Every finding on record at Camelot Rehabilitation at Magnolia Park

Based on observations, interviews, and record reviews, the facility failed to ensure that residents were provided respiratory care, consistent with professional standards of care for 1 (Resident #1) of 2 (Resident #1 and Resident #4) residents investigated for respiratory care, by failing to:Conduct a respiratory assessment per the facility's policy; and Wash hands/ use hand sanitizer after removing soiled gloves and before putting on clean gloves during tracheostomy care.Findings: On 08/18/2026 at 1:30 p.m., a review of the facility's policy titled, Tracheostomy Care with a last reviewed date of 10/2025, read in part, Purpose: The purpose of this procedure is to guide tracheostomy care.Procedure Guidelines: Preparation and Assessment.5. Remove supplemental oxygen mask from tracheostomy. 7. A. Measure residents' oxygen saturation with pulse oximeter. B. Listen to lung sounds with a stethoscope.9. Remove old dressings. Pull soiled glove over dressing and discard into appropriate receptacle. 10. Wash hands. Site and Stoma Care: 1. Apply clean gloves.Review of Resident #1's EMR (Electronic Medical Record) revealed she was admitted to the facility on [DATE] with diagnosis that included, but, were not limited to anoxic brain damage, dysphagia, acute respiratory failure with hypoxia, and tracheostomy status.On 08/18/2026 at 9:10 a.m., an observation was made of S3RT performing tracheostomy care on Resident #1. S3RT removed the supplemental oxygen from Resident #1 and then removed the old dressing and her soiled gloves and discarded them. S3RT then put on clean gloves. During tracheostomy care, S3RT did not measure Resident #1's oxygen saturation with a pulse oximeter. S3RT also, did not listen to Resident #1's lung sounds with a stethoscope. S3RT did not wash her hands or use hand sanitizer after she removed her soiled gloves and before she re-gloved. After tracheostomy care was completed, S3RT stated that she did not wash her hands or use hand sanitizer after removing her soiled gloves and before she re-gloved. S3RT stated she did not have to wash her hands or use hand sanitizer unless she was performing another task.On 08/18/2026 at 12:15 p.m., an interview was conducted with S1DON who was responsible for the facility's infection control program. S1DON stated that there is only one policy and procedure for respiratory care. S1DON stated that all employees should follow the policy and procedure for respiratory care, including respiratory therapists. A review was conducted with S1DON of the policy and procedure for respiratory care. S1DON confirmed that S3RT should have conducted a respiratory assessment after she removed supplemental oxygen from Resident #1. S1DON confirmed that S3RT should have checked oxygen saturation with a pulse oximeter and listened for breath sounds with a stethoscope after she removed the supplemental oxygen from Resident #1 per the facility's policy. S1DON also confirmed that after S3RT removed her soiled gloves, she should have washed her hands or used hand sanitizer and then put on clean gloves per the facility's policy.

Based on observation, interview and record review, the facility failed to maintain appropriate infection prevention and control practices, by failing to ensure staff utilized Enhanced Barrier Precautions (EBP) by wearing a gown when administering medications via enteral feeding tube for 1(Resident #4) of 2 (Resident #1 and Resident #4) residents observed for infection prevention. Findings:On 08/17/2026, a review of the facility's policy titled Enhanced Barrier Precaution. with a review date of 10/2025, read in part: Enhanced Barrier Precautions (EBP) expand the use of personal protective equipment and refer to the use of gowns and gloves during high-contact resident care activities. Examples of Enhanced-Based Precaution resident:.Indwelling medical devices.feeding tubes. Enhanced Barrier Precautions are indicated during: Device care or use:. feeding tube.A review of Resident #4's electronic health record revealed an admission date of 06/14/2021, with diagnoses, that included, but were not limited to, gastrostomy status, aphasia, and dysphagia.A review of Resident #4's physician orders revealed an order written on 07/26/2024 which read in part: Implement and maintain enhanced barrier precautions when performing high contact care activities. A review of Resident #4's current care plan revealed the following: Acute for Enhanced Barrier Precautions.resident has an indwelling medical device. Interventions: Provide patient standard precautions using gowns and gloves during. device care or use. On 08/17/2026 at 3:40 p.m., an observation was made of S2LPN administering medications to Resident #4 via PEG (Percutaneous Endoscopic Gastrostomy) tube. S2LPN was not wearing a gown. On 08/17/2026 at 3:44 p.m., an interview was conducted with S2LPN. S2LPN confirmed Resident #4 was on EBP. She also confirmed that she was not wearing a gown when she administered medications to Resident #4 via her PEG tube and stated she should have. On 08/18/2026 at 3:55 p.m., an interview was conducted with S1DON, who is responsible for the facility's infection control program. S1DON confirmed that S2LPN should have worn a gown when she administered medications to Resident #4 via PEG tube because the resident was on EBP.

