Every finding on record at Breezy Hills Rehab and Care Center

Based on observations and interviews, the facility did not follow professional standards for food service safety related to sanitary practices in one of one facility kitchens. Findings included: On 5/5/25 at 9:35 a.m., an initial tour of the kitchen was conducted with the Dietary Manager. An observation of the low temperature dish machine was in use by Staff A, Dietary Aide. An observation of Staff A, Dietary Aide revealed she was wearing gloves and putting soiled items with food debris in the machine. She conducted the testing of the sanitizing solution using the same gloves she had on while putting soiled items to be washed. She used two testing strips and one of them fell in the water of the dish machine, while the other was placed on a clean insulated lid. Staff A, Dietary Aide was not observed removing the testing strip from the insulated lid and the lid was not put back to be cleaned. On 5/5/25 at 9:42 a.m., an observation of the reach-in cooler revealed a brown plastic bag on one of the racks labeled [staff member name]. Observations of the brown plastic bag revealed there were clear, plastic water bottles inside. Further observations of the reach-in cooler revealed a Styrofoam cup, with a lid, next to the plastic bag. The Dietary Manager confirmed it was a staff member's personal items and proceeded to remove them. On 5/5/25 at 10:02 a.m., an observation of the ice machine revealed the ice chute cover had streaks of black residue towards the top of it. Further observation of the ice chute cover revealed the bottom ledge had the same black residue across it. Observations of the inside of the ice scoop holder revealed build-up of a white substance, as well as light brown bio growth/residue. The Dietary Manager said she thinks the maintenance staff cleans the ice machine and is not sure if cleaning the inside falls under the kitchen responsibilities. She said she would confirm with the District Manager. On 5/7/25 at 11:17 a.m., a follow-up tour revealed Staff C, Certified Nursing Assistant (CNA) and the Assistant Director of Nursing (ADON) were observed in the kitchen with no hair restraints. On 5/7/25 at 4:17 p.m., an observation of Staff L, [NAME] completing the hot holding dinner temperatures revealed a stryofoam cup with a brown liquid, with no lid, was on the table next to the steam table. The cup contained a staff member's beverage. On 5/7/25 at 4:48 p.m., interviews were conducted with the dietary manager and District Manager. The Dietary Manager said personal items are supposed to be stored in the breakroom refrigerator, in her office, or there are lockers where staff can store their belongings. The Dietary Manager stated the ice machine gets a deep clean quarterly by the service provider. The District Manager said general maintenance of the ice machine, as well as cleaning, falls under the maintenance staff. He said he thinks the daily cleaning should be under the kitchen's responsibility, however, it could also be nursing or maintenance. He said they need to confirm if the ice machine falls under the responsibility of maintenance. Regarding the observation of the dish machine on 5/5/25, the Dietary Manager confirmed Staff A, Dietary Aide was handling soiled dishes, operating the dish machine, and transferring clean items without changing gloves. She said the testing strip that was observed in the water is, going to be flushed down and would not contaminate the water. On 5/8/25 at 1:19 p.m., a follow-up interview was conducted with the Dietary Manager and District Manager. They said the kitchen staff are responsible for cleaning the outside of the ice machine as well as the scoop and scoop holder. The District Manager said the maintenance staff is responsible for cleaning the ice chute cover. A review of the facility's policy titled Dish Machine Best Practices Guidelines, revealed the following, Placing a sanitization test strip directly on a plate that has just come out of the dish machine, which his considered a sanitized surface, could be viewed as a foreign object. Further review of the policy revealed the following: - Hygiene: The plate is intended to be clean and sanitized, and the test strip, even if used to check the sanitizer, could introduce contaminants back onto the plate if it isn't handled properly. - Unintentional handling: If the strip is left on the plate and is inadvertently moved or touched, it could contaminate other surfaces or food if not properly disposed of. - Proper Procedure: Sanitization test strips are usually designed to be dipped into the sanitizer solution or placed in contact with a surface being tested, such as a warewashing rack, but they shouldn't be left on clean, sanitized surfaces. - Best Practices: Proper Disposal After using the test strip, it should be properly disposed of, not left on a clean plate or surface. A review of the facility's policy titled Outside Food Storage Standard Operating Procedures, revealed the following, Storing food in Dietary coolers by employees, especially without proper labeling, date marking, or temperature control, is a violation of food safety regulations and can pose a risk to residents. Further review of the policy revealed the following, Proper Storage: Food brought into the facility should be stored in designated areas, such as personal refrigerators or community refrigerators, with appropriate labeling and temperature control. A review of the facility's policy titled Ice, revealed the following under policy statement, Ice will be prepared and distributed in a safe and sanitary manner. Further review of the policy under procedures revealed the following: - 3. The exterior of the ice machine will be cleaned weekly. - 4. Ice bins will be cleaned monthly and as needed. - 5. Ice scoops will be cleaned and stored in a separate container that limits expose to dust and moisture retention. (Photographic evidence obtained).

2. Review of Resident #68's Level I PASARR dated 3/19/25, showed the resident had diagnoses of anxiety disorder, bipolar disorder, depressive disorder, and mood disorder. The level I PASARR showed the resident did not have validating documentation to support dementia or a related neurocognitive disorder. The review showed Resident #68 had no diagnosis or suspicion of Serious Mental Illness or Intellectual Disability and a Level II PASARR evaluation was not submitted for consideration. Review of Resident #68s admission Record revealed the resident was admitted on [DATE] and 9/2/24. The record included the following diagnoses with onset dates: moderate recurrent major depressive disorder (onset 6/14/24), other bipolar disorder (onset 9/2/24), generalized anxiety disorder (onset 9/2/24), and mood disorder due to known physiological condition with depressive features (onset 6/14/24). Review of Resident #68s quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident received antianxiety and antidepressant medications. Review of Resident #68s psychology providers note, dated 4/28/25 revealed the resident was being seen to follow up after a recent medication change. The note showed the patient had been recently depressed wth some changes in mood but had been under treatment for infections. The resident presented with no change from baseline. Resident is still not at our treatment goals and is being treated for some mood disorders. The assessment showed the resident was not currently responding to therapy and medication combination and the resident's diagnoses of anxiety, depression, and bipolar disorders were unstable. The diagnoses listed included dementia with behavioral disturbances and insomnia. The psychiatric medication instructed to continue Buspar and lorazepam was adjusted to 0.5 mg (milligram) three times a day, continue trazodone for major depressive disorder, discontinue Zonegran, taper Depakote for 7 days, and start Lithium 300 mg twice daily for mood instability. Review of the Psychotherapy note dated 5/7/25, revealed Resident #68 presents with depressed mood, sad affect, reporting interpersonal conflict, negative self-esteem, reduced self-confidence, (and) loss of interest and enjoyment. During an interview on 5/8/25 at 10:48 a.m. the Social Service Director (SSD) stated the resident would trigger for a Level II PASARR with a dementia diagnosis and bipolar diagnoses. Based on interview and record review the facility failed to submit Pre-admission Screening and Annual Resident Review (PASARR) Level II screenings for three (#42, #68, and #42) out of seven residents sampled. Findings Included: 1. Review of Resident #42's admission record revealed an admission date of 11/14/24 with diagnoses to include Major Depressive Disorder, Recurrent, Unspecified, Bipolar Disorder, Unspecified, Anxiety Disorder, and Unspecified, Post-Traumatic Stress Disorder (PTSD). Review of a level I PASARR for Resdient #42 dated 11/15/2024 revealed, Section IV. PASARR Screen Completion: No diagnosis or suspicion of Serious Mental illness or intellectual disability indicated. A level II PASRR evaluation was marked as not required. Review of Resident #42 's medical record revealed Resident #42 was not assessed for PASARR Level II and a recommendation was not submitted. 3. A review of Resident #2's admission record revealed an initial admission date of 4/9/13 and a re-admission date of 9/9/24 with diagnoses to include unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, unspecified mood affective disorder, and disorganized schizophrenia. A review of Resident #2's physician orders revealed orders for divalproex sodium capsule delayed release sprinkle 125 mg (milligrams) give 2 tablet by mouth three times a day related to unspecified mood affective disorder and Risperidone tablet 0.5 mg give 1 tablet by mouth one time a day related to disorganized Schizophrenia. A review of a quarterly note for Resident #2's progress notes, dated 3/14/25 revealed Resident #2 was alert with confusion and forgetfulness he is sometimes understood and sometimes understands staff to anticipate his needs his mental function varies. He has episodes of being verbally aggressive with staff, spitting, cursing and resisting and refusing treatment/care, Shaving, nailcare and medications at times. He hollers staff names for assistance rather than use his call light. He is followed by psych [psychiatry] for Mood disorder, Schizophrenia. we will continue to follow current plan of care. Review of a level I PASARR dated 1/19/2024 revealed the following was marked under section IV, PASARR screen completion: No diagnosis or suspicion of Serious Mental illness or Intellectual Disability indicated. The review showed a Level II PASARR evaluation was not required or submitted for consideration. On 5/8/25 at 10:26 a.m., an interview with the Social Services Director (SSD) was conducted. She said she reviews PASARRs for every resident that is admitted to the facility. She stated she makes sure the PASARR, diagnoses, and medications, All line up. The SSD said if a resident had any new medications then she made sure the new diagnosis was added. She stated, I make sure it's captured on the PASSAR. The SSD sttaed she and the interdisciplinary team (IDT) reviewed Minimum Data Set (MDS) assessments for accuracy. The SSD said she inputs the correct information on the level I PASSAR and depending on what is marked, they get an immediate response to submit for a level II PASARR. The SSD stated if a level II isn't triggered and she suspected the resident might need one submitted, she would email the vendor. A review of the facility's policy titled Social Services - PASARR, dated 4/1/22, revealed the following: Purpose: The facility shall ensure each resident in a nursing facility is screened for a mental disorder (MD) or intellectual disability (ID) prior to admission and that individuals identified with MD or ID are evaluated and receive care and services in the most integrated setting appropriate to their needs by coordinating with the appropriate, State-designated authority. Definitions: An individual is considered to have a serious mental illness (MI) if the individual meets the following requirements on diagnosis, level of impairment and duration of illness: (i) Diagnosis. The individual has a major mental disorder diagnosable under the Diagnostic and Statistical Manual of Mental Disorders, 3rd edition, revised in 1987. This mental disorder is - A) A schizophrenic, mood, paranoid, panic, or severe anxiety disorder, somatformdisorder; personality disorder; other psychotic disorder; or another mental disorder that may lead to a chronic disability; (B) Not a primary diagnosis of dementia, including Alzheimer's disease or a related disorder, or a non-primary diagnosis of dementia unless the primary diagnosis is a major mental disorder as defined in paragraph (b)(1)(i)(A) of this section.

Based on observations, interviews and record review the facility did not ensure 1.) Continuous Positive Airway Pressure (CPAP) equipment and maintenance was provided for one resident (#12) out of one resident observed and 2.) Signage for oxygen use for five out of 17 rooms in one hallway ([NAME]) out of 4 hallways for four out of four days observed. Findings included: 1.) On 5/05/2025 at 9:19 a.m., an observation and interview were conducted with Resident #12 in her room. Resident #12 was observed with a nasal cannula with settings at three liters per minute administered through an oxygen concentrator. Resident #12 stated she requires CPAP at night but stated her mask currently leaks. Resident #12 stated her mask was very old and in need of a replacement but the facility was unable to provide the mask she likes and one which fits her face. Resident #12 stated she has been in the facility for quite some time and an exchange of her CPAP machine occurred by the facility but obtaining a new mask has not occurred. Resident #12 stated someone came to her room several months ago with a new mask to try but she did not like the fit and requested a replacement for her current mask of which she has not received. Resident #12 stated she thinks the individual who came into her room was the representative for the CPAP machine. On 5/05/2025 at 9:26 a.m., an observation was made of Resident #12's CPAP mask in which there were two to three pieces of clear tape at the bottom of her mask. The resident stated she got the tape from one of the nurses and had placed the tape over the hole to try to minimize the air leak. Resident #12 stated she has had this mask for a long time. Resident #12 allowed the surveyor to look through her supplies for equipment for her CPAP. Upon observation, no extra masks, tubing or filters for her CPAP machine were seen. An observation was made of two commercial sealed cups of sterile water in which the resident stated the nurses will pour the water into her CPAP machine at night. A record review of Resident #12 admission Record showed an original admit date of 10/09/2020, a readmission date of 02/02/2023 with the following diagnoses to include but not limited to, Chronic Obstructive Pulmonary Disease, Chronic respiratory failure, unspecified whether with hypoxia or hypercapnia, Heart failure, Morbid obesity and Chronic rhinitis. A record review of Resident #12's Minimum Data Set (MDS), dated [DATE], Category C-Cognitive Patterns, showed a Brief Interview for Mental Status (BIMS) of 15 indicating the resident was cognitively intact. On 5/06/2025 at 1:51 p.m., an interview was conducted with Staff M, Licensed Practical Nurse (LPN). Staff M. LPN stated the nursing staff is responsible for respiratory equipment every week on Sunday night shift but as far as managing the CPAP machine and supplies the responsibility would be the Respiratory Therapist. On 5/06/2025 at 2:07 p.m., an interview was conducted with Staff N, LPN/Unit Manager (UM). Staff N, LPN/UM stated the nurses are responsible for supplying nasal cannulas, humidifiers, and nebulizers and these supplies are exchanged out weekly, every Sunday by the night shift nursing staff. On 5/06/2025 at 3:17 p.m., an interview was conducted with Staff O, Admissions Coordinator. Staff O stated he would order CPAP machine and supplies for all the new admissions requiring CPAP. Staff O stated he knew of the Resident #12 requesting a new CPAP mask and stated he ordered a new mask several months ago as a trial. Staff O stated Staff P, Respiratory Director requested a new mask for Resident #12 and he simply went on the manufacturer's website to order a mask. Staff O stated he routinely does not order CPAP supplies for any of the long-term residents, only new admissions normally, unless a request is made. On 5/06/2025 at 3:17 p.m., a telephone interview was conducted with Staff P, Respiratory Director. Staff P stated the facility was currently in the process of attempting to fill a vacancy for a respiratory therapist but in the interim of interviews, he was acting as the respiratory therapist for this facility and three other facilities in the area. Staff P stated he is accessible 24/7 for any concerns. Staff P stated he knew of the situation for Resident #12 and stated the mask could possibly be overnighted tonight. Staff P stated he will reach out to the Nursing Home Administrator who has access to a credit card to order the needed CPAP supplies. Staff O stated he will be at the facility this week to maintenance her CPAP machine and fit with a new mask. On 5/06/2025 at 4:02 p.m., an interview was conducted with the Director of Nursing (DON). The DON stated the nursing staff are responsible for respiratory supplies and changing the equipment every Sunday during the night shift and as needed. The DON stated respiratory therapy are not in the building but are available by phone for emergency situations. The DON stated currently there are four residents with either CPAP or BiPAP (Bilevel Positive Airway Pressure). The DON stated respiratory therapy will manage these residents' supplies and maintenance. The DON could not state how often respiratory therapy would manage these residents. The DON stated the nursing staff should document the resident's CPAP settings in the medical record on a daily basis. The DON stated a mask was provided for Resident #12 in February. The DON stated she has reached out to Staff O, Admissions Coordinator, to order a mask for her. The DON stated a mask arrived but it was not the same mask the resident currently had. The DON stated the resident told me she was fine with the mask she currently had. The DON stated she placed a note in her medical record on 02/25/2025. On 5/06/2025 at 3:40 a.m., Staff O shared a text message from Staff P of two CPAP masks. The image to the left was the image of the mask he stated he purchased for the resident of which she did not like the fit in comparison to the image on the right which was her current mask. The text was dated 01/31/2025. A record review of Resident #12's medical record progress notes showed a progress note from respiratory therapy dated 02/12/2024: visited with patient, on three liters per minute without SOB( shortness of breath). Changed filter out to CPAP. Patient currently using CPAP-patient compliant. Patient doing well at this time . No further progress note entries were observed. On 5/07/2025 at 8:48 a.m., an interview was conducted with Resident #12 who stated the nursing staff came in last night and cleaned out the filter to my concentrator and CPAP machine. Resident #12 stated she did not know there was a filter in her concentrator and could not recall the last time her concentrator had been cleaned. On 5/07/2025 at 11:55 a.m., an interview was conducted with Staff O, Admissions Coordinator. Staff O stated he would order supplies for CPAP upon admission but as far as long- term residents he does not order supplies unless specifically requested. Staff O reviewed his emails and demonstrated his order placed for Resident 12's CPAP mask but could not find any email order receipts for CPAP tubing. On 5/07/2025 at 11:43 a.m., an interview was conducted with Staff Q, central supply in the main central supply room. Staff Q stated she does not have supplies for CPAP and does not order supplies. Staff Q stated the NHA or Staff O in admissions will order CPAP supplies. On 05/07/25 12:29 p.m., an interview was conducted with the NHA. The NHA stated respiratory therapy would be managing Resident #12's CPAP and the maintenance. The NHA stated she was aware the regional respiratory came in to see the resident a few months ago to assist with finding a mask but the resident was not willing to try a new mask. The NHA stated she was not responsible for ordering supplies but confirmed she ordered a new mask from [on-line shopping network] last night for Resident #12. A record review of Resident #12's current physician orders showed the following: - Clean mask daily every day shift for hygiene - Clean the unit and filter of CPAP machine weekly every night shift every Sunday for hygiene - Clean tubing weekly CPAP every night shift every Sunday for hygiene - Device and settings CPAP AUTO 4 to 20 centimeters of water evening and night shift - Empty water chamber and air dry every AM every day shift - Fill water chamber with distilled water every evening shift - Replace tubing and mask every three months every night shift every three months starting on the 28th for one day for hygiene - Respiratory therapy to evaluate. On 5/08/2025 at 9:58 a.m., an interview was conducted with Staff P, Respirator Director. Staff P stated Resident #12 was fitted today for her CPAP machine and she chose the medium size which was what she currently had. Staff P stated he will put on his calendar to see the resident once a month for her CPAP maintenance and supplies. Staff P stated an Inservice may be in order to the nursing staff for cleaning the CPAP machine, tubing and mask. On 5/08/2025 at 12:46 p.m., an interview was conducted with Staff N, LPN/UM. Staff N stated she was not familiar with how to set up a CPAP machine but would defer to her DON. On 5/08/2025 at 12:48 p.m., an interview was conducted with Staff D, LPN/UM. Staff D stated new admissions will normally come with a CPAP machine and pre-set for settings but if they received a new CPAP machine, she would not know how to set it up and would defer to the DON or the respiratory therapist. On 5/08/2025 at 1:29 p.m., an interview was conducted with the DON. The DON stated she knows how to set up CPAP settings once ordered from the physician. The DON stated she recognized an opportunity for education on CPAP management including setting up the parameters as well as cleaning the tubing, mask and filters was needed. 2.) An observation was made in [NAME] hallway of five rooms out of 17 rooms of residents utilizing oxygen therapy for four days out of four days during survey without oxygen signage posted. On 5/06/2025 at 1:51 p.m., an interview was conducted with Staff M, LPN who confirmed the residents in her assignment were currently receiving oxygen. Staff M stated rooms 201, 210, 214, 215 and 216 had residents with orders for oxygen and were currently on oxygen. An observation was made of no signage outside those room to indicate oxygen was in use. On 5/08/2025 at 3:53 p.m., an interview was conducted with the DON related to oxygen signage. The DON walked to the front of the building entrance to demonstrate a small sign stating, Oxygen in Use. The DON reviewed the facility's policy on oxygen use and stated there should be signs in front of each residents' room requiring oxygen. A review of the facility's policy and procedures titled, Nursing- CPAP/BiPAP Support effective date 04/01/2022 showed the following purpose statement: 1.To provide the spontaneously breathing resident with continuous positive airway pressure with or without supplemental oxygen. 2.To improve arterial oxygenation (PAO2) in residents with respiratory insufficiency, obstructive sleep apnea., or restrictive /obstructive lung disease 3.To promote resident comfort and safety. Preparation: 1.Only a qualified and properly trained nurse or respiratory therapist should administer oxygen through a CPAP mask. 2.Equipment and supplies: 1.NO SMOKING sign for the resident's room. 2.General Guidelines for Cleaning: 1.General guidelines for cleaning specific cleaning instructions are obtained from the manufacturer supplier of the CPAP device 4.Machine cleaning : wipe machine with warm soapy water and rinse at least once a week and as needed 5.Humidifier (if used): a.Use clean, distilled water only in the humidifier chamber b.Clean humidifier weekly and air dry c.To disinfect, place vinegar water solution 1:3 and clean humidifier. Soak for 30 minutes and rinse thoroughly. 6.Filter cleaning: a.Rinse washable filter under warm water once a week to remove dust and debris Replace this filter at least once a year. b.Replace disposable filters monthly.

