflected she was at risk for aspiration pneumonia with an intervention of having her in her motorized wheelchair for all meals. It further reflected she had an ADL self-care performance deficit with an intervention of her requesting to feed herself and refusing to be fed by staff. Furthermore, it reflected she had a swallowing problem related to a diagnosis of dysphagia with an intervention of being up in her motorized wheelchair for all meals. Review of Resident #1's quarterly IDT Care Conference notes, dated 02/12/25, reflected Resident #1, FM A, FM B, the DON, the ADON, the ADM, the SW, the DOR, the SW, the OMB and the MDSC were in attendance. The daily plan for Resident #1 reflected the following: Day staff: Staff to provide ADL care and get [Resident #1] up out of bed and into motorized W/C between 6:00 AM and 7:30 AM daily. Breakfast: Staff to have to have [Resident #1] remain up in MWC to eat breakfast Lunch: Staff to have [Resident #1] remain up in MWC to eat lunch Dinner: Staff to have [Resident #1] remain up in MWC to eat dinner Bedtime: [Resident #1] to be placed in bed around 8:00 PM nightly Review of Resident #1's progress notes, dated 04/22/25 at 1:31 PM and documented by the SW, reflected the following: [Resident #1]'s light on when SW entered room. [FM D] was standing at [Resident #1]'s bedside. SW asked what [Resident #1] needed since light was on. [FM D] stated that [Resident #1] has been lying in bed in feces since this morning and no one has come into room . [Resident #1] asked to speak with SW once they were done. [Resident #1] stated her light had been on all morning and no one came into her room. Review of an email, dated 04/30/25 at 11:40 AM from the OMB, reflected she had been advocating for Resident #1 for months. She stated they isolate her, refuse to service her, and tell her to leave. She stated she was fragile and missing breakfast and lunch on a regular basis. She stated she believed it had caused Resident #1 physical and psychosocial harm. Review of Resident #1's weights in her EMR, on 04/30/25, reflected a 5.4% weight loss for the last three months indicating a significant weight loss: 01/24/25 - 95.6 Lbs. 02/10/25 - 94.2 Lbs. 03/06/25 - 92.6 Lbs. 04/09/25 - 91.2 Lbs. 04/18/25 - 90.2 Lbs. Review of video footage provided by Resident #1's FM A, on 04/30/25, reflected the following: - On 04/13/25, she was not assisted out of bed until 1:59 PM. - On 04/16/25, she was not assisted out of bed until 1:15 PM. - On 04/21/25, she was assisted to bed at 6:45 PM and not assisted out of bed on 04/22/25 until 2:03 PM. During an interview on 04/30/25 at 10:12 AM, the SW stated they had Resident #1's care plan meeting approximately three months ago. She stated Resident #1, her family members, the OMB, and facility leadership were there. She stated it was decided she needed to be gotten up before breakfast. She stated due to her arm/hand contractures, she was unable to eat in bed and needed to be in her wheelchair to feed herself. She stated Resident #1 refused to be fed by staff. She stated for the first couple weeks it happened and then it stopped. She stated Resident #1 had been labeled as a difficult resident because she was demanding and there were a lot of aides who refused to go into her room, including CNA C. She stated CNA C had been assigned her hall on 04/22/25. She stated she and the MDSC noticed her light had been on for a while around 1:30 PM and went to see what she needed. She stated Resident #1 had not had her brief changed or gotten up that entire day and did not eat breakfast or lunch. She stated Resident #1 was very upset and angry and felt like they did not take care of her. She stated Resident #1 did not want to move to another facility because she believed she deserved to be taken care of. She stated she believed she had lost weight but was unsure of how much. She stated this was an on-going problem. She stated that day (04/30/25) they had gotten her up around 8:45 AM, so she had not eaten breakfast. She stated the ADM let the staff choose if they were going to give her care and she believed it was neglectful. During an interview on 04/30/25 at 10:30 AM, RN E stated she worked Resident #1's hall on 04/22/25 and had heard around 1:15 PM she had still not been assisted out of bed, which meant she did not have breakfast or lunch. She stated that was not typical, but sometimes they just fell behind. She stated she knew that there were some staff members that did not like to go in her room because she could be difficult. During a telephone interview on 04/30/25 at 10:41 AM, Resident #1's FM A stated she just wanted her (Resident #1) to be treated with dignity and respect. She stated on the videos she sent were just three instances of her being left in bed during the day, she stated it happened all the time. She stated around 12:10 PM on 04/22/25, Resident #1 called her and told her she was not doing too good and had been laying in her poop for quite some time. She stated FM D walked into her room around 1:06 PM and her call light was still on. She stated he went to go find someone for assistants and two aides came in at 1:17 PM, and she was not in her wheelchair until 2:03 PM. She stated a few months ago, they agreed in a care plan meeting that they would be getting her out of between 6:30 AM and 7:00 AM. She stated that lasted a whole two weeks. She stated she knew Resident #1 had a tongue on her, but she was in her right mind and deserved to be cared for. During an observation and interview on 04/30/25 at 11:01 AM, revealed Resident #1 in her wheelchair in her room watching television. She stated she did not get breakfast that day and never did because the staff would not get her up. She stated when she was in bed all day, she felt like she was starving and empty. She stated they (staff) knew she wanted to be out of bed no later than 8:00 AM. She stated she was tired of being covered in poop, was tired of being neglected, and did not know what to do anymore. During an interview on 04/30/25 at 11:44 AM, the MDSC stated she spoke with Resident #1 that morning (04/30/25) around 9:30 AM and she was out of bed but had missed breakfast due to being assisted out of bed late. She stated she was not able to eat laying down and must be in her wheelchair to feed herself. She stated she had heard of staff members refusing to go into her room because they had their own opinions of her. She stated Resident #1 could be difficult at times but that did not mean they could just neglect and not take care of her. She stated there had been occasions where she had witnessed her being in bed for long periods of time. She stated her expectation was that every resident would be up and out of bed by the time she got there each morning at 8:00A AM. Her expectations were that every resident was checked on/changed every two hours and when they asked for something they got it. During an interview on 04/30/25 at 11:53 AM, CNA C stated he was always assigned Resident #1's hall but he barely went into her room because she used to accuse him of stuff like poisoning her or stealing her stuff. He stated those were very serious allegations and he was not going to go through that. He stated other staff had to go into her room to take care of her. He stated he knew she requested to get up early, but she usually was gotten out of bed around 1:00 PM. During an interview on 04/30/25 at 12:08 PM, the ADM stated Resident #1 was one of the toughest residents he had ever been part of caring for. He stated she threatens nurses and aides. He stated they have tried bending over backwards for her. He stated they did have a care plan and the OMB was present and they tried to get her up at the time she requested but she would sometimes refuse. He stated it was always a moving target with Resident #1. He stated she will keep staff in there for over an hour when there are other residents that need to be cared for. He stated she called staff names, berated them, and talked to them like dogs. During an interview on 04/30/25 at 12:48 PM, CNA F stated she was a floater, and floaters were not assigned a hall, but assigned to residents that were more high-demanding, such as Resident #1. She stated she knew of a few staff members that refused to go into her room. She stated she had no problems with Resident #1. She stated her shift was from 8:00 AM - 2:30 PM and when she got to work, she would go assist another resident who required assistance with feeding and then straight to Resident #1's room to get her up for the day. She stated it was after breakfast and often missed breakfast because no one would get her up. She stated she could not answer why no one got her up before she did around 9:00 AM on her days she worked. She stated she believed it was an issue. She stated Resident #1 could be cranky, but it did not mean she should be neglected. During a telephone interview on 04/30/25 at 1:17 PM, Resident #1's NP stated it did not meet her expectations for residents to not get assisted out of bed until 1:00 PM unless they refused to. She stated it did not meet her expectations for residents to go without meals or to not provide care for more difficult residents. She stated that was absolutely not okay. She stated that could lead to pressure wounds, skin breakdown, and weight loss. She stated even though Resident #1 had her preferences and was able to voice them, that did not mean she had the right to be neglected. During a telephone interview on 04/30/25 at 1:40 PM, Resident #1's FM D stated he went to visit her on 04/22/25 but could not remember the time. He stated he was so upset when he got there and saw the state she was in. He stated she had not eaten or been changed all day long. She stated she was starving and laying up in her own mess. He stated he went and asked CNA C to assist her, but he refused to go into her room. He stated that was straight-up neglect. He stated he then went and spoke to the ADM who told him, (Resident #1) just plays games. He stated he became so upset he had to walk out of the facility to calm down. He stated he would never in his life treat an elderly person the way they (staff) do. During an observation and interview on 04/30/25, this Surveyor along with the MDSC asked Resident #1 if it would be okay for her to get weighed, and she agreed. The MDSC went into the hall to find someone to assist them utilize the scale on the hoyer lift. CNA C was in the hall and the MDSC walked right by him. She was asked why she did not ask CNA C for assistance, and she stated that he did not like Resident #1 or going into her room. The MDSC, RN A, and CNA G utilized the hoyer and it reflected Resident #1's current weight was 89.6 pounds. During an interview on 04/30/25 at 4:01 PM, the ADM stated his expectations were that residents received every meal to get the full intake they needed. He stated he did not see why Resident #1 could not eat in her bed like other residents did. He stated he had never heard she had to be out of bed to eat due to a physical disability or that she had been missing meals. He stated he was aware there had been days she had been gotten up late but there could be a variety of reasons, such as her sending them away, or since they needed two people for transferring, a staff member could be waiting for someone else to be available. He stated she had threatened staff with their lively hood, and it was bullying on her part. He stated he was aware there were staff that did not like to go into Resident #1's room but he would tell them they still had to go in there and care for her. He stated they have been instructed to always have someone with them, so they had a witness. He stated floaters were assigned differently. He stated they were normally assigned to Resident #1 because she took up so much of their time. He stated missing meals and not getting out of bed could cause weight loss or skin breakdown. Review of the facility's Abuse, Neglect, and Exploitation Policy, revised April 2021, reflected the following: Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. . 2. Develop and implement policies and protocols to prevent and identify: a. abuse or mistreatment of residents; b. neglect of residents . Establish and maintain a culture of compassion and caring for all residents and particularly those with behavioral, cognitive or emotional problems. The ADM and ADON were notified on 04/30/25 at 4:19 PM that an IJ had been identified and an IJ template was provided. The following POR was approved on 05/01/25 at 11:01 AM: Corrective Action 1. Regional Director of Operations immediately in serviced Administrator on Abuse/Neglect. Responsibly Party: RDO Target Date: 4/30/25 and ongoing Follow-Up: Regional Director of Operations and Director of Clinical Services will attend (EMR) meetings 2x monthly for 3 months to ensure any resident issues identified have appropriate interventions. Corrective Action 2. Administrator in-serviced all team members on compliance 24-hour hot line where team members can report any concerns and or if administration is not taking corrective action or putting interventions in place to ensure residents are being cared for by staff appropriately. Compliance hotline notifications will be posted by time clock and breakrooms. Administrator trained by Regional Director of Operations. Responsible Party: Administrator The Surveyor monitored the POR on 05/01/25 as followed: Observation on 05/01/25 at 3:33 PM revealed the 24-hour hotline posted in the breakroom. During an observation and interview on 05/01/25 at 3:28 PM revealed Resident #1 in her wheelchair in her room. She stated she was gotten up before breakfast and was able to eat breakfast and lunch that day. During an observation and interview on 05/01/25 at 4:19 PM revealed a resident who required a mechanical lift transfer laying in her bed. She stated she opted to stay in bed yesterday and today because she had been tired. She stated the staff had offered to get her up before each meal. During interviews on 05/01/25 from 1:39 PM - 4:30 PM, one MA , two CNAs, and two RNs stated they were in-serviced before their shifts on abuse and neglect, checking on residents every two hours, getting all residents out of bed before all meals (if they desired), notifying the charge nurse of refusals, and they could not refuse to go in any resident rooms. They all knew who their abuse and neglect coordinator was and could name several types of abuse such as sexual, emotional, and psychosocial. They all knew where to find the 24-hour hotline number which was posted in the breakroom. During an interview on 05/01/25 at 2:20 PM, the ADM stated he was in-serviced on abuse and neglect on 04/30/25 and residents should always be free from any abuse or neglect while in the facility. Review of the facility's Ad HOC QAPI meeting agenda, dated 04/30/25, reflected the ADM, the MD, the RDO, and RDCS were in attendance. Review of an in-service dated 04/30/25 and conducted by the RDO, reflected the ADM and ADON were in-serviced on their Abuse and Neglect Policy. Review of an in-service, dated 04/30/25 and conducted by the RDO, reflected all staff were in-serviced on how they were not allowed to refuse care or refuse going into a resident room they were assigned to. Review of an in-service, dated 04/30/25 and conducted by the ADON, reflected all staff were in-serviced on rounding on residents every two hours to ensure their needs were being met. Review of an in-service, dated 04/30/25 and conducted by the ADON, reflected al staff were in-serviced on their Abuse and Neglect Policy. Review of Abuse and Neglect Prohibition Quizzes, dated 04/30/25, reflected staff completed the quizzes with no concerns. Review of Resident Surveys, dated 04/30/25 and conducted by the ADON, reflected all residents were interviewed (resulting in no concerns) the following questions: Do you get the care you need? Do you get out of bed when you need or want to? Do you receive 3 meals daily at the appropriate time of day? Review of documentation, dated 05/01/25 and documented by the ADM, reflected the following: Our ADON scheduled an in-person in-service for nurses and CNA's the evening of 4/30/25. There were multiple topics in the in-service, including a resident's right to refuse care. Within that context, she stated that employees cannot refuse to provide care for any resident in this building. This administrator was present throughout the in-service and reiterated that point. The ADM, RDO, and RDCS were notified on 05/01/25 at 5:58 PM that the IJ had been removed. While the IJ was removed, the facility remained at a scope of pattern and severity level of no actual harm with the potential for more than minimal harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems.

Based on interview and record review, the facility failed to ensure that all allegations involving abuse, neglect, and misappropriation were reported immediately to the State Survey Agency (HHSC), but no later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse, for 1 of 4 residents (Resident #1) reviewed for abuse. The facility did not report to the State Survey Agency (HHSC) an incident of alleged abuse/neglect for Resident #1. This failure could place residents at risk for harm to include physical abuse, a diminished quality of life, and psychosocial harm. The findings included: Record review of Resident #1 's face sheet, dated 4/15/2025 reflected a [AGE] year-old female resident readmitted to the facility on [DATE] with diagnoses that included: Acute Respiratory Failure with Hypercapnia (occurs when the lungs fail to adequately remove carbon dioxide from the blood), Congestive Heart Failure (a condition where the heart can't pump enough blood to meet the body's needs), and Chronic Obstructive Pulmonary Disease (a condition caused by damage to the airways or other parts of the lung). The resident is her own responsible party. Record review of Resident#1's quarterly MDS, dated [DATE], revealed: the resident's BIMS score was fifteen (intact cognition). During an interview on 4/15/2025 at 8:45 AM the ADM stated Resident #1 came to him seven days after the alleged incident on 2/26/2025. Resident #1 stated a male CNA, who previously worked for the facility and was visiting his girlfriend who worked there, came into her room around 2:00 AM and made a suggestive, vulgar comment to her. Resident #1 stated the male did not touch her. The ADM investigated the allegation, Resident #1 was assessed, and was deemed inconclusive. The ADM said he would normally report this type of situation and I did not report the allegation because Resident #1 said she did not want it reported. Later we decided to report it because we felt like she was playing games with us, as she shared the allegation with other staff and residents. During an interview on 4/15/2025 at 9:33 AM, Resident #1 stated, I do not feel unsafe here. I did not want to stir up anything. I did not want my family to know because they would have come in and tried to take things over. I said I did not want the state, or the police called. Resident #1 stated a male, who previously worked for the facility and was visiting his girlfriend who worked at the facility, came into her room around 2:00 AM and made a suggestive, vulgar comment to her. Resident #1 stated the male did not touch her. During a telephone interview on 4/15/2025 at 12:42 PM, the SW stated, Resident #1 reported the allegation to me after she reported to the ADM. She said she did not want it reported and I informed her I had to report it. I spoke with the ADM and told him we should report the allegation , he agreed. She said she was unsure why the ADM did not report it. Resident #1 stated a male, who previously worked for the facility and was visiting his girlfriend who worked at the facility, came into her room around 2:00 AM and made a suggestive, vulgar comment to her. Resident #1 stated the male did not touch her. Resident #1 stated she did not feel unsafe. During an interview on 4/15/2025 at 3:30 PM the ADM stated he did not report the allegation because he was honoring Resident #1's request to not have it reported. The ADM is the Abuse Coordinator and received the initial allegation. Review of the facility's policy titled Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating (MED-PASS, Inc. Revised September 20222) reflected the following: Reporting Allegations to the Administrator and Authorities 2. The administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies: a. The state licensing/certification agency responsible for surveying/licensing the facility; b. The local/state ombudsman; c. The resident's representative; d. Adult protective services (where state law provides jurisdiction in long-term care); e. Law enforcement officials; f. The resident's attending physician; and g. The facility medical director. 3. Immediately is defined as: a. within two hours of an allegation involving abuse or result in serious bodily injury; or b. within 24 hours of an allegation that does not involve abuse or result in serious bodily injury. 4. Verbal/written notices to agencies are submitted via special carrier, fax, e-mail, or by telephone. 5. Notices include, as appropriate: a. the resident's name; b. the resident's room number; c. the type of abuse that is alleged (i.e., verbal, physical, sexual, neglect, etc.); d. the date and time the alleged incident occurred; e. the name(s) of all persons involved in the alleged incident; and f. what immediate action was taken by the facility. 6. Upon receiving any allegations of abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source, the administrator is responsible for determining what actions (if any) are needed for the protection of residents.

Based on interview and record review the facility failed to ensure based on the comprehensive assessment of a resident, that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for one of three residents (Resident #1) reviewed for quality of care. The facility failed to schedule an order to apply TED hose (stockings that prevent blood clots and swelling) to Resident #1's lower extremities while he was at the facility from 09/14/24 - 09/20/24. This failure could place residents at risk of not receiving necessary medical care, harm, and hospitalization . Findings include: Record review of Resident #1's, undated, face sheet reflected a [AGE] year-old male who was admitted to the facility on [DATE] and discharged on [DATE]. Resident #1 had diagnoses which included end-stage renal disease, type II diabetes , morbid obesity, gout (inflammatory arthritis), thrombosis (the formation of a blood clot inside a blood vessel, obstructing the flow of blood through the circulatory system), and dependence on renal dialysis. Record review of Resident #1's discharge MDS assessment, dated 09/23/24, reflected his BIMS was not assessed. Record review of Resident #1's admission care plan, dated 09/14/24, reflected he had diabetes mellitus with an intervention of administering diabetes medication as ordered by the doctor. Record review of Resident #1's physician order, dated 09/14/24, reflected to apply TED hose to lower bilateral extremities daily in the morning and remove at bedtime. Record review of Resident #1's list of physician orders, on 09/26/24, reflected the order to apply/remove TED hose was never scheduled therefore it never triggered on the September TAR. Record review of Resident #1's TAR, September 2024, reflected no order for applying/removing TED hose. During an interview on 09/26/24 at 11:35 AM, MA A stated she only worked with Resident #1 one day while he was at the facility and could not remember if he was wearing TED hose. During an interview on 09/26/24 at 12:50 PM, LVN B stated in order for a physician's order to trigger on the TAR, it needed to be scheduled, giving it a start date. She observed Resident #1's orders in his EMR and stated it appeared the order for the TED hose was never scheduled, meaning it would not trigger in the TAR. She stated it was the responsibility of the admitting nurses to schedule physician orders. She stated because it was never scheduled, there would be no proof that it was being done. During an interview on 09/26/24 at 1:22 PM, the ADON stated it was very important to schedule physician orders, so they were active to ensure the orders were being followed. She stated it was the responsibility of the admitting nurses to schedule all orders, but she recently took over the responsibility about two weeks prior. She stated she could not remember if she scheduled the TED hose order for Resident #1 but did remember seeing him wearing his TED hose. She stated a negative outcome of not scheduling this order could be putting the resident at risk for edema or blood clots. A request was made for a policy on physician orders, but only a policy on medication orders was provided. Record review of an in-service conducted by the DON and the ADON, dated 09/10/24, reflected nurses were in-serviced on multiple topics one including completing all QUEUED (pending/in line) orders in resident's orders upon admission/readmission. Record review of the facility's Medication Orders Policy, revised November 2014, reflected there was nothing regarding entering/scheduling/following physician orders.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for one of one kitchen reviewed for sanitation. 1. The facility failed to ensure sanitation practices (covering waste receptacles, sanitizing the thermometer prior to use, cleaning the ice machine, cleaning the juice gun nozzle, cleaning utensil storage drawers, cleaning of ice scoop bin) were occurring in the kitchen. 2. The facility failed to ensure temperature logs were being completed. 3. The facility failed to ensure cleaning logs were being completed. 4. The facility failed to ensure all items were covered and stored properly. These failures could place residents at risk of foodborne illness. Findings included: Observation on 9/15/24 at 9:08 am of the facility kitchen reflected 55-gallon trash can in kitchen prep area without lid. Observation of utensil storage drawers with food debris and tiny bits of paper on bottom surface of drawer and lip of drawer where clean utensils were stored. Observation of leftover scrambled egg in blender uncovered, steamtable pan of sausage links uncovered sitting on prep counter, steamtable pan of toast and pancakes uncovered on prep table, baking sheet of chicken strips and chicken nuggets uncovered on prep table, steamtable pan of what appears to be melted butter on top of oven, and steamtable pan of white gravy on prep table. Observation of reddish pink buildup inside the juice gun nozzle. Observation of ice machine bucket for ice scoop with standing water in bottom with food debris and filmy substance floating on top of water. Observation of ice machine door upper inside of door and seal around ice machine entrance with what appeared to be black and gray dirt and mold buildup. Observation of trash can near hand hygiene sink in dish room revealed no cover on trash can. Observation on 9/16/24 10:36 am of facility kitchen pureed production of butter beans revealed [NAME] K did not clean the thermometer prior to taking temperatures. Observation on 9/17/24 10:05 am of facility kitchen pureed production of green beans, scalloped potatoes, sliced bread, and cornmeal crusted tilapia revealed [NAME] K did not clean the thermometer prior to taking temperatures. Record review of facility kitchen ice machine cleaning log reflected last documented cleaning dated 6/7/24. Record review of facility kitchen weekly cleaning schedule reflected the only documented cleaning to be of convection oven and sweeping and moping storeroom during week 1 of September. Weekly cleaning schedule had 5 weeks listed for September. Record review of facility kitchen daily cleaning schedule reflected documentation of cleaning log between 9/1/24-9/16/24 reflected missing documentation for 47 different tasks. Interview on 9/17/24 at 1:30 pm with [NAME] K revealed [NAME] K said the proper way to take food temperatures was to use an alcohol swab prior to taking food temperatures, again in between each food item, and then again after taking food temperatures. Interview on 9/17/24 at 1:42 pm with the DM J revealed DM J said it was their expectation for [NAME] K to use an alcohol swab to clean the thermometer prior to taking food temperatures, again in between each food item, and finally after taking all temperatures. DM J said it was their expectation for the kitchen to be clean and all staff to be completing the cleaning lists. DM J said each different staff member had cleaning duties depending on their job title. DM J said their expectation was for all food items to be covered and stored properly. DM J said it was their expectation for the cooks to be taking the temperature of the food items and completing the temperature logs. DM J said a negative of not completing cleaning lists, taking temperatures correctly storing food properly could be cross contamination for residents and write ups for staff. DM J said they make rounds in the kitchen frequently to ensure tasks are being completed and the RD makes monthly sanitation audits of the kitchen to ensure sanitation practices are being maintained. Interview on 9/17/24 at 2:40 pm with the Administrator revealed his expectation of the kitchen regarding sanitation was for the kitchen to be clean. The Administrator said a negative effect to residents of the kitchen not having good sanitation could be foodborne illness. Record review of Cleaning Schedules policy UNDATED reflected under heading Policy: The facility will maintain a cleaning schedule prepared by the Nutrition & Foodservice Manager and followed by employees as assigned to ensure that the kitchen is clean and free of hazards. Procedure: 1. The Nutrition & Foodservice Manager will develop a cleaning schedule for daily, weekly, and monthly cleaning. 2. Cleaning tasks will be assigned to positions and included in the job description. 3. The cleaning list will be posted weekly and initialed off and dated by each employee upon completion of the task. The Nutrition & Foodservice Manager or designee will verify that the tasks were completed as assigned. Record review of General Kitchen Sanitation policy dated 10/1/18 reflected under heading Policy: The facility recognizes that food-borne illness has the potential to harm elderly and frail residents. All Nutrition & Foodservice employees will maintain clean, sanitary kitchen facilities in accordance with the state and US Food Codes to minimize the risk of infection and food borne illness. Procedure: 1. Clean and sanitize all food preparation areas, food-contact surfaces, dining facilities and equipment. After each use, clean and sanitize all tableware, kitchenware, and food-contact surfaces of equipment, except cooking surfaces of equipment and pots and pans that are not used to hold or store food and are used solely for cooking purposes. 2. Clean food-contact surfaces of grills, griddles and similar cooking devices and the cavities and door seals of microwave ovens at least once a day: except for hot oil cooking equipment and hot oil filtering systems. 3. Keep food-contact surfaces of all cooking equipment free of encrusted grease deposits and other accumulated soil. 4. Clean and sanitize all multi-use utensils and food-contact surfaces of equipment used in the preparation or storage of potentially hazardous food prior to each use. Clean and sanitize food-contact surfaces of equipment and multi-use utensils used for preparation of potentially hazardous foods on a continuous or production line basis at scheduled intervals throughout the preparation period based on food temperature, type of food and amount of food particle accumulation. 5. After cleaning and until use, store and handle all food-contact surfaces of equipment and multi-use utensils in a manner that protects the surfaces from manual contact, splash, dust, dirt, insects, and other contaminants 6. Clean non-food-contact surfaces of equipment at intervals as necessary to keep them free of dust, dirt, and food particles and otherwise in a clean and sanitary condition. 7. Store, handle and dispense all single-service articles in a sanitary manner and use only once. 8. Make sure that cloths used for wiping occasional food spills on tableware are clean, dry, and not used for any other purpose. 9. Clean and rinse immediately prior to use, moist cloths used for wiping food spills on kitchenware and food-contact surfaces of equipment. Clean frequently during use in a sanitizing solution and do not use for any other purpose. When not in use, hold in a sanitizing solution of the proper concentration (100 ppm Chlorine, 200 ppm Quaternary Ammonia, or 25 ppm Iodine). 10. Clean and rinse in a sanitizing solution, moist cloths used for cleaning non-food-contact surfaces of equipment such as counters, dining tabletops and shelves and do not use for any other purpose. 11. Check restrooms regularly throughout the shift, and be sure they are stocked with soap, toilet paper and paper towels. If automatic hand dryers are used, make sure they are working properly. 12. Make sure hand-washing facilities are easily accessible and supplied with soap and paper towels. 13. Have a professional pest-control program in place. 14. Store toxic chemicals away from food products and be sure they are properly labeled.