Based on observations, interviews, and record review, the facility's staff failed to maintain appropriate infection prevention and control practices, by failing to appropriately dispose of medical waste and perform appropriate hand hygiene during the provision of care and services for 1 (Resident #1) of 4 sampled residents. Findings:On 08/04/2026, a review of the facility's policy titled, Handwashing/Hand Hygiene with a revised date of 12/22/2023, read in part: Policy Statement: This facility considers hand hygiene the primary means to prevent the spread of infections. Policy Interpretation and Implementation. 2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors.7. Use an alcohol-based hand rub containing at least 60-90% (percent) alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations.m. After removing gloves.9. The use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections.Applying and Removing Gloves 1. Perform hand hygiene before applying non-sterile gloves.4. Hold the removed glove in the gloved hand and remove the other glove by rolling it down the hand and folding it into the first glove. 5. Perform hand hygiene.On 08/04/2026, a review of the facility's policy titled Bedpan/Urinal, Offering/Removing with a last revised date of 05/2013, read in part: After assisting the Resident.7. Empty the bedpan or urinal into the commode. Flush the commode.A review of Resident #1's clinical records revealed she was admitted to the facility on [DATE] with diagnoses that included, but were not limited to diffuse traumatic brain injury with loss of consciousness of unspecified duration; absence epileptic syndrome, not intractable, without status epilepticus; obstructive hydrocephalus; chronic respiratory failure with hypoxia; tachycardia, and neuromuscular dysfunction of bladder. Further review of Resident #1's clinical records revealed she required a tracheostomy, an indwelling urinary catheter, a feeding tube, and wound care for a wound on her right ear.A review of hospital records revealed Resident #1 was admitted to the hospital on [DATE] and again on 07/18/2026 with diagnoses that included a urinary tract infection each time requiring antibiotic treatment.On 08/04/2026 at 11:47 a.m., an observation was made of S3CNA emptying Resident #1's urine from the collection drainage bag using a clear plastic urinal she retrieved from Resident #1's bathroom. She emptied the contaminated urinal in the resident's bathroom toilet, then S3CNA rinsed the urinal with water and immediately emptied the rinse water into the resident's bathroom sink. After placing the urinal in a clear plastic bag in the bathroom, S3CNA washed her hands in the contaminated sink. S3CNA confirmed pouring the water from the urinal into the resident's bathroom sink and stated she should have poured it in the toilet. She did not make an attempt to clean the sink.On 08/04/2026 at 11:54 a.m., S4TN attempted to wash her hands in Resident #1's contaminated sink before beginning wound care on Resident #1's right ear. S3CNA was immediately prompted by the surveyor to call housekeeping to clean the sink before it was used.On 08/04/2026 at 1:35 p.m., an interview was conducted with S1DON/IC who was responsible for the facility's infection control program. S1DON/IC stated that Resident #1 was extremely immunocompromised. She stated that after S3CNA rinsed the urinal, she should have poured the water into the toilet and flushed it. She acknowledge that the sink was contaminated and stated that housekeeping would need to sanitize it after it became contaminated. 08/04/2026 at 3:34 p.m., an observation was made of S2LPN administering medication through Resident #1's feeding tube. S2LPN was observed changing her gloves after cleaning the resident's feeding tube site and again after checking placement before she administered the medication. She did not sanitize her hands between the glove changes. S2LPN confirmed she did not perform hand hygiene between her glove changes and stated she should have.On 08/04/2026 at 4:00 p.m., an interview and review of the facility's hand hygiene policy was conducted with S1DON/IC. She confirmed that S2LPN should have sanitized her hands before and after glove use.