Based on interviews, observations, and record reviews, the facility failed to honor the choice of one (#58) out of twenty-three sampled residents related to the preferred use of side rails for mobility and the feeling of safety and failed to assist one (#93) of one sampled resident with planning a discharge to another facility closer to family. Findings included: 1. During an interview on 5/5/25 at 10:59 a.m. Resident #58 reported wanting to have bedrails, getting scared when staff roll the resident over, was told it was a [regulating agency] thing not to have siderails. The resident reported they were told by someone at the facility the regulating agency did not allow side rails. The observation revealed the resident lying on a large-sized mattress and without side rails or enablers. Review of Resident #58's admission Record revealed the resident was admitted to the facility on [DATE]. The record showed diagnoses of malignant neoplasm of endometrium, unspecified type 2 diabetes mellitus with diabetic neuropathy, and unspecified macular degeneration. Review of Resident #58's Order Audit Report showed the resident had received an order dated 5/3/24 for bilateral ¼ rails for bed positioning and mobility 4/5/24. The report showed this order was discontinued on 3/13/25. Review of Resident #58's annual Minimum Data Set (MDS), dated [DATE], revealed the resident had a Brief Interview of Mental Status (BIMS) score of 14 of 15, indicating an intact cognition. Under mobility, the assessment showed no range of motion (ROM) of bilateral upper and lower extremities and required partial/moderate assistance with rolling left and right, sit to lying on bed, and from lying to sitting on side of bed. Review of Resident #58's care plan revealed Resident #58 has an Activities of Daily Living (ADL) self-care performance deficit related to (r/t) Endometrial cancer and was on hospice - 6/12/23. The resident is weak with impaired balance and mobility and required assistance with needs. Further decline is expected r/t disease process. Resident #58 is primarily bedbound by choice. The resolved interventions revealed an intervention initiated on 4/25/24 for SIDE RAILS: ¼ bilateral side rails for positioning/mobility. This intervention was resolved on 3/13/25. The interventions showed the resident received a Bariatric bed on 3/27/25. An interview was conducted on 5/7/25 at 2:39 p.m. with Staff D, Licensed Practical Nurse/Unit Manager (LPN/UM). The staff member said residents needed to assessed for side/bed rails by therapy. Staff D, LPN reported Resident #58 had a history quarter rails, was able to hold onto bed rail to assist with repositioning, was not able to pull self-up in the bed with the rails, and when staff rolled the resident over, the resident was able to hold on to bedrail to hold self the on side during care. Staff D, LPN reviewed the resident's record and stated for the side rails intervention on 3/13/25, therapy went through the facility and did evaluations to determine if the rails were helping with mobility or keeping independence. Staff D stated therapy discontinued the intervention. An interview was conducted on 5/7/25 at 2:50 p.m. with the Director of Rehabilitation (DOR). The DOR stated the resident was assessed for bed mobility, rolling and repositioning. The DOR stated they looked at different devices such as trapezes and said, If we fail at other interventions, we look into bedrails. The staff member reported therapy went through the facility and audited for other devices to decrease the use of bed rails for safety. The DOR stated they assess if a resident was able to transition to trapeze and bigger beds, and if a resident wanted side rails, therapy would pick them up. He stated if a resident wanted side rails to feel safe, they would try other devices first. The DOR stated Resident #58 was picked up by therapy from 2/26 to 3/26/25 and was working on rolling, bed mobility and that the resident was maximum assist and was not using side rails for bed mobility. The DOR defined bed mobility as grabbing the bar (rail) and rolling. He reported the resident was a substantial to max assist with rolling right to left and could grip and hold the rail but did not know for how long. Review of Resident #58s Physical Therapy Evaluation and Plan of Treatment revealed a certification period of 2/26 to 4/9/25. The resident's baseline on 2/26/25 for rolling towards both sides safely without use of side rails with assist of 1 caregiver to improve functional mobility revealed the resident required a maximum assist to roll towards right side and moderate assist to roll towards left side with use of side rail. The goals for patient and caregiver was to Improve bed mobility/positioning without use of side rails with a fair potential for achieving rehab goals. The reason for referral/current illness revealed the resident was referred to skilled therapy services to address bed mobility/positioning without use of side rails. The assessment summary showed the reason for therapy showed the resident was currently positioned in standard bed with an air mattress. Patient refused to trial trapeze bar to assist with bed mobility. A change in the assessment, dated 2/26/25 at 2:18 p.m. revealed the Patient refused to trial trapeze bar to assist with bed mobility. A treatment encounter note, dated 3/13/25 (the day side rails were discontinued), showed Patient stated she was afraid to perform rolling in bed due side rails being removed. Patient was encouraged and reassured (pronoun) is safe. Certified Nursing Assistant (CNA) educated on performing patient care with another person to assist with bed mobility has patient is a max assist (A) with mobility. A follow up interview was conducted on 5/7/25 at 4:48 p.m. with the DOR who reported visiting the resident and Resident #58 did voice fear. The DOR said, it's back referring to the siderails. Review of the policy, procedure, and information, effective 4/1/23, showed to promote independence and well-being and as well as to not restrict freedom of movement. The facility recognizes that every resident deserves a safe as well as comfortable sleeping environment period to assure safety and optimum bed mobility. This facility will utilize an appropriate resident specific/ centered approach determining the use of side rails/ bed rails. 1. If a side rail does not restrict freedom of what's going on movement or normal access to one's body, it is not considered a restraint. 3. Side rails used for completely immobile residents are not considered restraints and may therefore be used if they provide access to bed controls/call bell. 4. Physical or occupational therapist to assess bed mobility and all residents within 72 hours of admission. If therapist determines that one or two half rails enhance bed mobility and/ or facilitate independent transfers from bed. These rails will be care-planned for resident use. 8. All side rails and use whether or not they are restraints must be carefully assessed for risk of entrapment. The maintenance department upon placement of the side rails will complete a bed system audit to ensure proper placement of the side rails. 9. The maintenance department will also complete a bed system audit anytime you've [NAME] is added or removed from a bed and whenever a mattress has changed, or bolster/ wedge is added or removed. They will be informed of these changes via the maintenance communication log book on each unit, which is checked daily by the maintenance staff. 2. During an interview on 05/05/2025 at 10:11 a.m., Resident #93 stated he was waiting to hear back from the facility about being transferred to another facility so that he can be closer to his family. During an interview on 05/06/2025 at 11:47 a.m., Resident #93's family member and Power of Attorney (POA) stated he had been trying to move Resident #93 to a facility closer to him. The POA said, I live 2 hours away and it is hard for me to be able to see him. He stated he had spoken with the facility and never heard back on what they could do to move Resident #93 to another facility closer to family. Review of Resident #93's admission record revealed an admission date of 11/26/2024 with an initial admission date of 06/28/2024. Resident #93 was admitted to the facility with diagnosis to include Cerebral Infarction Due To Thrombosis Of Bilateral Cerebellar Arteries, Unspecified Cirrhosis Of Liver, Unspecified Severe Protein-Calorie Malnutrition, Muscle Weakness (Generalized), Hypothyroidism, Unspecified, Gastro-Esophageal Reflux Disease Without Esophagitis, Spondylosis Without Myelopathy Or Radiculopathy, Cervical Region. Review of Resident #93's Care Plan dated 11/26/2024 revealed [NAME] is currently in long term care but plans to discharge to an Assisted Living Facility (ALF) when his nephew can find one close to his home. Review of Resident #93's social services quarterly progress note dated 3/4/2025 showed the resident was alert and oriented and able to make his needs known. He does have episodes of confusion and forgetfulness at times, and his mental function varies. He is here for long-term care and plans to discharge to an ALF (Assisted Living Facility) closer to family. During an interview on 05/05/2025 at 2:00 p.m., the Social Services Director (SSD) stated Resident #93's family has been expressing desire to get him to a facility closer to them. The SSD said, I do not know where the family lives. The resident has not mentioned wanting to go to another facility. I didn't know it was mentioned on his care plan. Who would add that to the care plan? During an interview on 05/08/2025 at 2:43 p.m., the Nursing Home Administrator (NHA) stated it was hard finding facilities for residents who are on Medicaid. The NHA asked, Why would the family want to remove a resident from a facility that knows the resident to another facility who will have to get to know the resident all over. It is confusing for the residents when they move facilities. Our residents are like our family. Review of the Resident Handbook revealed, you can discharge from our facility and receive care elsewhere. You have the right to refuse any care or services at our facility. You also have the right to receive care elsewhere. On 05/08/2025 at 5:16 p.m. a policy for discharge preferences was requested. The facility did not have related policy.

Based on observation, interview and record review the facility failed to follow treatment recommendations related to obtaining weights on a weekly basis for one (#93) out of four residents sampled for weight loss. Findings Included: During an observation on 05/05/2025 at 10:11 a.m., Resident #93 was observed laying in bed noted to be thin in appearance. During an observation on 05/07/2025 at 12:10 p.m., Resident #93 was observed in his room with his bedside table in front of him with his lunch tray. On his tray was a plate with spaghetti, green vegetables, a dinner roll, pudding and a piece of pie. In a follow up interview on 12:43 p.m., Resident #93 stated he ate his dinner roll and something else but could not remember what it was. During an interview on 05/07/2025 at 1:41 p.m., Staff E, Certified Nursing Assistant (CNA) stated Resident #93 ate about 25% of his meal. He ate his roll and his pudding. Staff E stated his appetite varies, sometimes it is good and sometimes he does not eat much. Staff C stated they are expected to document meal intake. Review of Resident #93's admission Record revealed an admission date of 11/26/2024 with diagnoses of cerebral infarction due to thrombosis of bilateral cerebellar arteries, unspecified cirrhosis of liver, unspecified severe protein-calorie malnutrition, muscle weakness (generalized), hypothyroidism, unspecified, gastro-esophageal reflux disease without esophagitis, spondylosis without myelopathy or radiculopathy, cervical region. Review of Resident #93's weights revealed on 4/1/2025 he weighed 126.9 Lbs.(pounds). On 3/21/2025 - 126.8 Lbs. On 3/14/2025 - 127.6 Lbs. on 2/11/2025 - 161.6 Lbs. On 1/8/2025 - 164.0 Lbs. On 12/04/2024 -142.6 Lbs. Review of Resident #93's standards of care progress note dated 4/4/25 revealed the resident is here long term. He is receiving a regular dysphagia advanced diet. His current weight is 126.9 Lbs.Registered Dietician (RD) spoke with him, and he agreed to try fortified food, which were added, he is stable x3 weeks. He is not currently on antibiotic therapy or dialysis services. A nutrition note for Resident #93 dated 4/1/25 revealed a weight warning: Value: 126.9 a -7.5% change [ 22.6% , 37.1 ] -10.0% change [ 11.0% , 15.7 ] and it is noted to continue on weekly weights A nutrition note for Resident #93 dated 3/25/25 revealed a weight warning: Triggered due to -5.0% change [Comparison Weight 2/11/2025, 161.6 Lbs., -21.0% , -34.0 Lbs. ]. Diet is Regular diet, Dysphagia Advanced texture, Regular/Thin Liquids consistency. with No: Rice. Right curved built-up utensils at meals. By mouth (PO) intake is 75%+ most meals. Body Mass Index (BMI) is underweight. Spoke with resident who was agreeable to trying out fortified foods for weight loss. RD follow up as needed. An IDT (Interdisciplinary note) dated 3/6/2025 showed a care plan meeting was held with resident at bedside- He continues to feed himself with right built-up utensil- dysphagia advanced diet- no issues or concerns. Weight 161.6 with a BMI of 23.2. No significant changes noted. Md (Medical Doctor). is in agreement with Plan of Care (POC). Floor staff updated on POC. No issues voiced. Will monitor and continue current POC (Plan of Care) A nursing progress note dated 1/17/25 showed weight warning - Triggered due to +5.0% change [Comparison Weight 12/4/2024, 142.6 Lbs., +15.0% , +21.4 Lbs. ]. Resident had no nutritional concerns right now but requested more food and agreeable to fortified foods. Requesting reweigh to confirm weight gain, resident did not desire weekly weights. RD follow up as needed. During an interview on 05/07/2025 10:33 a.m., Registered Dietician (RD) stated he first saw the resident in March 2025. He saw that he had dropped 30 Lbs. in a month and was not sure how. He stated he did a re-weight and confirmed. He puts Resident #93 on weekly weights and spoke with the resident about his diet who was agreeable to adding fortified foods. He stated he spoke to the nurses about their weight policy. He stated he was on his weekly weights, and noted the nurses had not weighed him for the 4th weight record. If he is missing a weight he follows up with the nurses but does not document. I am working on getting better at documenting. The RD confirmed Resident #93 should have a weekly weight effective March 2025. He confirmed there were only three entries since then. During an interview on 05/08/2025 at 10:01 a.m., Staff F, Registered Nurse (RN), stated they have 2 CNA's that do the weights. She stated if a resident needed to be weighed weekly, the Unit Manager would know and relays that to the CNA's. During an interview on 05/08/2025 at 10:03 a.m., Staff G., CNA stated 2 CNA's are assigned to obtain weights for the entire building. She stated they get a list of residents who needed to be weighed from the nurse. During an interview on 05/08/2025 at 10:09 a.m., Staff N, Licensed Practical Nurse (LPN)/Unit Manager (UM) stated the RD provides the list of residents that need to be weighed. During an interview on 05/08/2025 at 10:12 a.m., RD, stated 26-50% of a meal is less than half of the meal is consumed. He stated if the resident only ate a roll and a pudding, he would consider that 0-25% of the meal being consumed. During an interview on 05/08/2025 at 1:35 p.m., DON stated 2 CNA's are assigned to doing weights. They are given a list of residents that need to be weighed. She stated they had an issue with keeping up with obtaining weights for residents and they are working on ensuring residents are weighed per orders. Review of the facility's policy dated 02/21/2023 titled Nursing-Weights revealed, Purpose: It is the policy of this facility to ensure that all residents maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the residents clinical condition demonstrates that it is not possible or resident preferences indicate otherwise. Procedure: Weight can be a useful indicator of nutritional status. Significant unintended changes in weight (loss or gain) or insidious weight loss (gradual unintended loss over a period of time) may indicate a nutritional problem. 1. The facility should utilize a systematic approach to optimize our residents nutritional status. This process includes: A. Identifying and assessing each resident's nutritional status and risk factors. B. Evaluating/analyzing the assessment information. C. Developing and consisting consistently implementing pertinent approaches. D. Monitoring the effectiveness of the interventions and revising them as necessary 4. Intervention should be identified, implemented, monitored and modified parentheses as appropriate parentheses, consistent with the residents assessed needs, choices, preferences, goals and current professional standards to maintain acceptable parameters of nutritional status. 5. Weight monitoring schedule should be developed upon admission for all residents: A. Weight should be recorded timely. Residents with weight loss monitor weight weekly or per physician order until stable then monthly 8. Documentation A. The physician, resident, or responsible party should be informed of a significant change in weight. B. The physician should be encouraged to document the diagnosis of clinical conditions that may be contributing to the weight loss. The registered dietitian or dietary manager should be consulted to assist with interventions; actions are recorded in the nutrition progress notes. D. Observations pertinent to the residents weight status should be recorded in the medical record as appropriate.

Based on observations, record reviews, and interviews the facility failed to provide optimal nutrition for one (#78) of one resident sampled for enteral feeding. Findings included: An observation was made on 5/5/25 at 11:25 a.m. of Resident #78 lying in bed, non-verbal, with a bottle of Nepro 1.8 enteral nutrition hanging from the bedside pole with pump. The pump and the tubing showed the resident was not receiving nutrition. The observation showed the 1000 milliliters (mls) bottle contained approximately 350 ml of tan-colored liquid, was dated 5/3/24 at 22:04 (10:04 p.m.), and showed the resident was to receive 60 milliliter/hour (ml/hr) (60mL/hr x 20 hours = 1200 mLs). The bottle label instructed Hang product up to 48 hours after initial connection when clean technique and only one new feeding set are used. Otherwise, hang no longer than 24 hours. Review of Resident #78's physician orders revealed an order for Nepro at 60 ml/hr x 20 hours, down at 10:00 a.m. up at 2:00 p.m. to provide a total of 1200 ml's in a 24-hour period. Review of Resident #78's Nutrition Evaluation Initial, Annual and Significant Change, dated 3/18/25 showed the resident did have an oral diet order of puree texture with thin liquids and tube feedings of Nepro at 60 ml/hr x 20 hours (down at 10:00 a.m. and up at 2:00 p.m.) with 250 ml of water 5 times a day. The evaluation showed the resident received less than 25% of nutrition orally and 100% of total kilocalories (Kcal) via tube feedings in the 7 days prior to the evaluation. Review of Resident #78's late entry Nutrition Note showed- Monthly Enteral Note, created on 5/5/25, effective 4/29/25, showed the resident was ordered dysphagia puree texture, regular/thin liquids, small portions, and were for pleasure per Speech Language Pathologist (SLP). The note showed the resident's oral intake was usually 0-25% and the enteral order of 60 mls of Nepro for 20 hours provided 2160 kcal. Review of the observed nutrition bottle hanging on 5/5/25 at 11:25 a.m. showed the bottle was hung at 10:04 p.m. and according to physician orders when taken down 12 hours later at 10:00 a.m. on 5/4/25 the resident would have received 720 mls of nutrition leaving approximately 280 mls in the bottle. Review of Resident #78's care plan revealed the resident had a nutritional problem or potential nutritional problem. The interventions included instructions for nursing staff to provide tube feeding and water (H2O) flushes as ordered. An interview was conducted on 5/7/25 at 10:22 a.m. with the Registered Dietician (RD). The RD reported Resident #78 was on Nepro at full rate due to not being able to depend on the resident eating (orally). The resident received 2160 calories from Nepro at 60 ml/hr x 20 hours. The RD reviewed photograph of nutrition bottle observed hanging and stated if the bottle was of 300 mls the resident did not receive optimal nutrition on that day. During an interview on 5/8/25 at 11:27 a.m. the Director of Nursing stated liquid nutrition was good for 24 hours and wondered if Resident #78's observed liquid nutrition had been an incorrect date situation. Review of the policy, procedures, and information - Nursing Enteral Tube Feeding via Continuous Pump, revised on 2/21/23 showed The purpose of this procedure is to provide nourishment to the resident who is unable to obtain nourishment orally. The procedure for initiating the feeding instructed staff after attaching the primed feeding pump set to enteral tube and unclamping tube, to hang feeding bag on to pole, connect the infusion pump, set rate, and press start for continuous feeding. The formula label staff would document initials, date and time the formula was hung/administered, and initial that the label was checked against the order. (Photographic evidence was obtained)

Based on record review and interviews, the facility did not ensure there was documented communication of coordination of care with the dialysis center for one (#81) of one resident reviewed. Findings included: A review of Resident #81's admission record revealed an initial admission date of 7/23/24 and a re-admission date of 1/24/25. Further review of the admission record revealed diagnoses to include type 2 diabetes with diabetic polyneuropathy, end stage renal disease, and dependence on renal dialysis. A review of Resident #81's physician orders revealed the following to include: - hemodialysis [dialysis center name and address] chair time 0615 Monday, Wednesday, Friday (M/W/F) every night shift, with a start date of 1/27/25. A review of Resident #81's progress notes from 4/8/25 to 5/8/25 revealed no documentation related to communication with the dialysis center. A nurse's progress note on 5/2/25 revealed the following, [Name of dialysis center] Dialysis [telephone #]. A review of Resident #81's electronic medical record revealed dialysis communication notes dated 3/19/25 - 4/30/25 with no documentation from the dialysis center to the facility. A review of Resident #81's dialysis binder, that goes with the resident from the facility to the dialysis center, revealed communication notes dated 5/3/25 and 5/5/25. The documentation revealed no communication to and from the dialysis center. On 5/6/25 at 2:28 p.m. an interview was conducted with Staff R, Registered Nurse (RN). She confirmed Resident #81 is one of her assigned residents. She said nurses are expected to check the resident's vitals before and after going to dialysis. She said they also check the access site. Staff R, RN said she documents this information in the resident's electronic health record and on the dialysis communication form. She stated, The dialysis center doesn't always fill out the middle part and I don't know why. She said Resident #81 has been okay but has needed some extra dialysis sessions on Saturdays. On 5/6/25 at 2:58 p.m., an interview was conducted with Staff N, Licensed Practical Nurse (LPN)/Unit Manager (UM). She stated, The dialysis center sends over a mass amount of notes about once a month. She said the dialysis center does not fill out the middle part of the communication form. On 5/7/25 at 10:05 a.m., an interview was conducted with Staff D, LPN/UM. She said the dialysis center is good at communicating over the phone if a resident is staying later for treatment or if there's concerns about lab results. She said they are not good about filling out the middle part of the dialysis communication form. Staff D, LPN/UM said staff should be documenting in the residents' progress notes if they communicate with dialysis over the phone. She said the dialysis center sends their notes to the facility every few weeks. On 5/7/25 at 10:18 a.m., an interview was conducted with the Registered Dietitian (RD). He said he emails or calls the dietitian at the dialysis center every month, or more often as concerns appear. He stated, It's really hard to get notes from [dialysis center name] and [dialysis center name]. He confirmed Resident #81 goes to the dialysis center as scheduled and that it is hard to retrieve notes from the center. The RD said he had to reach out to request notes. On 5/7/25 at 10:56 a.m. a follow-up interview was conducted with the RD who stated the dialysis center Resident #81 goes to, Got hacked about a month ago, and there is a back log of notes. On 5/7/25 at 1:10 p.m., an interview was conducted with the Assistant Director of Nursing (ADON). She said the facility received Resident #81's dialysis treatment notes today, dated 4/2/25 to 4/30/25. She said the dialysis center's system was hacked and they are delayed in sending notes. On 5/7/25 at 5:10 p.m., an interview was conducted with the Director of Nursing (DON). She said if the area on the communication form for the dialysis center is not filled out, staff should be sending it back. The DON said if the communication form from the dialysis center is not filled out, they try to call. She said if something happens while the resident is at dialysis, the center will notify the facility. The DON stated nursing staff are expected to, Document what the facility tells them. She said she started a performance improvement plan (PIP) and audits, in April 2025, to review the dialysis communication forms in morning meetings and determine how they can better monitor the residents. The DON said the PIP and audits were brought to Quality Assurance and Performance Improvement (QAPI). The facility did not have a policy related to communication with dialysis.