Based on observations, interviews, and record review, the facility failed to maintain an effective pest control program so that facility was free of pests and rodents for the facility's only kitchen and dining room reviewed for physical environment. 1.The facility did not ensure the facility was free of flies and crickets in the kitchen. 2. The facility did not ensure the facility was free of flies in the dining room This failure could place residents at risk for an unsanitary environment and a decreased quality of life. The findings included: Observation and resident interviews on 9/15/24 at 11:38 am of the dining room revealed flies throughout dining room in windowsills (20 counted), on resident tables, landing on resident plates of food. Resident # 5 said the flies were always terrible in the dining room. Residents were observed covering their drinks with paper towels to keep flies out. Resident # 13 said he brings his own personal fly swatter to the dining room with him because of the flies. Resident # 26 was observed swatting at flies with an assistive eating built up spoon as flies were landing on his mashed potatoes and ground chicken. Observation on 9/15/24 at 12:11 pm of covered smoking patio area with door leading out from dining room revealed 4 cats lounging on patio, bird feathers all over patio, and a clump of unidentified biological material near entry door to dining room covered in flies. Observation on 9/15/24 12:19 pm of the kitchen revealed 1 dead fly on kitchen floor near the stove, 1 live fly in the dry storage on storage rack, dead crickets in kitchen dish room near storage rack of clean dishes. Interview on 9/17/24 at 1:30 pm with MD L revealed MD L said the facility had a contract with a company to come out once a month and spray for pests. MD L said he conducted rounds in the morning of the exterior of the facility looking for any evidence of pests. MD L said the facility has not had a problem with flies previously. MD L said the Administrator had asked him a couple of months ago to get something for the flies because flies had been seen in the room the department heads hold meetings. MD L said after that, he went and purchased Fly bait granules and placed them in the meeting room, near the dining room exit to the smoking patio, in the puzzle room, behind the vending machines in dining room, and outside on the patio. MD L said he went and got 2 fly traps and hung them outside on the covered patio smoking area. Interview on 9/17/24 at 1:42 pm with DM J revealed DM J said for any pests, they would MD L, and MD L will take care of the issue. DM J said they were aware of the problem with the flies, and they had discussed this matter with the MD L to address the issue. DM J said the pest control company comes once a month and sprays for pests. DM J said the facility had in the past had bug lights in the hallway across from kitchen door to catch flying pests, but they no longer has those, and she was unsure as to why. Interview on 9/17/24 at 2:07 pm with the DON revealed they deferred all pest control questions to the MD L as that is not their area of knowledge, but any pest control concerns are discussed in the staff morning meetings. DON said they could not answer any questions concerning pest control. Interview on 9/17/24 at 2:40 pm with the Administrator revealed he expected the facility to be pest free. The Administrator said a negative outcome of not being pest free could be that first it would be gross, resident bites or stings, and dirtiness. Record review of the facility's pest control invoices reflected the facility common areas, kitchen, 400 and 500 halls were treated for roaches and ants with last service being on 8/26/24. Record review of facility maintenance logs reflected daily monitoring of outside of building for pests by MD L with last documented date of 9/14/24. Requested pest control policy on 9/16/24 at 8:54 am, and facility administrator said they did not have a pest control policy.

40884 Based on observations, interviews, and record review, the facility failed to ensure residents unable to conduct activities of daily living (ADLs) received the necessary services to maintain good grooming and personal hygiene for four of eight residents (Resident # 5, Resident #6, Resident #7, and Resident #20) reviewed quality of life. 1. The facility failed to ensure Resident #5's facial hair was removed. 2. The facility failed to ensure Resident # 6's, Resident # 7's and Resident #20's nails were cleaned and trimmed. These failures could place residents at risk for poor hygiene, dignity issues, and decreased quality of life. Findings included: 1. Record review of Resident # 5's Face Sheet dated,09/16/2024, reflected a 73 -year-old female admitted on [DATE] with a diagnoses of type 2 diabetes mellitus with unspecified complications (a chronic condition that occurs when the body does not produce enough insulin), unspecified dementia without behaviors ( dementia- a general term for a range of brain conditions that cause a loss such as thinking, remembering, and reasoning- unspecified means- without a specific diagnosis), and macular cyst, hole, or pseudo hole, left eye ( can cause loss of central vision). Record review of Resident #5's Quarterly MDS Assessment, dated 08/30/2024, reflected the resident had a BIMS score of 13 indicating her cognition was intact. Resident #5 had impaired vision. Resident #5 required supervision or touching assistance with personal hygiene, oral hygiene, showers, and dressing. Resident #5 required partial/moderate assistance with transfers. Record review of Resident #5's Comprehensive Care Plan , dated 09/11/2024 , reflected Resident #5 had ADL self -care performance deficit related to history of falls and macular degeneration of bilateral eyes and retinopathy ( an eye disease that damages a part of the retina- a light sensitive layers of nerve tissue at the back of the eye- that controls central vision) related to diabetes mellitus. Intervention: Resident #5 required supervision of staff with personal hygiene. Observation on 09/15/2024 at 12:30 PM revealed Resident #5 was sitting in the main dining room alone at a table. Her tablemates had already left the dining room. She had facial hair on the right side, middle and underneath her chin. The hair was approximately 1 inch long. Observation on 09/15/2024 at 1:33 PM revealed Resident #5 was sitting in her wheelchair near the television in her room. The facial hair on and underneath her chin had not been removed. Interview on 09/15/2024 at 1:35 PM with Resident #5 revealed she did not realize she had facial hair. Resident #5 stated she would not have left her room with facial hair on her face. Resident #5 stated she was very embarrassed. She stated she was not leaving her room until someone removed the facial hair. 2. Record review of Resident #6's Face Sheet , dated 09/16/2024, reflected a [AGE] year-old female admitted on [DATE] and readmitted on [DATE] with diagnoses of other lack of coordination (uncoordinated movement due to a muscle control problem that causes inability to coordinate movements), unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (impairment of memory) and muscle weakness ( a loss of muscle strength that can make it difficult to move a muscle normally). Record review of Resident #6's Quarterly MDS Assessment, dated 06/04/2024, reflected the resident had a BIMS score of 3 indicated her cognitive status was severely impaired. Resident #6 was also assessed to require substantial/maximal assistance with the following ADLs: personal hygiene, oral hygiene, upper body dressing, transfers, and toileting hygiene. Resident #6 was dependent on staff for showering and, lower body dressing. Record review of Resident #6's Comprehensive Care Plan, revised on 08/13/2024, reflected Resident #6 had an ADL self- care performance deficit. Interventions: Bathing/Showering: check nail length, trim and clean on bath days and as needed. Report any changes to the nurse. Personal hygiene: Resident #6 required one staff assistance. Observation on 09/15/2024 at 9:19 AM revealed Resident #6 was in her room lying in bed. Resident #6 had blackish/ brownish substance underneath the forefinger, ring finger and middle fingernails on her right and left hand. There was an odor of excreta (excreted matter, like feces) near her fingernails on her right hand. An attempted interview on 07/29/2024 at 9:02 AM with Resident #6 revealed she was not interview able. Record review of Resident # 7's Face Sheet dated, 09/16/2024, reflected a [AGE] year-old female admitted on [DATE] with diagnoses of polyosteoarthritis, unspecified (five or more joints in the body have arthritis at the same time), anxiety disorder ( a condition in which a person had excessive worry and feelings of fear, dread, and uneasiness), and combined forms of age-related cataracts ( a common eye condition characterized by the clouding and thickening of the natural lens in the eye, leading to decreased vision) Record review of Resident #7's Quarterly MDS Assessment, dated 07/11/2024, reflected the resident had a BIMS score of 9 indicating her cognition was moderately impaired. Resident #7 required set up assistance with personal hygiene, repositioning in bed, and dressing. She required supervision with bathing, repositioning in bed, and transfers. Record review of Resident #7's Comprehensive Care Plan dated, 07/19/2024, reflected Resident #7's ADLs was not assessed on her care plan. Resident #7 had impaired visual function related to age-related bilateral cataracts. Intervention: Inform Resident #7 where her personal items were being placed. Resident #7 had a mood problem related to anxiety. Resident #7 was referred to Senior Psych services. Intervention: Behavioral health consults as needed. Observation on 09/15/2024 at 9:35 AM revealed Resident #7 was lying in bed. She had blackish substance underneath her middle finger, ring finger and fore fingernails on her right hand. There was an odor of excreta (excreted matter, like feces) near her fingernails on her right hand. Interview on 09/15/2024 at 9:35 AM with Resident # 7 revealed she had asked someone the previous day to clean her nails. She stated she did not recall the staff name. Resident #7 stated the person worked there said it was not her day for a shower, and they only cleaned nails during showers. Resident #7 stated she was embarrassed for anyone to get near her because it was stuff from her bottom on her fingernails. She stated it was poop (feces) from her bottom. Resident #7 stated sometimes her bottom itched, she has to scratch her bottom, and gets poop on her fingers and in her fingernails. Resident #7 stated it had been on her fingers and under her fingernails since past Friday (09/13/2024). Review of Resident #20's Face sheet reflected a [AGE] year-old female admitted to the facility on [DATE] with the following diagnoses chronic respiratory failure with hypoxia (a condition in which your lungs have a hard time loading your blood with oxygen or removing carbon dioxide. It can leave you with low oxygen, high carbon dioxide, or both.), cerebral palsy (A group of disorders that affect movement, muscle tone, balance, and posture.) and tracheostomy status (hole that surgeons make through the front of the neck and into the windpipe (trachea). Review of Resident #20's quarterly MDS assessment dated [DATE] reflected Resident #20 was assessed to have a BIMS score of 00 indicating severe cognitive impairment. Resident #20 was assessed to be dependent on staff for all ADLs. Review of Resident #20's comprehensive care plan reflected a problem with the initiation date of 06/07/2022 The resident has an ADL self-care performance deficit . Interventions included .check nail length and trim and clean on bath day and as necessary . Observation on 09/15/2024 at 10:00 AM revealed Resident #20 in her room in bed. Resident #20 was not interview able. Resident #20 was observed to have mycotic (is a fungal infection that affects your toenails or fingernails. It separates your nail from your nail bed, making it thick and fragile.) fingernails to her right hand . Resident #20's left hand fingernails were long and observed to have a dark substance underneath the nails. In an interview on 09/15/2024 at 3:14 PM, LVN H stated Resident 20's fingernails were dirty. LVN H stated the brown substance was probably blood from her scratching her face. He further stated Resident #20's fingernails were long and should be trimmed to prevent her from scratching her face. In an interview on 09/17/2024 at 8:25 AM, ADON LVN A stated the nurses and the CNAs were responsible for nail care. She stated the nurses were responsible to trim and clean all residents' nails with a diagnosis of diabetes. ADON LVN A stated it was the CNA's responsibility to clean and trim all other residents' nails. She stated if there was a blackish substance underneath the residents' nails, there was a possibility the substance had bacteria underneath the residents' nails. She stated if a resident swallowed the bacteria there was a possibility a resident may become extremely ill with stomach issues such as diarrhea or vomiting. ADON LVN A stated she was only aware of one resident refusing nail care. ADON LVN A stated it was not Resident #6 or Resident #7. She stated if a female resident had facial hair on their chin, there was a possibility the resident may become embarrassed with their appearance and may isolate themselves in their room. In an interview on 09/17/2024 at 9:10 AM, the DON stated it was a joint effort between the CNAs and the nurses to complete nail care on the residents. She stated the nurses was responsible for residents with diagnosis of diabetes ( a disease in which the body's ability to produce or respond to the hormone insulin was impaired). The DON stated nail care was given during showers and as needed. She stated if a resident had blackish substance underneath their nails there was a possibility the substance may be some type of bacteria. The DON stated she could not answer any further questions about dirty fingernails and the potential of a resident becoming ill. She stated if a female resident had facial hair there was a possibility the female resident may not want to leave their room due to embarrassment of the hair on their face. In an interview on 09/17/2024 at 10:05 AM, CNA E stated the nurses completed all diabetic fingernails and the CNAs were responsible for all other residents' nails. He stated the CNAs were responsible to complete nail care such as trimming, filing, and cleaning the nails. CNA E stated if a resident's nails needed to be cleaned, trimmed, or filed, and it was not their shower day, the staff were expected to do any type of nail care as needed. He stated if a resident had blackish substance underneath their nails, it was probably some type of bacteria such as bowel movements. He stated if a resident swallowed bacteria it was a potential the resident may become ill with major stomach problems such as diarrhea. He stated he had given care to Resident #5, Resident #6, and Resident #7 , and he was not aware of them refusing nail care. CNA E stated if a female resident had facial hair on their chin, a resident may become embarrassed over their appearance and there was a possibility the resident may isolate themselves in their room. CNA E stated it was the CNAs or nurses' responsibility to remove facial hair from the female's chin in the resident's room or during showers. CNA E stated she was not aware of any female resident refusing to allow staff to remove unwanted facial hair from their face. Record review of the facility's Policy on ADLs revised March 2018 reflected A resident who was unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal, and oral hygiene.

Based on observation, interview, and record review, the facility failed to provide a safe, clean, comfortable, and homelike environment for 3 (Resident # 5, Resident # 25, and Resident # 39) of 13 resident reviewed for resident rights. 1. The facility failed to ensure Resident # 5 and # 25's bedroom had no foul odors, the restroom floor did not have bags of soiled briefs in the corner by the toilet, and pair of pants with a soiled brief on the restroom floor. 2. The facility failed to ensure Resident # 25's over bed table was clean and free from food and beverage debris. 3. The facility failed to ensure Resident # 5 and # 25's restroom baseboard was secured to wall and not a fall hazard. 4. The facility failed to ensure Resident # 5 and # 39's bed sheets were clean. These deficient practices could place residents at risk of infection and a decreased quality of life. Findings included: 1. Record review of Resident # 5's Admission Face sheet dated 9/16/24 reflected a [AGE] year-old female admitted to the facility on [DATE] with a diagnosis of dementia, chronic kidney disease stage 3, type 2 diabetes, hypertension, atherosclerotic heart disease, acute pain due to trauma, severe protein calorie malnutrition, chronic foot ulcers due to diabetes, diabetic retinopathy, history of pulmonary embolism, febrile neutrophilic dermatosis, and vascular dementia. Record review of Resident # 5's Quarterly MDS assessment dated [DATE] reflected, Resident # 5 had a BIMS score of 13 indicating the Resident's cognition was intact. Resident # 5 had a diagnosis of non-Alzheimer's dementia, diabetes mellitus, renal insufficiency, renal failure, or end stage renal disease, diabetic retinopathy with macular edema, and chronic foot ulcers related to diabetes. Resident # 5 needed partial to moderate assist for toileting transfers and supervision or touching assist for toileting hygiene. Record review of Resident # 5's Comprehensive Care Plan initiated 2/25/23 revised on 6/20/24 with a target date of 9/10/24 reflected Resident # 5 has an ADL self-care deficit related to history of falls, diabetic foot ulcer, macular degeneration, and retinopathy due to diabetes. Interventions include resident requires supervision of staff for toileting, personal hygiene, and transfers. 2. Record review of Resident # 25's Admission Face sheet dated 9/16/24 reflected a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of hemiparesis and hemiplegia following CVA, hypertension, major depressive disorder, anxiety disorder, insomnia, GERD, muscle weakness, epilepsy, anemia, acquired absence of kidney, disorder of kidney and ureter, convulsions, dementia, obstructive and reflux uropathy. Record review of Resident # 25's Quarterly MDS assessment dated [DATE] reflected, Resident # 25 had a BIMS score of 15 indicating the Resident's cognition was intact. Resident # 25 had a diagnosis of obstructive uropathy, non-Alzheimer's dementia, hemiplegia or hemiparesis, Epilepsy, disorder of kidney and ureter, and acquired absence of kidney. Resident # 25 was dependent on staff for all toileting needs. Record review of Resident # 25's Comprehensive Care Plan initiated 2/10/21 and revised on 8/28/24 reflected Resident # 25 has mobility impairment and is dependent for ADL's. Interventions include staff will ensure resident has access to needed DME and assist resident with ADL's without prejudice throughout stay. Resident # 25 has an ADL performance self-care deficit related to hemiplegia due to stroke. Interventions include resident is not toileted resident is incontinent of bowel. Resident requires total assist x 2 staff per mechanical lift for all transfers. Resident # 25 requires assistance by 1 staff with personal hygiene. Resident # 25 has bowel incontinence. Interventions include check resident every 2 hours and assist with toileting as needed. Provide peri care after each incontinence episode. See care plans on mobility, ADL's, cognitive deficit, and communication. 3. Record review of Resident # 39's Admission Face sheet dated 8/16/24 reflected a [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE] with a diagnosis of dementia, spinal stenosis, depressive episodes, hypercholesterolemia, cervical disc disorder, chronic obstructive pulmonary disease, vascular dementia, and vitamin D deficiency. Record review of Resident # 39's Quarterly MDS assessment dated [DATE] reflected, Resident # 39 had a BIMS score of 9 indicating the Resident's cognition was moderately impaired. Resident # 39 had a diagnosis of non-Alzheimer's dementia. Resident # 39 was partial to moderate assist for toilet transfer and supervision or touching assist for toileting and personal hygiene. Record review of Resident # 39's Comprehensive Care Plan initiated 2/24/21 and revised on 2/26/24 and a target date of 8/28/24 reflected Resident # 39 has an ADL self-care performance deficit related to cervical myopathy. Interventions include the resident requires assist by 1 staff for personal hygiene and supervision of staff for toileting. Resident # 39 is incontinent of urine at times and resident refuses to allow staff to assist during incontinence episodes. Interventions include clean peri area after each incontinence episode. Encourage resident to allow assistance during incontinence episode. Check resident every 2 hours and as required for incontinence. Wash, rinse, and dry perineum. Change clothing PRN after episodes. Monitor and document for signs and symptoms of UTI. Monitor, document, and report PRN any possible causes of incontinence. Observation on 9/15/24 at 10:15 am of Resident # 5 and Resident # 25's room revealed the room to have a foul odor of urine. Resident # 25's over bed table to had food debris and red sticky dried liquid substance all over table. Observation of resident restroom revealed 2 bags of soiled briefs in the corner next to the toilet. Observation of baseboard wall molding to be loose and away from wall falling onto floor. Observation 9/15/24 at 2:06 pm of Resident # 39's room revealed Resident # 39's room to have a foul odor of urine. Observation of Resident # 39's bed linen had what appeared to be urine stain covered in flies and gnats on side of bed linen. Observation on 9/16/24 at 9:41 am of Resident # 5 and Resident # 25's room revealed room to have a foul odor of urine. Resident # 25's over bed table to had food debris and red sticky dried liquid substance all over table. Observation of resident restroom revealed pair of pants and soiled brief on restroom floor. Observation of baseboard wall molding to be loose and away from wall falling onto floor. Observation of Resident # 5's bed linen to have what appeared to be dried feces and brown stain on side of bed linen. Interview on 9/15/24 at 10:15 am with Resident # 5 revealed Resident # 5 said they have no concerns and are happy with their care. When asked about the bags of soiled briefs in the restroom Resident # 5 said housekeeping will be around later today and get them then. Resident # 5 was in bed watching television at time of interview. Resident # 5 gave short answers then went back to watching television. Interview on 9/15/24 at 10:15 am with Resident # 25 revealed Resident # 25 said housekeeping comes in and cleans the room daily. Resident # 25 said they had no concerns and wanted to get back to their television program. Interview on 9/17/24 at 1:15 pm with HSK M revealed when cleaning resident rooms the first thing done would be to gather all the trash and remove from room. HSK M said the restroom is cleaned first starting with the toilet, behind toilet, baseboard, mirrors, replace paper goods, clean the sink, underneath the sink, sweep, and mop then change mop head prior to cleaning the rest of the room. In resident room clean over bed table the tops and side, then windowsills, blinds, corners, door frames, bed rails, under beds, bedside table, light fixture, vents, sweep, and mop then change mop head between resident rooms. Last, clean door handles and perform hand hygiene before moving to next resident room. HSK M said mop water is changed after 3 rooms. Interview on 9/17/24 at 1:30 pm with MD L revealed MD L said for any building maintenance issues that a work order is put into the maintenance documentation system. MD L said all staff have access to be able to put work orders in. MD L said once a work order is received then he addresses whatever the need is. MD L said if a resident reports a issue to staff then that staff member is responsible for creating the work order. Interview on 9/17/24 at 2:07 pm with the DON revealed it would be their expectation that housekeeping, nursing, and CNAs are responsible for keeping resident rooms clean. DON said whoever sees an issue first is to address the issue. DON said a negative outcome for residents of not maintaining clean resident rooms could be infection control and odors. Interview on 9/17/24 at 2:40 pm with the Administrator revealed his expectation of room cleanliness was that the rooms would be clean. Administrator said a negative outcome to residents of not keeping their rooms clean could be unsanitary and unsafe conditions. Record review of Cleaning and Disinfecting Residents' Rooms with a revision date of 8/2013 reflected Purpose: The purpose of this procedure is to provide guidelines for cleaning and disinfecting resident rooms. General Guidelines: 1. Housekeeping surfaces (floors, tabletops) will be cleaned on a regular basis, when spills occur, and when these surfaces are visibly soiled. 2. Environmental services will be disinfected (or cleaned) on a regular basis (daily, three times a week) and when surfaces are visibly soiled. Under Resident Room Cleaning 4. Change mop solution water at least every three (3) rooms, or as necessary. 5. Change cleaning cloths when they become soiled. Wash cleaning cloths daily and allow cloths to dry before reuse. 6. Clean horizontal surfaces (e.g., bedside tables, overbed tables, and chairs) daily with a cloth moistened with disinfectant solution. Do not use feather dusters. 7. Clean personal use items (e.g., lights, phones, call bells, bedrails, etc.) with disinfectant solution at least twice weekly. 8. When cleaning rooms of residents on isolation precautions, use personal protective equipment as indicated.