Based on observations, record review, and staff interviews, the facility failed to ensure that services were provided to meet professional standards of quality for safe administration of medications evidenced by the staff nurse leaving 20 medications unattended at the bedside for 1 (#74) out of 32 initial pool residents.Findings:Review of Resident #74's electronic medical record revealed she was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, gout, epilepsy, peripheral vascular disease, and diabetes mellitus.A review of Resident #74's Minimum Data Set (MDS) dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition.Review of Resident #74's March 2026 MAR (Medication Administration Record) revealed S6ALPN had initialed that the following medications had been administered on the morning of 03/02/2026: Amiodarone HCl (hydrochloride) oral tablet 200 mg (milligram); Ascorbic Acid tablet 500 mg; Cholecalciferol oral tablet 50 mcg (microgram); Fexofenadine HCl oral tablet 60 mg; Furosemide oral tablet 40 mg; Multivitamin oral tablet; Omeprazole capsule delayed release 40 mg; Oxybutynin Chloride oral tablet extended release 15 mg; Zinc sulfate 220 mg; Allopurinol oral tablet 100 mg; Colace oral capsule 100 mg; Cranberry oral tablet 450 mg; Duloxetine HCl oral capsule delayed release particles 60 mg; Eliquis oral tablet 5 mg; Ferrous Gluconate oral tablet 324 mg; Levetiracetam oral tablet 500 mg; Metformin HCl oral tablet 500 mg; Mucinex oral tablet extended release 600 mg; Oxcarbazepine oral tablet 150 mg; and Senna Plus oral tablet 8.6-50 mg.On 03/02/2026 at 10:02 a.m., an observation was conducted of Resident #74's room that revealed 20 oral medications, in the forms of tablets and capsules, were observed on a small tray resting on Resident's 74's chest. No nurse was present in the resident's room. Resident #74 stated the nurses always left the medications with her for her to take herself.On 03/02/2026 at 10:05 a.m., S1DON entered Resident #74's room and observed the 20 oral medications, in the forms of tablets and capsules, on a small tray resting on the resident's chest.On 03/02/2026 at 10:07 a.m., and interview was conducted with S1DON who confirmed medications should not have been left unattended in Resident #74's room. Review of Resident #74's electronic medical record failed to reveal documentation that Resident #74 had been assessed or authorized to self-administer mediations.On 03/04/2026 at 11:49 a.m., another interview and record review was conducted with S1DON. S1DON reviewed Resident #74's March 2026 MAR and confirmed the 20 medications listed above had been documented as administered and were left unattended at the resident's bedside.S1DON confirmed all medications should be administered to the resident before the nurse leaves the resident's room. S1DON also confirmed Resident #74 had not been assessed or authorized to self-administer mediations.