Based on observations, interviews, and record review, the facility failed to execute physician orders as recommended by the Consulting Pharmacist for two residents (#68 and #81) out of five residents sampled for unnecessary medications. Findings included: 1) Review of Resident #68's admission Record revealed the resident was admitted on [DATE]. The record included diagnoses of not limited to not elsewhere classified lymphedema, morbid (severe) obesity due to excess calories, moderate recurrent major depressive disorder, other bipolar disorder, generalized anxiety disorder, other seizures, gastro-esophageal reflux disease without Esophagitis, and abdominal distension (gaseous). Review of Resident #68's record showed the resident was on Hospital Paid Leave on 3/23/25, returning to the facility on 3/25/25. On 5/5/25 at 11:37 a.m. Resident #68 was observed sitting upright in bed, wearing a nasal cannula delivering 4 liters per minute (lpm) of oxygen. Review of Resident #68's Medication Regimen Recommendations made by the Consultant Pharmacist on 3/12/25 revealed the following: -Currently with active order for Ondansetron (Zofran) as needed (prn) which has not been used in over 30 days. Please evaluate current need and discontinue if appropriate. The physician response was Agree; Will do and signed by the provider on 3/25/25. -Currently receiving Divalproex (Depakote). Unable to locate recent serum level in chart. Recommended 2 weeks after start then every 6 months thereafter. Please consider ordering. The physician response was Agree; Will do and signed by the provider on 3/25/25. Review of Resident #68's April 2025 Medication Administration Record (MAR) showed an order for Ondansetron 4 milligram (mg) - Give one tablet by mouth every 4 hours prn for nausea and vomiting, started on 3/25/25 at 7:51 p.m. The MAR revealed the resident had received the medication fifteen times during the month of April. Review of Resident #68's laboratory results showed a Complete Blood Count (CBC with differential), Comprehensive Metabolic Panel (CMP), and a thyroid-stimulating hormone 3rd generation panel had been completed on 3/5/25. The results revealed the next testing the resident had was a stool culture on 4/30/25. The results did not show the resident had a Depakote level completed after 3/25/25 as ordered by the physician. During an interview on 5/8/25 at 1:41 p.m. the Director of Nursing (DON) reported not knowing why Resident #68's Zofran had not been discontinued, a new order for Zofran was ordered on 3/25/25, and the Depakote level was not ordered or obtained. She stated she searched the orders and results and was unable to locate either. 2) A review of Resident #81's admission record revealed an initial admission date of 7/23/24 and a re-admission date of 1/24/25. The admission record revealed diagnoses to include inflammatory polyneuropathy, unspecified, Type 2 Diabetes with diabetic polyneuropathy, End Stage Renal Disease, dependence on renal dialysis, major depressive disorder, recurrent, moderate, and mood disorder due to known physiological condition with mixed features. A review of Resident #81's physician orders revealed the following: -Sertraline Hydrochloride (HCl) tablet 100 milligrams (mg) give 1 tablet by mouth one time a day for depression related to major depressive disorder, recurrent, moderate. - Oxycodone HCl oral tablet 10 mg (Oxycodone HCl) *controlled drug* give 1 tablet by mouth every 4 hours as needed for moderate to severe pain. - Apixaban oral tablet 2.5 mg (Apixaban) give 1 tablet by mouth two times a day related to acute embolism and thrombosis of deep veins of right upper extremity. -Gabapentin capsule 300 mg give 1 capsule by mouth three times a day related to Type 2 Diabetes Mellitus with diabetic polyneuropathy. - Humalog injection solution 100 unit/milliliters (ml) (insulin Lispro) inject subcutaneously three times a day for Diabetes Mellitus (DM). - Sevelamer Carbonate 800 mg tablet give 1 tablet by mouth before meals related to End Stage Renal Disease do not send, supplied by dialysis. - Tresiba subcutaneous solution 100 unit/ml (insulin Degludec) inject 27 unit subcutaneously one time a day related to Type 2 Diabetes Mellitus with diabetic polyneuropathy. - Biscolax suppository 10 mg (Bisacodyl) inset 1 suppository rectally every 24 hours as needed for constipation or no results from Milk of Magnesia (MOM). -Enulose solution 19 grams (gm)/ml (Lactulose) give 30 ml by mouth every 24 hours as needed for no bowel movement (BM) in 3 days for (x) 1 dose. If ineffective by next shift see as needed (prn) Bisacodyl dialysis resident only. -Miralax enema insert 1 applicator rectally as needed for constipation/no results from Bisacodyl suppository if no or poor results from Miralax enema, notify primary care provider (PCP). A review of Resident #81's medication regimen review (MRR) by the consultant pharmacist, dated 3/12/25, revealed the following recommendations: - Currently receiving Gabapentin in dose exceeding maximum recommended dose based on estimated creatinine clearance (CrCl) below 30 ml/minute (min). To decrease risk of central nervous system adverse effects including ataxia, dizziness, and drowsiness consider taper Gabapentin to 600 mg daily at bedtime, if appropriate. - Currently with an active order for Miralax enema which is not recommended for use in residents on dialysis. Please evaluate risk versus benefit of use and discontinue, if appropriate. -The MRR revealed no response was marked for the Gabapentin recommendation, and Agree; Will do, was marked for the Miralax enema recommendation. There was no physician/prescriber signature observed on the MRR, dated 3/12/25. A review of Resident #18's Medication Administration Record (MAR) for March, April, and May 2025 revealed the following orders: - Gabapentin capsule 300 mg give 1 capsule by mouth three times a day related to Type 2 Diabetes Mellitus with diabetic polyneuropathy, with a start date of 2/26/25, was administered as ordered. - Miralax enema insert 1 applicator rectally as needed for constipation/no results from Bisacodyl suppository if no or poor results from Miralax enema, notify primary care provider (PCP), with a start date of 1/27/25, was not administered. On 5/8/25 at 3:25 p.m., an interview was conducted with the Director of Nursing (DON). She said the facility does not have documentation the physician acknowledged the pharmacy recommendations made in March 2025. The DON confirmed the physician did not document whether they considered the pharmacy suggestions or their rationale for not agreeing with the recommendations. A review of the facility's policy titled Pharmacy Services - Drug Regimen Review, dated 4/1/22, revealed the following: . Procedure: 1. The drug regimen of each resident should be reviewed at least monthly by a licensed pharmacist and the pharmacist should report any irregularities to the attending physician, the facility's medical director and the director of nursing and these reports should be acted upon . 5. The attending physician shall document in the resident's medical record that the identified irregularity has been reviewed and what, if any, action has been taken to address it. If there is to be no change in the medication, the attending physician should document his or her rationale in the resident's medical record.

Based on observations, interviews, and record review, the facility failed to administer pain medication as ordered for one resident (#13) out of five residents sampled for pain management. Findings Included: Review of Resident #13's admission record revealed an admission date of 04/03/2024. Resident #13 was admitted to the facility with diagnosis to include other sequelae following unspecified cerebrovascular disease, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, need for assistance with personal care, muscle weakness (generalized), sedative, hypnotic or anxiolytic dependence, uncomplicated, anxiety disorder, unspecified, Opioid dependence, uncomplicated, major depressive disorder, recurrent, moderate. Review of Resident #13's annual Minimum Data Set (MDS), dated [DATE], revealed in Section N- Medications: Anti-Depression, Hypnotic, Anticoagulant, Diuretic, Opioid, and Anticonvulsant. Review of Resident #13's orders revealed: -Norco Oral Tablet 10-325 MG (milligrams) (Hydrocodone Acetaminophen) Give 1 tablet by mouth every 4 hours as needed for Moderate/Severe pain -Start Date 02/17/2025. -Acetaminophen Tablet 325 MG Give 2 tablet by mouth every 6 hours as needed for general discomfort 2 tabs=650 MG not to exceed 3 gm (grams) in 24 hours- Start Date 02/17/2025. Review of Resident #13's Medication Administration Record (MAR), dated February 2025 revealed: -Norco Oral Tablet 10/325 MG was dispensed for a pain level of 0 on 2/8/2025 and 2/23/2025 -for a pain level of 3 on 2/4/2025, and 2/12/2025 -for a pain level of 4 on 2/03/2025, 2/05/2025, 2/09/2025, 2/10/2025, 2/13/2025, 2/17/2025, 2/18/2025, 2/19/2025, 2/21/2025, 2/22/2025, and 2/27/2025. Review of Resident #13's Medication Administration Record (MAR), dated March 2025, revealed: -Norco Oral Tablet 10/325 MG was dispensed for a pain level of 0 on 3/2/2025 and 3/31/2025 -for a pain level of 2 on 03/20/2025 and 3/30/2025 -for a pain level of 3 on 3/4/2025, 3/8/2025, 3/17/2025, 3/22/2025, 3/25/2025, and 3/26/2025 -for a pain level of 4 on 3/3/2025, 3/5/2025, 3/9/2025, 3/10/2025, 3/11/2025, 3/12/2025, 3/13/2025, 3/18/2025, 3/19/2025, 3/23/2025, 3/24/2025, and 3/27/2025. Review of Resident #13's Medication Administration Record (MAR), dated April 2025, revealed: -Norco Oral Tablet 10/325 was dispensed for a pain level of 0 on 4/25/2025 -for a pain level of 2 on 4/11/2025, 4/12/2025 4/27/2025 -for a pain level of 3 on 4/4/2025 4/10/2025 4/15/2025, 4/20/2025, and 4/30/2025 -for a pain level of 4 on 4/2/2025, 4/5/2025, 4/6/2025, 4/9,2025, 4/14/2025, 4/16/2025, 4/19/2025,4/21/2025, 4/23/2025, 4/24/2025, and 4/28/2025. During an interview on 05/05/2025 at 3:35 p.m., Staff Q, Licensed Practical Nurse (LPN) stated moderate/severe pain is a level of 5 or 6 and above. During an interview on 05/05/2025 at 3:36 p.m., Staff R, Registered Nurse (RN) stated moderate/severe pain would be a pain level of 6/7 or above. During an interview on 05/05/2025 at 3:48 p.m., the Director or Nursing (DON) stated moderated/severe pain would be at a level of 4-10. During a phone interview on 05/06/2025 at 4:40 p.m. the Physician stated a moderate/severe pain level would be 7-10. He stated if the order is scheduled, he would expect for the pain medication to be given as ordered even with a pain level of 0. He stated Resident #13's order is as needed and he would not expect pain medication to be given with a pain level of 0 or 2. He stated he would expect Tylenol to be given for a pain level in the lower range. The facility was asked to provide a policy for unnecessary medication and stated they did not have a policy for unnecessary medication.

Based on observations, interviews, and record reviews, the facility failed to ensure the medication error rate was less than 5.00%. Thirty medication administration opportunities were observed, and three errors were identified for one resident (#35) of five residents observed. These errors constituted a 10% medication error rate. Findings included: On 5/6/25 at 9:40 a.m., an observation of medication administration with Staff H, Licensed Practical Nurse (LPN), was conducted for Resident #35. Staff H reported the resident's blood pressure of 135/80 and heart rate of 86 had been obtained approximately four minutes prior to the observation. The staff member dispensed the following medications: - Carvedilol 3.125 milligram (mg) tablet - Sevelamer 800 mg tablet - Hydralazine 50 mg tablet - Amlodipine 5 mg tablet - Folic acid 1000 microgram (mcg) over-the-counter (OTC) tablet - Aspirin low dose enteric-coated 81 mg OTC tablet (order: chewable 81 mg tablet) - acetaminophen 325 mg - 2 OTC tablets The staff member confirmed dispensing 8 tablets prior to entering the resident room. The resident was observed lying in bed and the oral medications were administered. Staff H returned to the medication cart and reported holding the resident's Midodrine due to the blood pressure was too high. Review of Resident #35's May Medication Administration Record (MAR) showed the following errors: -Aspirin 81 (mg) chewable - Give 1 tablet by mouth one time a day related to peripheral vascular disease unspecified. The observation showed the staff member administered an enteric-coated 81 mg tablet of Aspirin. -Midodrine 5 mg - Give 1 tablet by mouth one time a day every Tuesday (Tues), Thursday (Thu), and Saturday (Sat) for hypotension to give in AM (morning) before Dialysis. The order was started on 4/22/25 and did not include blood pressure parameters to hold the medication. -[NAME]-Vite (B complex/C/Folic Acid) - Give 1 tablet by mouth one time a day for nutrition. The staff member documented this medication had been administered, however, it was not observed. Review of Resident #35's Medication Admin Audit Report for the 7 a.m. - 3 p.m. shift on 5/6/25 showed Staff H had administered the following medications at 9:55 a.m.: Carvedilol, Sevelamer, Hydralazine, Amlodipine, Folic Acid, and Aspirin. The following medications were documented as given on 5/6/25 at 9:57 a.m.: Carvedilol, Sevelamer, Hydralazine, Amlodipine, Folic Acid, Aspirin, Acetaminophen and [NAME]-Vite (also administered at 9:57 a.m.). During an interview on 05/08/25 at 11:16 a.m. the Director of Nursing (DON) reviewed Resident #35's MAR. She confirmed the documentation from the nurse. Review of the policy - Administering Medications, revised 2/21/23, showed the following: Purpose: To ensure that medications are administered in a safe and timely manner, and as prescribed. 3. Medications are administered in accordance with prescriber orders, and current standards of practice. 6. If a dosage is believed to be inappropriate or excessive for a resident, or a medication has been identified as having potential adverse consequences for the resident or suspected of being associated with adverse consequences, the person preparing or administering the medication should contact the prescriber, the resident's Attending Physician, or the facility's Medical Director to discuss the concerns. 20. The individual administering the medication initials the resident's MAR on the appropriate line after giving each medication and before administering the next ones.

2. On 5/5/25 at 11:49 a.m. Resident #68 was observed sitting upright in bed wearing a nasal cannula delivering 4 liters per minute (lpm) of oxygen. The resident stated there was a dressing on the right hip and something on left hip. The resident granted permission to view and photograph for evidence abdominal pad dressing on right hip, dated 5/3/25. The observation of left hip did not reveal any injury or dressing. Review of Resident #68's admission Record showed the resident was admitted on [DATE]. The record included diagnoses not limited to not elsewhere classified lymphedema, morbid (severe) obesity due to excess calories, intra-abdominal and pelvic swelling mass and lump unspecified site, and other sites of candidiasis. Review of Resident #68's quarterly Minimum Data Set (MDS), target date 3/3/25, revealed the resident scored 15 of 15 for the Brief Interview of Mental Score (BIMS) indicating an intact cognition. A request was made for the facility to provide Resident #68's Non-pressure and Pressure Skin Reports. The facility provided one Non-pressure Wound Report, dated 4/29/25, revealing one left lower leg - lymphedema, one left foot lymphedema wound, one right lower leg - lymphedema, and one right foot - lymphedema. The skin report did not reveal a right hip wound. Review of the medical record revealed a Non-pressure Wound Report, dated 4/8/25 showing a right hip wound measuring 1.0-centimeter (cm) x 0.5 cm x 0.2 cm which was acquired on 3/4/25. Review of a Skin Evaluation, dated 4/9/25 revealed wounds to bilateral lower extremities, right hip, raised areas to trunk, bilateral buttocks, and thighs with a reddened coccyx. Review of Resident #68's May 2025 Treatment Administration Record (TAR), printed on 5/8/25 at 10:56 a.m. did not include treatment orders to place a dressing to the right hip of the resident. An interview was conducted on 5/8/25 at 11:45 a.m. with the Director of Nursing (DON). The DON reported knowing of the resident's right hip wound and thought it was there on the resident's admission. The DON reported Staff D, Licensed Practical Nurse/Unit Manager (LPN/UM) said the wound was like a little blister in between (skin) folds, from the edema, clear liquid leaking out. The DON confirmed there should be documentation related to the right hip blister. A request was made for a policy regarding Skin Evaluations. The facility reported they did not have a policy related to Skin Evaluations. Photographic Evidence was Obtained. Based on observations, interviews and record review, the facility failed to ensure complete and accurate documentation was in the resident's medical record for two (#93 and #68) out of 23 residents sampled. Findings Included: During an interview on 05/06/2025 at 11:47 a.m., Resident #93's Family Member and Power of Attorney (POA) stated he had received a call from the facility on Friday letting him know they were putting an order for Hospice for Resident #93. He stated he was told it was because Resident #93 had recently declined and there was a change in his appetite. The POA stated he tried calling back a few times to speak with someone in regard to the Hospice Order and had not received a call back. Review of Resident #93's admission Record revealed an initial admission date of 06/28/2024 and a readmission admission date of 11/26/2024 . Resident #93 was admitted to the facility with diagnosis to include Cerebral Infarction Due To Thrombosis Of Bilateral Cerebellar Arteries, Unspecified Cirrhosis Of Liver, Unspecified Severe Protein-Calorie Malnutrition, Muscle Weakness (Generalized), Hypothyroidism, Unspecified, Gastro-Esophageal Reflux Disease Without Esophagitis, Spondylosis Without Myelopathy Or Radiculopathy, Cervical Region. Review of Resident #93 Orders revealed on 05/02/2025, Consult Hospice as per family and patient request Review of Resident #93's progress notes revealed there were no progress notes documenting Resident #93, family or POA elected Hospice care. During an interview on 05/05/2025 at 2:00 p.m., the Social Services Director (SSD) stated when residents or families request for a Hospice consult, she gives them brochures for all of the hospice companies they have information for. The SSD sends the referral once the family has chosen the hospice company. She stated Resident #93 asked the Advanced Registered Nurse Practitioner (ARNP) about going on hospice. The ARNP came and verbally told her that Resident #93 was requesting to go on Hospice. The SSD stated this conversation was not documented and there was no note. The SSD stated she had reached out to Resident #93's family in regards to the hospice order, but they are very hard to get a hold of and never returns her calls. She stated she did not document the phone calls attempts. During an interview on 05/08/2025 at 1:37 p.m., Director of Nursing (DON) stated anytime a conversation happens with a resident or family member it should be documented in the resident's chart.

Based on observation, interview, and record review, the facility failed to provide medically related social services for one of three sampled residents (#2) related to assistance with a room change or assistance with a transfer to another facility as requested. Findings included: On 03/27/2025 at 9:30 AM, Resident #2 was observed lying in bed. Resident #2 said she spoke to the Social Service Director (SSD) in the past about a room change. Resident #2 stated she cannot sleep because her roommate talks all night and keeps the lights on. Resident #2 stated she also talked to the SSD about transferring to a rehab in Jacksonville that specialized in Guillain-Barre Syndrome because the rehab could maybe help her get better. A follow-up interview was conducted on 03/27/2025 at 11:30 AM with Resident #2. Resident #2 stated she talked to the SSD a couple of weeks ago about the room change and was told they did not have any room available. Review of Resident #2's Admission Record showed she was admitted to the facility in 2023 and most recently readmitted on [DATE]. Review of the quarterly Minimum Data Set (MDS) dated [DATE] showed a Brief Interview for Mental Status (BIMS) score of 14, indicating cognitively intact. Review of a 02/17/2025 Social Service Progress Note electronically signed by the SSD showed Quarterly note-2/14/25, [Resident #2] is alert and oriented and able to make all of her needs known .She has a [family member] that calls daily and visits monthly and has an occasional visit from prior coworkers. [Resident #2] prefers to stay in bed most days. She plans to stay here for long term care but understands she may choose to discharge if she chooses. She also has episodes of feeling tired and feeling down/depressed trouble sleeping and poor appetite at times. She is followed by psychosocial for history of Trauma. We will continue to follow current plan of care. A review of Resident #2's progress notes and assessment forms for February 2025 through March 27, 2025 at 2:58 PM showed no documentation relating to a room change, roommate concerns, or a request to transfer to another facility. During an interview on 03/27/2025 at 12:37 PM, with the Nursing Home Administrator (NHA), the Director of Nursing (DON), and the SSD, the SSD stated when Resident #2 requested a room change, they only had a male room available. The SSD stated, When I went back to her room, she decided they [her and her roommate] were getting along, and she did not want a room change. It [the conversation] happened a few days before 2/4/2025, before she went out to the hospital. She declined to move. The SSD stated that a room was available at the time, but the resident did not want that room. The SSD stated, I spoke with her [Resident #2] this morning, and she did not say anything. She has not voiced anything to me since then. The SSD stated Resident #2 had talked to her family member about moving to another facility in Jacksonville. The SSD stated that was about a month ago, and the SSD called the family member at that time but never received a return call. The SSD confirmed Resident #2 told her it was a facility for Guillain-Barre. The SSD was unable to find the facility and did not know the name of the facility. The SSD confirmed she had not documented or followed up on any of the prior conversations with Resident #2 regarding a room change or the request to transfer to another facility prior to the day of the survey. Review of the Social Worker Job Description showed duties and responsibilities included: Assisting in planning, developing, organizing, implementing, evaluating, and directing the social service programs of the facility. Assisting in providing solutions for social and practical environmental problems including seeking financial assistance, discharge planning, (including collaboration with community agencies), and referrals to other community agencies when specialized assistance is required. Ensuring all charted progress notes are informative and descriptive of the services provided and of the resident's response to the service. Involving the resident and family in planning objectives and goals for the resident. Review of the Resident Handbook, signed as received by Resident #2 on 09/22/2023, showed: Residents' have the right to move to another care facility at any time, if we cannot meet your needs and you are not satisfied here. You can change room or roommates. Please ask, although there is no guarantee that another room or roommate will be available. Review of the Resident Rights and Responsibilities signed as received by Resident #2 on 0/22/2023, showed the resident has the right to be treated with respect and dignity, including their right to: reside and receive services in the facility with reasonable accommodation of your needs and preferences; share a room with another resident of your choice if you both desire; be notified in writing in advance of room or roommate changes; and refuse to transfer to another room in the facility under certain circumstances.