Based on interview and record review, the facility failed to ensure all Pre-Admission Screening and Resident Review (PASARR) Level I screenings were completed correctly and residents with a mental illness were provided with a PASSAR Level II assessment for 2 (Resident #33 and Resident # 32) of 8 residents reviewed for PASARR assessments. 1. Resident #33 did not have a new PASARR Level I although diagnosis of mental illness was diagnosed after the admitted . 2. Resident # 32 did not have a PASARR Level I completed correctly although diagnosis of mental illness was diagnosed upon admission. These failures could place all residents who had a mental illness or intellectual or developmental disability at risk for not receiving needed assessment, care, and services to meet their needs. Findings included: 1. Record review of Resident #33's Face sheet, dated 09/17/2024, reflected at [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with the diagnoses of post-traumatic stress disorder (a disorder that develops in some people who have experienced a shocking, scary, or dangerous event) with onset of 07/14/2023, anxiety disorder ( a condition in which a person has excessive worry and feeling of fear, dread or uneasiness), dependence on renal dialysis (someone who uses technology to sustain their life because their kidneys are no longer able to perform their normal functions) and chronic pain syndrome ( a constant condition that involves persistent pain that lasts longer than the usually recovery period, or that occurs along with a chronic health condition). Record review of Resident #33's Face sheet, dated 9/17/2024, reflected Resident #33 had a new diagnosis of post-traumatic stress disorder with onset of 07/14/2023. Record review of Resident #33's Quarterly MDS Assessment, dated 08/13/2024, reflected Resident #33 had a BIMS score of 15 indicating the Resident's cognition was intact. Resident #33 had a diagnosis of anxiety disorder and Post Traumatic Stress Disorder. She was assessed to require pain management. Record review of Resident #33's Comprehensive Care Plan, with start date of 08/19/2024 and completion date of 8/27/2024 reflected Resident #33 used psychotropic medications (a drug or other substance that affects how the brain works and causes change in mood, awareness, thoughts, feelings, or behavior) related to anxiety and Post Traumatic Stress Disorder. Interventions: Monitor for side effects and effectiveness every shift. Consult with pharmacy, medical doctor to consider dosage reduction when clinically appropriate at least quarterly. Monitor/ document/report as needed any adverse reactions of psychotropic medications. Reduce the number of psychotropic medications. Resident received hemodialysis. Intervention: Work with resident to relieve discomfort for side effects of the disease and treatment. Resident was assessed to be at risk for pain. Intervention: anticipate the resident's need for pain relief and respond immediately to any complaint of pain. Record review of Resident #33's PASSAR records reflected a PASSAR Level 1 was completed on 04/13/2023 indicated Resident did not have a mental illness. Resident #33 had a Mental Illness/ Dementia Resident review by the facility on 05/09/2023 reflected Resident #33 did not have a mental illness. Reviewed Resident #33's PASRR Level 1 Screening dated 01/01/2024 reflected Resident #33 did not have a mental illness. 2. Record review of Resident 32's Admission Face sheet dated 9/16/24, reflected a [AGE] year-old male admitted to the facility on [DATE] with a diagnoses of cerebral infarction (Stroke), dysphagia following cerebral infarction (difficulty swallowing foods or liquids), age-related physical debility, bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs), left knee contracture, heart failure, mixed hyperlipidemia (a genetic disorder that causes high levels of cholesterol, triglycerides, and other lipids in the blood), major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities), anxiety disorder (a condition in which a person has excessive worry and feeling of fear, dread or uneasiness), insomnia (persistent problems falling and staying asleep), chronic pain (persistent pain that last weeks to years), hypertension (high blood pressure), contracture of muscle multiple sites, hemiplegia and hemiparesis (muscle weakness or partial paralysis on one side of the body that can affect the arms, legs, and facial muscles), muscle wasting and atrophy, vitamin B12 deficiency anemia (a condition where the body doesn't have enough vitamin B12 to produce healthy red blood cells, which results in anemia), convulsions, shortness of breath, and benign prostatic hyperplasia (enlarged prostrate). Record review of Resident # 32's Quarterly MDS assessment dated [DATE], reflected Resident # 32 had a BIMS score of 15 indicating the Resident's cognition was intact. Resident # 32 had a diagnosis of anxiety disorder, depression, and bipolar disorder. He was assessed to require pain management. Record review of Resident # 32's Comprehensive Care Plan, with an initiation date of 2/26/24 and a target date of 8/21/24 reflected Resident #32 used psychotropic medications (a drug or other substance that affects how the brain works and causes change in mood, awareness, thoughts, feelings, or behavior) related to depression. Interventions include administer psychotropic medications as ordered by physician. Monitor for side effects and effectiveness every shift. Resident # 32 has a mood problem related to bipolar disorder, anxiety, and major depression. Interventions include Administer medications as ordered. Monitor for side effects and effectiveness. Behavioral health consults as needed. Resident # 32 has chronic pain. Interventions include Anticipate the resident's need for pain relief and respond immediately to any pain complaint. Monitor and document for probable cause of each pain episode. Monitor and document for side effects of pain medications. Monitor, record, and report to nurse any signs or symptoms of non-verbal pain. Notify physician if interventions are unsuccessful or if current complaint is a significant change from resident's experience of pain. Record review of Resident # 32's PASSAR records reflected a PASSAR Level 1 was completed on 2/24/21 indicated Resident did not have a mental illness. Resident #32 had a Mental Illness/ Dementia Resident review by the facility on 5/9/23 reflected Resident #32 did not have a mental illness. Reviewed Resident #32's PASRR Level 1 Screening dated 3/19/24 reflected Resident #32 did not have a mental illness. In an interview on 09/15/2023 at 10:45 AM Resident #33 stated she had anxiety and there were times when she had triggers of her PTSD. She stated she had several triggers especially when someone comes in her room, and she does not know they are in the room, and they don't knock on the door. She stated there were certain sounds when staff was talking to each other in the room and was very loud. Resident #33 stated it would help her anxiety and PTSD if the staff did know her triggers. She stated sometimes after staff leaves her room, she becomes more anxious, and it affects her PTSD. Resident #33 did not specify how it affected her PTSD. She stated she did receive psych services at one time when she lived at the facility. She stated she did feel she may benefit from a lot of services if she was assessed by someone from the state office gives services for people with PTSD. In an interview on 09/17/2024 at 8:25 AM the Assistant Director of Nurses LVN A stated anyone with a new mental illness diagnosis was expected to have a PASSR 1 reflected the resident had a new mental illness. She stated if the mental illness was PTSD the resident had a potential to benefit from different services. The Assistant Director of Nurses LVN A stated she did not know all the services provided but she did believe psychiatric care would benefit the resident. In an interview on 09/17/2024 at 8:45 AM, MDS Coordinator LVN B stated if any resident had a new diagnosis of PTSD, the resident was required to have a new PASRR Level 1 completed if the previous PASRR reflected the resident did not have a mental illness. LVN B stated a resident may need psychiatric services or any services that was not being provided for the resident. She stated a resident's PTSD may become worse and the resident may isolate themselves in their rooms or not want to interact with anyone. In an interview on 09/17/2024 at 9:10 AM, the Director of Nurses stated she would need to review the PASRR policy before she could respond to any questions related to PASRR's. In an interview on 9/17/24 at 9:12 am. the MDS Coordinator LVN B stated if a resident came into the facility with a positive diagnosis of mental illness on their PASSAR Level 1 then they would trigger for a PASSAR Level 2 to be completed. MDS Coordinator LVN B then said if a resident was already at the facility and later received a mental illness diagnosis then a new PASSAR Level 1 would be completed which in turn would trigger a PASSAR Level 2 to be completed. MDS Coordinator LVN B said there would not be a reason as to why a resident with a diagnosis of mental illness would not trigger a PASSAR Level 2 to be completed unless it was just missed. In an interview on 9/17/24 at 2:07 pm, the DON reflected she did not know much about PASSAR except that a screening must be completed, and 6 months of data is required. DON said I refer all PASARR questions to my MDS Coordinator LVN B. In an interview on 9/17/24 at 2:40 pm, the Administrator reflected their expectation concerning PASSAR was that the facility remained compliant and that the residents received the needed services. Administrator said a negative outcome of the facility not following PASSAR's was resident not receiving needed services. Record review of the facility PASSAR policy, not dated, reflected facility provided the Preadmission Screening and Resident Review Critical Element Pathway as their policy.

Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs and describes the services that are to be furnished to attain and maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 8 residents ( Resident #7) reviewed for care plans. The facility failed to ensure the comprehensive care plans for Resident #7 included ADLs. This failure could affect residents by placing them at risk of not receiving appropriate physical care. Findings included: Record review of Resident # 7's Face Sheet dated, 09/16/2024, reflected a [AGE] year-old female admitted on [DATE] with diagnoses of polyosteoarthritis, unspecified (five or more joints in the body have arthritis at the same time), anxiety disorder ( a condition in which a person had excessive worry and feelings of fear, dread, and uneasiness), and combined forms of age-related cataracts ( a common eye condition characterized by the clouding and thickening of the natural lens in the eye, leading to decreased vision) Record review of Resident #7's Quarterly MDS Assessment, dated 07/11/2024, reflected the resident had a BIMS score of 9 indicating her cognition was moderately impaired. Resident #7 required set up assistance with personal hygiene, repositioning in bed, and dressing. She required supervision with bathing, repositioning in bed and transfers. Record review of Resident #7's Comprehensive Care Plan dated, 07/19/2024, reflected Resident #7's ADLs was not assessed on her care plan. Resident #7 had impaired visual function related to age-related cataract bilateral. Intervention: Inform Resident #7 where her personal items are being placed. Resident #7 had a mood problem related to anxiety. Resident #7 referred to Senior Psych services. Intervention: Behavioral health consults as needed. In an interview on 09/17/2024 at 8:25 AM, the Assistant Director of Nurses LVN A stated all residents ADLs was expected to be documented on the care plan. She stated if a resident's ADLs were not on their care plan, it would be difficult to know the exact type of care a resident would need during bathing, hygiene, transfers, eating, etc. (other similar things). She stated the staff was to follow the comprehensive care plan. She stated there was a possibility the wrong type of ADL care may be given to a resident if it was not documented on their care plan. She stated it was the MDS Coordinator LVN B responsibility to ensure all the care plans were documented correctly. In an interview on 09/17/2024 at 8:45 AM, MDS Coordinator LVN A stated all areas of care and psycho-social needs assessed from the MDS were to be care planned. She stated the ADLs were expected to be documented on every resident's comprehensive care plan. MDS Coordinator LVN A stated if the ADLs were not documented on a resident's care plan, it would be difficult for the nursing staff to know what type of care the resident needed and could result in an injury. MDS Coordinator LVN A stated it was her responsibility to ensure all residents care plans had information coded on the MDS Assessment. She stated Resident #7's ADLs was not documented on the care plan. In an interview on 09/17/2024 at 9:10 AM, the Director of Nurses stated she would need to review the protocol for care plans and would need to discuss with the MDS Coordinator LVN A of her process of completing care plans. In an interview on 09/17/2024 at 10:05 AM, CNA E stated it would be difficult to know the care of residents if the ADLs were not entered into the computer on the resident plan of care. CNA E stated he did give care sometimes to Resident # 7 and he did not recall if the ADLs was on the care system he reviewed. He stated he would always ask the nurse about the resident's care if he never gave care to a resident or if he only gave care very few times, such as 4 times. In an interview on 09/17/2024 at 10:15 AM, the Administrator stated anything documented on the MDS was to be documented on the care plan. He stated all residents' ADLs were expected to be documented on the comprehensive care plan. He stated the staff may not know what type of ADL care to give the resident. The Administrator stated it was the MDS Coordinator LVN A responsibility to ensure all care plans were completed according to the MDS and each residents' needs. On 09/17/2024 at 9:10 AM , requested policy from MDS LVN A policy on comprehensive care plan. This was not provided at time of exit.

Based on interview, observation, and record review, the facility failed to ensure the resident environment remained free of accident hazards and each resident received adequate supervision and assistance devices for 1 (Resident #31) of 2 residents reviewed for quality of care. The facility failed to ensure there was supervision present for Resident # 31 while he was smoking. The facility failed to provide Resident # 31 with a smoking apron listed under adaptive equipment in this smoking-safety screen. This failure could place residents at risk of harm and/or injury and contribute to avoidable accidents. Findings included: Record review of Resident 31's Admission Face sheet dated 9/16/24, reflected a [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of dementia (a group of thinking and social symptoms that interferes with daily functioning), severe protein calorie malnutrition, bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs), legal blindness, hypertension (high blood pressure), schizoaffective disorder bipolar type (a rare mental health condition that involves a combination of schizophrenia and bipolar disorder), gastro-esophageal reflux disease (a digestive disease in which stomach acids or bile irritates the food pipe lining), bullous pemphigoid (a rare skin condition causing large fluid filled blisters), personal history of TIA (mini stroke) and cerebral infarction (stroke). Record review of Resident 31's Quarterly MDS assessment dated [DATE] reflected Resident # 31 had a BIMS score of 15 indicating the Resident's cognition was intact. Resident # 31 had a diagnosis of non-Alzheimer's dementia, bipolar disorder, schizophrenia, and legal blindness. Resident # 31 ability to see in adequate light documented as moderately impaired. Resident # 31 documented under behaviors as having delusions. Resident #31 documented as needing supervision or touching assistance for all types of transfers. Record review of Resident # 31's Comprehensive Care Plan with a start date of 9/14/23 and a revision date of 3/6/24 reflected Resident # 31 was ambulatory with a walker due to impaired vision and unsteady gait. Interventions of assist resident as needed. Monitor resident during ambulation. Resident # 31 is a smoker and requires a smoking apron during smoke breaks. Intervention of redirect resident when noted in designated area smoking without smoking apron. Inform resident of the risk of smoking without apron. Supervision during smoking. Staff should monitor resident after each smoke break for burns in clothing or skin. Resident may not have cigarettes or a lighter on his person at any time while resident in this facility. Record review Resident # 31 Smoking Safety Screen with date of 8/19/24 reflected Resident # 31 has documented need for adaptive equipment of smoking apron and supervision. Resident # 31 was deemed safe to smoke with supervision. Resident # 31 smoking screen states it is the facility policy for all smokers to be supervise while smoking. Resident has vision deficit and uses a smoking apron. Observation on 9/16/24 at 11:28 pm of designated smoking area revealed 2 residents sitting in smoking area without staff supervision. Resident # 31 observed smoking while talking with fell ow resident. Resident # 31 did not have smoking apron on or supervision present. Interview on 9/17/24 at 2:07 pm with the DON revealed their expectation would be that smoking evaluations are completed for all residents who admit that are known smokers. If a resident is not a smoker upon admission and later starts smoking, then a smoking evaluation is completed. DON said after the smoking evaluation is completed it would then be uploaded into the resident chart and their expectation is that the staff would follow the recommendations from the smoking evaluation. DON said a negative impact to residents of not completing a smoking evaluation could be multiple things hazards, decrease in health status, burns and basic common-sense things. Interview on 9/17/24 at 2:40 pm with the Administrator revealed the Administrator said his expectation would be that if the resident is deemed safe to smoke then the lighters be checked in with the facility and smoking screen completed for all residents. Administrator said after the smoking screen was completed his expectation would be for staff to follow the recommendations in the smoking screen. Administrator said a negative outcome for not completing a resident smoking screen could be resident injury. Record review of facility's undated smoking policy reflected under heading General Guidelines: A resident will be evaluated upon admission to determine if he or she is a smoker or non-smoker. If a smoker the evaluation will include: 1. Current level of tobacco consumption 2. of tobacco consumption 3. Desire to quit smoking 4. Ability to smoke safely with or without supervision (Resident ability to smoke safely will be updated quarterly, upon significant change, and as determined by staff) Any smoking privileges, restrictions, and concerns shall be noted in the care plan, and all persons caring for resident shall be notified.

Based on observation, interview, and record review, the facility failed to ensure respiratory care was provided consistent with professional standards of practice for 2 of 4 Residents (Resident #38 and #20) reviewed for quality of care. A1. The facility failed to ensure Resident #38 received aseptic technique (a procedure that healthcare providers use to prevent the spread of germs that cause infection. Placing barriers, using sterile equipment, and following strict guidelines that help create an environment free of germs.) during tracheostomy care. 2. The facility further failed to ensure Resident #38's oxygen concentrator and oxygen compressor air intake filters were clean and free from dust and debris. B. The facility failed to ensure Resident 20's oxygen concentrator air intake filter was clean and free from dust and debris. These failures could place residents who use respiratory equipment and have tracheostomies at risk for respiratory infections. Findings included: A) Review of Resident #38's face sheet dated 09/16/2024 reflected a [AGE] year-old female admitted to the facility on [DATE] with the following diagnoses, tracheostomy (a hole that surgeons make through the front of the neck and into the windpipe (trachea), hemangioma of skin and subcutaneous tissue (growths of blood vessels found on your skin. These growths can appear anywhere on your body, especially on your face, chest and back, as red, or purple lumps.), Anoxic brain damage (damage to the brain due to a lack of oxygen supply) and chronic respiratory failure with hypoxia (a condition in which your lungs have a hard time loading your blood with oxygen or removing carbon dioxide. It can leave you with low oxygen, high carbon dioxide, or both). Review of Resident #38's quarterly MDS assessment dated [DATE] reflected she was assessed to be in a persistent vegetative state with no discernible consciousness. Resident #38 was assessed to be dependent on staff for all ADLs. Resident #38 was further assessed to receive oxygen therapy, suctioning and require tracheostomy care. Review of Resident #38's comprehensive care plan reflected a problem dated 11/18/2022 Resident has a tracheostomy. Interventions included .oxygen setting via tracheostomy per MD orders . Review of Resident #38's consolidated physician orders reflected an order dated 05/22/2024 Oxygen at 6 LPM via trach collar continuously . Further review of Resident #38's physician orders reflected an order dated 11/01/2023 Check O2 filter for placement and cleanliness every week on Sunday and PRN .Trach Care every shift and PRN . Observation on 09/15/2024 at 9:21 AM revealed Resident #38 in room in bed. Resident #38 was observed to have a tracheostomy with oxygen being administered via a tracheostomy mask from an oxygen concentrator set at 6 LPM with a 50-psi air compressor and large volume nebulizer in use (A 50 psi air compressor usually powers the large volume nebulizer which is used to turn liquid into a mist so that it can be inhaled. A large volume nebulizer may be used for patients who have a tracheostomy or otherwise need to deliver a mist that moisturizes their airway.) Observation of the oxygen concentrator revealed the air intake filter was covered in a gray substance. Further observation revealed the 50-psi air compressors air intake filter was also covered in a gray substance. In an interview on 09/15/2024 at 3:14 PM, LVN H stated Resident #38's filters on her oxygen concentrator and compressor were dirty and needed to be cleaned. He stated they were supposed to be cleaned on Sunday nights. He stated failure to keep them clean could lead to a respiratory infection. Observation on 09/16/2024 at 10:00 AM revealed Resident #38's oxygen concentrator's filter remained covered in a gray substance. Further observation revealed the 50-psi air compressor filter also remained covered with a gray substance. Observation on 09/16/2024 at 10:41 AM revealed RN I entered Resident #38's room to perform tracheostomy care. RN I entered Resident #38's room with a small bottle of mouth wash and two oral swabs. RN I obtained an incontinent wipe from Resident #38's dresser and wiped the over bed table with the incontinent wipe and placed the items on the table. RN I then donned gloves without washing her hands and removed the soiled gauze from under Resident #38's trach and trach ties (ties that go around the neck to ensure the trach stays in place). RN I then, without washing her hands, donned a new pair of gloves then left the room and came back with a piece of wax paper. Without cleaning the overbed table, placed the wax paper on the over bed table. Using the same pair of gloves RN I gathered supplies from a cart in Resident #38's room that included a new inner cannula for her trach and a sterile suction tubing. RN I grabbed Resident #38's old Yankauer suction wand (used for oral suctioning) which was attached to the suction machine. RN I removed the suction wand from the suction machine, attached the new suction tubing ,and placed it on the over bed table; partly on the wax paper and partly on the table. RN I removed the water basin from the suction kit and filled with distilled water. RN I left Resident #38's side, went to the bathroom, and got a new pair of gloves from a box stored there. Further observation of Resident #38 revealed her tracheostomy mask (used to deliver oxygen) had an accumulation of mucus in the mask covering the exhalation port. RN I, without washing her hands, donned the new gloves and returned to Resident #38's bed side. RN I then inserted the suction tubing through the exhalation port on the mask through the mucus and into her tracheostomy and began suctioning Resident #38. RN I repeated this action one more time. RN I then removed her gloves and went to the bathroom. RN I washed her hands and donned new gloves. RN I returned to Resident #38's bedside and pulled down her trach mask, removed the old inner cannula from Resident #38's trach, and inserted a new inner cannula without changing her gloves, cleaning around the trach, or cleaning the trach mask. RN I was further observed to not have a trach care kit. RN I then replaced the mucus filled trach mask over Resident #38's trach. RN I stated she was going to do oral care for Resident #38 , and she was done with trach care. In an interview on 09/16/2024 at 10:52 AM, RN I stated she wiped Resident #38's over bed table with an incontinent wipe. When asked if the incontinent wipe would sanitize the table, she stated no she should have used the purple top wipes (a disposable germicidal wipe). RN I stated she only washed her hands one time during the procedure. RN I stated she should have washed her hands at the beginning of the procedure and before donning new gloves. When RN I was asked why she did not wash her hands, she only stated she used hand sanitizer before coming into the room. When asked if she cleaned around Resident #38's trach stoma or cleaned Resident #38's trach mask to remove the mucus build up, she stated she did not. RN I further stated she should not have introduced the suction tubing through the trach mask exhalation port and through the old mucus. RN I stated by doing so, she could introduce bacteria into Resident #38's trach and it could cause an infection. B) Review of Resident #20's face sheet reflected a [AGE] year-old female admitted to the facility on [DATE] with the following diagnoses chronic respiratory failure with hypoxia ( a condition in which your lungs have a hard time loading your blood with oxygen or removing carbon dioxide. It can leave you with low oxygen, high carbon dioxide, or both.), cerebral palsy (A group of disorders that affect movement, muscle tone, balance, and posture.) and tracheostomy status (a hole that surgeons make through the front of the neck and into the windpipe (trachea). Review of Resident #20's quarterly MDS assessment dated [DATE] reflected Resident #20 was assessed to have a BIMS score of 00 indicating severe cognitive impairment. Resident #20 was assessed to be dependent on staff for all ADLs. Resident #20 was further assessed to receive oxygen therapy, suctioning, and tracheostomy care. Review of Resident #20's comprehensive care plan reflected a problem with the initiation date of 05/03/2022 The resident had a tracheostomy related to acute respiratory failure . Interventions included oxygen setting apply O2 at 4-5 liters per [minute] trach mask . Review of Resident #20's consolidated physician orders reflected an order dated 05/22/2024 oxygen at 4 LPM continuously via trach collar . Observation on 09/15/2024 at 10:00 AM revealed Resident #20 in her room in bed with the oxygen concentrator on and set at 4 LPM. Observation of her concentrator revealed the air intake filter was covered in a gray substance. In an interview on 09/15/2024 at 3:14 PM, LVN H stated Resident #20's filter on her oxygen concentrator was dirty and needed to be cleaned. He stated they were supposed to be cleaned on Sunday nights. He stated failure to keep them clean could lead to a respiratory infection. Observation on 09/16/2024 at 10:15 AM revealed Resident #20 in her room in bed with the oxygen concentrator on and set at 4 LPM. Observation of her concentrator revealed the air intake filter was still covered in a gray substance. In an interview on 09/16/2024 at 3:24 PM, the DON stated that the respiratory equipment should be cleaned on Sundays and the filters should be cleaned at that time. The DON stated it was an expectation that they should remain clean to prevent infections. The DON stated she expected the nurses to perform trach care as outlined in the facilities policy and failure to do so could cause residents infections. Review of the facility's policy tracheostomy Care dated August 2013 reflected The purpose of this procedure is to guide tracheostomy care and the cleaning of reusable tracheostomy cannulas . 1.Aseptic technique must be used: a. During cleaning and sterilization of reusable tracheostomy tubes; b. During all dressing changes until the tracheostomy wound has granulated (healed), and c. During tracheostomy tube changes, either reusable or disposable. 2. Gloves must be used on both hands during any or all manipulation of the tracheostomy. Sterile gloves must be used during aseptic procedures. 3. A mask and eyewear must be worn if splashes, spattering, or spraying of blood or body fluids is likely to occur when performing this procedure . tracheostomy care should be provided as often as needed, at least once daily for old, established tracheostomies, and at least every eight hours for residents with unhealed tracheostomies. 6. A replacement tracheostomy tube must be available at the bedside at all times. 7. A suction machine, supply of suction catheters, exam and sterile gloves, and flush solution, must be available at the bedside at all times . Procedure Guidelines: Preparation and Assessment; .3. Wash hands. 4. Put exam gloves on both hands. 5. Remove supplemental oxygen mask from tracheostomy. 6. Inspect skin and stoma site for signs or symptoms of infection, leakage, subcutaneous crepitus, or dislodged tube. 7.Assess resident for respiratory distress. a. Measure resident's oxygen saturation with pulse oximeter. b. Listen to lung sounds with a stethoscope. c. Observe for asymmetrical chest expansion. 8. Remove old dressings. Pull soiled glove over dressing and discard into appropriate receptacle. 9. Wash hands. Clean the Removable Inner Cannula: l. Open tracheostomy cleaning kit. 2. Set up supplies on sterile field. 3. Maintaining sterile field, pour equal parts hydrogen peroxide and normal saline in one compartment of opened kit. Pour normal saline in another compartment. 4. Open four gauze pads and saturate with hydrogen peroxide. 5. Open two gauze pads and saturate with antiseptic solution. 6.Open two gauze pads and saturate with sterile saline. 7. Open two gauze pads; keep them dry. 8.Put on sterile gloves. 9. Secure the outer neck plate with non-dominate gloved hand. 10.Unlock the inner cannula with gloved dominate hand. 11. Gently remove the inner cannula, rotating counterclockwise while lifting away from the resident. 12. Soak the cannula in hydrogen peroxide/saline mixture. 13. Clean with brush. Rinse with saline and dry with pipe cleaners. 14. Remove and discard gloves into appropriate receptacle. 15.Wash hands and put on fresh gloves. 16.Replace the cannula carefully and lock in place. 17. Ensure there is an emergency tracheostomy set up at resident's bedside. Site and Stoma Care: 1.Apply clean gloves. 2.Clean the stoma with two peroxide-soaked gauze pads (using a single sweep for each side). 3. Rinse the stoma with saline-soaked gauze pads (using a single sweep for each side). 4. Wipe with dry gauze (using a single sweep for each side). 5. Disinfect the stoma with the antiseptic-soaked gauze pads (using a single sweep for each side). Allow to air dry or wipe with clean, dry gauze. 6. Remove neck ties and replace with clean ones. a. If the resident's condition is unstable, or if the stoma is less than two weeks old, apply new ties before removing old ones. 7.Apply a fenestrated gauze pad around the insertion site. 8. Replace supplemental oxygen mask over tracheostomy. 9. Remove gloves and discard into appropriate receptacle. 10.Wash hands . Review of the facility's policy Respiratory therapy- prevention of infection dated November 2011 reflected The purpose of this procedure is to guide prevention of infection associated with respiratory therapy tasks and equipment, including ventilators, among residents and team .Wash filters from oxygen concentrators every seven days with soap and water. Rinse and squeeze dry .

Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections and follow accepted national standards for one of two residents reviewed infection control (Resident #38). The facility failed to ensure RN I used aseptic technique during tracheotomy suctioning and tracheotomy care for Resident #38. These failures could place residents at risk for developing wound and upper respiratory infections. Findings included: Review of Resident #38's Face Sheet dated 09/16/2024 reflected a [AGE] year-old female admitted to the facility on [DATE] with the following diagnoses Tracheostomy (hole that surgeons make through the front of the neck and into the windpipe (trachea)., Hemangioma of skin and subcutaneous tissue (growths of blood vessels found on your skin. These growths can appear anywhere on your body, especially on your face, chest and back, as red, or purple lumps.), Anoxic brain damage (is damage to the brain due to a lack of oxygen supply) and chronic respiratory failure with hypoxia (is a condition in which your lungs have a hard time loading your blood with oxygen or removing carbon dioxide. It can leave you with low oxygen, high carbon dioxide, or both). Review of Resident #38's Quarterly MDS dated [DATE] reflected she was assessed to be in a persistent vegetive state with no discernible consciousness. Resident #38 was assessed to be dependent on staff for all ADLs. Resident #38 was further assessed to have oxygen therapy, suctioning and require tracheostomy care. Review of Resident #38's Comprehensive Care Plan reflected a problem dated 11/18/2022 Resident has a tracheostomy. Interventions included .oxygen setting via tracheostomy per MD orders . Review of Resident #38's consolidated physician orders reflected an order dated 05/22/2024 Oxygen at 6 liters via trach collar continuously . Further review of Resident #38's physician orders reflected an order dated 11/01/2023 Check O2 filter for placement and cleanliness every week on Sunday and PRN .Trach Care every shift and PRN . Observation on 09/16/2024 at 10:41 AM revealed RN I entered Resident #38's room to perform tracheostomy care. RN I entered Resident #38's room with a small bottle of mouth wash and two oral swabs. RN I obtained an incontinent wipe from Resident #38's dresser and wiped the over bed table with the incontinent wipe and placed the items on the table. RN I then donned gloves without washing her hands and removed the soiled gauze from under Resident #38's trach and trach ties (ties that go around the neck to ensure the trach stays in place). RN I then without washing her hands donned a new pair of gloves then left the room and came back with a piece of wax paper and without cleaning the overbed table placed the wax paper on the over bed table. Using the same pair of gloves RN I gathered supplies from a cart in Resident #38's room that included a new inner cannula and a sterile suction tubing. RN I then grabbed Resident #38's old Yankauer suction wand (used for oral suctioning) which was attached to the suction machine. RN I then removed the suction wand from the suction machine and attached the new suction tubing and placed it on the over bed table partly on the wax paper and partly on the table. RN I then removed the water basin from the suction kit and filled with distilled water. RN I left Resident #38's side and went to the bathroom and got a new pair of gloves from a box stored there. Observation of Resident #38 revealed her tracheostomy mask (used to deliver oxygen) had an accumulation of mucus in the mask covering the exhalation port. RN I without washing her hands donned the new gloves and returned to Resident #38's bed side. RN I then inserted the suction tubing through the exhalation port on the mask through the mucus and into her tracheostomy and began suctioning Resident #38. RN I repeated this action one more time. RN I then removed her gloves and went to the bathroom. RN I washed her hands and donned new gloves. RN I returned to Resident #38's bedside and pulled down her trach mask removed the old inner cannula from Resident #38's trach and inserted a new inner cannula without changing her gloves, cleaning around the trach, or cleaning the trach mask. RN I then replaced the mucus filled trach mask over Resident #38's trach. RN I then stated she was going to do oral care for Resident #38 stating she was done with trach care. In an interview on 09/16/2024 at 10:52 AM RN I stated she wiped Resident #38's over bed table with an incontinent wipe. When asked if the incontinent wipe would sanitize the table she stated no she should have used the purple top wipes (a disposable germicidal wipe). RN I stated she only washed her hands one time during the procedure. RN I stated she should have washed her hands at the beginning of the procedure and before donning new gloves. When RN I was asked why she did not wash her hands she only stated she used hand sanitizer before coming into the room. When asked if she cleaned around Resident #38's trach stoma or cleaned Resident #38's trach mask to remove the mucus build up she stated she did not. RN I further stated she should not have introduced the suction tubing through the trach mask exhalation port and through the old mucus. RN I stated by doing so she could introduce bacteria into Resident #38's trach and it could cause an infection. In an interview on 09/16/2024 at 3:24 PM The DON stated she expected the nurses to perform trach care as outlined in the facilities policy and procedure. The DON stated that failure to do so could cause residents infections. The DON further stated she expected the nurses to use aseptic technique when performing trach care. Review of the facility's policy Tracheostomy Care dated August 2013 reflected The purpose of this procedure is to guide tracheostomy care and the cleaning of reusable tracheostomy cannulas . 1. Aseptic technique must be used: a. During cleaning and sterilization of reusable tracheostomy tubes Gloves must be used on both hands during any or all manipulation of the tracheostomy. Sterile gloves must be used during aseptic procedures Review of the facility's policy Handwashing- Hand Hygiene dated August 2019 reflected This facility considers hand hygiene the primary means to prevent the spread of infection. All personnel shall be trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections. All personnel shall follow the handwashing/ hand hygiene procedures to help prevent the spread of infection . The use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections.

Based on interview, and record review, the facility failed to care for residents in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for 1 of 4 residents (resident #17) reviewed for resident rights. The facility failed to ensure Resident #17 was not given showers late at night since that was not his preference. This failure could place residents at risk for diminished quality of life. The findings include: Record review of Resident #17's face sheet revealed Resident #17 was a [AGE] year-old male with an admitted [DATE] into the facility. Resident #17 has a primary diagnosis of bacterial infection (infection inside the body created by bacteria), resistance to carbapenem (when germs are not healed by antibiotics), acute respiratory failure (not enough oxygen or too much carbon dioxide in your body), and quadriplegia (paralysis of all four limbs). Record review of Resident #17's MDS assessment revealed a BIMS score of 15 which noted the resident had no cognitive impairment. The MDS revealed that Resident #17 was dependent for ADL needs including showering and bathing. Resident #17 being dependent meant the helper does all of the effort while the resident does not effort in completing the task. Or the assistance of two or more helpers is needed to complete the task. Record review of Resident #17's care plan revealed there were no preferences for a late shower at the facility. It also revealed that Resident #17 is dependent for ADL's due to a diagnosis of functioning quadriplegia, with staff would anticipate and meet the needs of the resident. Record review of Resident #17's shower log revealed he had received his showers multiple times after 09:00 PM in the month of August and September. The log showed: 1. Shower provided on 08/25/2024 at 12:10AM with total assistance provided 2. Shower provided on 08/31/2024 at 11:10PM with total assistance provided 3. Shower provided on 09/07/2024 at 11:53PM with total assistance provided 4. Shower provided on 09/11/2024 at 12:03AM with total assistance provided 5. Resident's shower schedule was for Tuesday, Thursday and Saturdays provided on the evening shift. On 09/15/2024 at 01:54 PM, an interview was conducted with Resident #17. Resident #17 stated that he received showers three times a week at night. On 09/16/2024 at 11:00 AM, an interview with Resident #17 revealed that his typical shower times had been any time after 9:00 pm. He stated that it was not a preference of his, but the staff shower everybody else first before him. He stated they wait to shower him so that he can get his treatment and then go to bed. He stated that a late shower was better than no shower. Resident #17 stated that he would wait in his wheelchair until after staff gave him a shower so he could go to bed. On 09/17/2024 at 12:03 PM an interview was conducted with CNA G that revealed Resident #1's showers were provided at night. CNA G stated that Resident #17 would often leave the premises early in the morning and would be gone all day. CNA G believed that it was preference of Resident #17 to receive showers late at night. On 09/17/2024 at 12:45 PM, an interview was conducted with CNA F that revealed residents are offered at least 3 showers per week. CNA F stated that Resident #17 typically received showers on Tuesdays, Thursdays and Saturdays at night. CNA F stated that Resident #17 is provided showers late at night due to Residents #17 being out of the facility until 9 PM. CNA F believed that it was Resident #17's preference to shower at night then go to bed. CNA F stated Resident #17 has not wanted to take a shower early. CNA F stated that Resident #17 could feel upset for having to wait for showers until late at night. CNA F reported she received training on resident rights. She stated an example of resident rights are the right to be treated with dignity and respect, right to take showers and the right to come and go whenever they want. On 09/17/2024 at 01:47PM, an interview was conducted with DON that revealed residents are offered showers three times a week at minimum with Sunday being a day without showers. DON A stated showers are provided on day and evening shifts depending on where the resident resided in the facility. DON A stated there was not a specific time that the showers should get completed each day. DON A stated that the schedule is flexible for residents. DON A stated that there are residents that leave the facility in their wheelchair and do not return until late at night which resulted in late showers. DON A stated it is not normal to receive a shower after midnight but it has happened before due to residents not returning to the facility until late at night. DON A stated that there is no documentation to identify when a resident was late to the facility resulting in a late shower. DON A stated that residents have the right to shower when they want to. DON A stated that Resident #17 will typically arrive back to the facility late at night and refuses a shower. DON A stated Resident #17 likes to get up in the morning and leave the facility. DON A denied offering an earlier shower time to Resident #17. DON A stated documentation for late showers for Resident #17 meant that Resident #17 got back to the facility late that night. On 09/17/2024 at 2:09PM, an interview was conducted with ADM. ADM reported that showers are provided during the day and night shift depending on the preferences of the resident. ADM reported his expectation is that all residents are offered showers 3 times a week or as needed. ADM reported that there was no expectation for when showers should be completed by during the night shift due to residents not wanting to take a shower until later. ADM stated Resident #17 would stay out in the community a lot, and he will come and go late at night. ADM stated that Resident #17's out of the facility schedule is not routinely documented to know when a late night shower occurred due to resident being out of the facility. ADM stated that Resident #17 had been offered earlier shower times but denied Resident #17 wanting an earlier shower time. RR of facility provided policy titled Your Rights and Protections as a Nursing Home Resident with an unknown date revealed that resident have the right to: 1. To participate in the decisions that affects your care.

Based on interviews and record reviews, the facility failed to ensure residents who are trauma survivors received culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for residents' experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization for 1 ( Resident # 33) of two residents reviewed for quality of care. The facility failed to ensure that Resident #33's potential triggers were care planned. This failure could place residents at increased risk for psychological distress due to re-traumatization. Findings included: Record review of Resident #33's Face sheet, dated 09/17/2024, reflected at [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with the diagnoses of post-traumatic stress disorder (a disorder that develops in some people who have experienced a shocking, scary, or dangerous event) with onset of 07/14/2023, anxiety disorder ( a condition in which a person has excessive worry and feeling of fear, dread or uneasiness), dependence on renal dialysis (someone who uses technology to sustain their life because their kidneys are no longer able to perform their normal functions) and chronic pain syndrome ( a constant condition that involves persistent pain that lasts longer than the usually recovery period, or that occurs along with a chronic health condition). Record review of Resident #33's Quarterly MDS Assessment, dated 08/13/2024, reflected Resident #33 had a BIMS score of 15 indicating the Resident's cognition was intact. Resident #33 had a diagnosis of anxiety disorder and Post Traumatic Stress Disorder. She was assessed to require pain management. Record review of Resident #33's Comprehensive Care Plan, with start date of 08/19/2024 and completion date of 8/27/2024 reflected Resident #33 used psychotropic medications ( a drug or other substance that affects how the brain works and causes change in mood, awareness, thoughts, feelings, or behavior)related to anxiety and Post Traumatic Stress Disorder. Interventions: Monitor for side effects and effectiveness every shift. Consult with pharmacy, medical doctor to consider dosage reduction when clinically appropriate at least quarterly. Monitor/ document/report as needed any adverse reactions of psychotropic medications. Reduce the number of psychotropic medications. Resident #33's triggers was not assessed and documented on comprehensive care plan. In an interview on 09/15/2023 at 10:45 AM, Resident #33 stated she did not have anxiety and there were times when she did have triggers of her PTSD. She stated she had several triggers especially when someone comes in her room and she does not know they are in the room and they don't knock on the door. She stated there were certain sounds when staff was talking to each other in the room and was very loud. Resident #33 stated it would help her anxiety and PTSD if the staff did know her triggers. She stated sometimes after staff leaves her room she becomes more anxious and it affects her PTSD. Resident #33 did not specify how it affected her PTSD. She stated she did receive psych services at one time when she lived at the facility. She stated she did feel she may benefit from a lot of services if she was assessed by someone from the PASRR office. In an interview on 09/17/2024 at 8:45 AM, MDS Coordinator LVN A stated that a resident with a diagnosis of PTSD should identify the resident's triggers of PTSD on the resident's care plan. The MDS Coordinator LVN A stated failure to properly care plan a resident for PTSD and triggers could result in a resident being re-traumatized. She stated she was responsible for including PTSD with triggers in resident's care plan. In an interview on 09/17/2024 at 9:10 AM, The Director of Nurses stated if a resident had PTSD ( post-traumatic stress disorder) the residents' triggers were expected to be documented on their comprehensive care plan. She stated if the staff was not aware of the triggers for the resident there was a possibility it could affect their quality of life. She did not respond to any further questions about PTSD triggers such as how it would affect their quality of life. The Director of Nurses stated the MDS Coordinator LVN A was responsible to care plan triggers of any resident with PTSD. Requested policy on revision of care plans and comprehensive care plans and it was not provided at time of exit. In an interview on 09/17/2024 at 10:15 M, the Administrator stated care plans were individualized and specific to the resident's needs and must be accurate. The Administrator stated care plans were accomplished with input from the interdisciplinary team and the DON signs off on them. The Administrator stated a resident with PTSD care plan should have included the residents' triggers to help manage behaviors that may arise during the resident's care.

Based on observation, interview and record review, the facility failed to implement their written policies and procedures to prohibit abuse, neglect, exploitation, or misappropriation of resident property for 1 of 3 residents (Resident #1) reviewed for abuse. The facility failed to implement their policies and procedures related to reporting allegations of abuse when Resident #1 alleged Resident #2 choked him on 9/5/23. This failure could place residents at risk for abuse. Findings included: A review of the facility's policy titled Abuse Prevention Program revised December 2016 reflected in part, Investigate and report any allegations of abuse within timeframes as required by federal requirements. A review of the facility's policy titled Abuse Investigation and Reporting, revised July 2017, reflected in part, All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source (abuse) shall be promptly reported to local, state and federal agencies (as defined by current regulations) and thoroughly investigated by facility management. A review of Resident #1's face sheet printed on 11/14/23 reflected a [AGE] year-old male originally admitted on [DATE] and readmitted on [DATE] with diagnoses including Quadriplegia (loss of motor function in the arms and legs), chronic pain, urinary tract infection, depression (persistent sadness and loss of interest in daily activities), and anxiety (a state of being apprehensive, nervous or distressed). A review of Resident #1's 5-day MDS assessment, dated 10/20/23, reflected a BIMS score of 15 indicating intact cognition. He was assessed as having verbal behavioral symptoms directed towards others 1 to 3 days during the assessment period. The MDS reflected he used a motorized wheelchair and a mechanical lift; he had impairment on both sides, upper and lower extremities. He was dependent on staff for all ADL care. A review of Resident #1's comprehensive care plan initiated on 8/6/20 reflected the problem, Resident has been assessed for actual trauma symptoms as manifested by: upsetting thoughts or memories against their will; upsetting dreams; bodily reactions such as fast heartbeat/stomach churning; difficulty falling asleep or staying asleep; irritability anger or depression; difficulty concentrating; being jumpy or startled at something unexpected; inability to cope with normal stresses of daily living; inability to trust, cognitive difficulties; other. Goals for the problem included, Resident will verbalize/display feeling/disposition of safeness in the community and Trauma symptoms will not interfere with residents POC or rehabilitation. Interventions included, ask and observe the situations and interactions that create well-being, engagement and a sense of safety on the part of the resident/pt recognizing that many individuals who are long-stay residents have some level of cognitive impairment that may require additional sensitivity. A review of Resident #1's social service progress note dated 9/6/23 at 4:46 PM reflected, During IDT meeting, resident made SW aware of incident that occurred with another resident the night prior 9/5. Resident stated that he came back to facility at approximately 8:30 PM and the doors were locked .Resident stated other residents were sitting in the area and he asked them to open the door but they would not. Resident managed to get the door open. Resident stated he got into an argument with another resident sitting in the area. Resident stated other resident stood and walked toward him. Resident stated other Resident put his hands around his neck. SW asked if resident feels safe. Resident stated he did not. SW informed administrator. A review of Resident #1's progress notes on 9/5/23 reflected no documentation regarding Resident #1's allegation regarding another resident choking him nor a nursing note to indicate if the resident was assessed for injuries. A review of Resident #2's face sheet printed on 9/14/23, reflected a [AGE] year-old male admitted to the facility 2/11/23 with diagnoses including Unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety (a group of symptoms affecting memory, thinking and social abilities) essential hypertension (high blood pressure) and chronic obstructive pulmonary disease (a chronic inflammatory lung disease that causes obstructed airflow from the lungs). A review of Resident #2's quarterly MDS dated [DATE] reflected a BIMS score of 9 indicating moderately impaired cognition. He was assessed as requiring setup or clean-up assistance or supervision with ADLs. He was assessed to have an active diagnosis of dementia. A review of Resident #2's comprehensive care plan initiated 2/11/22 reflected the problem The resident has impaired cognitive function/dementia or impaired thought process related to diagnosis. Goals included maintaining current level of cognitive function, be able to communicate basic needs and develop skills to cope with cognitive decline. Interventions included administer medications and keep the resident's routine consistent and try to provide consistent care givers to decrease confusion. A review of Resident #2's nursing progress note dated 9/5/23 at 11:33 PM reflected he was found sitting on the floor in the dining room. There was no documentation that Resident #2 was involved in an incident with another resident. During a telephone interview on 11/14/23 at 9:48 AM with the SW, she stated the ADM had been made aware of the incident the night it happened and he got statements from the staff who worked that night. She identified Resident #2 as the person Resident #1 alleged choked him. Observation and interview on 11/14/23 at 11:10 AM revealed Resident #1 was sitting in his motorized wheelchair. He stated there was an incident one evening around 8:30 PM when he came into the facility and his music was playing loud on his phone. Resident #2 cussed at him and yelled at him to turn off the music. Resident #1 stated because of his quadriplegia he had trouble turning off the music. He stated, The guy got up and came at me and he put his hands on my neck . He stated he was afraid to move. He stated a nurse saw what happened but, she said he put his hands on my face. He stated he was not able to dial his phone, so the Social Worker helped him to file a complaint. Observation and interview on 11/14/23 at 11:25 AM revealed Resident #2 was sitting in a chair in his room. When asked if he had ever had any altercations with other residents at the facility, he replied, You mean other prisoners? No, I haven't had any problems. During an interview on 11/14/23 at 3:00 PM, the ADM stated he was aware of the incident where Resident #1 stated he was choked. He stated he asked for statements from the staff who worked when the event occurred. The ADM stated, We have two or three residents with personality issues, and I think this was just personality issues. He stated. One RN said he wasn't choked but the other resident touched his face. The ADM stated when a resident alleged abuse, we will investigate it immediately and ask staff for statements regardless of whether they saw it. He stated he did not report the incident to the State because the eyewitness said he was not choked. When asked if allegations of abuse needed to be reported he stated, I can't say it doesn't need to be reported. I know Resident #1 and Resident #2 had personality conflicts. It felt more personality conflict than anything else. After review of the abuse policy, the ADM verified that it was the current policy then stated, In retrospect, yes, I should have reported it. The ADM stated he did look at the video but because of the angle of the camera, he could not see above Resident #1's legs. He stated, I could see the other resident walk over to him, but I couldn't see what happened. He stated an adverse outcome of not reporting was lose trust in the system, for sure. Not get the appropriate care . During an interview on 11/14/23 at 3:17 PM, the ADON stated when an allegation of abuse was made, the first thing was to assess the resident and see if anything looked abnormal. She stated she would talk with the aide to see what they saw. She would expect to see the incident documented. She stated if behaviors were not documented in the care plan, It could trigger negative behaviors. A review of the facility's incident and accident log from 8/13/23 to 11/4/23 reflected no entry for an incident involving Resident#1 and Resident #2.