Based on observations, interviews, and policy and procedure reviews, the facility failed to:1. Maintain a clean and sanitary kitchen; and 2. Store food in accordance with professional standards for food service safety;This had the potential to affect 101 residents who ate meals prepared from the facility's kitchen. The facility's census was 125.Findings: Review of the facility's policy, Sanitization, with a last review date of 10/13/2025, revealed in part: Policy Statement: The food service area shall be maintained in a clean and sanitary manner. 1. All kitchen, kitchen areas and dining areas shall be kept clean, free from litter and rubbish and protected from rodents, roaches, flies and other insects. 2. All utensils, counters, shelves and equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosion, open seams, cracks and chipped areas that may affect their use or proper cleaning. Seals, hinges and fasteners will be kept in good repair. 3. All equipment, food contact surfaces and utensils shall be washed to remove or completely loosen soils by using manual or mechanical means necessary to sanitize using hot water and/ or chemical sanitizing using solutions. Review of the facility's policy, Food Receiving and Storage, with a last review date of 10/13/2025, revealed in part: Foods shall be received and stored in a manner that complies with safe food handling practices. 6. Dry foods that are stored in bins will be removed from original packaging, labeled and dated ( use by date). Such foods will be rotated using a first in - first out system. An initial tour of the kitchen was conducted on 03/02/2026 at 08:50 a.m. with S2KS and revealed the following:1. Inspection of the Culitek Tilt Skillet revealed a metal gas pipe and shut off valve covered in a yellow, black, greasy, sticky substance. 2. Inspection of the flooring around and beneath the Culitek Tilt Skillet also revealed a black sticky substance with crumbling debris. 3. Dry storage area revealed a clear plastic container with white granulated substance inside. Inspection of the container revealed no label indicating what was in the container and use by date. 4. The reach-in refrigerator contained 16 individual single serve containers of Jello. Upon inspection, the expiration date on all 16 containers read 02/21/2026. Immediately after conducting the kitchen observations, an interview was conducted with S2KS. S2KS confirmed the metal gas pipe and shut off valve were covered in a yellow, black, greasy, sticky substance and should have been cleaned. S2KS confirmed the flooring around and beneath the tilt skillet had a black sticky substance with crumbling debris and should have been cleaned. S2KS confirmed the clear plastic container located in the dry storage area contained a white granulated substance and was not labeled with name and use by date and should have been labeled with name and use by date. S2KS confirmed the reach-in refrigerator contained 16 single serve containers of Jello with an expiration date of 02/21/2026 and these food items should have been discarded on their expiration date.

Based on record review and interviews, the facility failed to ensure individual financial records were provided to the resident through quarterly statements for 1 (Resident #68) out of 1 (Resident #68) resident investigated for personal funds.Findings:Review of Resident #68's electronic medical record revealed she was admitted to the facility on [DATE].A review of Resident #68's Minimum Data Set (MDS) dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition.A review of Resident #68's admission Record under the Contacts section revealed Resident #68's name, contact type: Responsible Party (RP), and relationship: self.On 03/02/2026 at 11:07 a.m., an interview was conducted with Resident #68. Resident #68 stated she did not receive quarterly statements for her personal funds account.On 03/04/2026 at 8:50 a.m., an interview was conducted with S5BM. S5BM stated financial statements for personal fund accounts were sent out quarterly. She stated if a resident is his or her own RP then the statement is given to the resident. S5BM confirmed Resident #68 is her own RP. S5BM could not provide any documentation or evidence that quarterly statements were given to Resident #68 for the following statement dates: March 31, 2025; June 30, 2025; and September 30, 2025.

Based on record review and interview, the facility failed to ensure the resident's Minimum Data Set (MDS) assessment was completed accurately for 3 (Resident #12, Resident # 74, and Resident #91) out of 37 sampled residents, as evidenced by:Inaccurate coding of administration of Insulin injections and orders for insulin in Section N- Medications for Resident #12 and Resident #74, and Inaccurate coding for serious mental illness in Section A for Resident #91.Findings:Resident #12 Review of Resident #12's EHR (Electronic Health Record) revealed he was admitted to the facility on [DATE] with diagnoses including diffuse traumatic brain injury with loss of consciousness, encephalopathy, gastrostomy status, tracheostomy status, dysphagia, aphasia and persistent vegetative state. Further review of the record revealed no evidence the resident was diabetic and receiving insulin. Review of Resident #12's February 2026 eMAR (electronic Medication Administration Record) revealed the resident was not administered insulin. Review of