43453 Based on observation, interviews, and record review, the facility, 1. failed to ensure allegations of neglect were investigated for one (#8) of two residents reviewed for neglect and 2. failed to have evidence that alleged violations were thoroughly investigated for two (#2 and #7) of five residents sampled for alleged violations. Findings included: On 07/02/24 at 12:30 p.m., an observation and interview was conducted with Resident #8. She was observed in her room laying on her bed. Her Right leg was observed in a cast and was elevated. She stated she was in pain. The resident stated she was involved in a [mechanical lift] accident. She stated she remembered the incident very well. She said two CNAs (Certified Nursing Assistants) were transferring her from the bed to her wheelchair. During the transfer, the [mechanical lift] tipped when she was in mid-air. She stated the staff put her to the ground, but the metal part of the side table caught her ankle. She said, One of the CNAs was standing away from the lift holding on to the wheelchair. One CNA was operating the lift. She stated the side table was very close to the lift and it caught the leg of the lift, causing the lift to tip. The resident stated she broke her ankle. She stated she was frustrated because she could not get out of bed any longer and she probably would not for a very long time. She stated she was struggling with pain and realizing her recovery had been a set back. The resident said, I am a big girl, I think the CNA who was moving me could not do it without help. The resident stated there were two CNAs in the room. She stated when the tray table fell , everything fell over her and the aide had to lower her down. She stated they were calling for help and no one was answering. Review of the Admission Record for Resident #8 showed the resident was originally admitted to the facility on [DATE] and readmitted on [DATE]. Review of a quarterly Minimum Data Set (MDS) dated [DATE], showed Resident #8 had a BIMS (Brief Interview for Mental Status Score) of 15, which indicated the resident was cognitively intact. Review of section GG - functional abilities showed Resident #8 was dependent, which indicated a helper provided all effort to transfer to and from bed to wheelchair. Review of a progress note dated 06/27/24 at 11:26 p.m., showed Resident #8 returned from [name of hospital] via stretcher . Resident with right fracture of ankle and placed in a cast. Review of an Advanced Registered Nurse Practitioner (ARNP) progress note dated 06/27/24 showed, Resident was seen today in facility after receiving a call the resident was being transferred from bed to wheelchair with [mechanical lift] and 2 Staff members when the [mechanical lift] began to tilt, staff were able to keep her from further tilting. Her right ankle/foot hit the bedside table and multiple staff eased her down to the floor to prevent the [mechanical lift] from tilting further over. She is seen with soft tissue swelling over her right ankle and mild ecchymosis. X-rays of her right ankle were ordered and returned showing, age -indeterminate tib-fib fracture by 2 views. Review of a hospital discharge summary dated 06/27/24, showed Resident #8 was discharged with a diagnosis of distal end of fibula, Fracture of distal end of tibia. Review of a CNA task log as of 7/2/24, showed for transferring, the resident required a Mechanical lift with 2- plus assistance. Review of a care plan for Resident #8 with a transfer goal initiated on 04/14/22, showed the resident required a mechanical lift for transfers, with 2 plus assistance. On 07/02/24 at 2:30 p.m., an interview was conducted with the Nursing Home Administrator (NHA). She stated she went to see Resident #8 after the fall. She said the resident reported she had an accident with a [mechanical lift]. The NHA said, This resident normally likes to get up. She said she was afraid of transfers. I told her not to let this hold her back. The NHA stated both CNAs walked them through the process. They said the lift legs were open. The CNAs reported during the transfer, the lift started to tilt, and they lowered the resident to the floor. The NHA stated they did not investigate the incident any further because the CNAs were following the right process. She said, I spoke to both CNAs briefly that day. I asked if the [mechanical lift] could accommodate her weight. We ruled that out. The Director of Maintenance confirmed the lift was functioning properly. I believe the CNAs wrote statements. I have to check with the Unit Manager. She was leading the investigation. The NHA stated there were two staff members in the room and she went by that. She stated she would have expected them to write statements. An incident report should have been documented. She stated she was glad there were two staff members in the room. She stated that was her main focus. The NHA said, I don't have any documentation on any interviews. We did not think we had a problem. We did not get to the bottom of how the injury occurred. We did not conclude anything other than there were two staff members in the room. On 07/02/24 at 4:15 p.m., an interview was conducted with the Director of Nursing (DON). She said, Looking back, I feel bad. I think we failed that resident. I should have conducted the investigation myself. I now know better. On 07/02/24 at 5:13 p.m., a follow-up was conducted with the Regional Nurse Consultant (RNC). She stated she did not think the fall should have been reported. She said, Based on our initial investigation, we did not find a reason to report. She stated, a thorough investigation should have been conducted. 2. A review of Resident #2's medical record revealed Resident #2 was admitted to the facility on [DATE]. Resident #2 was discharged from the facility to the hospital on 2/4/2024. A review of the facility's reportable incidents log revealed an allegation of neglect was reported for Resident #2 on 2/13/2024. On 7/2/2024 at 3:00 p.m. during an interview with the NHA, she stated an allegation of neglect was reported to her on 2/13/2024, which involved Resident #2 being sent to the hospital on 2/4/2023 and not wishing to return to the facility due to the facility causing pressure injuries. The NHA also stated during the investigation of the allegation of neglect for Resident #2 other alert and oriented residents in the same hallway where Resident #2 resided were interviewed and expressed no concerns with the care they received. The NHA was not able to provide a list of residents who were interviewed and was not able to provide evidence the interviews were conducted with the residents during the investigation. The NHA left the room and attempted to locate the investigation file. The NHA returned to the room at 4:32 p.m. and stated she was not able to locate the investigation file for the allegation of neglect for Resident #2 on 2/13/2024. The NHA also stated the investigation files were transferred between herself and the DON because she also conducted parts of the investigation. The NHA stated the facility interviewed the facility staff as part of the investigation, but was not able to provide a list of staff who were interviewed or evidence of the interviews being conducted at the time. A review of Resident #7's medical record revealed Resident #7 was admitted to the facility on [DATE]. A review of the facility's reportable incidents log revealed an allegation of abuse was reported for Resident #7 on 4/24/2023. An interview was conducted on 7/2/2024 at 5:11 p.m. with the NHA regarding the allegation of abuse for Resident #7 on 4/24/2023. The NHA stated an allegation of abuse was reported to her on 4/24/2023 by another staff member involving a verbal argument between Resident #7 and the resident's nurse on 4/24/2023. The NHA also stated during the investigation of the allegation of abuse other alert and oriented residents in the same hallway where Resident #7 resided were interviewed and expressed no concerns related to abuse. The NHA was not able to provide a list of residents who were interviewed and was not able to provide evidence the interviews were conducted with the residents during the investigation. The NHA stated she was not able to locate the investigation file for the allegation of abuse for Resident #7 on 4/24/2023 and was not able to provide evidence of the investigation being conducted. Review of a facility policy titled, Abuse, Neglect, exploitation, Misappropriation, Mistreatment, injury of unknown source and investigations, dated 4/01/22, showed it will be the policy of this facility to honor resident's rights and to address with employees the seven (7) components regarding mistreatment, abuse, neglect . Under Investigation, The facility shall conduct their own internal investigation including, but not limited to staff(work history and background screening), resident, and family/resident representative interviews, medical record reviews, 24-hour reports reviews, full body skin exam, etc. The resident/representative and physician should be notified that there is an on-going investigation regarding the alleged incident.

Based on observations interviews, and record review the facility failed to prevent a fall with injury for one (#8) of two residents reviewed for falls. Findings included: On 07/02/24 at 12:30 p.m., an observation and interview was conducted with Resident #8. She was observed in her room laying on her bed. Her Right leg was observed in a cast and was elevated. She stated she was in pain. The resident stated she was involved in a [mechanical lift] accident. She stated she remembered the incident very well. She said two CNAs (Certified Nursing Assistants) were transferring her from the bed to her wheelchair. During the transfer, the [mechanical lift] tipped when she was in mid-air. She stated the staff put her to the ground, but the metal part of the side table caught her ankle. She said, One of the CNAs was standing away from the lift holding on to the wheelchair. One CNA was operating the lift. She stated the side table was very close to the lift and it caught the leg of the lift, causing the lift to tip. The resident stated she broke her ankle. She stated she was frustrated because she could not get out of bed any longer and she probably would not for a very long time. She stated she was struggling with pain and realizing her recovery had been set back. The resident said, I am a big girl, I think the CNA who was moving me could not do it without help. The resident stated there were two CNAs in the room. She stated when the tray table fell , everything fell over her and the aide had to lower her down. She stated they were calling for help and no one was answering. Review of the Admission Record for Resident #8 showed the resident was originally admitted to the facility on [DATE] and readmitted on [DATE]. Review of a quarterly MDS dated [DATE], showed Resident #8 had a BIMS (Brief Interview for Mental Status Score) of 15, meaning the resident was cognitively intact. Review of section GG - functional abilities showed Resident #8 was dependent, meaning a helper provided all effort to transfer to and from bed to wheelchair. Review of June 2024 Active Physician Orders for Resident #8 showed an order to send the resident out for imaging to Right foot and ankle on 06/27/24, one time only related to acute pain due to trauma. Review of a Hospital Transfer Form dated 06/27/24 showed Resident #8 was transferred to a local hospital for a possible fracture. Review of a Change in Condition form dated 06/27/24 showed Resident #8 had a fall. The form showed the resident was her own person. Review of Physical Therapy evaluation and plan of treatment dated 06/28/24 -07/27/24 showed the resident was referred by nursing staff to PT (Physical Therapy) services, after sustaining a (R) ankle fracture during a [mechanical lift] transfer from the bed to wheelchair as patient was being lowered into wheelchair by nursing staff. Patient stated her table somehow tilted hitting her (R) ankle. Patient went to the hospital and returned with (R) ankle fracture with a soft cast in place. Review of a progress note dated 06/27/24 showed the resident was in the process of being transferred by 2 staff members via [mechanical lift] from bed to chair when she experienced a fall. In the process of transfer, the [mechanical lift] tilted in a way that was uncomfortable for staff and for safety purposes staff decided to lower resident to the floor . Upon reassessing resident had an abrasion 3 inches long on her lower leg. There were no open areas or further skin tears noted at the time. Review of a progress note dated 06/27/24 at 11:26 p.m., showed Resident #8 returned from [name of hospital] via stretcher . Resident with right fracture of ankle and placed in a cast. Review of an Advanced Registered Nurse Practitioner (ARNP) progress note dated 06/27/24 showed, Resident was seen today in facility after receiving a call the resident was being transferred from bed to wheelchair with [mechanical lift] and 2 Staff members when the [mechanical lift] began to tilt, staff were able to keep her from further tilting. Her right ankle/foot hit the bedside table and multiple staff eased her down to the floor to prevent the [mechanical lift] from tilting further over. She is seen with soft tissue swelling over her right ankle and mild chamois. X-rays of her right ankle were ordered and returned showing, age -indeterminate tib-fib fracture by 2 views. Review of a hospital discharge summary dated 06/27/24, showed Resident #8 was discharged with a diagnosis of distal end of fibula, Fracture of distal end of tibia. Review of a CNA task log as of 7/2/24 showed for transferring, the resident required Mechanical lift with 2- plus assistance. Review of a care plan for Resident #8 with a transfer goal initiated on 04/14/22 showed the resident required a mechanical lift for transfers, with 2 plus assistance. An interview was conducted on 07/02/24 at 12:43 p.m. with Staff B, CNA. She stated Staff C, CNA was assigned to the resident but had asked her for help with the transfer. She said, The resident was in bed and was being transferred to her wheelchair. I was the one in control of the [mechanical lift]. [Staff C] was standing behind the chair, guiding her as I was turning the lift. Once she was over the chair, she was leaning a bit and was tipping to her right. The problem started when Staff B went to pull her to the chair, the lift was tipping and I called her, I said '[Staff B], she is about to fall!' We could not pull her. She was heavy. We were calling for help. We were both holding her, and her body was on top of the bedside table. We should have moved that out of the way. We were holding her, she is not particularly small, her feet were in a dangling position. I raised the lift all the way up. We were calling for help. Another resident went and got Staff D, CNA and another staff member, I don't remember her name. They came as we were lowering her down. She was all the way down when they got to the room. The nurse [Staff E, Licensed Practical Nurse (LPN)] came. She was kind of guiding us to position her. She told us to wait for EMS (Emergency Medical Service). It happened so fast we were trying to get her to the floor. We got her down to the floor and called 911. They came and helped lift her up. When we got her to bed, I saw she had an abrasion on the opposite leg, her left I believe. I notified the nurse. Later, the resident reported to Staff B that she had pain to her ankle. Staff B stated they talked about the incident later. Staff C was supposed to have had the resident ready. Her role was to help. Staff C was standing behind the chair the whole time. She was ready to pull her and guide her behind the chair. We used the lift that was in the room. The [mechanical lift] limit was 450 lbs. She stated the resident was already hooked up when she entered the room. She did not remember what sling size she had on. She said, it should have been the new bigger size. They just ordered new ones since the incident. She has one designated for her now. Staff B stated after the incident, the Nursing Home Administrator (NHA) and the Assistant Director of Nursing (ADON) asked what had happened. Staff B said, I told them there were two of us in the room. They did not ask about the sling or the lift. They asked if the lift legs were open. I told them they were, but the table was in the way a little bit. They did not ask me to write a statement. No one followed up with me after that. On 07/02/24 at 1:04 p.m., an interview was conducted with the ADON. She said, We were in a meeting when we were told [Resident #8] was on the floor. They were trying to put her in a chair before lunch. The Unit Manager Staff F, Registered Nurse (RN) went to the room and was told there were two CNAs in the room. The resident was on the floor. They said the lift was tilted and they lowered the resident to the floor. We asked if the lift base was open. That's what should have happened. We would want the base to be open to balance the weight. They said she was positioned correctly. At that moment we got the Director of Maintenance to inspect the lift. It had no faults. The ADON stated she could not speak to anything else. She stated she was not present. The ADON stated they concluded they had two staff in the room, and they followed the care plan. The ADON stated she did not confirm the size of the sling. She stated the resident went out and the X-rays came back positive for a fracture. The ADON stated in response they started the in-service about the transfers, use of the [mechanical lift] and demonstrations. The ADON stated they did not conduct any further investigation. She stated they had not educated all CNAs, but they were in the process. On 07/02/24 at 1:28 p.m., an interview was conducted with Staff F, RN. She stated she was made aware by the floor nurse Resident #8 had a fall. Staff F, RN said, there was a malfunction of the equipment at the start. The floor nurse said the lift tilted over during the transfer and they lowered the resident to the ground. Upon investigation, I asked the resident what happened. She said she hit her leg on the bedside table. Staff F stated she removed that particular [mechanical lift] from the room and tagged it so no one could use it. She stated she did not remember the weight limit. She said, That was not a question we asked. We were trying to figure out if the [mechanical lift] was functioning properly. Staff F stated she did not ask the nurse what she meant by the lift was the problem. Staff F said she did not have her write a statement. I asked the two CNAs what happened, and their stories lined up. I did not ask how the injury happened. I did not collect any statements. I did not investigate it further. On 07/02/24 at 2:04 p.m., an interview was conducted with the Director of Maintenance (DOM). He stated after the incident, he inspected the [mechanical lift] that was used to transfer the resident. He stated the [mechanical lift] was fully operational. He said, I would not know the weight limit. All I know was that there was nothing wrong with the lift. That should be something the CNA should now. On 07/02/24 at 2:30 p.m., an interview was conducted with the Nursing Home Administrator (NHA). She stated she went to see Resident #8 after the fall. She said the resident reported she had an accident with a [mechanical lift]. The NHA said, This resident normally likes to get up. She said she was afraid of transfers. I told her not to let this hold her back. The NHA stated both CNAs walked them through the process. They said the lift legs were open. The CNAs reported during the transfer, the lift started to tilt, and they lowered the resident to the floor. The NHA stated they did not investigate the incident any further because the CNAs were following the right process. She said, I spoke to both CNAs briefly that day. I asked if the [mechanical lift] could accommodate her weight. The DOM confirmed the lift was functioning properly. I believe the CNAs wrote statements. I have to check with the Unit Manager. She was leading the investigation. The NHA stated there were two staff members in the room and she went by that. She stated she would have expected them to write statements. An incident report should have been documented. She stated she was glad there were two staff members in the room. She stated that was her main focus. The NHA said, I don't have any documentation on any interviews. We did not think we had a problem. We did not get to the bottom of how the injury occurred. We did not conclude anything other than there were two staff members in the room. On 07/02/24 at 3:20 p.m. an interview was conducted with the Regional Nurse consultant (RNC). She stated the day the fall happened she was in the building. She remembered them going over the fall and they mentioned there were two staff in the room because she was a 2-person transfer. She said, I asked if the equipment was okay, and they said the DOM inspected the lift and determined there was nothing wrong with it. I understand nothing is documented but we asked those questions. On 07/02/24 at 4:15 p.m., an interview was conducted with the DON. She said, Looking back, I feel bad. I think we failed that resident. I should have conducted the investigation myself. I now know better. On 07/02/24 at 5:13 p.m., a follow -up was conducted with the RNC. She stated she did not think the fall should have been reported. She said, Based on our initial investigation, we did not find a reason to report. She stated a thorough investigation should have been conducted. Review of a facility policy titled, Falls and Fall risk-managing, dated 04/01/22, showed based on previous evaluations and current data the staff should identify interventions related to the residents specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. Per the MDS (minimum data set) a fall is defined as unintentionally coming to rest on the ground, floor or other lower level but not as a result of an overwhelming external force (e.g. A resident pushes another resident). Fall risk factors include (d). Obstacles in the footpath. Under resident's centered approaches to managing falls and fall risk, (1.) The staff, with the input of the attending physician, should implement a resident-centered fall prevention plan to reduce the specific risk factor(s) of falls for each resident at risk with the history of falls. (7.) In conjunction with the attending physician, staff should identify and implement relevant interventions . to try to minimize serious consequences of falling. Under monitoring subsequent falls and fall risk (1.) The staff should monitor and document each resident's response to interventions intended to reduce falling or the risk of falling. (3.) If the resident continues to fall, staff should reevaluate the situation and whether it is appropriate to continue or change current interventions. (4.) The staff and all physician should document the basis of conclusions that specific irreversible risk factors exist that continue to present a risk or injury due to falls.

Based on observations, interviews, and record review, the facility failed to assess, care plan and identify triggers related to trauma for one (#10) of two residents reviewed. Findings included: On 7/1/24 at 10:10 a.m., an observation of Resident #10 revealed she was lying in bed watching television. An interview with Resident #10 revealed she was upset by an experience she had on 6/21/24. She stated a nurse, who she could not recall her name, and [Staff A, Certified Nursing Assistant (CNA)] were providing catheter care. Resident #10 stated the door was closed. She stated a female resident entered her room and saw Resident #10 exposed from the waist down. Resident #10 stated, I was spread eagle and she saw me. An observation of Resident #10 revealed she was tearful and stated, I felt violated. She stated the nurse assisting Resident #10 escorted the female resident out of the room and closed the door. Resident #10 stated she reported the experience to another nurse, but she could not recall her name, and the Physician Assistant (PA) who followed her for catheter care at the facility. Resident #10 stated the second nurse who she told about the experience stated, The resident is demented and there's not much they can do as the resident is allowed to be in the halls. She stated the Administrator was supposed to see her regarding the experience, however, Resident #10 stated she has not. Further interview and observation of Resident #10 revealed she was tearful while describing an incident at a previous facility. She stated, I was raped by a female staff. She stated the previous facility was aware of the assault and she was sent to the hospital for examination. Resident #10 was visibly upset and crying while communicating about the sexual assault. A review of Resident #10's Admission Record revealed an original admitted [DATE] and a readmitted [DATE]. Further review of the Admission Record revealed no diagnosis related to trauma. A review of Resident #10's active physician orders revealed, Psychiatry as needed, and, Psychology as needed, both dated 11/17/23. A review of Resident #10's psych notes, dated 6/10/24, revealed for abuse and neglect, There is no known history of physical, sexual, emotional abuse, or emotional neglect. Further review of psych notes revealed, Patient denies symptoms of PTSD [Post Traumatic Stress Disorder]. Denies experiencing traumatic events that involved actual or threatened death or serious injury. An initial review of Resident #10's current care plan revealed a focus related to a mood problem which revealed, r/t [related to] feeling tired and poor appetite at times. Interventions related to the mood problem focus revealed, Monitor/record/report to MD prn [as needed] acute episode feelings or sadness, and Monitor/record/report to MD prn mood patterns s/sx [signs and symptoms] of depression. Further review of the current care plan revealed no evidence of a focus associated with Resident #10's trauma history or interventions related to identified triggers. A review of Resident #10's progress notes revealed no notes related to the incident on 6/21/24. A review of a nursing progress note dated 6/21/24 revealed, resident c/o [complaint of] abdominal pain catheter irrigated. A review of the facility's Grievance Logs, dated January 20224 to May 2024, revealed no evidence regarding the resident's grievance/concern on 6/21/24. A review of the facility's matrix revealed the response regarding PTSD/Trauma was blank for Resident #10. On 7/1/24 at 1:02 p.m., an interview was conducted with the Director of Social Services and the Nursing Home Administrator. The Regional Nurse (RN) Consultant was present during the interview. The Director of Social Services initially stated the resident had a care plan for PTSD. She stated, The resident came to us from another facility with a statement that she'd been sexually assaulted. She stated the statement, regarding Resident #10 being sexually assaulted, was in paperwork from the other facility. The Director of Social Services reviewed the current plan and stated, I don't see a trauma care plan. She stated Resident #10 was assessed by her and she received psych services. The Director of Social Services stated she could not recall if Resident #10 was assessed for triggers. She confirmed Resident #10 should have been assessed for trauma. She stated if a resident had a past or current trauma, she assessed the resident, and a care plan was put in place. The Director of Social Services revealed the incident that occurred on 6/21/24 during catheter care with Resident #10 was not reported to her. The Nursing Home Administrator revealed she was not aware Resident #10 had a history of sexual abuse and she stated the incident on 6/21/24 was not reported to her. On 7/1/24 at 2:29 p.m. an interview with the Director of Social Services revealed when a resident was identified with trauma, a care plan was put in place. She stated she reviewed previous trauma assessments for Resident #10, which revealed no documentation of trauma. A review of the facility's policy titled, Social Services - Trauma Informed Care, with a revised date of 4/1/22, revealed the following: Purpose: It is the policy of this facility to provide care and services, which in addition to meeting professional standards, are delivered using approaches which are culturally competent, account for experiences and preferences, and address the needs of trauma survivors by minimizing triggers and/or re-traumatization. Procedure: . 2. The facility should use a multi-pronged approach to identifying a resident's history of trauma . This should include asking the resident about triggers that may be stressors or may prompt recall of a previous traumatic event, as well as screening and assessment tools such as the Resident Assessment Instrument (RAI), Admission Assessment, the history and physical, the social history/assessment and others. Further review of the facility's policy, under procedure, revealed the following, 7. Trauma-specific care plan interventions should recognize the interrelation between trauma and symptoms of trauma .

Based on observation, interview, and photogenic evidence, the facility failed to store food in accordance with professional standards for food service safety. The facility failed to label and date food items and did not ensure the dishwasher temperature log was up to date. The failed practice had the potential to effect more than a limited number of Residents. Findings included: 1. An observation on 02/05/23 at 9:15 a.m., during the initial tour of the kitchen, showed the walk in refrigerator contained food items that were not labeled or dated. The following items were noted with photogenic evidence obtained: A bag of lettuce was not labeled or dated A container of white substance was not labeled or dated A container of chopped meat was not labeled or dated. During an interview 02/05/23 at 9:17 a.m., Staff J, Cook confirmed the bag of lettuce should have been labeled and dated. Staff J confirmed the container of white substance that was identified as cottage cheese was not labeled or dated and should have been. Staff J also confirmed the chopped meat identified as chopped chicken should have been labeled and dated. Staff J stated all food should be labeled and dated. 2. An observation on 02/05/23 at 9:00 a.m., during the initial tour of the kitchen, showed a dish washer temperature log that was not completed for the evening of 02/04/23. Photogenic evidence was obtained. During an interview on 02/05/23 at 9:10 a.m., Staff J confirmed the dish washer log was not completed for the evening shift of 02/04/23 and should have been. An observation on 02/05/23 at 9:20 a.m., showed Staff K, Cook completing the dish washer temperature log for the 02/04/23 evening shift. In an immediate interview on 02/05/23 at 9:20 a.m., Staff K stated he should have completed the dishwasher temperature log last night. Staff K stated the dishwasher temperature log should have been completed on the evening shift but he forgot to complete it at that time. A review of the facility's policy titled, Food Storage: Cold Foods with revision date on 04/2018 stated, All foods will be stored wrapped or in covered containers, labeled and dated, and arranged in a manner to prevent cross contamination.