Based on interviews and record review, the facility failed to ensure response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must have evidence that all alleged violations are thoroughly investigated and prevent further abuse, neglect, exploitation, or mistreatment while the investigation is in process for two (Residents #1 and #2) of five residents reviewed for abuse and neglect. The facility failed to have evidence of a thorough investigation when Resident #1 alleged Resident #2 choked him on 9/5/23. This failure could place residents at risk for abuse. Findings included: A review of Resident #1's face sheet printed on 11/14/23 reflected a [AGE] year-old male originally admitted on [DATE] and readmitted on [DATE] with diagnoses including Quadriplegia (loss of motor function in the arms and legs), chronic pain, urinary tract infection, depression (persistent sadness and loss of interest in daily activities), and anxiety (a state of being apprehensive, nervous or distressed). A review of Resident #1's 5-day MDS assessment, dated 10/20/23, reflected a BIMS score of 15 indicating intact cognition. He was assessed as having verbal behavioral symptoms directed towards others 1 to 3 days during the assessment period. The MDS reflected he used a motorized wheelchair and a mechanical lift; he had impairment on both sides - upper and lower extremities. He is dependent on staff for all ADL care. A review of Resident #1's comprehensive care plan initiated on 8/6/20 reflected the problem, Resident has been assessed for actual trauma symptoms as manifested by: upsetting thoughts or memories against their will; upsetting dreams; bodily reactions such as fast heartbeat/stomach churning; difficulty falling asleep or staying asleep; irritability anger or depression; difficulty concentrating; being jumpy or startled at something unexpected; inability to cope with normal stresses of daily living; inability to trust, cognitive difficulties; other. Goals for the problem included, Resident will verbalize/display feeling/disposition of safeness in the community and Trauma symptoms will not interfere with residents POC or rehabilitation. Interventions included, Ask and observe the situations and interactions that create well-being, engagement and a sense of safety on the part of the resident/pt recognizing that many individuals who are long-stay residents have some level of cognitive impairment that may require additional sensitivity. A review of Resident #1's social service progress note dated 9/6/23 at 4:46 PM reflected, During IDT meeting, resident made SW aware of incident that occurred with another resident the night prior 9/5. Resident stated that he came back to facility at approximately 8:30 PM and the doors were locked .Resident stated other residents were sitting in the area and he asked them to open the door but they would not. Resident managed to get the door open. Resident stated he got into an argument with another resident sitting in the area. Resident stated other resident stood and walked toward him. Resident stated other Resident put his hands around his neck. SW asked if resident feels safe. Resident stated he did not. SW informed administrator. A review of Resident #1's progress notes reflected no documentation regarding the incident nor a nursing note to indicate if the resident was assessed for injuries. A review of Resident #2's face sheet printed on 9/14/23, reflected a [AGE] year-old male admitted to the facility 2/11/23 with diagnoses including Unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety (a group of symptoms affecting memory, thinking and social abilities) essential hypertension (high blood pressure) and chronic obstructive pulmonary disease (a chronic inflammatory lung disease that causes obstructed airflow from the lungs). A review of Resident #2's quarterly MDS dated [DATE] reflected a BIMS score of 9 indicating moderately impaired cognition. He was assessed as requiring setup or clean-up assistance or supervision with ADLs. He was assessed to have an active diagnosis of dementia. A review of Resident #2's comprehensive care plan initiated 2/11/22 reflected the problem The resident has impaired cognitive function/dementia or impaired thought process related to diagnosis. Goals included maintaining current level of cognitive function, be able to communicate basic needs and develop skills to cope with cognitive decline. Interventions included administer medications and keep the resident's routine consistent and try to provide consistent care givers to decrease confusion. A review of Resident #2's nursing progress note dated 9/5/23 at 11:33 PM reflected he was found sitting on the floor in the dining room. There was no documentation that Resident #2 was involved in an incident with another resident. During a telephone interview on 11/14/23 at 9:48 AM with the SW, she stated the ADM had been made aware of the incident the night it happened and he got statements from the staff who worked that night. She identified Resident #2 as the person Resident #1 alleged choked him. During an interview on 11/14/23 at 3:00 PM, the ADM stated he was aware of the incident where Resident #1 stated he was choked. He stated he asked for statements from the staff who worked when the event occurred. The ADM stated, We have two or three residents with personality issues, and I think this was just personality issues. He stated. One RN said he wasn't choked but the other resident touched his face. The ADM stated when a resident alleged abuse, we will investigate it immediately and ask staff for statements regardless of whether they saw it. He stated he did not report the incident to the State because the eyewitness said he was not choked. When asked if allegations of abuse needed to be reported he stated, I can't say it doesn't need to be reported. I know Resident #1 and Resident #2 had personality conflicts. It felt more personality conflict than anything else. After review of the abuse policy, the ADM verified that it was the current policy then stated, In retrospect, yes, I should have reported it. The ADM stated he did look at the video but because of the angle of the camera, he could not see above Resident #1's legs. He stated, I could see the other resident walk over to him, but I couldn't see what happened. He stated an adverse outcome of not investigating was lose trust in the system, for sure. Not get the appropriate care. During an interview on 11/14/23 at 3:17 PM, the ADON stated when an allegation of abuse was made, the first thing was to assess the resident and see if anything looked abnormal. She stated she would talk with the aide to see what they saw. She would expect to see the incident documented. She stated if behaviors were not documented in the care plan, It could trigger negative behaviors. A review of the facility's incident and accident log from 8/13/23 to 11/4/23 reflected no entry for an incident involving Resident#1 and Resident #2.

Based on interview and record review, the facility failed to use the services of a registered nurse 8 consecutive hours a day, 7 days a week for 1 (7/9/23) of 60 days reviewed. The facility failed to ensure they had an RN was on duty on 7/9/23. The failure places residents at risk for missed nursing assessment, interventions, care, and treatment. Findings included Record review of daily staffing sheets for May 1st , 23 thru August 7, 23 indicate d that no RN was on the schedule on 6/17,6/18,7/8,7/9 and 8/6. Time sheets revealed an RN was present for 8 hours on 6/17,6/18,7/8, and 8/6. There was no evidence of RN coverage on 7/9/23. Interview of DON on 8/9/23 at 11:55 am revealed she was a new DON and had been at the facility since October 2022 and that she was not aware of the 8 consecutive hours requirement for RN coverage and she thought since they had 12-hour shifts and some of the night shift were RN that counted, she is not sure what happened on 7/9/23 but they have been working with their RN staff to get the weekends covered. When asked about the PBJ report from last quarter , that revealed no RN coverage consistently on the weekends, she stated that they have hired more RN's since then. The DON stated that she is responsible for making sure staffing levels are appropriate for each shift. DON stated that lack of RN coverage could effect proper assessments and interventions for residents. Interview with ADM on 8/9/23 at 12:15 pm revealed that he was not aware they had a hole in their RN coverage and would work with the DON to ensure lack of 8 consecutive RN hours does not occur again ADM stated that the DON is responsible for the staffing of the nurses . There is 4 RNs on staff and with the staffing rotation lack of coverage should not have occurred. ADM stated there is potential for lack of supervision of the resdients care if an RN is not on duty at least 8 hours a day.

Based on observation, interview, and record review, the facility failed to provide pharmaceutical services to ensure the accurate acquiring, receiving, dispensing, administering, and securing of medications for 1 (nurse medication cart) of 4 medication carts reviewed for pharmacy services. The facility failed to ensure prompt identification of a potential diversion of medications when Nurse A did not report a damaged blister pack of Resident #41's Tramadol 50 mg tablet. LVN A did not discard the medication according to facility policy. This failure could place residents at risk of not having the medication available due to possible drug diversion and at risk of not receiving the intended therapeutic benefit of the medications. Findings Included: Review of Resident #41's quarterly MDS assessment, dated [DATE], reflected the resident was a 54 -year-old male with an admitted [DATE]. Resident #41's diagnoses included other chronic pain; cerebral infarction (stroke) due to unspecified occlusion (blockage or closing) or stenosis (narrowing) of unspecified cerebral artery. Review of Resident #41's physician's orders, dated [DATE], revealed an order for Ultram Tablet 50 mg (tramadol HCl) *Controlled Drug*, Give 1 tablet by mouth every 8 hours as needed for pain. An observation on [DATE] at 10:25 AM of the nurse medication cart in hall 300 revealed the backside of the blister pack for Resident #41's tramadol 50 mg had 3 (#4, #7, and #8) of 15, torn, punctured, or ripped foil seals exposing the individual tablets. In an interview on [DATE] at 11:38 AM LVN A stated she was unaware when the blister pack seals became broken, and she was not aware who might have damaged the blisters. She said the risk of damaged blisters was giving a wrong medication to the resident. She said the nurses and medication aides were responsible for checking the medication blister packs for broken seals during the count of narcotics. She said the count was done at shift change and the count was correct. During the interview the count sheets were compared to the blister packs and the count was correct. In an interview on [DATE] 12:09 PM with the DON revealed she expected if a blister pack medication seal was broken the pill should be discarded. The DON said it would not be acceptable to keep a pill in a blister pack that was opened. The DON said the risk would be giving the wrong medication and a potential for a drug diversion. She said nurses and medication aides were responsible for checking the medication blister packs for broken seals during the count at the beginning of each shift. She said she would in-service nursing staff to discard pills if the blister was opened. Review of the facility's policy Storage and Expiration Dating of Medications, Biologicals, Syringes and Needles, revised [DATE], reflected, . 13.3 Facility should ensure that all controlled substances are stored in a manner that maintains their integrity and security . 17. Facility should destroy or return all discontinued, outdated/expired, or deteriorated medications or biologicals in accordance with Pharmacy return/destruction guidelines and other Applicable law