Section I of Resident #12's quarterly MDS (Minimum Data Set) assessment dated [DATE] included resident's active diagnoses which did not include diabetes or use of insulin. Further review of Resident #12's quarterly MDS assessment Section N, revealed the resident was coded as receiving 7 days of insulin injections. On 03/03/2026 at 12:45 p.m., an interview was conducted with S5LPN. S5LPN stated she was familiar with Resident #12 and confirmed the resident did not have diabetes and had never received insulin injections. On 03/04/2026 at 3:16 p.m., an interview was conducted with S4MDS. S4MDS confirmed she completed Sections I and N on Resident #12's quarterly MDS assessment dated [DATE]. After reviewing Resident #12's EHR, S4MDS confirmed the resident had not received insulin injections and inaccurately coded Section N. Resident #74 A review of Resident #74's electronic health record (EHR) revealed she was admitted to the facility on [DATE] with a diagnosis that included in part, type 2 diabetes mellitus. A review of Resident #74's February 2026 Physician orders and Medication Administration Record (MAR) revealed the resident did not receive insulin or have insulin order changes at any time in the month of February 2026. A review of Resident #74's Quarterly MDS with an Assessment Reference Date (ARD) of 02/17/2026 revealed the following in part: Section N0350 Insulin. A. Insulin Injections. Record the number of days that insulin injections were received during the last 7 days. (Enter days = one). B. Orders for insulin. Record the number of days the physician changed the resident's insulin orders during the last 7 days. (Enter days = one). On 03/04/2026 at 4:30 p.m., an interview and review of Resident #74's EHR was conducted with S1DON. She confirmed that Resident #74 did not receive an injection of insulin nor have any changes to an insulin order in the 7 days prior to the Quarterly MDS, ARD of 02/17/2026. She further confirmed that the coding for Section N0350, A and B was inaccurate. Resident #91 Review of Resident #91's EHR (Electronic Health Record) revealed he was admitted to the facility on [DATE] and had diagnoses including bipolar disorder, unspecified psychosis due to a substance or known physiological condition, and major depressive disorder. Review of Section A of Resident #91's significant change MDS (Minimum Data Set) assessment dated [DATE] revealed the following in part: Section A1500: Preadmission Screening and Resident Review PASRR -Is the resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition? Response- No. Section A1510. Level II Preadmission Screening and Resident Review (PASRR) Conditions disabled due to answer of no in section A1500. Review of Resident #91's care plan revealed the following in part: The resident has been identified as having PASRR positive related to severe mental illness. Review of Resident #91's EHR revealed the resident had a PASRR Level II Evaluation Summary and Determination notice dated 11/18/2025. Further review of the notice revealed following statement: Evaluation Placement Recommendations - The individual has a serious mental illness and is recommended nursing home admission. On 03/04/2026 at 9:48 a.m., an interview was conducted with S3MDS who confirmed she completed Resident #91's MDS assessment dated [DATE]. S3MDS confirmed Resident #91 had diagnoses of bipolar disorder, unspecified psychosis due to a known physiological condition, and major depressive disorder. She also confirmed that these diagnoses are considered serious mental illnesses. Resident #91's MDS assessment dated [DATE] was reviewed with S3MDS. She confirmed that the resident's MDS assessment was coded incorrectly and Section A1500 should have been coded as yes for serious mental illness.

Based on record review and interview, the facility failed to ensure an effective Quality Assurance and Performance Improvement (QAPI) program was developed, implemented, and/or maintained in an effective and comprehensive manner. The facility failed to maintain documentation of evidence of its ongoing facility QAPI program. This deficient practice has the potential to affect 133 residents residing in the facility. Findings: Review of a facility policy on 02/04/2025 at 3:00 PM titled, QAPI Program (unknown original date documented) with a revised date of 12/2016, revealed the following in part .all employees will participate in ongoing QAPI efforts .the QAPI program has been developed to incorporate the continuous quality improvement and quality assurance processes consisting of ongoing analysis of clinical data and program results, identifying and prioritizing opportunities for improvement, implementing interventions, and evaluating the effectiveness of those intervention on the quality of care and services. On 02/04/2025 at 11:40 AM and 2:45 PM, the surveyor requested that S2DON (Director of Nursing) provide the facility's QAPI Program information. On 02/04/2025 at 3:12 PM, S2DON revealed in an interview that she could not locate the facility's QAPI binder, which had evidence of the facility's ongoing QAPI program. On 02/04/2025 at 3:45 PM, S2DON revealed in an interview that she did not know what happened to the QAPI binder and believed it was misplaced. On 02/04/2025 at 4:15 PM, S2DON stated in an interview that she could not provide evidence of the facility's QAPI program due to the QAPI binder being misplaced.