Based on record review and interview, the facility failed to ensure the arbitration agreement explicitly granted the resident or his or her representative the right to rescind the agreement within 30 calendar days of signing it and the agreement did not explicitly state that neither the resident nor his or her representative was required to sign an agreement for binding arbitration as a condition of admission to, or as a requirement to continue to receive care at the facility for three (Resident #205, Resident #55, and Resident #293) of the sampled three residents. Findings included: Section G of the Admission Agreement included the arbitration agreement and it read the following: G. Disputes. Any controversy, dispute or disagreement arising out of or in connection with this Agreement, the breach thereof, or the subject matter thereof, including Facility's obligation thereof, shall be settled by binding arbitration, which shall be conducted in Jersey City, New Jersey in accordance with the American Health Lawyers Association Alternative Dispute Resolution Service Rules of Procedure for Arbitration, and which to the extent of the subject matter of the arbitration, shall be binding not only on all the parties to this Agreement, but on any other entity controlled by, in control of or under common control with the party to the extent that such affiliates joins in the arbitration, and judgement on the award rendered by the arbitrator may be entered in any court having jurisdiction thereof. The form was signed by Resident #205 on 01/27/23. The form was signed by Resident #55 on 02/07/23. The form was signed by Resident #293 on 01/30/23 The arbitration agreement did not grant the resident or his or her representative the right to rescind the agreement within 30 calendar days of signing the agreement. The arbitration agreement did not explicitly state that neither the resident nor his or her representative was required to sign an agreement for binding arbitration as a condition of admission to, or as a requirement to continue to receive care at, the facility. On 02/07/23 at 1:32 p.m., the Admissions Director reported she explained the arbitration agreement to the residents on their level. It was a small blurb in the Admissions Agreement. She explained to them that if there were any issues, they should try to resolve it with the facility first. She also lets the residents know that they could hire an attorney. The residents were signing and acknowledging that they understood the agreement. On 02/08/23 at 9:30 a.m., the Admissions Director stated she had concerns with the arbitration agreement also especially with the Jersey City, New Jersey part. The agreement did not include the residents could rescind the agreement and signing the agreement was voluntary. They were working with the legal team to change it. The legal team sent a new arbitration agreement that they were working on. They were just waiting for legal to approve it.

Based on record review and interviews, the facility failed to ensure the arbitration agreement provided for the selection of a venue that was convenient to both parties for three (Resident #205, Resident #55, and Resident #293) of three sampled residents. Findings included: Section G of the Admission Agreement included the arbitration agreement and it read the following: G. Disputes. Any controversy, dispute or disagreement arising out of or in connection with this Agreement, the breach thereof, or the subject matter thereof, including Facility's obligation thereof, shall be settled by binding arbitration, which shall be conducted in Jersey City, New Jersey in accordance with the American Health Lawyers Association Alternative Dispute Resolution Service Rules of Procedure for Arbitration, and which to the extent of the subject matter of the arbitration, shall be binding not only on all the parties to this Agreement, but on any other entity controlled by, in control of or under common control with the party to the extent that such affiliates joins in the arbitration, and judgement on the award rendered by the arbitrator may be entered in any court having jurisdiction thereof. The form was signed by Resident #205 on 01/27/23. The form was signed by Resident #55 on 02/07/23. The form was signed by Resident #293 on 01/30/23. The arbitration agreement did not provide for the selection of a venue that was convenient to both parties. It indicated that the binding arbitration agreement shall be conducted in Jersey City, New Jersey. On 02/08/23 at 9:30 a.m., the Admissions Director stated she had concerns with the arbitration agreement also especially with the Jersey City, New Jersey part. They were working with the legal team to change it. The legal team sent a new arbitration agreement that they were working on. They were just waiting for legal to approve it.

Based on record review, staff interviews, and review of the facility's policy, the facility failed to 1.) complete the Preadmission Screening and Resident Review (PASARR) Level II upon a new qualifying mental health diagnosis for two (Residents #3 and #78); and 2.) ensure the accuracy of a PASARR Level I for two (Residents #65 and #143) admitted with mental health diagnoses of four residents sampled for PASARR. Findings included: 1. Review of the Face Sheet for Resident #3 revealed admission to the facility on [DATE], with diagnoses that included cirrhosis, benign prostate hypertrophy and hepatitis. Further review revealed additional diagnoses identified after admission to the facility; they included: -schizophrenia, diagnosed [DATE] -major depressive disorder (MDD), diagnosed [DATE] -dementia, diagnosed [DATE] Review of a Psychiatric Note dated 01/06/2023 revealed psychiatric diagnoses and history that included dementia, schizophrenia, MDD and dysphagia. Review of the Annual Minimum Data Set (MDS) dated [DATE] revealed in Section I diagnoses that included non-Alzheimer's dementia, depression, and schizophrenia. Section N of the MDS revealed antipsychotic medications had been administered to the resident during the past seven days. Review of the current Care Plan for Resident #3 revealed focus areas that included: -history of being resistive to care/treatment r/t [related to] hx [history] of anxiety, dementia, mood d/o [disorder] and schizophrenia at times. -history of behavioral problems r/t cognitive loss/dementia, depression, mood d/o, med [medication] use, disorganized schizophrenia. -[Resident] has impaired cognitive function or impaired thought process r/t dementia, depression, and mental illness. -on antipsychotic therapy r/t schizophrenia, mood disorder. -[Resident] has a mood problem r/t hx of anxiety, dementia with behavioral disturbances, disorganized schizophrenia, and unspecified mood disorder. Further review of the documents section of the clinical record revealed a PASARR Level I completed 04/10/2013 with history of mental illness checked 'no', and history of mental retardation checked 'no.' No additional PASARR assessments (Level I nor Level II) were evident in the clinical record. During an interview with Staff A, Assistant Director of Nursing (ADON) on 02/06/2023 at 4:13 p.m., she stated it was the responsibility of the Social Services department to ensure PASARRs were complete. On 02/07/2023 at 10:54 a.m., an interview was conducted with Staff B, Social Services Director (SSD) and the Nursing Home Administrator (NHA). The SSD stated she reviewed PASARRs that were completed prior to admission for accuracy and said she did not complete a new PASARR when a resident had a new psychiatric or mental health diagnosis after admission. The SSD reviewed the clinical record for Residents #3 and #78 and confirmed both residents had a new psychiatric diagnoses identified since admission to the facility and completion of the last PASARR Level I. The SSD also reviewed the clinical record for Residents #65 and #143 and confirmed both residents were admitted to the facility with a psychiatric diagnosis that was not reflected on their pre-admission Level I PASARR. Review of a facility-provided policy titled Role of Admissions and Social Services in PASRR dated 4/1/2022 revealed: Policy: The facility will ensure each resident in a nursing facility is screened for a mental disorder (MD) or intellectual disability (ID) prior to admission and that individuals identified with MD or ID are evaluated and receive care and services in the most integrated setting appropriate to their needs a by coordinating with the appropriate State-designated authority. IV 2. Referring all Level II residents and all residents with newly evident or possible serious mental disorder, intellectual disability, or a related condition for Level II Resident Review upon a significant change in status. 37999 2. A review of the Admission Record identified Resident #143 was admitted on [DATE]. The record included the diagnoses of moderate dementia in other diseases classified elsewhere with mood disturbance, uncomplicated alcohol abuse, unspecified persistent mood (affective) disorder, unspecified psychosis not due to a substance or known physiological condition, unspecified recurrent major depressive disorder, and unspecified anxiety disorder. A review of Resident #143's Preadmission Screening and Resident Review (PASRR), completed by an acute facility on 1/30/23, did not identify the residents' diagnoses of substance abuse, depressive disorder, psychotic disorder and/or anxiety disorder. The document identified that the findings were based on Documented History and did not indicate findings from behavioral observations and/or medications. The PASRR indicated the resident may be admitted to the facility as a Level II evaluation was not required. Review of the acute facility's History and Physical (H&P) identified that a Care Coordination note, dated 1/31/23 at 1:01 p.m., indicated Resident #143 was also currently in Mitts and roll belt , must be 24 hours (hrs) before patient (pt) can discharge (dc) without having restraints on. The acute facility's H&P identified Resident #143 had a past medical history that included dementia, alcohol abuse, anxiety, and insomnia. The inpatient medications that Resident #143 was ordered included 0.5 milligrams (mg) of Lorazepam three times daily, Quetiapine 100 mg at bedtime, Divalproex Sodium Delayed Release 125 mg three times a day, mirtazapine 15 mg at bedtime, and trazodone 50 mg at bedtime. The Order Summary Report, as of 2/7/23 at 11:31 a.m., included the following medications: - Divalproex Sodium Delayed Release 125 mg three times a day for mood disorder, started 2/4/23; - Lorazepam 0.5 mg three times a day for anxiety, hold for lethargy or sedation, started 2/4/23; - Mirtazapine 15 mg at bedtime for depression, started 2/4/23; - Quetiapine Fumarate 50 mg at bedtime for psychosis, started 2/4/23; - Thiamine 100 mg daily for alcohol abuse, started 2/4/23; - Trazodone 50 mg at bedtime for depression/insomnia, started 2/4/23. Resident #143's care plan identified the following focuses: - is on antipsychotic therapy related to (r/t) psychosis, initiated 2/4/23. - uses psychotropic medications r/t behavior management, initiated 2/4/23. - uses antidepressant medication r/t depression. (resident) also has insomnia and mood disorder, initiated 2/4/23. - uses anti-anxiety medication r/t Anxiety disorder. (resident) has a history of alcohol abuse, initiated 2/4/23. - has dementia with psychosis, failure to thrive. (resident) is confused and mental function varies. At risk for further cognitive loss related to progressive disease process, initiated 2/4/23 and revised 2/7/23. - at risk for falls and for fall related injury secondary to C-Diff, pancolitis, diarrhea. Also has dementia with confusion and forgetfulness, failure to thrive (FTT), severe malnutrition, hypertension (HTN), alcohol abuse, dysphagia, mood disorder, psychosis, depression, and anxiety. Requires extensive assistance with needs and mobility, incontinent of bowel and bladder on admission, initiated 2/4/23. - has behaviors r/t dementia, wanders out of room despite being reminded currently on isolation, frequently undresses self, and easily redirected. An interview was conducted on 2/7/23 at 10:46 a.m. with the Social Service Director (SSD). The SSD reviewed Resident #143's PASRR and confirmed the document should been changed to include psychiatric diagnoses. 3. A review of Resident #78's medical record showed a new diagnosis of Schizophrenia, unspecified and Schizophreniform Disorder dated 12/02/22. A physician order dated 01/25/23 stated, Quetiapine Fumarate Tablet 25 Mg- give 3 tablets by mouth daily for Schizophrenia. The Quarterly Minimum Data Set (MDS) dated [DATE] showed a diagnosis of Schizophrenia under section I of the MDS with an antipsychotic given all seven (7) days during the look back period. A Preadmission Screening and Resident Review (PASARR) dated 10/14/22 was available. No additional PASARR was available after the new diagnosis of Schizophrenia. During an interview on 02/07/23 at 10:45 a.m., Staff B, SSD stated,I didn't know I needed to re-do a PASARR with a new psych diagnosis. 4. Resident #65 was admitted into the facility on [DATE] with admitting diagnoses of unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, anxiety, major depressive disorder, and unspecified psychosis not due to a substance or known physiological condition. A review of Resident #65's Preadmission Screening and Resident Review (PASARR) dated 12/29/22 revealed no qualifying mental health diagnosis and that no PASARR Level II was required. Section I of the 5 Day Minimum Data Set (MDS) revealed the resident had the following active diagnoses: non-Alzheimer's dementia, depression, and psychotic disorder. A review of the medical record revealed the resident was not assessed for a PASARR Level II. On 02/07/23 at 10:56 a.m., the Social Services Director (SSD) confirmed the Level I PASARR was inaccurate and should be redone. 41015 39438

Based on observations, record reviews, and interviews, the facility failed to implement an effective infection control program as evidence by not ensuring the appropriate hand hygiene was completed after delivering a meal tray to one (Resident #143) of one resident infected with Clostridioides Difficile (C Diff) on one of four units, failed to designate Contact precautions for one (Resident #55) of 35 sampled residents, and failed to ensure that non-dedicated equipment was cleaned in between two (Residents #7 and #145) of five residents observed during medication administration. Findings included: 1. A review of the Admission Record revealed Resident #143 was admitted on [DATE] with a primary diagnosis of Enterocolitis due to Clostridium Difficile not specified as recurrent. The Order Summary Report for the resident included a physician order, dated 2/3/23, for Isolation C Diff every shift for isolation and Isolation maintained for shift, activities, and services brought to room C Diff every shift for Isolation. On 2/5/23 at 12:53 p.m., Staff H, Certified Nursing Assistant (CNA), donned gown, gloves, and a face shield then entered Resident #143's room with a meal tray. The staff member removed gown and eye protection in the hallway outside of the residents' room and crossed the hall to utilize the wall dispenser of hand sanitizer in between rooms [ROOM NUMBERS]. The staff member stated that the hand sanitizer was sticky. Staff H asked Staff Member N, Licensed Practical Nurse (LPN) (as the LPN left room [ROOM NUMBER]) what Resident #143 was on precautions for and Staff N said for C Diff. Staff Member H stated the appropriate hand hygiene was to wash hands. Staff H traveled from outside of rooms [ROOM NUMBERS] to the nursing station at the other end of the hallway and was observed entering a room behind the desk. The Centers of Disease Control and Prevention (CDC) indicated at cdc.gov/cdiff, that washing with soap and water is the best way to prevent the spread from person to person. A CDC informational indicated that C. diff spreads when people touch surfaces that are contaminated with poop from an infected person or when people don't wash their hands with soap and water. The information identified that healthcare professionals can prevent C. diff by: wearing gloves and gowns when treating patients with C. diff and remembering that hand sanitizer doesn't kill C. diff. Review of the facility policy - Hand Hygiene, effective 9/5/2016 and revised 2/5/2021, indicated its purpose was To reduce the spread of germs in the healthcare setting. The process section of the policy identified Hands should be washed with soap and water when they are visibly soiled or before and after eating and with bathroom use. Use of soap and water to perform hand hygiene is recommended when caring for a resident(s) with known or suspected Clostridium difficile, when caring for a resident(s) with known or suspected infectious diarrhea or Norovirus outbreaks. 2. The Admission Record for Resident #55 identified an admitted [DATE]. The record included diagnoses not limited to acute hematogenous osteomyelitis of right femur and unspecified paraplegia. An observation was conducted, on 2/5/23 at 2:02 p.m., of Resident #55. The resident reported a wound infection to the right thigh. Review of Resident #55's Order Summary Report included a physician order, dated 1/23/23, that indicated Isolation type - Contact every shift for Methicillin-resistant Staphylococcus aureus (MRSA) until 2/19/23. The February Treatment Administration Record (TAR) for the resident identified that staff had documented every shift (minus day shift on 2/2/23) that the resident was on Contact isolation. An observation, on 2/6/23, of the door and area outside of Resident #55's room did not identify that the resident was on contact precautions. Photographic evidence was obtained. Staff O, Licensed Practical Nurse (LPN) confirmed, on 2/6/23 at 2:18 p.m., that Resident #55 was on contact isolation. The staff member confirmed there was no sign on the door or Personal Protective Equipment available outside of the room. Staff O reported just finding the order in the computer and that the resident was on isolation until the 19th. The Director of Nursing (DON) confirmed, on 2/6/23 at 2:24 p.m., that Resident #55 was on contact isolation due to wound until 2/19/23. The DON confirmed that the order did not indicate that contact isolation was for the wound and that it should identify where the MRSA was and that isolation was needed for wound care. An observation with the DON identified that there were no signs on the resident door indicating the necessity for contact precautions. The Centers of Disease Control and Prevention (CDC) guideline - Methicillin-resistant Staphylococcus aureus (MRSA), reviewed January 31, 2019, indicated that to prevent MRSA infections, healthcare personnel: Use Contact Precautions when caring for patients with MRSA (colonized, or carrying, and infected). The instructions indicated that Healthcare providers will put on gloves and wear a gown over their clothing while taking care of patients with MRSA. 3. On 2/7/23 at 7:58 a.m., an observation was made with Staff C, Registered Nurse (RN) of the administration of medication with Resident #7. Observed from the hallway of Staff C obtain vital signs with a wrist blood pressure cuff. The staff member returned to the medication cart, laid the cuff on top of the cart without cleaning it and reported vital signs of 115/70, pulse 75, temperature of 97.2, 97% oxygen saturation on room air, and 17 respirations. Staff C dispensed medications and administered the medications to the resident. Staff C moved the medication cart to in front of Resident #145's room. The staff member removed the wrist blood pressure cuff and pulse oximeter from top of the medication cart, that was previously used on Resident #7 and obtained vital signs from Resident #145. Staff C removed a canister of Microkill wipes from the medication cart and used a wipe to clean the oximeter then the wrist cuff. On 2/7/23 at 8:33 a.m., Staff C reported thinking that cleaning of the cuff and pulse oximeter was done after leaving Resident #7's room. The policy - Cleaning and Disinfection of Resident-Care Items and Equipment, revised October 2018, indicated Resident-care equipment, including reusable items and durable medical equipment will be cleaned and disinfected according to current CDC recommendations for disinfection and the OSHA Bloodborne Pathogens Standard. The policy identified that a blood pressure cuff was considered a non-critical item and Most non-critical reusable items can be decontaminated where they are used (as opposed to being transported to a central processing location). Reusable items are cleaned and disinfected or sterilized between residents (e.g., stethoscopes, durable medical equipment). The Director of Nursing stated, on 2/8/23 at 9:28 a.m., that staff were to clean reusable equipment in between residents with bleach wipes.