Based on observations, interviews, and record reviews, the facility failed to maintain an effective pest control program for 7 (Resident #1 thru Resident #7) of 20 residents reviewed, in that: The facility failed to ensure the building was free of ants as Resident #1 was found with ants crawling on her, causing severe ant bites and [CONDITION(S)]. This failure resulted in an immediate jeopardy on 10/06/21. While the IJ was removed on 10/8/21 the facility remained out of compliance at a scope of isolated and a severity of actual harm due to the facility requiring more time to monitor the plan of removal for effectiveness. The IJ template was provided to facility staff at this time. This failure placed residents at risk for pain, disease, infection, harm, and a diminished quality of life. Findings included: Review of Resident #1's undated face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses of COVID-19, unspecified dementia without behavioral disturbance, [CONDITION(S)], [CONDITION(S)], other migraine, not intractable, with status migrainosus, and a displaced fracture of sternal end of clavicle. Review of Resident #1's most recent MDS, dated [DATE], reflected a BIMS of 99, indicating the resident was unable to complete the interview due to severe cognitive impairment and her functional activities of daily living (ADL) abilities range from extensive assistance to total dependence. Review of progress notes for Resident #1 dated 8/17/2020 reflected a CNA reported finding ants in Resident #1's bed while changing the resident's brief, so the CNA dressed her, transferred her from her bed, and reported the incident to the nurse and the maintenance supervisor at that time. Review of Resident #1's progress notes reflected on 10/03/2021 around 11:50 AM the aide alerted this nurse to resident's room where hundreds of ants were observed crawling on resident's body. Resident's throat was red, swollen, and had multiple bites from the ants. Her clothing and bedding were removed, and staff attempted to remove the ants from her body before she was placed in the shower to remove them all. The nurse administered 50mg of [MEDICATION(S)]. Resident is non-verbal and was scratching her neck and body and had facial grimaces. She was transferred to the emergency room to monitor for [MEDICATION(S)]. Record review of a facility investigation report, dated 10/4/21 reflected the following: CNA A fed Resident #1 breakfast at 8am at which time there were no ants. Checked on Resident #1 & Resident #2 again between 9:30-10am. At 11:45am she observed ants in the bed and on the resident and informed the nurse. There was no food in the room at the time. The resident was showered, assessed, given [MEDICATION(S)], and sent to the hospital for monitoring. Housekeeping and Maintenance were alerted and responded by cleaning the room, treating the windowsill, and outside. The pest control company was notified. Employees have been using the pest control log as instructed when there are ants in the building No other rooms has signs of ants. Skin assessments were conducted on the residents on Resident #1's hall and rounds were made through resident rooms to ensure food was sealed properly. Pest control treated room 403 on 10/4. Skin assessments were conducted on the residents on all other hallways 10/7. Interior and exterior perimeter rounds were conducted 10/7/21 and 10/8/21 and will continue to monitor. In-servicing on proper notification of ants was conducted. A review of the Discharge Orders for Resident #1 from a local emergency department dated 10/03/2021, reflected Resident #1's vitals were 1st checked at 12:30pm on 10/03/2021. She was diagnosed with hundreds of fire ant bites and prescribed [MEDICATION(S)] (commonly known as [MEDICATION(S)], for allergies) 4 times daily PRN and [MEDICATION(S)] prn for itchiness and swelling. She was discharged back to TLC West on 10/03/2021 at 2:30pm. Review of Resident #1's skin assessment dated [DATE] reflects multiple ant bites to upper torso and to both shoulders anterior and posterior, pustule filled, and cluster to right shoulder. On 10/6/21 at 12:01pm observation of Resident # 1 revealed she was not interviewable due to her dementia. She was seated in her wheelchair and did not respond verbally to questions or greetings, She did not move other than to turn her head very slowly towards the person speaking when she was spoken to and she smiled at one point during the observation when she heard laughter. It was observed she had hundreds of raised, red, pustule filled ant bites across her right arm, face, neck, and the section of chest visible above her clothing. In an interview on 10/6/2021 at 3:25pm NP stated yesterday she diagnosed Resident #1 with [CONDITION(S)] related to the ant bites. NP stated she observed a huge ant bed outside of Resident #1's window but could not be sure how preventable was the incident of Resident #1 being bitten by ants. NP stated she has only observed ants once at the facility, in April 2021, in a room where a resident was hoarding food and the facility treated the room. In an interview on 10/7/21 at 2:40pm NP stated she had no update on Resident #1. She stated a potential outcome of the ant bites is infection, and her skin may not look the same aka skin distortion. NP stated even in if the resident were to get an infection, she does not believe there is any risk of death. Review of Resident #2's undated face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses of [CONDITION(S)], major depressive disorder, [CONDITION(S)], unspecified disorder of psychological development, [CONDITION(S)], history of falling, unspecified convulsions, and chronic obstructive pulmonary disease. Review of Resident #2's face sheet reflected she lives in the same room as Resident #1. Review of Resident #2's most recent MDS, dated [DATE], reflected a BIMS of 00, indicating the resident was unable to complete the interview due to severe cognitive impairment and is a total assist in transferring and use of her wheelchair. In an observation of Resident #2 on 10/6/2021 at 11am it was observed that Resident #2 relies on a wheelchair and was unable to answer or respond appropriately to this surveyor's greeting or to simple questions. Review of Resident #3's undated face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses of hypertensive heart and chronic kidney disease with heart failure, congestive heart failure, chronic pain syndrome, shortness of breath, [CONDITION(S)] disorder, and [CONDITION(S)] disorder, depressive type. Review of Resident #3's most recent MDS dated [DATE], reflected she was cognitively intact as indicated by her BIMS score of 15 and can self-transfer to her wheelchair. In an interview on 10/06/2021 at 9:20am, Resident #3 stated last Saturday or Sunday she observed several ants on her bedside table, on her bed, and around her window. She stated she told the facility but feels that due to her diagnosis and history at other facilities they did not believe her. However, they did spray her room for ants after she reported seeing them. In an interview on 10/06/2021 at 2:03pm LA stated she saw ants in Resident #3's room on Monday sometime between 8am-10am while retrieving the resident's laundry. The ants were attracted to a cup of soda on the resident's bedside table. LA emptied the cup and alerted someone at the nurse's station but did not recall who it was she informed. In an interview on 10/06/2021 at 2:07pm RT A stated that on Saturday 10/2/21 Resident #3 told her about ants in her room. In an interview on 10/06/2021 at 2:07pm RT A did not see the ants but informed LVN A, who called MNT who then in turn came and sprayed the resident's room that same day, around noon. Review of Resident #4's undated face sheet reflected a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses of Alzheimer's disease, [CONDITION(S)], [CONDITION(S)] disorder, unspecified [CONDITION(S)], and age-related physical debility. Review of Resident #4's most recent MDS dated [DATE] reflected he was cognitively intact as indicated by his BIMS score of 15 and requires staff transfer to his wheelchair. In an interview on 10/06/2021 at 9:55am, Resident #4 stated he has occasionally observed a few ants near his window but did not consider it a problem and so he did not inform staff. In an interview on 10/6/21 at 11:28am, MNT stated he began working for the facility two months ago. The pest control company last came around, 9/27 for the monthly treatment and sprayed inside and outside the building. That Thursday, 09/30/21, MNT treated the yard outside with ant poison. He got a call on Sunday about ants in a room, he came out that day and treated the ant piles in the grassy area outside Resident #1's room and the windowsills of the resident rooms in that area. He treated the windowsill and outside Resident #1's room. He only saw 2 ants in the room, he came back the next day (Monday) and saw no signs of ants. He called pest control and Monday morning they came out and treated that room again. Once the residents were moved from the room, on Monday, he put silicone on the outside and on the inside of the windows to seal any possible but did not see any possible cracks when he inspected the windows prior to that. He has added checking windows to his list of make-ready when rooms are vacated and has started a program since this incident to treat the yards 3x per week by sprinkling Ortho Orthene ant powder on ant piles. He wants to keep the residents safe. He had not observed any ants in rooms prior to this. Resident #3 complains about ants, he has checked that room, DON has checked her room, ADM has checked the room, and pest control sprayed the room. The building is old, and he is trying to get the building where it needs to be. In an interview on 10/6/21 at 12:09pm, MA A stated she was working as a CNA on Sunday 10/3/21 and arrived at 7:30am. She fed Resident #1 from 8am-8:30am in the resident's bed. She checked on Resident #1 and #2 around 9:30am. When she returned around 11:45am she observed ants all over Resident #1's chest, the side of her face, and arm. Her bed was by the window, and there were a [NAME] of ants coming in the window, from the right-hand corner of the windowsill crawling all over, her linen was touching the window, she pulled the linens back and they were all in the bed with Resident #1. MA A got the nurse and they showered Resident #1 to remove the ants and EMS arrived to pick her up. MA A stated she had never seen ants in that room, but on Saturday 10/2/21, while working as a CMA, she did see ants on Resident #3's bedside table around noon. She stated she cleaned up the ants and informed LVN A but does not know what happened after that. MA A stated she was told by LA there had been ants in Resident #5's room on Saturday, but MA A did not observe this personally. MA A stated she had not seen any issues with ants prior to this past weekend. Review of Resident #7's undated face sheet reflected a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses of cervical disc disorder with [CONDITION(S)], [CONDITION(S)], spinal stenosis, vascular dementia without behavioral disturbances, other specified depressive episodes, and chronic obstructive pulmonary disease. Review of Resident #7's most recent MDS dated [DATE] reflected he was moderately cognitively impaired as indicated by his BIMS score of 12 and can transfer to his wheelchair on his own. In an interview on 10/06/2021 at 1:25 pm Resident #7 stated he observed the trail of ants in August 2021. The facility cleaned up the ants and treated the room. He stated he had not observed ants in his room prior to this and has not observed them since. In an interview on 10/06/2021 at 1:20pm HKS B stated in late August 2021 she saw a trail of ants in Resident #7's room. The trail led from the window to a drawer in which the resident had cookies. There were also ants coming from the wall separating Resident #7 and Resident #3's rooms. HKS B cleaned up the ants, mopped, closed the cookies, and alerted MNT, who sprayed the room for ants that day. HKS B has not observed ants since then. In an interview on 10/06/2021 at 3:34pm with the pest control company representative, he would not provide information over the phone but offered to come out the next day and look at the ant issue. He stated the ants are coming in through the air conditioning units or are situational. He would not say if he felt there was anything the facility should be doing or not doing or if a full facility-treatment or focused treatment was a better approach. In an interview on 10/6/21 at 2:30pm DON stated on Monday, 10/4/21 skin assessments were done on every resident on Resident #1's hall and charted in the medical records. On Monday morning management had their morning meeting and she, the ADON, DCO, ADM, and MNT discussed the incident and what needed to be done. As far as a plan to mitigate risks, staff were in-serviced to report any sightings of ants and to be vigilant about any open containers of food in resident rooms and were to close the containers of food as a means to control ants in the room. Also, on Monday she and MNT went room to room, checking for ant attractants and any gaps, which were sealed by MNT if found. In an interview on 10/6/21 at 3:50pm CNA A stated she worked 10/1/21 thru 10/3/21. Resident #5 told her on 10/3/21 he had some ants in his room in the morning, around 10am, she looked around and didn't see any. She knew they had sprayed recently so she looked around and checked every time she came in the room and didn't see any until lunchtime, she was checking the windowsill and saw 2 on the windowsill, she thinks she told nurse one of the nurses on Sunday that she killed the two ants. In an interview on 10/6/21 at 4:12pm CNA B stated he helped on the 500 hall 6p-6am two weekends ago on Saturday night, he also worked on the 300 hall. He did not see any ants and had no concerns with ants at the facility. In an interview on 10/6/21 at 4:15pm CNA C confirmed she worked 6pm-6am on Saturday night, she helped on 500 with CNA B and also worked the 200 hall. She did not see ants and had not seen ants prior, but stated she heard that the weekend before Resident #6 had some ants on his wall, she did not see this herself, and heard that CNA B cleaned it up and might have told LVN B. In an interview on 10/6/21 at 4:28pm LVN A stated in the late winter or spring of 2021, she was alerted to ants in Resident #1's bed but could not remember the exact time or what staff were involved. She stated she pulled back the covers and there were indeed ants in Resident #1's bed with the resident, but the resident had not been bitten. LVN A stated she removed the resident from the room and reported it to the ADM or DON the same day and thinks that maintenance sprayed the room. This was not documented anywhere to LVN A's knowledge. This past Saturday, CNA A reported to her that Resident #5 had ants coming through his window. LVN A informed RN A and they went to Resident #5's room and saw ants coming through his window in the left bottom where the window meets the frame. He was up in his chair so did not get bit and his bed is away from the window. RN A informed LVN A she would handle it. She stated on the afternoon of 10/3/21, Resident #6 reported to her that something was crawling on him. LVN A checked him and saw nothing. She stated she had not heard of another incident involving ants and Resident #6. When this Surveyor shared concerns there had been another ant incident with this resident, but the CNA involved denied it, LVNA A stated, that sounds about right. LVN A stated Resident #3 has complained about ants I don't even know how many times, and that she has notified management and housekeeping. LVN A stated MA A notified her of ants last weekend, and she followed the chain of command and notified RN A. LVN A is not sure what RN A did about the concern but found out that ADM was not notified about the ants and the incident with Resident #1 until Monday morning. LVN A stated the first week of September 2021, Resident #7 had ants in his room, coming along his wall from the window on the wall that shares with Resident #3, they were in his dresser and a line to his closet. Management had the housekeeper clean out all the drawers in his nightstand, where it was found he had an unsealed bag of cookies in his drawer. LVN A stated the ant problem was an on-going issue and thought it was the lack of care by management, as management did not act on what the staff said and the only time management were out of their office is when state was in the building. She has seen someone come in and spray but not often and never the whole facility. In an interview on 10/7/21 at 9:33am RN A stated she was the weekend supervisor and worked this past weekend. She stated she never saw ants until Resident #1's ant attack. She denied that any mention was made of ants to her during the weekend until the attack occurred. Staff removed Resident #1's clothing and put her in the shower to wash off the ants. They called the on-call nurse practitioner and gave Resident #1 a [MEDICATION(S)] then sent her to the hospital. They removed the roommate, Resident #2, from the room and performed a skin assessment, no sign of ants or ant bites were found on Resident #2. RN A stated she did not alert management. On Sunday 10/3/21, MNT came in the building for another matter and was alerted to what happed at that time. He showed up sometime between noon and 1:30pm. He sprayed the room and treated the outside of the building. RN A said her understanding now is that they are supposed to contact the DON in a situation such as that. RN A believes regular fumigation for ants may limit the chance of reoccurrence. In an interview on 10/7/21 at 2:08pm MNT stated prior to this incident, he did not have any training or expectations on how to monitor and prevent pest infestations beyond responding to work orders and the work log as issues arose. He has never worked in a building with this kind of ant issue. He stated there was a maintenance book for logging requests in addition to entering work orders and any staff could write in the logbook but is unsure who can enter the work orders. He checked that logbook several times a day. There was also a pest control book that can be written in at the nurse's station. This ant issue has been going on for a while, since before he came on board two months ago, according to what he has heard from staff. He is not sure if the rest of management is aware of the ant issues. He spoke to his regional manager today who only told him to call the pest control company. He stated he wanted the pest control company to help him in implementing a pest prevention plan instead of just reacting after pests have been seen. Review of Resident #9's undated face sheet reflected a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses of primary [CONDITION(S)], [CONDITION(S)] disorder, [CONDITION(S)], [CONDITION(S)], acute kidney failure, left ventricular failure, hypertension, respiratory failure, [CONDITION(S)], and [CONDITION(S)]. Review of Resident #9's most recent MDS, dated [DATE], reflected he was cognitively intact as indicated by his BIMS score of 15 and is able to get up on his own. In an interview on 10/07/2021 at 3:15pm Resident #9 stated he had observed a few ants in his room lately and had mentioned it to staff but did not recall who he told. Review of Resident #8's undated face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses of heart failure, hypertension, major depressive disorder, anxiety disorder, end stage renal disease, [CONDITION(S)], pulmonary disease, and [CONDITION(S)]. Review of Resident #8's most recent MDS dated [DATE], reflected she was cognitively intact as indicated by her BIMS score of 14 and requires staff transfer to her wheelchair. In an interview on 10/07/2021 at 3:30pm Resident #8 stated last Thursday 9/30/21 she had been out of the room and staff alerted her to the presence of several ants on the foot of her bed. She did not recall which staff let her know. Resident #8 stated later that same day someone sprayed a pest control product in her room and in the grass outside of her room. In an interview on 10/7/2021 at 3:48pm MA B stated she has observed a few ants on the 400 hall but the facility will spray right away when informed and she will mop the floor to remove the ant pheromones to deter them. In an interview on 10/06/2021 at 2:07pm RT A stated on Thursday 9/30/21 or Friday 10/1/21 she entered the room of Resident #5, who was sitting in his chair and was observed to have several ants on him. RT A stated she brushed the ants off Resident #5 and informed LVN A. RT A is not sure what time this happened or what was done by staff in response to the ants that day. Review of Resident #5's undated face sheet reflected a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses of [CONDITION(S)], [CONDITION(S)], mixed anxiety disorders, chronic obstructive pulmonary disease, and megaloblastic anemias. Review of Resident #5's most recent MDS dated [DATE] reflected he was cognitively intact as indicated by his BIMS score of 15 and requires staff transfer to his wheelchair. In an interview on 10/07/2021 3:54pm Resident #5 stated he saw several ants on Friday 10/1/21 or Saturday 10/2/21 along his windowsill. He informed a staff but could not provide the name of the staff. He stated he had not observed ants before and has not seen them since. In an interview on 10/07/2021 4:11pm ADM confirmed he was not informed of the many recent ant sightings in the facility. He stated he was alerted to an ant sighting in May 2021 and the facility did a focused treatment of that area for ants at that time. The only other additional complaint he has received of ants prior to the incident with Resident #1 was when Resident #3 complained last week of ants on her bedside table. He stated he was unsure if this was true as Resident #3 has been refusing her mediation and has had some resulting delusional/accusatory behaviors. ADM stated he went to her room and spoke to her and did not see any ants in her room, but had the room treated for ants that same day. He did not learn of the incident with Resident #1 on Sunday until he came arrived at the facility Monday morning. Review of Resident #6's undated face sheet reflected a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses of [CONDITION(S)], incomplete, unspecified, cerebral infarction, unspecified, non-ST elevation [CONDITION(S)] infarction, chronic respiratory failure with hypercapnia and [CONDITION(S)], type 2 diabetes mellitus with unspecified complications, and heart disease. Review of Resident #6's most recent MDS dated [DATE] reflected he was cognitively intact as indicated by his BIMS score of 14 and requires staff transfer to his wheelchair. In an interview on 10/07/2021at 4:22pm Resident #6 stated the weekend before last he felt something crawling on his neck while he was lying in bed. He alerted a male CNA who came and discovered there were ants on Resident #6. The CNA called for help and the nurse working that night was an agency nurse. They brushed the ants off and changed Resident #6's clothes and bedding. No one ever followed up after this incident or sprayed his room. He stated prior to this incident he had observed a few ants on his table, but never on his bed or person. During on observation on 10/6/2021 at 1pm of the grassy area located in the V shape where the 300 and fall halls meet, numerous large ant mounds were observed near the window of Resident #1's room and in other areas, mostly along that wall. The ant beds located nearest the building were observed to have been treated with white power, which was also observed on the window ledges. The closest ant bed to Resident #1's window was estimated to be about 6 feet away. Further from the rooms, two smaller ant beds were found that were not treated and when disturbed, resulted in teeming ants. MTN was notified. During an observation on 10/7/2021 at 9am the two ant beds observed yesterday had white powder on them and did not result in ants when the beds were disturbed. However, another small, active ant bed was observed to have come into existence near a tree about 100 feet or more from the earlier ant beds. This ant bed was still on facility property but not near a resident's window. Review of work orders from 9/1/21 thru 10/7/21 reflected work orders for ants in room 306 on 9/3/21, ants on bed in room 303, and ants in room 403 on 9/30/21. Review of the monthly pest control invoices for 2021 from the local pest control company that show ants were not part of the routine treatment, just roaches and rodents. Record review of the morning meeting agenda on 10/4/21 under discussion was ant treatment of room 403, housekeeping to deep clean 200 hall focus area crumbs/food (ants). Ants in 403 was listed under incidents. Review of in-services reflected in services were given several times during the week starting on 10/4/21 to nursing and housekeeping staff on pest control in rooms Review of the in-service given on 10/4/21 was signed by LVN A and stated she is to report incidents, including insect bites. Review of the undated Ant treatment plan provided by MNT on 10/7 reflected on Monday 10/4/2021 the outside ant beds were treated by MNT and a local pest control company was called. Wednesday 10/6/21 all ant beds were treated with a pesticide by MNT. Review of MNT's timecard for 10/1/21 thru 10/7/21 reflected MNT did clock in for two hours on both 10/02/21 and 10/03/21, supporting he was at the facility spot treating for ants as indicated in interviews. The Administrator and the Director of Nursing were notified on 10/07/21 at 4.55pm an Immediate Jeopardy situation had been identified due to above failure and a plan of removal was requested. The IJ template was provided to the Administrator and the Regional Director of Clinical Operations on 10/07/21 at 5:00 pm. The following Plan of Removal was submitted by the Administrator on 10/08/21 and accepted at 7:04 pm. The Plan of Removal reflected the following: Summary of Details which lead to outcomes On 10/06/2021, an abbreviated survey was initiated at (facility name and address). On 10/07/2021, a surveyor provided an IJ Template notification that the Survey Agency has determined that the conditions at the community constitute immediate jeopardy to resident health and safety. The notification of the alleged immediate jeopardy states as follows: Pest Control The facility failed to follow their policy for proper pest control procedures to prevent fire ants on 10/03/2021. The facility maintenance director failed to do routine outside rounds or preventative inside checks for ants 10/06/2021. The facility failed to complete skin assessments on the other halls where ant sightings were observed on 10/03/2021. The contracted services for housekeeping failed to train staff on what to do to identify, control, or respond to the presence of ants. The pest control company failed to routinely perform preventative ant treatment. The facility failed to have an effective pest control program and an active ant colony was still observed on the exterior perimeter of 400 Hall. The facility failed to protect Resident #1 from ants. Identify residents who could be affected All Residents have the potential to be affected. Facility census on 10/07/2021- 52. Identify responsible staff/ what action taken The maintenance director treated the ant mounds that was found on 10/07/21. A local pest control company was contacted 10/07/21 for return visit as soon as possible. Director of Nursing immediately started an in-service with all facility staff which includes Direct Care (RN, LVN, CNA, CMA, RNA), housekeeping, laundry, dietary, maintenance, office staff, and rehabilitation staff. Any agency staff utilized by facility will receive in-services prior to starting their assigned shift. The in-service addresses proper notifications when pest/ants are identified inside or outside the facility. Any resident that is identified that has been exposed to ants will immediately be removed from that area, head to toe assessment completed, will receive a shower and then proper notifications will be made to the responsible party, attending physician, the administrator, the director of maintenance and the director of nursing. The in-service also included conducting proper skin assessments on residents and complete rounds on all rooms/areas that pest or ants have been identified. This in-service was started on 10/07/21 and will be completed on 10/08/21. Any staff who are unable to attend will receive the in-service prior to beginning their shift and will not work until they receive the in-service. New hires will receive same in-service as part of their onboarding and will not work the floor until in-service completed. Residents on halls 200, 300 and 500 skin assessment initiated on 10/07/2021 and 10/08/2021. The administrator completed a thorough assessment of the perimeter of the facility on 10/07/2021. The department managers conducted a thorough assessment of all resident rooms in the facility no other ants/pest were identified on 10/07/2021. In-Service conducted Director of Nursing immediately started an in-service with all facility staff which includes Direct Care (RN, LVN, CNA, CMA, RNA), housekeeping, laundry, dietary, maintenance, office staff, and rehabilitation staff. Any agency staff utilized by facility will receive in-services prior to starting their assigned shift. The in-service addresses proper notifications when pest/ants are identified inside or outside the facility. Any resident that is identified that has been exposed to ants will immediately be removed from that area, head to toe assessment completed, will receive a shower and then proper notifications will be made to the responsible party, attending physician, the administrator, the director of maintenance and the director of nursing. The in-service also included conducting proper skin assessments on residents and complete rounds on all rooms/areas that pest or ants have been identified. If the administrator, director of maintenance or director of nursing did not answer the staff must continue to call department managers until they are able to reach someone. This in-service was started on 10/07/21 and will be completed on 10/08/2021. Any staff who are unable to attend will receive the in-service prior to beginning their shift and will not work until they receive the in-service. New hires will receive same in-service as part of their onboarding and will not work the floor until in-service completed Implementation of Changes A local pest control company will service the facility weekly x4 weeks starting 10/08/2021 and then monthly and as needed thereafter. A local pest control company was asked to provide explicit details on invoices for services provided starting 10/08/2021. In additional to the routine ant preventative, pest control has added treatment that will provide blanket coverage for all grass areas with the product Topchoice. Topchoice was applied on 10/08/2021. The maintenance director/designee will conduct thorough rounds throughout the facility Q shift starting 10/07/2021 x 30days and then prn thereafter to monitor for any pest/ant activity. The maintenance director/designee will round and ensure all food items are stored properly to prevent pest/ant activity daily x 30days and prn starting 10/07/2021. During morning meeting TELS (building management system) will be reviewed for any new concerns regarding pest/ant activity and that appropriate interventions have been implemented daily x 30days and prn st

Based on interview and record review the facility failed to ensure that residents are free of any significant medication errors for one of six residents reviewed for medication administration (Resident #6). On 1/13/16, MA A administered 30 ml of [MEDICATION NAME] (opioid pain medication) and two tablets of 10/325 [MEDICATION NAME] (combination of [MEDICATION NAME] and [MEDICATION NAME] is an opioid pain medication) to Resident #6, which was ordered for another resident. The administration of this medication resulted in Resident #6 becoming unresponsive and being transferred to a local hospital. The resident was diagnosed with [REDACTED]. This was determined to be past non-compliance at immediate jeopardy level from 1/13/16 until 1/14/16 due to the facility having implemented actions that corrected the non-compliance prior to the beginning of the survey. This failure could place all 13 residents residing on 400 Hall receiving prescribed medications at risk of injury or death due to administration of another resident ' s medications. Findings include: Review of Resident #6 ' s face sheet reflected Resident #6 ' s date of birth as 11/12/1959 and an admission date of [DATE] with the following Diagnoses: [REDACTED]. Review of Resident #6 ' s MDS dated [DATE] and 10/7/15 reflected a BIMS as 15, cognitively intact mental state. The MDS also reflected no prescribe order of medications for [MEDICATION NAME] or [MEDICATION NAME]. Review of the Provider Self Reporting of Incidents, SR16- 4 dated 1/14/16 reflected a hand written statement by MA A of the incident: I was passing out medications on 400 hall and got to the end of the hall where there was a lot going on. While getting medications ready, I had people needing to get by so I would have to move, due to all the things in the hall from them doing the floor in a room. I had a resident wanting me to look on the bed to find her remote the resident thought she lost. As I got down to the last room, the resident in there was saying pill lady over and over again and Resident #6 was behind me wanting his medications all at once. Before I realized what she had done, I gave Resident #6 another resident ' s medications. When I went to give another resident their medications, I realized I had already signed the pain medication out and that it was given to Resident #6. I immediately went and told the charge what happened Review of Resident ' s #6 nurse ' s notes dated 1/13/16 at 10:30 a.m. reflected MA A informed charge nurse Resident #6 received 30 mg of [MEDICATION NAME] and two tablets of [MEDICATION NAME] 10-325 mg. MA A stated the incident had just occurred. The ADON and the DON and the NP were notified immediately. The emergency kit was checked for [MEDICATION NAME] (a medication used to reverse the effects of opioids, especially in overdose) to be in-house. Resident #6 to monitored closely. During a phone interview on 1/15/16 at 2:30 p.m. MA A stated she did give Resident #6 the wrong medications. MA A stated on the 1/13/16 there was a lot of commotion on 400 Hall where she was administering medications. MA A stated Housekeeping was deep cleaning a room at the end of the hall, and furniture was in the hallway. MA A stated she was at the end of the hall giving meds when she heard one resident yelling for someone to get her remote control, another resident yelling pill lady, I want my medications and Resident #6 propelling his wheelchair behind her stating he needed his medications. MA A further stated the hallway was crowded, she was being asked to move with the medicine cart, she stated there was a lot going on that morning. MA A stated she realized she gave Resident #6 the wrong medications when she was going to administer another resident ' s medication and saw she had already initialed her signature as medication given on the resident ' s MAR. MA A stated she realized then she had given Resident #6 the wrong medication. MA A stated she immediately reported it to the first nurse she saw, which was LVN C. Review of Resident #6's consolidated physician orders [REDACTED]. [MEDICATION NAME] Sodium 100 mg tablet BID [MEDICATION NAME] 80 mg tab BID Aspirin EC 81 mg QD Folic Acid 400 mcg tab QD MVT with minerals t tab QD [MEDICATION NAME] 20 mg tab QD [MEDICATION NAME] powder 17 gm QD [MEDICATION NAME] 80 mg tablet 2 tabs Q AM [MEDICATION NAME] 800 mg tablet 3 tabs TID Phoslo 667 mg gelcap TID [MEDICATION NAME] 20 mg tablet Q HS [MEDICATION NAME] 12.5 mg tablet BID Further review of Resident #6 ' s consolidated physician order [REDACTED]. Review of Resident #6 ' s nurse ' s note dated 1/13/16 reflected the following: 11:00 a.m., LVN B was notified that Resident #6 received [MEDICATION NAME] 30 mg and [MEDICATION NAME] 10/325 mg two tablets by mouth. During assessment Resident #6 was alert and oriented to person, place and time (A&OX3). Resident #6 denies any pain or discomfort. Resident #6 was sitting in a wheelchair beside his bed, with no respiratory distress noted. Resident #6 has oxygen at three liters per with nasal cannula (O2 @3L/Per NC). The NP is here and is aware of Resident #6 ' s condition. Staff will continue to monitor. 11:15 a.m., during assessment Resident #6 is noted to be sitting on the side of his bed holding a trash can. Resident #6 stated I should not have eaten. Resident #6 was given four ounces of sprite and Resident #6 tolerated it well. Resident #6 denied any pain or discomfort, was alert and oriented to person, place and time, and call light within reach. Staff will continue to monitor. 11:30 a.m., Resident #6 noted to be vomiting a clear liquid into trash can while sitting on side of his bed. Resident #6 remains alert and oriented to person, place and time (no respiratory distress noted, blood pressure (BP) stable, vital signs (VS) 113/59, 93, 18, 97.8, oxygen 93%, O2@3L per NC. 11:50 a.m., Resident #6 noted having respiratory status of 16, oxygen stats is 91%. The NP stated to monitor Resident #6 closely and to obtain his VS. The ADON, DON and the NP are at Resident #6 ' s bedside. Resident #6 is slow to respond but still alert. The staff is to begin every five minute blood pressure checks. 12:30 p.m., Resident #6 noted to be in bed resting with eyes closed, but easily aroused. Resident #6 responded to verbal questions, slurred speech, VS were 137/72, 93% on room air, 88. The NP is in on rounds and updated to monitor resident. 1:30 p.m., Resident #6 noted to be unresponsive, RR even and unlabored, VS 110/54, 83, 18, 90% on 4 liters per nasal cannula. Resident #6 was placed on non rebreather. The NP, DON, ADON and RT at Resident #6 ' s bedside. New orders received for IM [MEDICATION NAME] (an opioid antagonist), VS stable, heart rate (HR) in the 80 ' s and BP ranging from upper SP 90 ' s-100s and DP in the 50s and 60s. VS are taken every 5 minutes X 30 minutes. Resident #6 received two doses of [MEDICATION NAME] IM, first dose was given at 1:38 p.m. and the 2nd dose was given at 2:05 p.m. Resident #6 responded to second dose of [MEDICATION NAME], he became aroused, was able to communicate verbally, his speech was slurred. Resident stated he felt tired, staff offered to call EMS to take Resident #6 to the local hospital ER, Resident #6 refused to go the ER. Resident #6 requested assistance to get out of bed and into his wheelchair. Resident #6 was able to transfer hiss self with stand by assist to his wheelchair. Resident #6 became nauseated and had an episode of dry heaving with no emesis noted. Resident #6 was taken to the nurses' station where resident requested some coffee and food. Resident #6 was given one cup of coffee and one cup of water. A new order was received for [MEDICATION NAME] to be given to Resident #6. In an interview on 1/15/16 at 2:30 p.m. LVN B stated the incident with Resident #6 started happening between the hours of 11:00 a.m. though 2:00 p.m. LVN B stated LVN C told her Resident #6 was given the wrong medication. LVN B stated at that time Resident #6 was assessed, he was A&OX3, he was sitting up in his wheelchair, he appeared to be okay, resident stated he was fine, his breathing sounds were good, O2 saturations was good. LVN B stated everything appeared to be fine with Resident #6. LVN B further stated Resident #6 was assessed by the DON, ADON and the NP. LVN B stated no medications were issued to Resident #6 at that time because he appeared to be doing fine. LVN B stated she remembers Resident #6 ' s first dosage of [MEDICATION NAME] being given approximately around 12:00 p.m. to 1:00 p.m. LVN B also stated there was commotion on the 400 hall because they were renovating a room and stripping floors, she further stated the police also was present during the disruption (related to a separate issue). Review of Resident #6 ' s nurse ' s note dated 1/13/16 reflected the following: 2:30 p.m., Resident #6 was at the nurse ' s station talking with staff, eyes were opened, speech slurred, RR even and unlabored, 96% on 4 liters per nasal cannula, RR 18. 3:00 p.m., Resident #6 noted to be in his wheelchair resting eyes closed, when resident was aroused, he did not respond, Resident #6 was taken back to his room. Resident #6 was administered two doses of intravenous (IV) [MEDICATION NAME] at 22 grams into the left forearm by the DON. The first dose was at 3:33 p.m. and the second dose was given at 4:03 p.m. The IV [MEDICATION NAME] was ordered by the NP. Resident #6 did not respond, VS stable throughout administration, BP 96/54, 84, 18, 96% 4 liters per nasal cannula. VS were taken every 5 minutes X one hour with a nurse at bedside with resident at all times. Plan of care was coordinated, a new order received to transfer Resident #6 to the local hospital ER. The EMS was called at 4:40 p.m. Resident #6 ' s point of contact was called twice, there was no answer, and a message was left on both calls. Resident #6 was transferred to the local hospital at 5:00 p.m. In an interview on 1/15/16 at 3:30 p.m. the ADON stated on 1/15/16 she saw MA A walking down the hallway and she looked awful. The ADON state she asked MA A what was wrong and MA A told her she had given the wrong medications to Resident #6. The ADON stated she saw the NP and LVN C talking and the NP ordered for Resident #6 to monitor closely. The ADON further stated the NP and LVN C told Resident #6 what had happened, Resident #6 state he felt fine and went outside to have a cigarette. The ADON stated when Resident #6 came back in from smoking, he had an episode of vomiting, so he went to his room and laid down. The ADON stated she remember LVN C getting Resident #6 a sprite. The ADON stated she didn ' t hear anything else until about 1:30 p.m., she went to Resident #6 s room and he was not responding. The ADON state LVN C took resident ' s vitals and they were stable, Resident #6 was aroused with physical stimuli rubs to his chest. At that time, Resident #6 stated he was fine and just needed some sleep. The ADON stated the NP ordered Resident #6 be given a IM of [MEDICATION NAME] at approximately 1:30 p.m. After the dosage was given, the resident was not responding. The ADON stated Resident #6 was given a second dose of [MEDICATION NAME], and the resident was still not responding. The ADON stated she, the DON, and LVN C stayed in the room with Resident #6 and the NP was in and out until it was decided the resident would go to the ER. The ADON stated Resident #6 was told they wanted to send him to the ER, Resident #6 refused to go. The ADON stated the NP stated Resident #6 could get up in his wheelchair if he doesn't want to go to the ER, but monitor him closely. The ADON stated when Resident #6 had another episode of vomiting, he was given [MEDICATION NAME] (anti-nausea medication). The ADON stated Resident #6 had gone to the nurses station and fell asleep. The ADON stated his vitals were good and the NP ordered a third dose of [MEDICATION NAME] given at 3:30 p.m., Resident #6 still not responding and a fourth dose of [MEDICATION NAME] was given. According to the ADON, Resident #6 was not responding so EMS was called, and Resident #6 was still unresponsive when EMS arrived. In an interview on 1/15/16 at 3:38 p.m. the DON stated she was in a room with another resident when then incident occurred with Resident #6 at approximately 10:30 a.m. on 1/13/16. The DON stated she was told by the ADON, NP and charge nurse what happened. The DON stated LVN C and the ADON went to tell Resident #6 what happened, he stated he was fine and decided to go outside and smoke a cigarette. The DON stated after resident had a cigarette he went to his room to watch television. The DON stated Resident #6 did not have any adverse actions at that time and staff was to monitor him closely. The DON stated at around 1:38 p.m. Resident #6 was given a first dose of [MEDICATION NAME] and at that time Resident #6 was not left alone up until he was sent to the ER. The DON stated at around 2:00 p.m. Resident #6 was given a second dose of [MEDICATION NAME], at that point, it was decided Resident #6 should go to the ER, but he refused. Resident #6 was given two doses of [MEDICATION NAME] IV, and when he was unresponsive at approximately 3:30/4:00 p.m. it was decided to send Resident #6 to the ER. In an interview on 1/15/16 at 3:50 p.m. the Administrator stated she was contacted by the DON and told there was a medication error, and that MA A had given Resident #6 the wrong medications. The Administrator stated she wasn ' t sure if Resident #6 was unresponsive at that time, because she was not in the building when incident occurred. The Administrator stated when she was told about the incident she called the RVP. During an interview on 1/15/2016 at 4:00 p.m., the NP stated she was at the facility seeing residents on 1/13/2016 and around 10:00 to 10:30 a.m., she was informed of Resident #6 receiving one 30 mg [MEDICATION NAME] and two 10/325 [MEDICATION NAME] tablets which were not prescribed for Resident #6. The NP examined Resident #6 around 10:45 a.m. At that time, Resident #6 was sitting up in a wheelchair with stable vital signs and was in no distress. The NP stated, He began to decline around 3:30. The NP stated she ordered 0.2 mg [MEDICATION NAME]. At that point during the interview, NP stated, I feel like I should not answer any more questions. I dropped off my notes at the facility this morning. The surveyor asked the NP if she spoke to the physician throughout the day of the incident. The NP responded, No. I don't need to. The NP stated she spoke to the physician after the resident was admitted to the hospital. In an interview on 1/15/16 at 4:45 p.m. the MD stated he was contacted by the NP and told about the incident that occurred with Resident #6. The MD stated the NP did the correct procedures by administering Resident #6 the [MEDICATION NAME] and then waiting to see Resident #6 ' s response to the medication, by monitoring his vitals closely. The MD stated if a resident/patient refuses to go to the ER and that resident is A&OX3, their wishes must be honored. The MD further stated once that resident/patient is not capable of making that decision (ex: due to effects of medication) then the facility staff can determine that decision and send the resident to the ER. The MD stated this incident was an unfortunate mistake, but does believe the staff responded to the incident in an appropriate manner. A review of the ER nursing notes dated 01/13/2016, at 5:20 p.m., reflected Resident #6 arrived via stretcher with EMS. The nurses notes further reflected that per the EMS report the resident received 2, 10/325 [MEDICATION NAME] (2 tablets, each with 10 mg [MEDICATION NAME] and 325 mg Tylenol) and 30 mg [MEDICATION NAME] at approximately 10:00 a.m. by mistake. Per the notation, the last known normal (level of consciousness) was 1:30 p.m. this afternoon. The nursing facility gave a total of 0.8 mg of [MEDICATION NAME] (an antidote for opioid narcotics). While en route the resident was hypotensive (low blood pressure), received 2 mg [MEDICATION NAME] and 100 cc NS (Normal Saline), O2 4L by nasal cannula, SPO2 94% (amount of [MEDICATION NAME] blood). Upon arrival to the ER, the resident remained nonresponsive, pupils pinpoint and has no gag reflex. A review of the ER physician's notes dated 01/13/16 at 5:45 p.m. reflected the following: Resident #6 presents with Drug Overdose, Hypercapnic (high carbon [MEDICATION NAME]) [MEDICAL CONDITION]. Resident #6 presented to the ER for Altered Mental Status. Upon arrival to the ER, the resident was unresponsive with shallow respirations. The initial Glascow Coma Score was 3 (a person with no deficits would have a score of 15). Given 0.4 mg [MEDICATION NAME] on arrival to ER with some improvement in mental status, but lasted less than one minute and was again unresponsive. The resident received an additional 4 doses of 0.4 mg [MEDICATION NAME] and was then put on a [MEDICATION NAME] drip (continuous IV infusion). Initial venous blood gases showed pCO2 69 (normal venous carbon [MEDICATION NAME] level is 38-52) and pH 7.23 (normal venous pH is 7.32-7.42; pH 7.23 is profound acidosis). Repeat venous blood gases 30 minutes later showed pH 7.17 and PCO2 76 (resident status worsening). Decision to intubate made at that time. Successful intubation in the ER. [MEDICATION NAME] drip stopped. Started IV [MEDICATION NAME] and Versed for sedation. admitted to the MICU. An observation on 01/15/2016 at 12:50 p.m. revealed Resident #6 in the MICU at a local hospital. Resident #6 was lying in bed, unconscious, unresponsive, had a right internal jugular venous catheter and was connected to mechanical ventilation via an endotracheal tube. During an interview on 01/15/216 at 12:50 p.m., the MICU nurse, stated Resident #6 was transferred to MICU from theER on [DATE] after receiving another resident's medication at the nursing facility. Review of the facility ' s policy and procedure titled Medication Administration revised dated 6/1/13 reflected the following: Policy: Mediations are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. Personnel authorized to administer medications do so only after they have been properly oriented to the medication management system in the facility. The facility has sufficient staff and a medication distribution system to ensure administration of medications without unnecessary interruptions. Procedure: D. Five Rights-Right resident, right drug, right dose, right route, and right time are applied for each medication being administered. A triple check of these 5 Rights is recommended at three steps in the process of preparation of a medication for administration: (1) when the medication is selected, (2) when the dose is removed from the container, and finally (3) just after the dose is prepared and the medication put away. a. Check #1: Select Medication - label, container and contents are checked for integrity, and compared against the MAR by reviewing the 5 Rights. b. Check #2: Prepare the dose - the dose is removed from the container and verified against the label and the MAR by reviewing the 5 Rights. c. Check #3: Complete the preparation of the dose and re-verify the label against the MAR by reviewing the 5 Rights. It was determined this failure placed Resident #6 in an IJ situation form 1/13/16 - 1/14/16. The facility ' s Administrator was notified on 1/15/16 at 5:35 p.m. The facility took the following action to correct the non-compliance on 1/13/16: Review of MA A ' s personnel file reflected MA A was suspended pending investigation. Review of in-services on 1/13/16 revealed staff attendance for the 8 rights to medication pass: 1. Right Client 2. Right Medication 3. Right Dose 4. Right Time 5. Right route 6. Right documentation 7. Right reason 8. Right response Review of an inservice on 1/14/16 revealed staff attendance for how to walk away from unneccessary interruptions during medicaitons pass. Review of inservices reflected the manager to help redirect if noticed unnecessary interruption to medication aide during med pass. The DON and ADON will conduct med pass audits for next 120 days. New Certified Medication Aides will conduct on the job training for 10 days and will not be on the cart alone until after on the job training and approval by DON/ADON. The surveyors observed two med pass and two demonstrations of the correct way to pass meds using the new 8 rights of med pass procedures. It was confirmed the facility now has procedures in place to address giving the right medication to the right resident. In an interview on 1/15/16 at 12:55 p.m. MA D was able to demonstrate the eight rights of medication pass. MA D stated she was not at work the day Resident #6 was administered the wrong medication. MA D also stated if a resident is given the wrong medication it is to be reported to the charge nurse immediately. In an interview on 1/15/16 at 1:00 p.m. MA E was able to demonstrate the eight rights of medication pass. MA E also stated if a resident is given the wrong medication it is to be reported the charge nurse immediately. In an interview on 1/15/16 at 1:10 p.m. CNA F stated she was working on 1/13/16 and remembers Resident #6 being fine that morning. CNA F also stated she noticed Resident #6 breathing harder than usual at approximately 1:00 p.m., and reported it to the charge nurse. Review of the facility ' s resident roster reflected 13 residents residing on 400 Hall.