Based on record review and interview, the facility failed to provide documentation of the Quality Assurance and Performance Improvement (QAPI) program that addresses the facility's performance improvement activities and projects. The facility failed to provide evidence of the number and frequency of improvement projects conducted, which addressed the scope and complexity of the facility's provided services. This deficient practice had to potential to affect 133 residents residing in the facility. Findings: Review of a facility policy on 02/04/2025 at 3:00 PM titled, QAPI Program (unknown original date) with a revised date of 12/2016 revealed the following in part .all employees will participate in ongoing QAPI efforts .the QAPI program has been developed to incorporate the continuous quality improvement and quality assurance processes consisting of ongoing analysis of clinical data and program results, identifying and prioritizing opportunities for improvement, implementing interventions, and evaluating the effectiveness of those intervention on the quality of care and services . The facility was unable to present any documented evidence of activities, projects, frequency of improvement projects addressing services for the Quality Assurance and Performance Improvement (QAPI) program during the survey. On 02/04/2025 at 3:12 PM, S2DON (Director of Nursing) revealed in an interview that she could not locate the facility's QAPI binder which had evidence of the facility's ongoing QAPI program in place. On 02/04/2025 at 4:15 PM, S2DON stated in an interview that she could not provide evidence of the facility's QAPI program due to the QAPI binder being misplaced.

Based on record review and interview, the facility failed to: 1. Provide evidence that Quality Assessment and Assurance (QAA) committee met at least quarterly and as needed; and 2. Provide evidence that ensured the QAA committee was composed of at a minimum: the DON (Director of Nursing, Medical Director or his/her designee, the Infection Preventionist (IP), and at least three other staff, one of whom must be the facility's administrator, owner, board member, or other individual in a leadership role who has knowledge of facility systems and the authority to change those systems. This deficient practice had to potential to affect 133 residents residing in the facility. Findings: Review of a facility policy on 02/04/2025 at 3:00 PM titled, QAPI Program (unknown original date) with a revised date of 12/2016, revealed the following in part .all employees will participate in ongoing QAPI efforts .the QAPI program has been developed to incorporate the continuous quality improvement and quality assurance processes consisting of ongoing analysis of clinical data and program results, identifying and prioritizing opportunities for improvement, implementing interventions, and evaluating the effectiveness of those intervention on the quality of care and services . The facility was unable to present any documented evidence of the facility QAA committee meetings. The facility was unable to present any documentation of who attended the facility QAA committee meetings. On 02/04/2025 at 3:12 PM, S2DON revealed in an interview that she could not locate the facility's QAPI binder which had evidence of the facility's ongoing QAPI program and evidence of QAA committee meeting information. On 02/04/2025 at 4:15 PM, S2DON stated in an interview that she could not provide evidence of the facility's QAPI program due to the QAPI binder being misplaced.

Based on record review and interview, the facility failed to ensure a residents with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing and prevent the development of new pressure ulcers for 2 (#95 and #108) out of 6 (#8, #10, #53, #95, #108 and #112) residents investigated for pressure ulcers by: 1. Filing to perform weekly wound assessments for pressure ulcers for Resident # 95; and 2. Failing to conduct accurate skin assessments for Resident # 108 Resident #95 Review of Resident #95's electronic health record revealed an admitted [DATE] with diagnoses which included, but were not limited to, Morbid Severe Obesity Due To Excess Calories, Chronic Diastolic Congestive Heart Failure, Cirrhosis Of Liver, and Diarrhea. Review of Resident #95's Nurses' Notes dated 01/15/2025 revealed in part: Resident admitted from LGMC .Wound care assessment done .Resident noted having stage 3 pressure ulcer to sacral cornu .measuring 1.5cm (centimeter) x 1cm