Based on medical record review and interview, the facility failed to ensure that treatment and services were provided in accordance with professional standards of practice for five (#1, #6, #7, #8, and #9) of six residents sampled related to obtaining physician ordered laboratory and radiology tests, notifying the provider of critical lab values, and assessing two (#1 and #6) of two residents for change in condition. Review of the medical record for Resident #1 revealed the resident had a history of [REDACTED]. On [DATE] the Advanced Practical Registered Nurse (APRN) ordered a Complete Blood Count (CBC) and a guaiac stool sample, a test to detect blood in the feces. The facility failed to obtain either of these test samples. On [DATE], the APRN ordered STAT (immediately) diagnostic tests: CBC, Basic Metabolic Panel (BMP) and a Kidney/Ureter/Bladder (KUB) x-ray. On [DATE] the BMP results indicated that the CBC blood sample had clotted. The facility failed to have the sample redrawn or to notify the provider that the sample had been clotted. On [DATE] the APRN ordered another CBC. The facility failed to carry out this order. On [DATE], a Patient Care Attendant observed that Resident #1 had vomited black/brown bile and notified the nurse of the change in condition. The nurse failed to assess Resident #1 for a change in condition. The physician was not notified of the resident's change in condition. On [DATE], the APRN gave orders for a STAT CBC, BMP, and KUB. The facility failed to obtain the STAT diagnostic testing. On the morning of [DATE], Resident #1's respirations ceased, and staff were unable to obtain a Blood Pressure, CPR (Cardiopulmonary Resuscitation) was initiated, 911 was called, and staff and Emergency Medical Services (EMS) reported blood coming from Resident #1's mouth. EMS stopped life-saving treatment after no response from Resident #1. The resident passed away at 8:37 a.m. on [DATE]. The facility ' s failure to ensure physician/APRN diagnostic orders were carried out and prompt physician/APRN notification of diagnostic results, to include critical laboratory results, were provided resulted in findings of Immediate Jeopardy, occurring on [DATE], removed at 8:45 p.m. on [DATE], and reduced to a scope and severity of a E. Findings included: 1. Clinical record review for Resident #1 revealed an original admission date of [DATE] and readmission on [DATE] following an acute facility stay with [DIAGNOSES REDACTED]. The physician's order [REDACTED]. According to Mayo Clinic, https://www.mayoclinic.org/diseases-conditions/[MEDICAL CONDITION]/symptoms-causes/syc- 360, [MEDICAL CONDITION] is a condition in which you lack enough healthy red blood cells to carry adequate oxygen to your body's tissues . This can happen if: Your body doesn't make enough red blood cells; Bleeding causes you to lose red blood cells more quickly than they can be replaced; Your body destroys red blood cells . Left untreated, [MEDICAL CONDITION] can cause many health problems, such as: . Heart problems. [MEDICAL CONDITION] can lead to a rapid or irregular heartbeat (arrhythmia). When you're anemic your heart must pump more blood to make up for the lack of oxygen in the blood. This can lead to an enlarged heart or heart failure. Death . Losing a lot of blood quickly results in acute, severe [MEDICAL CONDITION] and can be fatal . Continued review of Resident #1's record revealed: -An annual Minimum Data Set (MDS), dated [DATE], that identified a Brief Interview of Mental Status score of 9, indicative of moderate cognitive impairment. The MDS assessment indicated the resident did not have a condition or chronic disease that may have resulted in a life expectancy of less than 6 months. -A History and Physical from a previous facility, dated [DATE], indicated the resident had an episode of black tarry stools and had a [MEDICAL CONDITION] (GIB) status [REDACTED]. -A nursing note, dated [DATE] at 4:02 a.m., indicated Resident #1 was transferred to an acute facility for Altered Mental Status. The note indicated the resident had a critical hemoglobin level of 5.3, the facility was unable to redraw labs, and the resident complained of stomach pain. The corresponding Skilled Nursing Facility/Nursing Facility (SNF/NF) to Hospital Transfer Form, dated [DATE], indicated the reason for transfer was a critical hemoglobin, change in mental status, and stomach pain. -A nursing note, dated [DATE], indicated Resident #1 was in the hospital from [DATE] - [DATE] for pneumonia, [MEDICAL CONDITION], and GI bleed. -A Care Plan, created [DATE] and revised on [DATE], indicated the resident had [MEDICAL CONDITION] related to (r/t) GI bleed, hospitalized ,[DATE] -[DATE] for [MEDICAL CONDITION] with hemoglobin of 5.3. The interventions related to this focus instructed staff to obtain and monitor lab/diagnostic work as ordered. Report results to MD and follow up as indicated. -A physician order, dated [DATE] at 18:46 (6:46 p.m.), indicated the Advanced Practice Registered Nurse (APRN) had ordered a Complete Blood Count and stool for guaiac (a test for blood) once for black tarry stools for one day. There was no documentary evidence of the results of the CBC and guaiac stool that was ordered on [DATE]. There was no documentary evidence the blood and stool samples were collected as ordered on [DATE]. A review of the progress notes did not indicate that Resident #1 had refused the laboratory samples. According to Mayo Clinic, https://www.mayoclinic.org/tests-procedures/complete-blood-count/about/pac- 919, A complete blood count (CBC) is a blood test used to evaluate your overall health and detect a wide range of disorders, including [MEDICAL CONDITION], infection and [MEDICAL CONDITION]. A complete blood count test measures several components and features of your blood, including: Red blood cells, which carry oxygen; White blood cells, which fight infection; Hemoglobin, the oxygen-carrying protein in red blood cells; Hematocrit, the proportion of red blood cells to the fluid component, or plasma, in your blood; Platelets, which help with blood clotting. Abnormal increases or decreases in cell counts as revealed in a complete blood count may indicate that you have an underlying medical condition that calls for further evaluation. -A nursing note, dated [DATE] at 10:53 a.m., indicated Resident #1 had blood in stool and was feeling weak, STAT (immediately) CBC and Basic Metabolic Panel (BMP), and a Kidney, Ureter, and Bladder (KUB) radiography was ordered. The laboratory results, dated [DATE], indicated the BMP results were reported to the facility on [DATE] and the CBC was clotted (could not be used/no result and needed to be recollected). Resident #1 was seen by the APRN on [DATE]. The APRN noted the results of the KUB, BMP, and that the CBC had been clotted. There was no documented evidence a blood sample CBC was recollected. There was no documented evidence of a CBC result for the STAT laboratory ordered on [DATE]. The progress notes for Resident #1 did not indicate that the resident refused the recollection of the CBC. On [DATE] at 2:00 p.m., the Director of Nursing confirmed the CBC on [DATE] was not recollected after the lab results indicated the previous sample had been clotted. When asked what her expectation was, she stated that if a lab was found to be clotted then the physician should be informed and the blood redrawn. -A physician order [REDACTED]. There was no documentary evidence the ordered CBC, on [DATE], was requested or that it was completed. There was no documentary evidence of CBC results collected on [DATE]. The progress notes for Resident #1 did not indicate the resident had refused any laboratory services on [DATE]. Further review of Resident #1's Nursing progress notes indicated the following: -[DATE] 12:42 Resident has c/o vomiting blood on night shift . -[DATE] 07:49 Alerted by CNA .resident unresponsive, respirations erratic, unable to obtain BP .While at bedside respirations ceased, Code called, CPR initiated, 911 called. -[DATE] 09:26 Resident passed away 0827. During an interview, on [DATE] at 2:24 p.m., Staff D, Patient Care Attendant (PCA), stated she was assigned to Resident #1 on [DATE]. She stated she had been called to Resident #1's room by the resident and that the resident showed her that she had vomited brown/black bile. The PCA reported using her personal cell phone to text message the personal cell phone of the assigned nurse (Staff Member A) to report the emesis. The PCA stated she cleaned up the emesis and went on with her day. Staff D stated the nurse did not respond to the text and that she had not followed up with Staff A. The PCA reported that it, was a very busy day and did not remember informing anyone else that Resident #1 had vomited. She reported that she had been trained to let the nurse know first of emesis then to clean it up after the nurse had time to see it. A photograph was taken of Staff D's personal cell phone that indicated a text was sent to Staff A on [DATE] at 4:11 p.m. that reported Resident #1 had vomited brown/black bile. The sequential text message did not indicate Staff A had responded to the report of Resident #1's emesis. There was no documented evidence in Resident 1's record that Staff A had assessed or noted, on [DATE], Resident #1's emesis of brown/black bile. An interview was conducted on [DATE] at 2:00 p.m., with Staff Member A, Licensed Practical Nurse (LPN). Staff A revealed that Resident #1 had typically been part of her caseload and had been on her assignment during the 7 a.m. - 7 p.m. shift on [DATE]. She reported that the resident had no complaints of pain, nausea, or vomiting for the entire shift. She reviewed the staff schedule for [DATE] and confirmed Staff Member D had been assigned to the unit. Staff A reported getting texts from staff and doctors on her personal phone. When asked if Staff Member D had sent her a text message on [DATE], she reviewed her personal phone and stated no. A progress note dated [DATE] at 22:33 (10:33 p.m.) written by Staff Member I, Licensed Practical Nurse (LPN), indicated that Resident #1 had complained of pain in the abdomen, had refused any medication, and that the MD (medical doctor) was aware. An interview was conducted, on [DATE] at 11:37 a.m., with Resident #1's Power of Attorney (POA). He reported that the day before Resident #1 had expired, a family member was window visiting and that the resident expressed that she was vomiting blood. The family member called the facility office and reported the vomiting. He stated he did not receive any phone calls from the facility regarding the resident's vomiting, and he questioned why nothing was done or why she wasn ' t sent to the hospital. During an interview, on [DATE] at 2:00 p.m., Staff E, LPN, stated she had worked with the resident on [DATE] and [DATE] and had gotten report from the previous shift nurse but nothing unusual was reported. She stated that the family of Resident #1 had called the Admissions Coordinator, on [DATE], and informed the Coordinator that the resident had vomited blood the night before, which was reported to her, around lunch time by the Coordinator. Staff E stated she went immediately to Resident #1, completed an assessment and found nothing unusual. She stated she had made a note in the chart, contacted the APRN who informed Staff E she was on her way to the facility and would visit with Resident #1. The staff member stated the APRN had arrived at the time of shift change, and she had not received any orders from the provider at that time. The APRN note, dated [DATE], indicated Resident #1 had pointed to her abdomen and informed the APRN that it hurt. The APRN indicated the plan was for a STAT CBC, BMP, and KUB. A handwritten physician order, dated [DATE], indicated a STAT CBC, BMP and KUB for abdomen pain/vomiting. During an interview, in the presence of the DON, on [DATE] at 1:37 p.m., the APRN stated she did not know if the facility redrew Resident #1's CBC on [DATE]. The APRN reported that Staff E had informed her that Resident #1 had vomited on [DATE] and when she saw the resident later that day, the resident wasn ' t herself so I ordered a STAT CBC, BMP, and KUB. She, felt something was off regarding Resident #1 so she informed Staff Member H, LPN, directly of the STAT diagnostic testing and believed Resident #1's chart was the only chart with new orders. The APRN ' s expectation was that labs were drawn and that STAT labs were drawn as soon as the lab could do them. The APRN also reported that the guaiac stool (ordered [DATE]) was not obtained. The DON exited the interview, at which time the APRN reported that she does have trouble getting results from the facility on labs and must access the results herself from her home. During a follow-up interview, on [DATE] at 3:01 p.m., the APRN stated her expectation for a clotted blood sample was for the facility to redraw the sample, and the facility did not need another physician order [REDACTED]. The laboratory results for Resident #1 did not include laboratory or radiology results for the STAT CBC, BMP, or KUB, that was ordered on [DATE]. The laboratory tracking sheet for [DATE] indicated no bloodwork. The laboratory result inquiry for Resident #1 did not include test results for STAT CBC or BMP. A review of the Order Summary Report for Resident #1 did not indicate the order, dated [DATE], for a STAT CBC, BMP and KUB had been entered electronically. The Radiology vendor result inquiry list, from ,[DATE] - [DATE], did not include the results for a STAT KUB on [DATE]. There was no documentary evidence the STAT CBC, BMP, or KUB, that was ordered on [DATE], by the APRN was carried out. On [DATE] at 12:10 p.m., the Director of Nursing (DON) stated if a nurse received an order they were to input the order into the computer and if the provider verbally speaks with the nurse the order was placed into the computer by that nurse. She stated her expectation was for the night shift nurses to check charts to make sure orders were in the computer. The DON stated her expectation was when a laboratory and/or radiology diagnostic test was ordered, they were placed on the laboratory/radiology tracking form. During an interview, on [DATE] at 8:25 a.m., the Attending Physician for Resident #1 stated his expectation for following STAT physician orders [REDACTED]. He stated that diagnostic results were reported timely to either himself or the APRN. When asked what his expectation was for a clotted blood sample, he stated he would expect staff to report it to himself or the APRN, and an order would be given to redo the sample. When asked if he was aware of Resident #1 complaining about abdominal pain and an episode of vomiting blood, he stated, yes but it wasn ' t documented clearly if she had vomited blood, if she had I would have sent her out, and the X-ray was ordered due to abdominal pain. The Attending Physician expressed that a change in condition should be reported to him or his APRN. The policy titled Notification of Change in Condition, effective [DATE] and revised [DATE], identified that the center was to promptly notify the patient/resident, the attending physician, and the resident representative when there is a change in the status or condition. The procedure included that the nurse was to notify the attending physician and resident representative when there was a: -Significant change in the patient/resident's physical, mental, or psychosocial status; -Need to alter treatment significantly for a new treatment and exacerbation of a chronic condition; -Patient/resident consecutively refuses medication and/or treatment (i.e. two or more times) The policy titled Laboratory, Diagnostic, and X-ray, effective date [DATE] and revised [DATE], identified the policy was to provide guidance on ordering, obtaining, documenting, and reporting laboratory, diagnostic, and x-ray results. The procedure portion of the policy included the following: -Obtain a physician's order [REDACTED]. -Complete the required requisition form(s); -Schedule laboratory work, diagnostic test, and or x-ray as indicated; -If the laboratory work, diagnostic test or x-ray requires the resident to obtain the test outside of the Center, the Center to schedule the appointment and transportation as indicated; -Results of the laboratory work, diagnostic test, and x-ray to be sent to the Center; -Stat testing results or critical values to be called to the Center; -The Center to notify the ordering practitioner (or the covering physician if after hours) of values outside the reference range or per physician order; -Document any new orders; -Document notification of the practitioner and resident/resident representative of results; -Laboratory work, diagnostic testing, and x-rays to be filed in the medical record. 2. Resident #6 was admitted on [DATE]. The Admission Record included [DIAGNOSES REDACTED]. The discharge-return not anticipated Minimum Data Set (MDS), dated [DATE], indicated Brief Interview of Mental Status (BIMS) score of 15, cognitively intact. The MDS indicated the resident received 5 days of an anticoagulant. An AHCA form ,[DATE], dated [DATE], identified the [DIAGNOSES REDACTED]. The medical record indicated a physician order, dated [DATE], indicated Resident #6's code status was Full Code. A review of the Order Summary Report included the following physician orders: -- ordered [DATE] and end [DATE], PT/INR STAT one time for monitoring for 1 day; -- ordered [DATE] and to start [DATE], for a [MEDICATION NAME] Time and International Normalized Ratio (PT/INR) to be drawn every Monday and Thursday night shift for anticoagulant therapy; -- Last PT/INR result in the evening for monitoring, started [DATE]; -- started on [DATE], [MEDICATION NAME] Sodium tablet 2 milligram (mg) - give one tablet by mouth one time a day for anticoagulant. According to MedlinePlus at https://medlineplus.gov/lab-tests/[MEDICATION NAME]-time-test-and-inr-ptinr/, a [MEDICATION NAME] time (PT) test measures how long it takes for a clot to form in a blood sample and an INR is a type of calculation based on PT test results. A PT/INR test helps find out if your blood is clotting normally and it also checks to see if a medicine that prevents blood clots is working the way it should. The information at MedlinePlus indicated if someone was taking [MEDICATION NAME] and the INR levels that are too high may mean you are at risk for dangerous bleeding. A review of the [DATE] Treatment Administration Record (TAR) indicated the staff were ordered to check for bleeding and bruising every (q) shift for monitoring of anticoagulants. The TAR revealed that staff had not documented if Resident #6's had episodes of bleeding and bruising during the day shift on ,[DATE], ,[DATE], ,[DATE]-,[DATE], evening shift on ,[DATE]-,[DATE] and ,[DATE], and during the night shift on ,[DATE] - [DATE]. A review of the [DATE] Medication Administration Record [REDACTED]. The order started on [DATE] and the MAR indicated [REDACTED]. On [DATE] at 3:29 p.m., the Director of Nursing (DON) stated that NA meant not applicable. A review of the laboratory results drawn on [DATE] indicated a critical high [MEDICATION NAME] time of 59.2 seconds whereas the normal range is 9.6 -12.2 and a critical high INR result of 6.09 with a therapeutic range for patients with mechanical prosthetic heart valves or recurrent systemic embolism of 2XXX,[DATE].50. The results indicated the APRN had noted to Hold [MEDICATION NAME], Vit K 2.5 mg Intramuscular (IM), and PT/INR on [DATE]. The October Order Summary Report did not include any orders to hold Resident #6's [MEDICATION NAME], to administer Vitamin K, or to draw a PT/INR on [DATE]. The October MAR indicated [REDACTED]. A review of the October MAR, TAR, and laboratory results did not indicate a PT/INR was drawn as ordered on [DATE] and the MAR indicated [REDACTED]. An electronic medication administration note, dated [DATE], identified that Resident #6 given vitamin K x1 dose yesterday. Continuing dose. On [DATE] at 1:37 p.m., the APRN stated she had troubles getting lab results and that last week she did not receive the critical high PT/INR for Resident #1. On [DATE] at 3:01 p.m., the APRN reported that Resident #6 was on a low dosage of [MEDICATION NAME], 2 or 3 mg and if she had been injured, she could have bled heavily. She stated that the critical high INR results were not called to her, she had located the results herself on the computer, then attempted to call the facility and was placed on hold for 10 - 15 minutes. The APRN stated she had spoken with the Assistant DON and when he indicated he was still in the building, she gave him verbal orders to hold that days [MEDICATION NAME], administer Vitamin K and a PT/INR draw on [DATE]. She stated she wanted to catch them (staff) before they administered the next dose of [MEDICATION NAME]. The APRN stated she knew the Vitamin K had been administered because Resident #6 had informed her and when she looked on Monday, she saw that the facility had administered [MEDICATION NAME] all weekend. The APRN reported that Resident #6 was to be discharged on ,[DATE] but she informed the facility to absolutely not discharge the resident until the INR was therapeutic level. When asked if a critical high INR could affect the residents ' [MEDICAL TREATMENT] treatment, she stated yes the critically high INR could have caused bleeding at the end of the treatment and that even though she did not have many residents with [MEDICAL CONDITION] cell disease she thought it could have interfered with the disease. On [DATE] at 4:43 p.m., the Assistant DON (ADON) confirmed he had spoken with the APRN regarding Resident #6's critical high labs. He stated he was working a cart on a different hallway and that the APRN had called him, and that he received orders from her. The ADON stated he wrote the orders down and took them to Resident #6's nurse, who he stated was an agency nurse, and assisted her with obtaining the Vitamin K vial from the Emergency Drug Kit (EDK) and finding other supplies needed to administer the injection. He stated it was not until Monday that he found out the [MEDICATION NAME] had not been held, the orders (he had received) was not inputted into the computer, and the PT/INR was not drawn on [DATE] as ordered. During an interview on [DATE] at 12:10 p.m., the Director of Nursing (DON) stated her expectation was if a nurse received a physician order [REDACTED]. She stated her expectation was for the night shift nurses to check charts to make sure orders were in the computer. A review of the [DATE] Nightly Chart Checks for Resident #6 indicated staff did not complete checks on ,[DATE] - [DATE] and was completed on ,[DATE] - [DATE]. The care plan for Resident #6 did not include a focus related to the anticoagulation therapy. The care plan did identify Resident #6 had a nutritional problem or potential nutritional problem related to (r/t) Urinary Tract Infection [MEDICAL CONDITIONS] ([MEDICAL CONDITION]), dependent on [MEDICAL TREATMENT], [MEDICAL CONDITIONS], Chronic Embolism, [MEDICAL CONDITION] reflux disease (GERD), [MEDICAL CONDITIONS] (HLD), hypertension (HTN), Diabetes mellitus (DM), and pressure ulcer, created and revised [DATE]. The interventions instructed staff to obtain and monitor lab/diagnostic work as ordered, report results to MD, and follow up as indicated. 3. Resident #7 was originally admitted on [DATE] and re-admitted on [DATE]. The Admission Record included [DIAGNOSES REDACTED]. A review of physician orders [REDACTED]. This order was signed by the APRN on [DATE] and the nurse who received the order also signed the order. The Order Summary Report indicated a Kidney, Ureter, Bladder (KUB) X-ray was ordered on [DATE] and was to be obtained on [DATE]. The Order Summary indicated a KUB was completed on [DATE]. A review of the Resident #7's Order Summary did not include an active, completed or discontinued order for an abdominal ultrasound. The Administration Record for [DATE] indicated that a KUB was not administered. The review of X-ray Abdomen Radiology Report, dated [DATE] at 11:05 p.m., concluded there was no change and nonspecific bowel gas pattern. The results indicated if symptoms persist Computed tomography (CT) recommended. The progress notes dated ,[DATE] - [DATE], did not indicate the provider changed the Abdominal Ultrasound to an X-ray of the abdomen. The radiology vendor tracking form indicated that a KUB was ordered on [DATE] and did not include the order for an abdominal ultrasound for Resident #7. An insurance vendor notes, dated [DATE], identified that a discussion was held with the Nurse Practitioner (NP) for Attending Physician. The NP informed the vendor that Resident #7 had a distended abdomen and some discomfort in the epigastric and right upper quadrant (RUQ) and that a KUB had been ordered on [DATE]. The vendor noted moderate abdominal distention and epigastric to RUQ discomfort on palpation. The plan portion of the note indicated Resident #7 had abdominal distention and epigastric RUQ discomfort and a KUB was ordered on [DATE]. The plan was to check CBC, CMP, amylase, and lipase and for an abdominal ultrasound due to RUQ pain. During an interview on [DATE] at 9:50 a.m., Staff Member N, Licensed Practical Nurse/Unit Manager (LPN/UM) stated that the electronic Medical Record was new and some of the nurses did not know that a written telephone order had to be put in the electronic record also. She stated Staff Member C, Licensed Practical Nurse (LPN) had ordered a KUB X-ray instead of an abdominal ultrasound. The UM reported that the night nurse had called her when the Radiology technician arrived at the facility for Resident #7's X-ray and was confused because the order said abdominal ultrasound so the night shift nurse wrote an order for [REDACTED]. The UM stated the Radiology vendor does not do ultrasounds on weekends and if the test required nothing by mouth (NPO) that it wouldn ' t get done right away. She reviewed the Abdominal ultrasound order, written on [DATE] at 1:20 p.m. and confirmed that the ultrasound could have been done on Friday, [DATE]. A review of the Radiology vendors website identified that Staff Member C had ordered the ultrasound for the resident on [DATE]. The Radiology results for the abdominal ultrasound dated [DATE] at 12:40 p.m., indicated Resident #7 had hepatic steatosis and a 4-centimeter benign appearing right renal cyst. When asked, on [DATE] at 10:53 a.m., if Staff C, LPN, knew the difference between a KUB and abdominal ultrasound, Staff Member C stated yes, one was an X-ray and one was an Ultrasound. She stated she had ordered an ultrasound and did not know why the radiology technician thought it was a KUB. She stated the facility does not have duplicates of the radiology requisitions. She stated she did not know the ultrasound had not been performed until the ARNP had asked for the results and informed the staff member that there were 2 KUB results (,[DATE] and [DATE]) and no ultrasound results at that time. The [DATE] Nightly Chart Checks indicated no checks were completed from ,[DATE] - [DATE]. 4. Resident #8 was originally admitted on [DATE] and re-admitted on [DATE]. The Admission Record included [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS), dated [DATE], revealed a Brief Interview of Mental Status score of 15 out of 15. The quarterly assessment included active [DIAGNOSES REDACTED]. The Daily Skilled Note dated [DATE] at 1:00 a.m., reported that Resident #8 continued to have some nausea/vomiting brown to greenish clear emesis and the resident reported nausea medication was not effective. At 6:00 a.m. on [DATE], the note identified that Resident #8 complained of abdominal burning, nausea and large amount of greenish-clear emesis. During the ,[DATE] shift on [DATE], the resident continued with vomiting. The medical record included a physician order, dated [DATE], identified that After midline is inserted start [MEDICATION NAME] 500 milligrams (mg) Intravenous (IV) every day (qd) x 7 days. Obtain blood cultures STAT x2, please send [MEDICATION NAME] STAT for leukocytosis. The order was signed by the receiving nurse. A progress note, at 2:30 p.m. on [DATE], indicated that the writer had received orders for blood cultures x2, Urinalysis Culture and Sensitivity (UA C&S) obtained and in fridge. A nursing note, dated [DATE] at 3:00 p.m., indicated that Resident #8 had previous episodes of vomiting, nausea, and increased confusion. The note identified physician orders [REDACTED]. An Admission/Readmission Data Collection, dated [DATE] at 8:54 p.m., indicated Resident #8 was readmitted to the facility. Resident #8's record indicated that blood cultures x2 were collected on [DATE]. The laboratory results inquiry did not include blood culture results. The Care Plan for Resident #8 indicated a [DIAGNOSES REDACTED]. The interventions instructed nursing staff to obtain and monitor lab/diagnostic work as ordered, report results to MD and follow up as indicated. At 12:37 p.m. on [DATE], the Director of Nursing (DON) confirmed the facility did not have the laboratory results for Resident #8's blood cultures, that were ordered on [DATE] and collected on [DATE] (while resident was in the hospital). She stated she had attempted to call the former Unit Manager, who no longer works at the facility, to ask if the lab had been ordered. The DON stated her expectation was that physician orders [REDACTED]. At 12:58 p.m., the DON reviewed the electronic laboratory results on the vendors website and confirmed the website did not include the results of Resident #8's blood cultures and then reviewed the nursing notes and confirmed that there was no note that indicated why the cultures were not drawn or that the physician was notified that the blood cultures were not obtained. At 1:08 p.m., the DON stated the reason the blood cultures did not show up on the vendors result website was that STAT labs don ' t get put into the computer and they don ' t come out for STAT blood cultures so they were going to do it the next day.