Based on interview and record review the facility failed to implement written policies and procedures that prohibit neglect for one of six residents reviewed for medication administration (Resident #6). On 1/13/16, MA A administered 30 ml of [MEDICATION NAME] (opioid pain medication) and two tablets of 10/325 [MEDICATION NAME] (combination of [MEDICATION NAME] and [MEDICATION NAME] is an opioid pain medication) to Resident #6, which was ordered for another resident. The administration of this medication resulted in Resident #6 becoming unresponsive and being transferred to a local hospital. The resident was diagnosed with [REDACTED]. This was determined to be past non-compliance at immediate jeopardy level from 1/13/16 until 1/14/16 due to the facility having implemented actions that corrected the non-compliance prior to the beginning of the survey. This failure could place all 13 residents residing on 400 Hall receiving prescribed medications at risk of injury or death due to administration of wrong medications. Findings include: Review of the facility policy and procedure titled Abuse and Neglect Prohibition undated reflected the following: Our residents have the right to be free from abuse, neglect, misappropriation of resident property, corporal punishment and involuntary seclusion. Residents must not be subjected to abuse by anyone, including but not limited to facility staff, other residents, consultants or volunteer, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals Types of Abuse: Definition of Neglect is the failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. Review of the facility ' s policy and procedure titled Medication Administration revised dated 6/1/13 reflected the following: Policy: Mediations are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. Personnel authorized to administer medications do so only after they have been properly oriented to the medication management system in the facility. The facility has sufficient staff and a medication distribution system to ensure administration of medications without unnecessary interruptions. Procedure: D. Five Rights-Right resident, right drug, right dose, right route, and right time are applied for each medication being administered. A triple check of these 5 Rights is recommended at three steps in the process of preparation of a medication for administration: (1) when the medication is selected, (2) when the dose is removed from the container, and finally (3) just after the dose is prepared and the medication put away. a. Check #1: Select Medication - label, container and contents are checked for integrity, and compared against the Medication Administration Record [REDACTED] b. Check #2: Prepare the dose - the dose is removed from the container and verified against the label and the MAR by reviewing the 5 Rights. c. Check #3: Complete the preparation of the dose and re-verify the label against the MAR by reviewing the 5 Rights. Review of Resident #6 ' s face sheet reflected Resident #6 ' s date of birth as 11/12/1959 and an admission date of [DATE] with the following Diagnoses: [REDACTED]. Review of Resident #6 ' s MDS dated [DATE] and 10/7/15 reflected a BIMS as 15, cognitively intact mental state. The MDS also reflected no prescribe order of medications for [MEDICATION NAME] or [MEDICATION NAME]. Review of the Provider Self Reporting of Incidents, SR16- 4 dated 1/14/16 reflected a hand written statement by MA A of the incident: I was passing out medications on 400 hall and got to the end of the hall where there was a lot going on. While getting medications ready, I had people needing to get by so I would have to move, due to all the things in the hall from them doing the floor in a room. I had a resident wanting me to look on the bed to find her remote the resident thought she lost. As I got down to the last room, the resident in there was saying pill lady over and over again and Resident #6 was behind me wanting his medications all at once. Before I realized what she had done, I gave Resident #6 another resident ' s medications. When I went to give another resident their medications, I realized I had already signed the pain medication out and that it was given to Resident #6. I immediately went and told the charge what happened Review of Resident ' s #6 nurse ' s notes dated 1/13/16 at 10:30 a.m. reflected MA A informed charge nurse Resident #6 received 30 mg of [MEDICATION NAME] and two tablets of [MEDICATION NAME] 10-325 mg. MA A stated the incident had just occurred. The ADON and the DON and the NP were notified immediately. The emergency kit was checked for [MEDICATION NAME] (a medication used to reverse the effects of opioids, especially in overdose) to be in-house. Resident #6 to monitored closely. During a phone interview on 1/15/16 at 2:30 p.m. MA A stated she did give Resident #6 the wrong medications. MA A stated on the 1/13/16 there was a lot of commotion on 400 Hall where she was administering medications. MA A stated Housekeeping was deep cleaning a room at the end of the hall, and furniture was in the hallway. MA A stated she was at the end of the hall giving meds when she heard one resident yelling for someone to get her remote control, another resident yelling pill lady, I want my medications and Resident #6 propelling his wheelchair behind her stating he needed his medications. MA A further stated the hallway was crowded, she was being asked to move with the medicine cart, she stated there was a lot going on that morning. MA A stated she realized she gave Resident #6 the wrong medications when she was going to administer another resident ' s medication and saw she had already initialed her signature as medication given on the resident ' s MAR. MA A stated she realized then she had given Resident #6 the wrong medication. MA A stated she immediately reported it to the first nurse she saw, which was LVN C. Review of Resident #6's consolidated physician orders and MAR indicated [REDACTED] [MEDICATION NAME] Sodium 100 mg tablet BID [MEDICATION NAME] 80 mg tab BID Aspirin EC 81 mg QD Folic Acid 400 mcg tab QD MVT with minerals t tab QD [MEDICATION NAME] 20 mg tab QD [MEDICATION NAME] powder 17 gm QD [MEDICATION NAME] 80 mg tablet 2 tabs Q AM [MEDICATION NAME] 800 mg tablet 3 tabs TID Phoslo 667 mg gelcap TID [MEDICATION NAME] 20 mg tablet Q HS [MEDICATION NAME] 12.5 mg tablet BID Further review of Resident #6 ' s consolidated physician order and MAR indicated [REDACTED]. Review of Resident #6 ' s nurse ' s note dated 1/13/16 reflected the following: 11:00 a.m., LVN B was notified that Resident #6 received [MEDICATION NAME] 30 mg and [MEDICATION NAME] 10/325 mg two tablets by mouth. During assessment Resident #6 was alert and oriented to person, place and time (A&OX3). Resident #6 denies any pain or discomfort. Resident #6 was sitting in a wheelchair beside his bed, with no respiratory distress noted. Resident #6 has oxygen at three liters per with nasal cannula (O2 @3L/Per NC). The NP is here and is aware of Resident #6 ' s condition. Staff will continue to monitor. 11:15 a.m., during assessment Resident #6 is noted to be sitting on the side of his bed holding a trash can. Resident #6 stated I should not have eaten. Resident #6 was given four ounces of sprite and Resident #6 tolerated it well. Resident #6 denied any pain or discomfort, was alert and oriented to person, place and time, and call light within reach. Staff will continue to monitor. 11:30 a.m., Resident #6 noted to be vomiting a clear liquid into trash can while sitting on side of his bed. Resident #6 remains alert and oriented to person, place and time (no respiratory distress noted, blood pressure (BP) stable, vital signs (VS) 113/59, 93, 18, 97.8, oxygen 93%, O2@3L per NC. 11:50 a.m., Resident #6 noted having respiratory status of 16, oxygen stats is 91%. The NP stated to monitor Resident #6 closely and to obtain his VS. The ADON, DON and the NP are at Resident #6 ' s bedside. Resident #6 is slow to respond but still alert. The staff is to begin every five minute blood pressure checks. 12:30 p.m., Resident #6 noted to be in bed resting with eyes closed, but easily aroused. Resident #6 responded to verbal questions, slurred speech, VS were 137/72, 93% on room air, 88. The NP is in on rounds and updated to monitor resident. 1:30 p.m., Resident #6 noted to be unresponsive, RR even and unlabored, VS 110/54, 83, 18, 90% on 4 liters per nasal cannula. Resident #6 was placed on non rebreather. The NP, DON, ADON and RT at Resident #6 ' s bedside. New orders received for IM [MEDICATION NAME] (an opioid antagonist), VS stable, heart rate (HR) in the 80 ' s and BP ranging from upper SP 90 ' s-100s and DP in the 50s and 60s. VS are taken every 5 minutes X 30 minutes. Resident #6 received two doses of [MEDICATION NAME] IM, first dose was given at 1:38 p.m. and the 2nd dose was given at 2:05 p.m. Resident #6 responded to second dose of [MEDICATION NAME], he became aroused, was able to communicate verbally, his speech was slurred. Resident stated he felt tired, staff offered to call EMS to take Resident #6 to the local hospital ER, Resident #6 refused to go the ER. Resident #6 requested assistance to get out of bed and into his wheelchair. Resident #6 was able to transfer hiss self with stand by assist to his wheelchair. Resident #6 became nauseated and had an episode of dry heaving with no emesis noted. Resident #6 was taken to the nurses' station where resident requested some coffee and food. Resident #6 was given one cup of coffee and one cup of water. A new order was received for [MEDICATION NAME] to be given to Resident #6. In an interview on 1/15/16 at 2:30 p.m. LVN B stated the incident with Resident #6 started happening between the hours of 11:00 a.m. though 2:00 p.m. LVN B stated LVN C told her Resident #6 was given the wrong medication. LVN B stated at that time Resident #6 was assessed, he was A&OX3, he was sitting up in his wheelchair, he appeared to be okay, resident stated he was fine, his breathing sounds were good, O2 saturations was good. LVN B stated everything appeared to be fine with Resident #6. LVN B further stated Resident #6 was assessed by the DON, ADON and the NP. LVN B stated no medications were issued to Resident #6 at that time because he appeared to be doing fine. LVN B stated she remembers Resident #6 ' s first dosage of [MEDICATION NAME] being given approximately around 12:00 p.m. to 1:00 p.m. LVN B also stated there was commotion on the 400 hall because they were renovating a room and stripping floors, she further stated the police also was present during the disruption (related to a separate issue). Review of Resident #6 ' s nurse ' s note dated 1/13/16 reflected the following: 2:30 p.m., Resident #6 was at the nurse ' s station talking with staff, eyes were opened, speech slurred, RR even and unlabored, 96% on 4 liters per nasal cannula, RR 18. 3:00 p.m., Resident #6 noted to be in his wheelchair resting eyes closed, when resident was aroused, he did not respond, Resident #6 was taken back to his room. Resident #6 was administered two doses of intravenous (IV) [MEDICATION NAME] at 22 grams into the left forearm by the DON. The first dose was at 3:33 p.m. and the second dose was given at 4:03 p.m. The IV [MEDICATION NAME] was ordered by the NP. Resident #6 did not respond, VS stable throughout administration, BP 96/54, 84, 18, 96% 4 liters per nasal cannula. VS were taken every 5 minutes X one hour with a nurse at bedside with resident at all times. Plan of care was coordinated, a new order received to transfer Resident #6 to the local hospital ER. The EMS was called at 4:40 p.m. Resident #6 ' s point of contact was called twice, there was no answer, and a message was left on both calls. Resident #6 was transferred to the local hospital at 5:00 p.m. In an interview on 1/15/16 at 3:30 p.m. the ADON stated on 1/15/16 she saw MA A walking down the hallway and she looked awful. The ADON state she asked MA A what was wrong and MA A told her she had given the wrong medications to Resident #6. The ADON stated she saw the NP and LVN C talking and the NP ordered for Resident #6 to monitor closely. The ADON further stated the NP and LVN C told Resident #6 what had happened, Resident #6 state he felt fine and went outside to have a cigarette. The ADON stated when Resident #6 came back in from smoking, he had an episode of vomiting, so he went to his room and laid down. The ADON stated she remember LVN C getting Resident #6 a sprite. The ADON stated she didn ' t hear anything else until about 1:30 p.m., she went to Resident #6 s room and he was not responding. The ADON state LVN C took resident ' s vitals and they were stable, Resident #6 was aroused with physical stimuli rubs to his chest. At that time, Resident #6 stated he was fine and just needed some sleep. The ADON stated the NP ordered Resident #6 be given a IM of [MEDICATION NAME] at approximately 1:30 p.m. After the dosage was given, the resident was not responding. The ADON stated Resident #6 was given a second dose of [MEDICATION NAME], and the resident was still not responding. The ADON stated she, the DON, and LVN C stayed in the room with Resident #6 and the NP was in and out until it was decided the resident would go to the ER. The ADON stated Resident #6 was told they wanted to send him to the ER, Resident #6 refused to go. The ADON stated the NP stated Resident #6 could get up in his wheelchair if he doesn ' t want to go to the ER, but monitor him closely. The ADON stated when Resident #6 had another episode of vomiting, he was given [MEDICATION NAME] (anti-nausea medication). The ADON stated Resident #6 had gone to the nurses station and fell asleep. The ADON stated his vitals were good and the NP ordered a third dose of [MEDICATION NAME] given at 3:30 p.m., Resident #6 still not responding and a fourth dose of [MEDICATION NAME] was given. According to the ADON, Resident #6 was not responding so EMS was called, and Resident #6 was still unresponsive when EMS arrived. In an interview on 1/15/16 at 3:38 p.m. the DON stated she was in a room with another resident when then incident occurred with Resident #6 at approximately 10:30 a.m. on 1/13/16. The DON stated she was told by the ADON, NP and charge nurse what happened. The DON stated LVN C and the ADON went to tell Resident #6 what happened, he stated he was fine and decided to go outside and smoke a cigarette. The DON stated after resident had a cigarette he went to his room to watch television. The DON stated Resident #6 did not have any adverse actions at that time and staff was to monitor him closely. The DON stated at around 1:38 p.m. Resident #6 was given a first dose of [MEDICATION NAME] and at that time Resident #6 was not left alone up until he was sent to the ER. The DON stated at around 2:00 p.m. Resident #6 was given a second dose of [MEDICATION NAME], at that point, it was decided Resident #6 should go to the ER, but he refused. Resident #6 was given two doses of [MEDICATION NAME] IV, and when he was unresponsive at approximately 3:30/4:00 p.m. it was decided to send Resident #6 to the ER. In an interview on 1/15/16 at 3:50 p.m. the Administrator stated she was contacted by the DON and told there was a medication error, and that MA A had given Resident #6 the wrong medications. The Administrator stated she wasn ' t sure if Resident #6 was unresponsive at that time, because she was not in the building when incident occurred. The Administrator stated when she was told about the incident she called the RVP. During an interview on 1/15/2016 at 4:00 p.m., the NP stated she was at the facility seeing residents on 1/13/2016 and around 10:00 to 10:30 a.m., she was informed of Resident #6 receiving one 30 mg [MEDICATION NAME] and two 10/325 [MEDICATION NAME] tablets which were not prescribed for Resident #6. The NP examined Resident #6 around 10:45 a.m. At that time, Resident #6 was sitting up in a wheelchair with stable vital signs and was in no distress. The NP stated, He began to decline around 3:30. The NP stated she ordered 0.2 mg [MEDICATION NAME]. At that point during the interview, NP stated, I feel like I should not answer any more questions. I dropped off my notes at the facility this morning. The surveyor asked the NP if she spoke to the physician throughout the day of the incident. The NP responded, No. I don't need to. The NP stated she spoke to the physician after the resident was admitted to the hospital. In an interview on 1/15/16 at 4:45 p.m. the MD stated he was contacted by the NP and told about the incident that occurred with Resident #6. The MD stated the NP did the correct procedures by administering Resident #6 the [MEDICATION NAME] and then waiting to see Resident #6 ' s response to the medication, by monitoring his vitals closely. The MD stated if a resident/patient refuses to go to the ER and that resident is A&OX3, their wishes must be honored. The MD further stated once that resident/patient is not capable of making that decision (ex: due to effects of medication) then the facility staff can determine that decision and send the resident to the ER. The MD stated this incident was an unfortunate mistake, but does believe the staff responded to the incident in an appropriate manner. A review of the ER nursing notes dated 01/13/2016, at 5:20 p.m., reflected Resident #6 arrived via stretcher with EMS. The nurses notes further reflected that per the EMS report the resident received 2, 10/325 [MEDICATION NAME] (2 tablets, each with 10 mg [MEDICATION NAME] and 325 mg Tylenol) and 30 mg [MEDICATION NAME] at approximately 10:00 a.m. by mistake. Per the notation, the last known normal (level of consciousness) was 1:30 p.m. this afternoon. The nursing facility gave a total of 0.8 mg of [MEDICATION NAME] (an antidote for opioid narcotics). While en route the resident was hypotensive (low blood pressure), received 2 mg [MEDICATION NAME] and 100 cc NS (Normal Saline), O2 4L by nasal cannula, SPO2 94% (amount of [MEDICATION NAME] blood). Upon arrival to the ER, the resident remained nonresponsive, pupils pinpoint and has no gag reflex. A review of the ER physician's notes dated 01/13/16 at 5:45 p.m. reflected the following: Resident #6 presents with Drug Overdose, Hypercapnic (high carbon [MEDICATION NAME]) [MEDICAL CONDITION]. Resident #6 presented to the ER for Altered Mental Status. Upon arrival to the ER, the resident was unresponsive with shallow respirations. The initial Glascow Coma Score was 3 (a person with no deficits would have a score of 15). Given 0.4 mg [MEDICATION NAME] on arrival to ER with some improvement in mental status, but lasted less than one minute and was again unresponsive. The resident received an additional 4 doses of 0.4 mg [MEDICATION NAME] and was then put on a [MEDICATION NAME] drip (continuous IV infusion). Initial venous blood gases showed pCO2 69 (normal venous carbon [MEDICATION NAME] level is 38-52) and pH 7.23 (normal venous pH is 7.32-7.42; pH 7.23 is profound acidosis). Repeat venous blood gases 30 minutes later showed pH 7.17 and PCO2 76 (resident status worsening). Decision to intubate made at that time. Successful intubation in the ER. [MEDICATION NAME] drip stopped. Started IV [MEDICATION NAME] and Versed for sedation. admitted to the MICU. An observation on 01/15/2016 at 12:50 p.m. revealed Resident #6 in the MICU at a local hospital. Resident #6 was lying in bed, unconscious, unresponsive, had a right internal jugular venous catheter and was connected to mechanical ventilation via an endotracheal tube. During an interview on 01/15/216 at 12:50 p.m., the MICU nurse, stated Resident #6 was transferred to MICU from theER on [DATE] after receiving another resident's medication at the nursing facility. It was determined this failure placed Resident #6 in an IJ situation form 1/13/16 - 1/14/16. The facility ' s Administrator was notified on 1/15/16 at 5:35 p.m. The facility took the following action to correct the non-compliance on 1/13/16: Review of MA A ' s personnel file reflected MA A was suspended pending investigation. Review of in-services on 1/13/16 revealed staff attendance for the 8 rights to medication pass: 1. Right Client 2. Right Medication 3. Right Dose 4. Right Time 5. Right route 6. Right documentation 7. Right reason 8. Right response Review of an inservice on 1/14/16 revealed staff attendance for how to walk away from unneccessary interruptions during medicaitons pass. Review of inservices reflected the manager to help redirect if noticed unnecessary interruption to medication aide during med pass. The DON and ADON will conduct med pass audits for next 120 days. New Certified Medication Aides will conduct on the job training for 10 days and will not be on the cart alone until after on the job training and approval by DON/ADON. The surveyors observed two med pass and two demonstrations of the correct way to pass meds using the new 8 rights of med pass procedures. It was confirmed the facility now has procedures in place to address giving the right medication to the right resident. In an interview on 1/15/16 at 12:55 p.m. MA D was able to demonstrate the eight rights of medication pass. MA D stated she was not at work the day Resident #6 was administered the wrong medication. MA D also stated if a resident is given the wrong medication it is to be reported to the charge nurse immediately. In an interview on 1/15/16 at 1:00 p.m. MA E was able to demonstrate the eight rights of medication pass. MA E also stated if a resident is given the wrong medication it is to be reported the charge nurse immediately. In an interview on 1/15/16 at 1:10 p.m. CNA F stated she was working on 1/13/16 and remembers Resident #6 being fine that morning. CNA F also stated she noticed Resident #6 breathing harder than usual at approximately 1:00 p.m., and reported it to the charge nurse. Review of the facility ' s resident roster reflected 13 residents residing on 400 Hall.