x 0.1cm .Stage 3 pressure ulcer to medial sacrum .measuring at 1 X 0.5 X 0.1 .Stage 3 pressure to right buttocks .measuring 1.5cm x 1cm x 0.1cm On 02/04/2025 a review of Resident #95's electronic health record review was conducted, it revealed the last wound assessment for Resident #95's three pressure ulcers was dated on 01/15/2025. On 02/04/2025 at 10:28 AM, an interview was conducted with S2DON (Director of Nursing). S2DON confirmed that the only evidence she could find of Resident #95's 3 pressure ulcer wound measurements were in a nurses' note dated 01/15/2025. S2DON stated wound measurements should be conducted weekly and documented in the electronic health record. 39319 Patient #108 Review of Resident #108 clinical record revealed he was admitted to the facility on [DATE]. His diagnoses include in part, Cerebral Infarction; Type 2 Diabetes mellitus; Chronic respiratory failure; Unspecified Severe protein-calorie malnutrition; Dysphagia; Gastrostomy and tracheostomy status. Pressure ulcer of other site, Stage 3. Review of Resident #108's annual MDS (Minimum Data Set) dated 06/20/2024 revealed in part, BIMS (Brief Interview of Mental Status) not conducted due to resident rarely/never understood. He was total dependence with two+ person physical assist with bed mobility. Further review revealed under letter M: Skin Conditions, the resident wasn't coded for having an unstageable pressure ulcer. Review of Resident #108's quarterly MDS (Minimum Data Set) dated 08/26/2024 revealed under letter M: Skin Conditions, the resident was coded for having an unstageable pressure ulcer. Review of the resident's Wound Evaluation dated 08/09/24 read, Pressure-Unstageable (Slough and/or eschar). Body location: left elbow. New (7 days old). Acquired: in-house acquired.-Unstageable Dimensions: 6.25cm (centimeters) x 2.5cm x 2.5cm .wound bed-100% eschar .exudate: none . Review of Resident #108's skin assessment dated [DATE] revealed the resident's had no new wounds. On 02/04/2025 at 2:15PM, an interview was conducted with S2DON (Director of Nursing). She confirmed skin assessments should be conducted by the Treatment Nurse weekly. She also confirmed that the CNAs (Certified Nursing Assistant) are also responsible for assessing a resident's skin during bathing. She confirmed that Resident #108's left elbow pressure ulcer should have been identified before it had become an unstageable wound.

Based on record review, observations and interviews the facility failed to provide a safe, clean, comfortable, and homelike environment. This was evidenced by: 1. Observations made on 02/05/2025 on Hall U of multiple rooms walls with damaged sheetrock, unfinished sheetrock repair, and a call light unit detached from wall; 2. Housekeeping staff failing to clean and sanitize room [ROOM NUMBER] on Hall U after a resident was discharged to the hospital; 3. Observation made on 02/02/2025 at 2:50 PM of a light fixture that was not working properly in room [ROOM NUMBER] on Hall Y; 4. Observation made on 02/02/2025 at 1:07 PM of a call light box that was detached from the wall in room [ROOM NUMBER] on Hall Y; and 5. Observation made on 02/02/2025 at 2:01 PM of an electrical outlet cover plate that was bent away from wall making electrical wiring visible in room [ROOM NUMBER] on Hall Y. Findings: Review of the facility's policy, Maintenance Service with a revised date 10/30/24 revealed the following in part, Policy Statement: Maintenance service shall be provided to all areas of the building, grounds, and equipment. Policy Interpretation and Implementation: 1. The Maintenance Department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times. 2. Functions of maintenance personnel include, but are not limited to: .b. Maintaining the building in good repair and free from hazards .d. Maintaining the heat/cooling system, plumbing fixtures,, wiring, etc., in good working order .i. Providing routinely scheduled maintenance service to all areas .7. The Maintenance Director is responsible for maintaining the following records/reports. Inspection of building, work order request . On 02/04/2025 at 11:00 AM, an observation was made on Hall U. The following concerns were identified: Rm 1 -sheetrock damage to outer room wall Rm 2 -unpainted sheetrock repair on outer bathroom wall Rm 3 -Bed 1--sheetrock damage to right wall next to bed Bed 2-- sheetrock damage to outer room wall--hole to lower part of wall next to the air conditioner Rm 4 -room still not cleaned Rm 5-call