Based on medical record review, facility record review, and interview the facility failed to ensure that a resident who needed respiratory care, including emergent oral suctioning and tracheal suctioning, was provided care consistent with professional standards of practice for three (Resident #1, Resident #2, Resident #3) of three residents sampled for respiratory care. The facility failed to ensure implementation of emergency suctioning for Resident #1 during a Code Blue where Cardiac [MEDICAL CONDITION] Resuscitation (CPR) was being performed. The facility failed to ensure suctioning equipment was available and operational at the bedside for Resident #2, and Resident #3 who had tracheostomies and required suctioning. The provision of appropriate functioning of lifesaving suctioning equipment was not available during CPR for Resident #1 and for immediate access at the bedside for Resident #2 and Resident #3. This resulted in findings of Immediate Jeopardy, occurring on [DATE], removed on [DATE], and reduced to a scope and severity of an E. Findings Included: 1. Review of Resident #1's face sheet revealed that she was originally admitted to the facility on [DATE] and with the most recent re-admission date of [DATE]. Review of the AHCA Form ,[DATE] dated [DATE], revealed that the resident was admitted to the facility with [DIAGNOSES REDACTED]. Review of the facility's SNF/NF Hospital Transfer Form revealed a transfer date of [DATE], where the resident was transferred to the local hospital, with the reason for transfer as Critical hemoglobin, change in mental status, stomach pain. Review of the Hospital discharge summary dated [DATE], revealed that the resident was transferred to the hospital because of symptomatic [MEDICAL CONDITION] with a hemoglobin of 5 (normal range for women is 12.0 to 15.5). Review of the AHCA Form ,[DATE] dated [DATE], revealed that the resident was re-admitted to the facility on [DATE], and had a primary [DIAGNOSES REDACTED].#1's [DIAGNOSES REDACTED]. Review of the resident's physician orders revealed that she had an order dated [DATE], which indicated that she was a Full Code. Review of the Admission Nursing Note dated [DATE] at 8:30 p.m., revealed that the resident arrived via stretcher and was alert and oriented with confusion. The nurse's note indicated that the resident was Spanish speaking only, was continent of bowel and bladder, and was able to make her needs known. Review of the resident's quarterly Minimum Data Set ((MDS) dated [DATE], revealed that this resident had a Brief Interview for Mental Status (BIMS) of 9 (moderate cognitive impairment). Review of Resident #1's Interdisciplinary progress note composed by the social worker on [DATE], revealed, Resident is alert with some confusion. Can direct own social and leisure routine. Resident ' s family visits through the window frequently which she enjoys. Resident is Spanish speaking only and has a communication board. Responds well to Spanish speaking staff Review of the daily skilled nursing note dated [DATE], revealed under the comment section Hospital ,[DATE]-[DATE]- Pneumonia, [MEDICAL CONDITION] GI (gastrointestinal) bleed. Review of Resident #1's Nursing Progress Notes revealed the following: [DATE] at 12:42 p.m., Resident has c/o (complaint of) vomiting blood on night shift. Current nurse has no evidence of resident vomiting blood on current shift (7AM-3PM) Certified Nursing Assistant (CNA) has not currently reported resident vomiting blood. [DATE] at 10:17 a.m., Alerted by CNA of change in condition, resident unresponsive, Respirations erratic, unable to obtain BP (blood pressure). MD (medical doctor) notified, O2 (oxygen) applied, while at bedside respirations ceased, Code called, CPR initiated, 911 called. Interview on [DATE] at 1:18 p.m., with the Nursing Home Administrator (NHA) and the Director of Nursing (DON) revealed that when the facility staff found that the resident had no pulse and no respirations on [DATE], CPR was started by the staff and the facility Crash Carts were brought to the resident's room. The staff working the code and/or present in the room at the time, reported that attempts to suction the resident were unsuccessful as the suction machine on the Crash Carts did not work. When Emergency Medical Services (EMS) arrived on the scene, they attempted to use the facility's suction machines on the Crash Carts but found that they did not work. The NHA reported that she was unsure if EMS obtained their own suction machine. Interview on [DATE] at 11:33 a.m. with Staff A, Licensed Practical Nurse (LPN), revealed that she typically was assigned to Resident #1 as a part of her caseload. She reported that she worked on [DATE] and was assigned to Resident #1's hallway. Staff A reported that as soon as she walked in the building for her shift a Code Blue was being called over the intercom system. She reported that she responded to the Code Blue, and once the resident's code status was confirmed, she assisted with CPR by doing compressions while another staff brought in the crash cart and utilized the AMBU bag (self -inflating bag resuscitator). She reported that, There was so much blood coming from the resident's mouth. A staff person attempted to use the facility's suctioning machine on one of two crash carts but was unsuccessful as the suctioning machine did not work. Continued interview with Staff A revealed that a second attempt was made at suctioning Resident #1 using the suctioning machine from the second crash cart, without success as that suction machine did not work. Staff A reported that when EMS arrived, they took over CPR and attempted to use the facility's suctioning machine, found that it did not work, and had to go out to obtain their own suction machine. Interview on [DATE] at 11:43 a.m. with Staff B, LPN, revealed that on [DATE] he heard the Code Blue and grabbed one of two crash carts and took it to Resident #1's room. He reported that, He was using the AMBU bag and then switched off with Staff A to continue compressions. Staff B said, Facility staff tried to suction the resident with the facility's suction machine, but the suction machine did not work. He said, he remembered staff Trying to re-attach things on the suction machine to get it to work. He reported that a second suction machine was brought into the room but not sure if it was used. He reported that, When EMS arrived on the scene, they attempted to use the facility's suction machine, but it did not work, so they had to go outside and get their own. Interview on [DATE] at 2:00 p.m. with Staff E, LPN revealed that on [DATE] she was in Resident #1's room while the facility staff were working the Code Blue. She reported that she observed a staff member try to use the suctioning machine to suction the resident, but the suction machine would not suction. She reported that the tubing was not connected on the suction machine at the time of the code. She also reported that the suction machine could not suction due to the [MEDICATION NAME] (Oral Suctioning Tool) not being connected to the canister. She reported that another staff person put the machine together, but the secretions were thick and could not be sucked up, as blood was noted to be coming out of Resident #1's mouth. A telephone interview was conducted on [DATE] at 4:13 p.m. with the Local County Fire Rescue Battalion Chief. He said that if the facility equipment, such as a suction machine, was available EMS would use the facility equipment. He reported that he would need to speak to the paramedic that responded to 911 emergency call and get back to the surveyor regarding the facility's suction machine functionality. A second telephone interview was conducted on [DATE] at 8:02 a.m. with the Local County Fire Rescue Battalion Chief. He revealed that he obtained a report from the paramedic that responded to the 911 call for emergency assistance. The paramedic informed him that the suction machine was in the resident's room, but staff could not get it to work. There was no tubing available so even if they could get the machine working there was no tubing. The paramedic sent someone out to get ours. Interview on [DATE] at 8:25 a.m. with Resident #1's attending physician revealed that his expectation for the use of lifesaving equipment was that resident equipment should be in good working order. The attending physician reported that he expected that the Crash Carts should be fully stocked with necessary equipment including medications. 2. On [DATE] at 8:45 a.m., crash cart 1 which was housed at the Friar/Essex nursing station was brought into the conference room by the DON to allow for inspection of the cart. The cart was uncovered and immediately it was noted that multiple items were lying in different areas on top of the cart, which included a stethoscope, a pulse oximeter, and a manual blood pressure cuff, Additionally, hair, dust and debris was noted to be sitting on top of the cart. When asked by this surveyor if crash cart 1 was ready to go in an emergency, the DON stated No. The DON was unable to determine if the stethoscope, oximeter and manual blood pressure cuff were cleaned/ sanitized and ready for the next use. Observation of the suction machine that was on top of the cart revealed that the machine had tubing that was to be connected to the [MEDICATION NAME] and then to the suction canister and was left open to the elements. The DON confirmed that this tubing should not be there. Inspection on [DATE] at 9:15 a.m. of crash cart 1 with the DON and the Assistant Director of Nursing (ADON), revealed that it took 1 minute and 20 seconds to locate an oral airway on the cart. It was noted that three large oral airways were enclosed together in a plastic bag. The Emergency Cart Check for the month of [DATE] indicated that there should be two oral airways on the cart (1 medium and 1 large) When asked if the airways were sterile the DON stated No. The DON and ADON were asked to locate, from the crash cart, all items that were identified on the Emergency Cart Check List to include: O2 cylinder, 15 LPM regulator (1), nasal cannula (2), tank key (1), non-breather masks (2), AMBU bag with mask (2), oral airways (1 large, 1 medium), mouth barrier, nebulizer with mask (2), IV start kit (2), back board (1), B/P cuff & stethoscope, gloves, lubricating jelly, CPR arrest record/nursing note, flash light/batteries, personal protective equipment, personal protective equipment, and Suction Machine Equipment: portable machine (working), suction canister with lid (6 ' and 18 ' tubing & filter-set up, 14 french sx catheter kit (4), [MEDICATION NAME] (1), normal saline bullets (10). The DON and ADON were observed to rummage through two gray plastic basins to locate the items. The cart was observed to be disorganized with unbagged and unlabeled items. On [DATE] at 8:53 a.m., crash cart 2 which is housed in the kitchen was brought into the conference room by the DON to allow for inspection of the cart. When uncovered it was noted that this cart had dust, hair and debris on top of the cart. Also noted was that the tubing that was to be attached to the [MEDICATION NAME] was attached to the suction canister and resting in an open bag. Inspection on [DATE] at 9:30 a.m. of crash cart 2 with the DON and ADON revealed that there was no stethoscope present on the crash cart and only 1 oral airway. The DON and the ADON were again observed to have to rummage through two plastic basins to find all items listed on the Emergency Cart Check List. The cart contained suction tubing and three large airways were unbagged. The DON and ADON reported that the crash carts needed to be more organized. 3. Review of Resident #2's record revealed that the resident was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. Review of the resident's admission MDS dated [DATE], revealed a BIMS score of 15 (Cognitively intact). Review of the resident's care plan dated [DATE], revealed a focus area related to the resident having a [MEDICAL CONDITION] size 6XLT and required suctioning. She had Chronic [MEDICAL CONDITION] with interventions that included Suction q shift as needed. The resident had a current order dated [DATE] [MEDICAL CONDITION] q shift and prn; Suction Set up Change two times a day for HYGEINE, with an order date of [DATE] and a start date of [DATE]. An attempt to observe demonstration of the suction machine at Resident #2's bedside by Staff C, LPN on [DATE] from 9:05 a.m. to 9:17 a.m. revealed that Staff C obtained a sterile suction kit out of the resident dresser draw, set up the sterile kit and donned sterile gloves. Staff C was observed to pour sterile water into a sterile cup and turned on the suction machine. The suction machine could be heard with the motor running. When the [MEDICATION NAME] was placed into the sterile cup with the sterile water no fluid was observed to enter the [MEDICATION NAME]. At this time Staff C verbalized that the suction machine was not working and that the suction machine was not suctioning the sterile water. At 9:08 a.m., the Assistant Director of Nursing (ADON) who was present in the room started to manipulate the suction machine in order to get it to work, until he realized that the suction machine did not have tubing connecting the canister to the motor. At this time, the ADON left the resident room to obtain the tubing. At 9:10 a.m., Staff C was about to set up another sterile kit and realized that there were no more sterile kits in Resident #2's room. The ADON, again left the resident room to obtain the sterile kit. At 9:13 a.m., the ADON returned to the resident room with the sterile kit. Staff C proceeded with the demonstration of the suction and was completed at 9:17 a.m., 12 minutes after she started. Interview on [DATE] at 9:07 a.m. with Resident #2 revealed that she had a [MEDICAL CONDITION] (trach) and was recently admitted to the facility with the trach. The resident reported needing suctioning at times. She stated that there was a suction machine at her bedside. She reported that all supplies should already be in her room and was unsure why the staff could not find the supplies for suctioning. 4. Review of Resident #3's record revealed that he was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. Review of the resident's annual MDS dated [DATE] revealed a BIMS score of 15, (cognitively intact) and indicated that the resident received suctioning and [MEDICAL CONDITION] care. Review of the resident's care plan revealed a focus area related to, [MEDICAL CONDITION]-capped since 2016 which was initiated [DATE] with the most recent revision on [DATE], and interventions that included, [MEDICAL CONDITION] ordered-SEE MAR/TAR (Medication Administration Record/Treatment Administration Record) with an initiated date of [DATE]. The resident had a current physician order that included,[MEDICAL CONDITION] as needed with an order date of [DATE] and a start date of [DATE]; Respiratory: Suction as needed with an order date of [DATE] and a start date of [DATE]. Observations of Staff C on [DATE] from 9:22 a.m. to 9:40 a.m. while she demonstrated the use of the suction machine located at Resident #3's bedside revealed that there was no tubing in place connecting the canister to the suction machine, and she was not able to suction. Staff C attempted to obtain a sterile kit from the resident's dresser draw but found that there were no sterile kits available. The ADON who was present in the room at the time, left the room to obtain the tubing and the sterile kit. Interview with Staff C at this time revealed that all supplies for suctioning should be available in the resident's room and ready to go. She reported that everything should be stocked on the 11:00 p.m. to 7:00 a.m. shift, and that they were responsible to complete that task. At 9:29 a.m. Staff C left Resident #3's room to assist in finding the suction supplies. At 9:36 a.m. Staff C attempted to demonstrate the use of the suction machine again and was successful, 18 minutes after she started. Interview on [DATE] at 9:30 a.m. with Resident #3 revealed that he, Had a [MEDICAL CONDITION] and was suctioned a couple of times each shift. He reported that, Supplies were usually kept in his dresser draw and was unsure why there are none now. 5. Interview on [DATE] at 9:57 a.m. with the DON revealed that the suction machine canisters should be changed after each suction. She reported that the 11:00 p.m. to 7:00 a.m. shift nurse on the Essex hall was responsible for checking the Crash Carts. She reported that the nurse on the night shift should have a checklist to know what she was checking for and what was needed on the Crash Carts. The DON reported that there was no process currently in place for resident rooms with suction machines. During an Interview with the ADON and the DON on [DATE] at 9:58 a.m., the ADON and DON reported that in an emergency it would be a problem if the appropriate supplies were not available. Interview on [DATE] at 1:10 p.m. with Staff G, Maintenance Director, revealed that he checked all suction machines monthly. He reported that he checked all electrical wiring and checked to ensure that there was suction. He reported that he had no documentation that would indicate that the suction machines had been checked. Interview on [DATE] at 10:20 a.m. with Staff C, LPN, revealed that she had worked at the facility a little over 2 years. She reported that she was typically assigned to Friar hall, and typically assigned to care for the residents with tracheostomies. Staff C reported that on her shift, Resident #2 was not usually suctioned, and Resident #3 was usually suctioned one time per shift. Staff C reported that within the last couple of months after the residents with tracheostomies arrived on her floor, she typically must stop what she was doing to find supplies in order to suction the residents. She reported that usually the tubing and the sterile kits were missing. She reported that she had discussed this concern with the unit manager, DON and central supply. Central supply stocked the nutrition rooms with supplies and the assigned nurse stocked the resident rooms who have tracheostomies. The rooms were stocked for the day but then it goes back to having no supplies in the rooms. She reported that the 11:00 p.m. to 7:00 a.m. shift had the orders to make sure that all tubing and canisters were set up and stocked. She said, she had asked several times to have the rooms stocked with more than one sterile kit in case the resident had to be suctioned multiple times. She reported that she had not had training on suctioning [MEDICAL CONDITION] in over 1 year. 6. Review of the facility policy titled Suctioning with a revised date of [DATE] revealed that 6. Suction machines must be available at the bedside of resident's who require suctioning because they cannot clear nasal, oral, and /or respiratory secretions by themselves and also at the bedside of all [MEDICAL CONDITION] and ventilator residents . 7. When suction machines are available for use, the following items should also be available: a. Supply of exam gloves; b. Supply of sterile gloves, if tracheal suctioning is anticipated; c. Supply of suction catheters; d. Supply of sterile distilled water with which to flush suction catheters; and . Review of the facility policy titled Emergency Equipment Cart with an effective date of [DATE] and a revision date of [DATE] revealed, Center to maintain an Emergency Equipment Cart. The Procedure section of this policy indicated, -Establish an Emergency Equipment Cart that is accessible to nursing stations. -Check the Emergency Cart daily. -Emergency Cart should be restocked/replenished following each use and as needed. Review of the facility policy titled Bio-medical Equipment Management with an effective date of [DATE] revealed that An equipment management program shall be in effect to manage the clinical and physical risks associated with all fixed and portable equipment used for the diagnosis, treatment, monitoring and care of residents .1. Included in this program are: .c. all equipment used to sustain or enhance breathing. Review of the Facility policy titled Equipment Data Sheet with an effective date of [DATE] revealed that All maintenance performed on equipment shall be documented clearly and succinctly and in an organized manner so that it may be reviewed by the Management Team at any time. The Equipment Data Sheet will be utilized to document maintenance and as a tracking tool to aid in analysis of equipment and systems ' life span and cost. 7. The facility provided supporting documentation of their corrective action plan throughout the survey process from [DATE] - [DATE] to include: In-service sign in sheets for all facility staff on Code Blue, Suction Machine. This in-service included the use and documentation on [MEDICAL CONDITION] Setup Checklist, review of the Oropharyngeal Suctioning policy with an effective date of [DATE], and review of the Tracheal Suctioning policy dated [DATE]. In-service sign in sheets for licensed nurses on Suction machine set-up, PT/INR, labs f/u, which included review of the Use of Emergency Equipment and Supplies policy dated [DATE], and the review of the Risk Management/Quality Improvement Data collection form to address all suction machines on crash carts and resident rooms being set-up and ready for use properly. In-service sign in sheets for all staff on Code Blue and Code Blue Drills, which included review of the Cardiopulmonary Resuscitation (CPR) policy with an effective date of [DATE], review of the Code Blue Documentation form, review of the Code Blue Quality Assurance Drill form, review of Risk Management/Quality Improvement Data Collection Form to address code drills to be completed weekly every shift with documentation kept in a binder, review of the Risk Management/Quality Improvement Data Collection Form to address the crash cart being checked daily by a nurse to make sure all equipment is present and in working order, and review of the Emergency Cart Check List form. On [DATE] at 6:40 PM, an interview was conducted regarding the facility's corrective action plan with the Nursing Home Administrator (NHA), Director of Nursing, (DON), Regional Clinical Director, and the Regional Administrative Director. The NHA reported that the suction machine on the crash carts were not broken and that all staff had to do was to press down the cover of the canister to make it work. She reported that all the staff respond to a code blue and all staff should know how to set-up and operate the suction machine. She reported that all staff will be in-serviced in the use of the suction machines, crash carts and code blue drills. The DON reported that in addition to the suction machines on the crash carts, any suction machine at the resident bedside will follow the same process. Interview and record review on [DATE] at 8:30 PM with the DON, NHA, Regional Clinical Director, and the Regional Administrative Director revealed that 100% of employees from all departments to include: Nursing, Housekeeping, Dietary, Maintenance, Therapy and Management were trained on: -Change in condition -Code drills (Code drills to occur 1 X week per shift; 3 times weekly). During the Code Blue Drills, the nurses must obtain and utilize the suction machine and suction water to demonstrate competency. Two Code Blue drills were successfully completed on [DATE] and observed by the survey team. No concerns were observed with the function of the suction machine or staff use of the equipment. In addition, all 29 licensed nurses received training on suctioning. Beginning [DATE], eighteen staff members to include four licensed nurses, five certified nursing assistants and nine ancillary staff were interviewed related to their knowledge of code blues, change in condition, and the use of suction machines as it applies to their position. During the interviews, the nurses were able to verbalize their understanding of their role in a code blue and the use and maintenance of crash carts and suction machines. No concerns were identified with staff response during the verification interviews.