Based on interview and record review the facility failed to implement policies and procedures that prohibit neglect for one of six residents reviewed for medication administration (Resident #6). On 1/13/16, MA A administered 30 ml of [MEDICATION NAME] (opioid pain medication) and two tablets of 10/325 [MEDICATION NAME] (combination of [MEDICATION NAME] and [MEDICATION NAME] is an opioid pain medication) to Resident #6, which was ordered for another resident. The administration of this medication resulted in Resident #6 becoming unresponsive and being transferred to a local hospital. The resident was diagnosed with [REDACTED]. This was determined to be past non-compliance at immediate jeopardy level from 1/13/16 until 1/14/16 due to the facility having implemented actions that corrected the non-compliance prior to the beginning of the survey. This failure could place all 13 residents residing on 400 Hall receiving prescribed medications at risk of injury or death due to administration of wrong medications. Findings include: Review of Resident #6 ' s face sheet reflected Resident #6 ' s date of birth as 11/12/1959 and an admission date of [DATE] with the following Diagnoses: [REDACTED]. Review of Resident #6 ' s MDS dated [DATE] and 10/7/15 reflected a BIMS as 15, cognitively intact mental state. The MDS also reflected no prescribe order of medications for [MEDICATION NAME] or [MEDICATION NAME]. Review of the Provider Self Reporting of Incidents, SR16- 4 dated 1/14/16 reflected a hand written statement by MA A of the incident: I was passing out medications on 400 hall and got to the end of the hall where there was a lot going on. While getting medications ready, I had people needing to get by so I would have to move, due to all the things in the hall from them doing the floor in a room. I had a resident wanting me to look on the bed to find her remote the resident thought she lost. As I got down to the last room, the resident in there was saying pill lady over and over again and Resident #6 was behind me wanting his medications all at once. Before I realized what she had done, I gave Resident #6 another resident ' s medications. When I went to give another resident their medications, I realized I had already signed the pain medication out and that it was given to Resident #6. I immediately went and told the charge what happened Review of Resident ' s #6 nurse ' s notes dated 1/13/16 at 10:30 a.m. reflected MA A informed charge nurse Resident #6 received 30 mg of [MEDICATION NAME] and two tablets of [MEDICATION NAME] 10-325 mg. MA A stated the incident had just occurred. The ADON and the DON and the NP were notified immediately. The emergency kit was checked for [MEDICATION NAME] (a medication used to reverse the effects of opioids, especially in overdose) to be in-house. Resident #6 to monitored closely. During a phone interview on 1/15/16 at 2:30 p.m. MA A stated she did give Resident #6 the wrong medications. MA A stated on the 1/13/16 there was a lot of commotion on 400 Hall where she was administering medications. MA A stated Housekeeping was deep cleaning a room at the end of the hall, and furniture was in the hallway. MA A stated she was at the end of the hall giving meds when she heard one resident yelling for someone to get her remote control, another resident yelling pill lady, I want my medications and Resident #6 propelling his wheelchair behind her stating he needed his medications. MA A further stated the hallway was crowded, she was being asked to move with the medicine cart, she stated there was a lot going on that morning. MA A stated she realized she gave Resident #6 the wrong medications when she was going to administer another resident ' s medication and saw she had already initialed her signature as medication given on the resident ' s MAR. MA A stated she realized then she had given Resident #6 the wrong medication. MA A stated she immediately reported it to the first nurse she saw, which was LVN C. Review of Resident #6's consolidated physician orders and MAR indicated [REDACTED] [MEDICATION NAME] Sodium 100 mg tablet BID [MEDICATION NAME] 80 mg tab BID Aspirin EC 81 mg QD Folic Acid 400 mcg tab QD MVT with minerals t tab QD [MEDICATION NAME] 20 mg tab QD [MEDICATION NAME] powder 17 gm QD [MEDICATION NAME] 80 mg tablet 2 tabs Q AM [MEDICATION NAME] 800 mg tablet 3 tabs TID Phoslo 667 mg gelcap TID [MEDICATION NAME] 20 mg tablet Q HS [MEDICATION NAME] 12.5 mg tablet BID Further review of Resident #6 ' s consolidated physician order and MAR indicated [REDACTED]. Review of Resident #6 ' s nurse ' s note dated 1/13/16 reflected the following: 11:00 a.m., LVN B was notified that Resident #6 received [MEDICATION NAME] 30 mg and [MEDICATION NAME] 10/325 mg two tablets by mouth. During assessment Resident #6 was alert and oriented to person, place and time (A&OX3). Resident #6 denies any pain or discomfort. Resident #6 was sitting in a wheelchair beside his bed, with no respiratory distress noted. Resident #6 has oxygen at three liters per with nasal cannula (O2 @3L/Per NC). The NP is here and is aware of Resident #6 ' s condition. Staff will continue to monitor. 11:15 a.m., during assessment Resident #6 is noted to be sitting on the side of his bed holding a trash can. Resident #6 stated I should not have eaten. Resident #6 was given four ounces of sprite and Resident #6 tolerated it well. Resident #6 denied any pain or discomfort, was alert and oriented to person, place and time, and call light within reach. Staff will continue to monitor. 11:30 a.m., Resident #6 noted to be vomiting a clear liquid into trash can while sitting on side of his bed. Resident #6 remains alert and oriented to person, place and time (no respiratory distress noted, blood pressure (BP) stable, vital signs (VS) 113/59, 93, 18, 97.8, oxygen 93%, O2@3L per NC. 11:50 a.m., Resident #6 noted having respiratory status of 16, oxygen stats is 91%. The NP stated to monitor Resident #6 closely and to obtain his VS. The ADON, DON and the NP are at Resident #6 ' s bedside. Resident #6 is slow to respond but still alert. The staff is to begin every five minute blood pressure checks. 12:30 p.m., Resident #6 noted to be in bed resting with eyes closed, but easily aroused. Resident #6 responded to verbal questions, slurred speech, VS were 137/72, 93% on room air, 88. The NP is in on rounds and updated to monitor resident. 1:30 p.m., Resident #6 noted to be unresponsive, RR even and unlabored, VS 110/54, 83, 18, 90% on 4 liters per nasal cannula. Resident #6 was placed on non rebreather. The NP, DON, ADON and RT at Resident #6 ' s bedside. New orders received for IM [MEDICATION NAME] (an opioid antagonist), VS stable, heart rate (HR) in the 80 ' s and BP ranging from upper SP 90 ' s-100s and DP in the 50s and 60s. VS are taken every 5 minutes X 30 minutes. Resident #6 received two doses of [MEDICATION NAME] IM, first dose was given at 1:38 p.m. and the 2nd dose was given at 2:05 p.m. Resident #6 responded to second dose of [MEDICATION NAME], he became aroused, was able to communicate verbally, his speech was slurred. Resident stated he felt tired, staff offered to call EMS to take Resident #6 to the local hospital ER, Resident #6 refused to go the ER. Resident #6 requested assistance to get out of bed and into his wheelchair. Resident #6 was able to transfer hiss self with stand by assist to his wheelchair. Resident #6 became nauseated and had an episode of dry heaving with no emesis noted. Resident #6 was taken to the nurses' station where resident requested some coffee and food. Resident #6 was given one cup of coffee and one cup of water. A new order was received for [MEDICATION NAME] to be given to Resident #6. In an interview on 1/15/16 at 2:30 p.m. LVN B stated the incident with Resident #6 started happening between the hours of 11:00 a.m. though 2:00 p.m. LVN B stated LVN C told her Resident #6 was given the wrong medication. LVN B stated at that time Resident #6 was assessed, he was A&OX3, he was sitting up in his wheelchair, he appeared to be okay, resident stated he was fine, his breathing sounds were good, O2 saturations was good. LVN B stated everything appeared to be fine with Resident #6. LVN B further stated Resident #6 was assessed by the DON, ADON and the NP. LVN B stated no medications were issued to Resident #6 at that time because he appeared to be doing fine. LVN B stated she remembers Resident #6 ' s first dosage of [MEDICATION NAME] being given approximately around 12:00 p.m. to 1:00 p.m. LVN B also stated there was commotion on the 400 hall because they were renovating a room and stripping floors, she further stated the police also was present during the disruption (related to a separate issue). Review of Resident #6 ' s nurse ' s note dated 1/13/16 reflected the following: 2:30 p.m., Resident #6 was at the nurse ' s station talking with staff, eyes were opened, speech slurred, RR even and unlabored, 96% on 4 liters per nasal cannula, RR 18. 3:00 p.m., Resident #6 noted to be in his wheelchair resting eyes closed, when resident was aroused, he did not respond, Resident #6 was taken back to his room. Resident #6 was administered two doses of intravenous (IV) [MEDICATION NAME] at 22 grams into the left forearm by the DON. The first dose was at 3:33 p.m. and the second dose was given at 4:03 p.m. The IV [MEDICATION NAME] was ordered by the NP. Resident #6 did not respond, VS stable throughout administration, BP 96/54, 84, 18, 96% 4 liters per nasal cannula. VS were taken every 5 minutes X one hour with a nurse at bedside with resident at all times. Plan of care was coordinated, a new order received to transfer Resident #6 to the local hospital ER. The EMS was called at 4:40 p.m. Resident #6 ' s point of contact was called twice, there was no answer, and a message was left on both calls. Resident #6 was transferred to the local hospital at 5:00 p.m. In an interview on 1/15/16 at 3:30 p.m. the ADON stated on 1/15/16 she saw MA A walking down the hallway and she looked awful. The ADON state she asked MA A what was wrong and MA A told her she had given the wrong medications to Resident #6. The ADON stated she saw the NP and LVN C talking and the NP ordered for Resident #6 to monitor closely. The ADON further stated the NP and LVN C told Resident #6 what had happened, Resident #6 state he felt fine and went outside to have a cigarette. The ADON stated when Resident #6 came back in from smoking, he had an episode of vomiting, so he went to his room and laid down. The ADON stated she remember LVN C getting Resident #6 a sprite. The ADON stated she didn ' t hear anything else until about 1:30 p.m., she went to Resident #6 s room and he was not responding. The ADON state LVN C took resident ' s vitals and they were stable, Resident #6 was aroused with physical stimuli rubs to his chest. At that time, Resident #6 stated he was fine and just needed some sleep. The ADON stated the NP ordered Resident #6 be given a IM of [MEDICATION NAME] at approximately 1:30 p.m. After the dosage was given, the resident was not responding. The ADON stated Resident #6 was given a second dose of [MEDICATION NAME], and the resident was still not responding. The ADON stated she, the DON, and LVN C stayed in the room with Resident #6 and the NP was in and out until it was decided the resident would go to the ER. The ADON stated Resident #6 was told they wanted to send him to the ER, Resident #6 refused to go. The ADON stated the NP stated Resident #6 could get up in his wheelchair if he doesn ' t want to go to the ER, but monitor him closely. The ADON stated when Resident #6 had another episode of vomiting, he was given [MEDICATION NAME] (anti-nausea medication). The ADON stated Resident #6 had gone to the nurses station and fell asleep. The ADON stated his vitals were good and the NP ordered a third dose of [MEDICATION NAME] given at 3:30 p.m., Resident #6 still not responding and a fourth dose of [MEDICATION NAME] was given. According to the ADON, Resident #6 was not responding so EMS was called, and Resident #6 was still unresponsive when EMS arrived. In an interview on 1/15/16 at 3:38 p.m. the DON stated she was in a room with another resident when then incident occurred with Resident #6 at approximately 10:30 a.m. on 1/13/16. The DON stated she was told by the ADON, NP and charge nurse what happened. The DON stated LVN C and the ADON went to tell Resident #6 what happened, he stated he was fine and decided to go outside and smoke a cigarette. The DON stated after resident had a cigarette he went to his room to watch television. The DON stated Resident #6 did not have any adverse actions at that time and staff was to monitor him closely. The DON stated at around 1:38 p.m. Resident #6 was given a first dose of [MEDICATION NAME] and at that time Resident #6 was not left alone up until he was sent to the ER. The DON stated at around 2:00 p.m. Resident #6 was given a second dose of [MEDICATION NAME], at that point, it was decided Resident #6 should go to the ER, but he refused. Resident #6 was given two doses of [MEDICATION NAME] IV, and when he was unresponsive at approximately 3:30/4:00 p.m. it was decided to send Resident #6 to the ER. In an interview on 1/15/16 at 3:50 p.m. the Administrator stated she was contacted by the DON and told there was a medication error, and that MA A had given Resident #6 the wrong medications. The Administrator stated she wasn ' t sure if Resident #6 was unresponsive at that time, because she was not in the building when incident occurred. The Administrator stated when she was told about the incident she called the RVP. During an interview on 1/15/2016 at 4:00 p.m., the NP stated she was at the facility seeing residents on 1/13/2016 and around 10:00 to 10:30 a.m., she was informed of Resident #6 receiving one 30 mg [MEDICATION NAME] and two 10/325 [MEDICATION NAME] tablets which were not prescribed for Resident #6. The NP examined Resident #6 around 10:45 a.m. At that time, Resident #6 was sitting up in a wheelchair with stable vital signs and was in no distress. The NP stated, He began to decline around 3:30. The NP stated she ordered 0.2 mg [MEDICATION NAME]. At that point during the interview, NP stated, I feel like I should not answer any more questions. I dropped off my notes at the facility this morning. The surveyor asked the NP if she spoke to the physician throughout the day of the incident. The NP responded, No. I don't need to. The NP stated she spoke to the physician after the resident was admitted to the hospital. In an interview on 1/15/16 at 4:45 p.m. the MD stated he was contacted by the NP and told about the incident that occurred with Resident #6. The MD stated the NP did the correct procedures by administering Resident #6 the [MEDICATION NAME] and then waiting to see Resident #6 ' s response to the medication, by monitoring his vitals closely. The MD stated if a resident/patient refuses to go to the ER and that resident is A&OX3, their wishes must be honored. The MD further stated once that resident/patient is not capable of making that decision (ex: due to effects of medication) then the facility staff can determine that decision and send the resident to the ER. The MD stated this incident was an unfortunate mistake, but does believe the staff responded to the incident in an appropriate manner. A review of the ER nursing notes dated 01/13/2016, at 5:20 p.m., reflected Resident #6 arrived via stretcher with EMS. The nurses notes further reflected that per the EMS report the resident received 2, 10/325 [MEDICATION NAME] (2 tablets, each with 10 mg [MEDICATION NAME] and 325 mg Tylenol) and 30 mg [MEDICATION NAME] at approximately 10:00 a.m. by mistake. Per the notation, the last known normal (level of consciousness) was 1:30 p.m. this afternoon. The nursing facility gave a total of 0.8 mg of [MEDICATION NAME] (an antidote for opioid narcotics). While en route the resident was hypotensive (low blood pressure), received 2 mg [MEDICATION NAME] and 100 cc NS (Normal Saline), O2 4L by nasal cannula, SPO2 94% (amount of [MEDICATION NAME] blood). Upon arrival to the ER, the resident remained nonresponsive, pupils pinpoint and has no gag reflex. A review of the ER physician's notes dated 01/13/16 at 5:45 p.m. reflected the following: Resident #6 presents with Drug Overdose, Hypercapnic (high carbon [MEDICATION NAME]) [MEDICAL CONDITION]. Resident #6 presented to the ER for Altered Mental Status. Upon arrival to the ER, the resident was unresponsive with shallow respirations. The initial Glascow Coma Score was 3 (a person with no deficits would have a score of 15). Given 0.4 mg [MEDICATION NAME] on arrival to ER with some improvement in mental status, but lasted less than one minute and was again unresponsive. The resident received an additional 4 doses of 0.4 mg [MEDICATION NAME] and was then put on a [MEDICATION NAME] drip (continuous IV infusion). Initial venous blood gases showed pCO2 69 (normal venous carbon [MEDICATION NAME] level is 38-52) and pH 7.23 (normal venous pH is 7.32-7.42; pH 7.23 is profound acidosis). Repeat venous blood gases 30 minutes later showed pH 7.17 and PCO2 76 (resident status worsening). Decision to intubate made at that time. Successful intubation in the ER. [MEDICATION NAME] drip stopped. Started IV [MEDICATION NAME] and Versed for sedation. admitted to the MICU. An observation on 01/15/2016 at 12:50 p.m. revealed Resident #6 in the MICU at a local hospital. Resident #6 was lying in bed, unconscious, unresponsive, had a right internal jugular venous catheter and was connected to mechanical ventilation via an endotracheal tube. During an interview on 01/15/216 at 12:50 p.m., the MICU nurse, stated Resident #6 was transferred to MICU from theER on [DATE] after receiving another resident's medication at the nursing facility. Review of the facility policy and procedure titled Abuse and Neglect Prohibition undated reflected the following: Our residents have the right to be free from abuse, neglect, misappropriation of resident property, corporal punishment and involuntary seclusion. Residents must not be subjected to abuse by anyone, including but not limited to facility staff, other residents, consultants or volunteer, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals Types of Abuse: Definition of Neglect is the failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. Review of the facility ' s policy and procedure titled Medication Administration revised dated 6/1/13 reflected the following: Policy: Mediations are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. Personnel authorized to administer medications do so only after they have been properly oriented to the medication management system in the facility. The facility has sufficient staff and a medication distribution system to ensure administration of medications without unnecessary interruptions. Procedure: D. Five Rights-Right resident, right drug, right dose, right route, and right time are applied for each medication being administered. A triple check of these 5 Rights is recommended at three steps in the process of preparation of a medication for administration: (1) when the medication is selected, (2) when the dose is removed from the container, and finally (3) just after the dose is prepared and the medication put away. a. Check #1: Select Medication - label, container and contents are checked for integrity, and compared against the Medication Administration Record [REDACTED] b. Check #2: Prepare the dose - the dose is removed from the container and verified against the label and the MAR by reviewing the 5 Rights. c. Check #3: Complete the preparation of the dose and re-verify the label against the MAR by reviewing the 5 Rights. It was determined this failure placed Resident #6 in an IJ situation form 1/13/16 - 1/14/16. The facility ' s Administrator was notified on 1/15/16 at 5:35 p.m. The facility took the following action to correct the non-compliance on 1/13/16: Review of MA A ' s personnel file reflected MA A was suspended pending investigation. Review of in-services on 1/13/16 revealed staff attendance for the 8 rights to medication pass: 1. Right Client 2. Right Medication 3. Right Dose 4. Right Time 5. Right route 6. Right documentation 7. Right reason 8. Right response Review of an inservice on 1/14/16 revealed staff attendance for how to walk away from unneccessary interruptions during medicaitons pass. Review of inservices reflected the manager to help redirect if noticed unnecessary interruption to medication aide during med pass. The DON and ADON will conduct med pass audits for next 120 days. New Certified Medication Aides will conduct on the job training for 10 days and will not be on the cart alone until after on the job training and approval by DON/ADON. The surveyors observed two med pass and two demonstrations of the correct way to pass meds using the new 8 rights of med pass procedures. It was confirmed the facility now has procedures in place to address giving the right medication to the right resident. In an interview on 1/15/16 at 12:55 p.m. MA D was able to demonstrate the eight rights of medication pass. MA D stated she was not at work the day Resident #6 was administered the wrong medication. MA D also stated if a resident is given the wrong medication it is to be reported to the charge nurse immediately. In an interview on 1/15/16 at 1:00 p.m. MA E was able to demonstrate the eight rights of medication pass. MA E also stated if a resident is given the wrong medication it is to be reported the charge nurse immediately. In an interview on 1/15/16 at 1:10 p.m. CNA F stated she was working on 1/13/16 and remembers Resident #6 being fine that morning. CNA F also stated she noticed Resident #6 breathing harder than usual at approximately 1:00 p.m., and reported it to the charge nurse. Review of the facility ' s resident roster reflected 13 residents residing on 400 Hall.