Based on observations, interviews with facility staff, an Advanced Practice Registered Nurse (APRN), an Attending Physician, the Local County Fire Rescue Battalion Chief, and a family member, and clinical record reviews, review of facility policies and procedures, and review of administrative job descriptions, it was determined that the facility's Administration failed to utilize its resources effectively by failing to recognize and respond to changes in condition, ensure laboratory and radiology diagnostics were completed as ordered, ensure physicians were notified of the results of diagnostic testing in a timely manner, and ensure life-saving suctioning equipment was in good working order for seven (#1, #2, #3, #6, #7, #8 and #9) of 11 sampled residents. Administration failed to ensure compliance with facility policies and procedures to ensure change in conditions were monitored and failed to identify the need for staff education related to following physician orders, completion of lab/diagnostic testing, and following up on change in conditions. The systemic breakdown led to missed laboratory/diagnostic testing for Resident #1 who was experiencing a critical change and exacerbation in her condition of [MEDICAL CONDITION] and [MEDICAL CONDITION] which led to the resident becoming absent of vital signs and bleeding from the mouth. Staff attempted to use lifesaving suctioning equipment during Cardiopulmonary Resuscitation (CPR) and found that it was not functional. Resident #1 expired in the facility on [DATE]. Following this event, facility administration failed to identify systemic breakdowns and record review identified 4 additional sampled residents (#6, #7, #8 and #9) with concerns related to laboratory and diagnostic testing and continued problems with the operation of life-saving suctioning equipment at the bedside for sampled residents (#2 and #3) who had tracheostomies and required suctioning. This resulted in findings of Immediate Jeopardy, occurring on [DATE], removed at 8:45 PM on [DATE], and reduced to a scope and severity of a E. Findings Included: 1. Review of the job description titled Executive Director I (Administrator), revealed: Purpose of Your Job Position-The Executive Director I is responsible for management of the facility in a manner which exemplifies (Corporation Name) Health Care's standard of operational excellence, to include but not limited to creating an environment in which employees demonstrate [MEDICATION NAME], Honesty, Integrity, and Respect for one another and everyone they come into contact with, and business practices are conducted with [MEDICATION NAME]. The primary purpose of the Executive Director is to direct the day to day functions of the facility in accordance with current federal, state, and local standards, guidelines, and regulations that govern nursing facilities to ensure that the highest degree of quality care can be provided to our residents at all times. You are entrusted to provide innovative, responsible healthcare with the creation and implementation of new ideas and concepts that continually improve systems and processes to achieve superior results. Job Functions: As Executive Director I, you are delegated the administrative authority, responsibility necessary for carrying out your assigned duties. Responsible for day to day clinical and administrative activities of the facility, including profit and loss responsibility and ensures compliance with all state and federal regulations. Supervises Director of Clinical Services, Business Office Manage, Business Office Coordinator, Director of Admission, Director of Rehabilitation Services, Director of Resident and Family Services, Director of Therapeutic Recreational Services, Director of Hospitality Services, Director of Dining Services, Director of Environmental Services Customer Service Associate. You will also provide leadership to all facility staff in meeting the goal of providing quality resident care . Duties and Responsibilities included: Schedule regular meeting with direct report staff to provide supervision, ensure communication and to monitor facility operations; Maintain and guide the implementation of facility policies and procedures in compliance with corporate, state, federal, and other regulatory guidelines; Support and guide the facility's quality improvement process; Ensure a safe, clean, and comfortable environment for residents, visitors, and staff. Maintain a file for and monitor incident reports; Attend to overall operation of the facility. Review of job description titled Director of Clinical Services I, revealed: Purpose of Your Job As a (Corporation Name) Health Care Director of Clinical Services, you are entrusted with the responsibility of caring for our residents, families, co-workers, visitors, and all others; as well as demonstrating in all interactions, (Corporation Name) Health Care's Five core values of [MEDICATION NAME], Honesty, Integrity, Respect, and [MEDICATION NAME]. The primary purpose of your job position is to plan, organize, develop and direct the overall operation of our Nursing Services Department in accordance with current federal, state, and local standards, guidelines, and regulation that govern our facility, and as may be directed by the Executive Director to ensure that the highest degree of quality care is maintained at all times. You are entrusted to provide innovative, responsible healthcare with the creation and implementation of new ideas and concepts that continually improve systems and processes to achieve superior results. Job Functions: As the Director of Clinical Services I, you are delegated the administrative authority, responsibility, and accountability necessary for carrying out your assigned duties. Responsible for planning, organizing and directing the functions for the nursing department. You will assume the primary role in ensuring the delivery of high quality, efficient nursing care. Supervises Nurse Practitioner, Assistant Director of Clinical Services, Clinical Nurses, and Nurse Techs. In the absence of the Executive Director, you are charged with carrying out the resident care policies established by this facility . Duties and Responsibilities included: Embrace health care's five core values of [MEDICATION NAME], honesty, integrity, respect, and [MEDICATION NAME], and incorporate them into daily job functions; Demonstrate respect and [MEDICATION NAME] in every interaction; Set and monitor achievement of goals and objectives for the nursing department consistent with established philosophy and standards of practice; Recruit and hire a sufficient number of qualified nursing staff to deliver efficient resident care in accordance with the established staffing plan; Establish, implement and continually update competency/skills checklist for nursing staff; Maintain and guide the implementation of current policies and procedures, which reflect adherence to corporate and external regulatory guidelines; Establish and monitor compliance with an effective medical record documentation system; Actively participate in the quality improvement process for the facility; Participate in/or provide in-service education sessions; Schedule, direct and document regular meetings with nursing staff to assure effective communication. 2. Resident #1's record was reviewed. Resident #1 was originally admitted on [DATE] and re-admitted on [DATE] following an acute facility stay with [DIAGNOSES REDACTED]. The physician's orders [REDACTED]. (Full code means that if a person's heart stopped beating and/or they stopped breathing, all resuscitation procedures will be provided to keep them alive, www.munsonhealthcare.org). The Annual Minimum Data Set (MDS), dated [DATE], identified a Brief Interview of Mental Status score of 9, indicative of moderate cognitive impairment. The MDS assessment indicated the resident did not have a condition or chronic disease that may have resulted in a life expectancy of less than 6 months. According to Mayo Clinic, https://www.mayoclinic.org/diseases-conditions/[MEDICAL CONDITION]/symptoms-causes/syc- 360, [MEDICAL CONDITION] is a condition in which you lack enough healthy red blood cells to carry adequate oxygen to your body's tissues . This can happen if: Your body doesn't make enough red blood cells; Bleeding causes you to lose red blood cells more quickly than they can be replaced; Your body destroys red blood cells . Left untreated, [MEDICAL CONDITION] can cause many health problems, such as: . Heart problems. [MEDICAL CONDITION] can lead to a rapid or irregular heartbeat (arrhythmia). When you're anemic your heart must pump more blood to make up for the lack of oxygen in the blood. This can lead to an enlarged heart or heart failure. Death . Losing a lot of blood quickly results in acute, severe [MEDICAL CONDITION] and can be fatal . Review of Resident #1's record revealed: -A History and Physical from a previous facility, dated [DATE], indicated the resident had an episode of black tarry stools and had a [MEDICAL CONDITION] (GIB) status [REDACTED]. -A nursing note, dated [DATE] at 4:02 a.m., indicated Resident #1 was transferred to an acute facility for Altered Mental Status. The note indicated the resident had a critical hemoglobin level of 5.3, the facility was unable to redraw labs, and the resident complained of stomach pain. The corresponding Skilled Nursing Facility/Nursing Facility (SNF/NF) to Hospital Transfer Form, dated [DATE], indicated the reason for transfer was a critical hemoglobin, change in mental status, and stomach pain. -A nursing note, dated [DATE], indicated Resident #1 was in the hospital from [DATE] - [DATE] for pneumonia, [MEDICAL CONDITION], and GI bleed. -A physician order, dated [DATE] at 18:46 (6:46 p.m.), indicated the Advanced Practice Registered Nurse (APRN) had ordered a Complete Blood Count (CBC) and stool for guaiac (a test for blood) once for black tarry stools for one day. There was no documentary evidence of the results of the CBC and guaiac stool that was ordered on [DATE]. There was no documentary evidence the blood and stool samples were collected as ordered on [DATE]. A review of the progress notes did not indicate that Resident #1 had refused the laboratory samples. According to Mayo Clinic, https://www.mayoclinic.org/tests-procedures/complete-blood-count/about/pac- 919, A complete blood count (CBC) is a blood test used to evaluate your overall health and detect a wide range of disorders, including [MEDICAL CONDITION], infection and [MEDICAL CONDITION]. A complete blood count test measures several components and features of your blood, including: Red blood cells, which carry oxygen; White blood cells, which fight infection; Hemoglobin, the oxygen-carrying protein in red blood cells; Hematocrit, the proportion of red blood cells to the fluid component, or plasma, in your blood; Platelets, which help with blood clotting. Abnormal increases or decreases in cell counts as revealed in a complete blood count may indicate that you have an underlying medical condition that calls for further evaluation. -A nursing note, dated [DATE] at 10:53 a.m., indicated Resident #1 had blood in stool and was feeling weak, STAT (immediately) CBC and Basic Metabolic Panel (BMP), and a Kidney, Ureter, and Bladder (KUB) radiography was ordered. The laboratory results, dated [DATE], indicated the BMP results were reported to the facility on [DATE] and the CBC was clotted (could not be used/no result and needed to be recollected). Resident #1 was seen by the APRN on [DATE]. The APRN noted the results of the KUB, BMP, and that the CBC had been clotted. There was no documented evidence a blood sample CBC was recollected. There was no documented evidence of a CBC result for the STAT laboratory ordered on [DATE]. The progress notes for Resident #1 did not indicate that the resident refused the recollection of the CBC. On [DATE] at 2:00 p.m., the Director of Nursing confirmed the CBC on [DATE] was not recollected after the lab results indicated the previous sample had been clotted. When asked what her expectation was, she stated that if a lab was found to be clotted then the physician should be informed and the blood redrawn. -A physician order [REDACTED]. There was no documentary evidence the ordered CBC, on [DATE], was requested or that it was completed. There was no documentary evidence of CBC results collected on [DATE]. The progress notes for Resident #1 did not indicate the resident had refused any laboratory services on [DATE]. Further review of Resident #1's Nursing progress notes indicated the following: -[DATE] 12:42 Resident has c/o vomiting blood on night shift . -[DATE] 07:49 Alerted by CNA .resident unresponsive, respirations erratic, unable to obtain BP .While at bedside respirations ceased, Code called, CPR initiated, 911 called. -[DATE] 09:26 Resident passed away 0827. During an interview, on [DATE] at 2:24 p.m., Staff D, Patient Care Attendant (PCA), stated she was assigned to Resident #1 on [DATE]. She stated she had been called to Resident #1's room by the resident and that the resident showed her that she had vomited brown/black bile. The PCA reported using her personal cell phone to text message the personal cell phone of the assigned Licensed Practical Nurse, (LPN, Staff Member A) to report the emesis. The PCA stated she cleaned up the emesis and went on with her day. Staff D stated the nurse did not respond to the text and that she had not followed up with Staff A. The PCA reported that it, was a very busy day and did not remember informing anyone else that Resident #1 had vomited. She reported that she had been trained to let the nurse know first of emesis then to clean it up after the nurse had time to see it. A photograph was taken of Staff D's personal cell phone that indicated a text was sent to Staff A on [DATE] at 4:11 p.m. that reported Resident #1 had vomited brown/black bile. The sequential text message did not indicate Staff A had responded to the report of Resident #1's emesis. There was no documented evidence in Resident 1's record that Staff A had assessed or noted, on [DATE], Resident #1's emesis of brown/black bile. An interview was conducted on [DATE] at 2:00 p.m., with Staff Member A, Licensed Practical Nurse (LPN). Staff A revealed that Resident #1 had typically been part of her caseload and had been on her assignment during the 7 a.m. - 7 p.m. shift on [DATE]. She reported that the resident had no complaints of pain, nausea, or vomiting for the entire shift. She reviewed the staff schedule for [DATE] and confirmed Staff Member D had been assigned to the unit. Staff A reported getting texts from staff and doctors on her personal phone. When asked if Staff Member D had sent her a text message on [DATE], she reviewed her personal phone and stated no. A progress note dated [DATE] at 22:33 (10:33 p.m.) written by Staff Member I, Licensed Practical Nurse (LPN), indicated that Resident #1 had complained of pain in the abdomen, had refused any medication, and that the MD (medical doctor) was aware. An interview was conducted, on [DATE] at 11:37 a.m., with Resident #1's Power of Attorney (POA). He reported that the day before Resident #1 had expired, a family member was window visiting and that the resident expressed that she was vomiting blood. The family member called the facility office and reported the vomiting. He stated he did not receive any phone calls from the facility regarding the resident's vomiting, and he questioned why nothing was done or why she wasn't sent to the hospital. During an interview, on [DATE] at 2:00 p.m., Staff E, LPN, stated she had worked with the resident on [DATE] and [DATE] and had gotten report from the previous shift nurse but nothing unusual was reported. She stated that the family of Resident #1 had called the Admissions Coordinator, on [DATE], and informed the Coordinator that the resident had vomited blood the night before, which was reported to her, around lunch time by the Coordinator. Staff E stated she went immediately to Resident #1, completed an assessment and found nothing unusual. She stated she had made a note in the chart, contacted the APRN who informed Staff E she was on her way to the facility and would visit with Resident #1. The staff member stated the APRN had arrived at the time of shift change, and she had not received any orders from the provider at that time. The APRN note, dated [DATE], indicated Resident #1 had pointed to her abdomen and informed the APRN that it hurt. The APRN indicated the plan was for a STAT CBC, BMP, and KUB. A handwritten physician order, dated [DATE], indicated a STAT CBC, BMP and KUB for abdomen pain/vomiting. During an interview, in the presence of the DON, on [DATE] at 1:37 p.m., the APRN stated she did not know if the facility redrew Resident #1's CBC on [DATE]. The APRN reported that Staff E had informed her that Resident #1 had vomited on [DATE] and when she saw the resident later that day, the resident wasn't herself so I ordered a STAT CBC, BMP, and KUB. She, felt something was off regarding Resident #1 so she informed Staff Member H, LPN, directly of the STAT diagnostic testing and believed Resident #1's chart was the only chart with new orders. The APRN's expectation was that labs were drawn and that STAT labs were drawn as soon as the lab could do them. The APRN also reported that the guaiac stool (ordered [DATE]) was not obtained. The DON exited the interview, at which time the APRN reported that she does have trouble getting results from the facility on labs and must access the results herself from her home. During a follow-up interview, on [DATE] at 3:01 p.m., the APRN stated her expectation for a clotted blood sample was for the facility to redraw the sample, and the facility did not need another physician order [REDACTED]. The laboratory results for Resident #1 did not include laboratory or radiology results for the STAT CBC, BMP, or KUB, that was ordered on [DATE]. The laboratory tracking sheet for [DATE] indicated no bloodwork. The laboratory result inquiry for Resident #1 did not include test results for STAT CBC or BMP. A review of the Order Summary Report for Resident #1 did not indicate the order, dated [DATE], for a STAT CBC, BMP and KUB had been entered electronically. The Radiology vendor result inquiry list, from ,[DATE] - [DATE], did not include the results for a STAT KUB on [DATE]. There was no documentary evidence the STAT CBC, BMP, or KUB, that was ordered on [DATE], by the APRN was carried out. On [DATE] at 12:10 p.m., the Director of Nursing (DON) stated if a nurse received an order they were to input the order into the computer and if the provider verbally speaks with the nurse the order was placed into the computer by that nurse. She stated her expectation was for the night shift nurses to check charts to make sure orders were in the computer. The DON stated her expectation was when a laboratory and/or radiology diagnostic test was ordered, they were placed on the laboratory/radiology tracking form. During an interview, on [DATE] at 8:25 a.m., the Attending Physician for Resident #1 stated his expectation for following STAT physician orders [REDACTED]. He stated that diagnostic results were reported timely to either himself or the APRN. When asked what his expectation was for a clotted blood sample, he stated he would expect staff to report it to himself or the APRN, and an order would be given to redo the sample. When asked if he was aware of Resident #1 complaining about abdominal pain and an episode of vomiting blood, he stated, yes but it wasn't documented clearly if she had vomited blood, if she had I would have sent her out, and the X-ray was ordered due to abdominal pain. The Attending Physician expressed that a change in condition should be reported to him or his APRN. The Care Plan for Resident #1, created [DATE] and revised on [DATE], indicated the resident had [MEDICAL CONDITION] related to (r/t) GI bleed, hospitalized ,[DATE] -[DATE] for [MEDICAL CONDITION] with hemoglobin of 5.3. The interventions related to this focus instructed staff to obtain and monitor lab/diagnostic work as ordered. Report results to MD and follow up as indicated. The policy titled Notification of Change in Condition, effective [DATE] and revised [DATE], identified that the center was to promptly notify the patient/resident, the attending physician, and the resident representative when there is a change in the status or condition. The procedure included that the nurse was to notify the attending physician and resident representative when there was a: - Significant change in the patient/resident's physical, mental, or psychosocial status; - Need to alter treatment significantly for a new treatment and exacerbation of a chronic condition; - Patient/resident consecutively refuses medication and/or treatment (i.e. two or more times) Interview on [DATE] at 11:33 AM with Staff A, Licensed Practical Nurse (LPN), revealed that she typically was assigned to Resident #1 as a part of her caseload. She reported that she worked on [DATE] and was assigned to the Resident #1's hallway. Staff A reported that as soon as she walked in the building for her shift a Code Blue was being called over the intercom system. She reported that she responded to the Code Blue, and once the resident's code status was confirmed, she assisted with CPR by doing compressions while another staff brought in the crash cart and utilized the AMBU bag. She reported that there was so much blood coming from the resident's mouth and that a staff person attempted to use the facility's suctioning machine on one of 2 crash carts but was unsuccessful as the suctioning machine did not work. Continued interview with Staff A at this time revealed that a second attempt was made at suctioning Resident #1 using the suctioning machine from the second crash cart, which was also unsuccessful as that suction machine also did not work. Staff A reported that when EMS arrived, they took over CPR and attempted to use the facility's suctioning machine and found that it did not work and had to go out to obtain their own suction machine. Interview on [DATE] at 11:43 AM with Staff B, LPN, revealed that on [DATE] he heard the Code Blue and grabbed 1 of 2 crash carts and took it to Resident #1's room. He reported that he was using the AMBU bag and then switched off with Staff A to continue compressions. Staff B reported that facility staff tried to suction the resident with the facility's suction machine, but that the suction machine did not work. He reported that he remembers staff trying to re-attach things on the suction machine to get it to work. He reported that a second suction machine was brought into the room but not sure if it was used. He reported that when EMS arrived on the scene, they attempted to use the facility's suction machine, but that it did not work, so they had to go outside and get their own. Interview on [DATE] at 1:18 PM with the Nursing Home Administrator (NHA) and the Director of Nursing (DON) revealed that when the facility staff found that the resident had no pulse and no respirations on [DATE], CPR was started by the facility staff and the facility Crash Carts were brought to the resident's room. The staff working the code and/or present in the room at the time reported that attempts to suction the resident were unsuccessful as the suction machine on the Crash Carts did not work. When Emergency Medical Services (EMS) arrived on the scene, they attempted to use the facility's suction machine on the Crash Carts but found that they did not work. The NHA reported that she was unsure if EMS obtained their own suction machine. Interview on [DATE] at 2:00 PM with Staff E, LPN revealed that on [DATE] she was in Resident #1's room while facility staff were working the Code Blue. She reported that she observed a staff member try to use the suctioning machine to suction the resident but that the suction machine did not suction at the time. She reported that she later found out that the suctioning was not working. She reported that the tubing was not connected on the suction machine at the time of the code. She also reported that the suction machine could not do the suction due to the [MEDICATION NAME] not being connected to the canister. She reported that another staff person put the machine together, but the secretions were thick and could not be sucked up, as blood was noted to be coming out of Resident #1's mouth. On [DATE] at 2:39 p.m., an interview was conducted with Staff Member J, Certified Nursing Assistant (CNA). The staff member stated she was the one who found Resident #1 on [DATE]. She reported visiting Resident #1 that morning because the day before ([DATE]), she didn't eat and looked pale so I went in that day to see if she would eat, she was lying in bed, breathing, spaced out, looking at the ceiling. The staff member described that once Resident #1 had coded, staff put her on her side to put the board underneath her, she had blood coming out of her mouth. Staff J reported stepping back as the nurses began CPR and witnessed the nurses attempt to suction Resident #1 with two separate suction machines. Inspection on [DATE] at 9:15 AM of Crash Cart 1 with the DON and the ADON revealed that it took 1 minute and 20 seconds to locate an oral airway on the cart. It was noted that 3 large oral airways were enclosed together in a plastic bag. The Emergency Cart Check for the month of [DATE] indicated that there should be 2 oral airways on the cart (1 medium and 1 large) When asked if the airways were sterile the DON stated No! The DON and ADON were asked to present off the crash cart various items that were identified on the Emergency Cart Check List to include to include: O2 cylinder, 15 LPM regulator (1), nasal cannula (2), tank key (1), non-breather masks (2), AMBU bag with mask (2), oral airways (1 large, 1 medium), mouth barrier, nebulizer with mask (2), IV start kit (2), back board (1), B/P cuff & stethoscope, gloves, lubricating jelly, CPR arrest record/nursing note, flash light/batteries, personal protective equipment, personal protective equipment, and Suction Machine Equipment: portable machine (working), suction canister with lid (6 ' and 18 ' tubing & filter-set up, 14 French sx catheter kit (4), [MEDICATION NAME] (1), normal saline bullets (10). The DON and ADON were observed to rummage through 2 gray plastic basins to locate the items. The Cart was observed to be disorganized with several items unbagged or unlabeled. Inspection on [DATE] at 9:30 AM of Crash Cart 2 with the DON and ADON revealed that there was no stethoscope present on the crash cart, only 1 oral airway. The DON and the ADON was again observed to have to rummage through 2 plastic basins to find requested items The Cart contained several items that were unbagged and unlabeled. The DON and ADON reported that the Crash Carts needed to be more organized. Phone Interview on [DATE] at 4:13 PM with the Local County Fire Rescue Battalion Chief revealed that if the facility equipment, such as a suction machine, was available EMS would use the facility equipment. He reported that he would need to speak to the paramedic that attended the visit and get back to the surveyor regarding if the facility suction machine was working. A follow-up phone interview with the Battalion Chief on [DATE] at 8:02 AM revealed that he obtained a report from the paramedic that attended the visit and that she informed him that the suction machine was in the room but staff could not get it working, and there was no tubing available so if they could get the machine working there still was no tubing so she sent someone out to get ours. Interview on [DATE] at 8:25 AM with Resident #1's attending physician revealed that his expectation for the use of lifesaving equipment was that resident equipment should be in good working condition. The attending physician reported that he expected the Crash Carts to be fully stocked with necessary equipment including medications. 3. Review of Resident #6's clinical record revealed an admission date of [DATE]. The Admission Record included [DIAGNOSES REDACTED].#6's had and End stage [MEDICAL CONDITION]. The discharge-return not anticipated Minimum Data Set (MDS), dated [DATE], indicated a Brief Interview of Mental Status (BIMS) score of 15, cognitively intact. The MDS indicated the resident received 5 days of an anticoagulant. The medical record included a physician order, dated [DATE], indicating Full Code. A review of the Order Summary Report included the following physician orders: -ordered [DATE] and end [DATE], PT/INR STAT ([MEDICATION NAME] Time and International Normalized Ratio) one time for monitoring for 1 day; -ordered [DATE] and to start [DATE], PT/INR to be drawn every Monday and Thursday night shift for anticoagulant therapy; -Last PT/INR result in the evening for monitoring, started [DATE]; -started on [DATE], [MEDICATION NAME] Sodium tablet 2 milligram (mg) - give one tablet by mouth one time a day for anticoagulant. A review of the [DATE] Treatment Administration Record (TAR) indicated the staff were ordered to check for bleeding and bruising every (q) shift for monitoring of anticoagulants. The TAR revealed that staff had not documented if Resident #6 had episodes of bleeding and bruising during the day shift on ,[DATE], ,[DATE], ,[DATE]-,[DATE], evening shift on ,[DATE]-,[DATE] and ,[DATE], and during the night shift on ,[DATE] - [DATE]. A review of the [DATE] Medication Administration Record [REDACTED]. The order started on [DATE] and the MAR indicated [REDACTED]. On [DATE] at 3:29 p.m., the Director of Nursing (DON) stated that NA meant not applicable. A review of the laboratory results drawn on [DATE] indicated a critical high [MEDICATION NAME] time of 59.2 seconds whereas the normal range was 9.6 -12.2 and a critical high INR result of 6.09 with a therapeutic range for patients with mechanical prosthetic heart valves or recurrent systemic embolism of 2XXX,[DATE].50. The results indicated the APRN had noted to hold [MEDICATION NAME], inject Vitamin K 2.5 mg Intramuscular (IM), and draw PT/INR on [DATE]. The October Order Summary Report did not include any orders to hold Resident #6's [MEDICATION NAME], to administer Vitamin K, or to draw a PT/INR on [DATE]. The October MAR indicated [REDACTED]. A review of the October MAR, TAR, and laboratory results did not indicate a PT/INR was drawn as ordered on [DATE] and the MAR indicated [REDACTED]. On [DATE] at 1:37 p.m., the APRN stated she had trouble getting lab results from the facility and that last week she did not receive the critical high PT/INR for Resident #6. On [DATE] at 3:01 p.m., the APRN reported that Resident #6 was on a low dosage of [MEDICATION NAME], 2 or 3 mg and if she had been injured, she could have bled heavily. She stated that the critical high INR results were not called to her, she had located the results herself on the computer, then attempted to call the facility and was placed on hold for 10 - 15 minutes. The APRN stated she had spoken with the Assistant DON and when he indicated he was still in the building, she gave him verbal orders to hold that days [MEDICATION NAME], administer Vitamin K and perform a PT/INR draw on [DATE]. She stated she wanted to catch them (staff) before they administered the next dose of [MEDICATION NAME]. The APRN stated she knew the Vitamin K had (TRUNCATED)