bell detached from wall Rm 6 -sheetrock damage to outer wall next to bed Rm 7 -Bed 1 -unpainted sheetrock repair to outer bathroom wall next to bed Rm 8 -Bed 2 -sheetrock damage to wall at the head of the bed On 02/04/2025 at 11:20 AM, an observation of room [ROOM NUMBER] was conducted with S10Housekeeping Supervisor. The resident's bed cover was noted on the bed. Items were noted on the adjacent bed and trash was noted in the trash can. S10Housekeeping Supervisor confirmed that the room had not been cleaned and sanitized after the resident was discharged from the facility on 01/28/2025 On 02/04/2025 at 11:30AM, an interview was conducted with S3Maintenance Supervisor. He confirmed that the above findings with the rooms were all issues and should have been taken care of. 50950 On 02/02/2025 at 2:50 PM, an observation was made of room [ROOM NUMBER]. The light above the bed did not turn on when the cord attached to the light fixture was pulled. On 02/03/2025 at 12:05 PM, a concurrent observation and interview was conducted with S3 Maintenance Supervisor. S3 Maintenance Supervisor observed that the light would not turn on. S3 Maintenance Supervisor confirmed the light should not be in this condition and should be working properly. On 02/02/2025 at 1:07 PM an observation was made of room [ROOM NUMBER]. The call light box was detached from the wall and was hanging by a red wire. A hole was observed in the wall where call light should have been attached. On 02/03/2025 at 11:29 AM, a concurrent observation and interview was conducted with S3 Maintenance Supervisor. S3 Maintenance Supervisor observed the call light box detached and hanging off of the wall. S3 Maintenance Supervisor confirmed the call light box should not have been detached and hanging from wall. On 02/02/2025 at 2:01 PM, an observation was made of room [ROOM NUMBER]. The electrical outlet cover plate covering the electrical outlet was observed next to the resident's bed. The cover plate was bent and protruding off of the wall. A hole in wall was observed with wiring exposed behind the cover plate. On 02/03/2025 at 11:27 AM, a concurrent observation and interview was conducted with S3 Maintenance Supervisor. S3 Maintenance Supervisor observed the bent electrical outlet cover plate. S3 Maintenance Supervisor confirmed the electrical outlet cover plate should not have been bent and protruding from the wall.

Based on observation, interview, and record review the facility failed to ensure drugs and biologicals used in the facility were stored in accordance with currently accepted professional principles. The facility failed to ensure expired medications were not available for administration to residents in 1 (Med Room C) of 4 (Med Room A, Med Room B, Med Room C, and Med Room D) medication rooms. This deficient practice had to potential to affect 133 residents residing in the facility. Findings: Review of a facility policy on 02/04/2025 at 12:38 PM titled Storage of Medications (unknown original date) with a revised date of 04/2019, revealed the following in part . the facility stores all drugs and biologicals in a safe, secure, and orderly manner . 3. The nursing staff is responsible for maintaining medication storage and preparation areas are in a safe manner . 5. Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed . Observation on 02/02/2025 at 2:50 PM, of Med Room C with S9LPN (Licensed Practical Nurse), revealed the following expired items: 1. Forty-Nine (49) 0.9% Sodium Chloride 10ml pre-filled flushes (normal saline flush) with an expiration date of 08/2024. 2. Forty-Nine (49) 0.9% Sodium Chloride 10ml pre-filled flushes (normal saline flush) with an expiration date of 09/2024. 3. Ten (10) 0.9% Sodium Chloride 10ml pre-filled flushes (normal saline flushes) with an expiration date of 11/2024. 4. Two (2) Heparin 500usp/5ML (100usp units/ml in 0.9% Sodium Chloride) 6ml prefilled syringes with an expiration date of 11/2023. 5. Seven (7) Heparin 50usp units/5ml (10usp units/ml) in 0.9% Sodium Chloride (5ml pre-filled in 12ml syringe) with an expiration date of 07/2022. 6. Twenty-Eight (28) Heparin 50usp units/5ml (10usp units/ml) in 0.9% Sodium Chloride (5ml pre-filled in 12ml syringe) with an expiration date of 01/2023. 7. Ten (10) Heparin 50usp units/5ml (10usp units/ml) in 0.9% Sodium Chloride (5ml pre-filled in 12ml syringe) with an expiration date of 02/2024. 8. Five (5) Heparin 50usp units/5ml (10usp units/ml) in 0.9% Sodium Chloride (5ml pre-filled in 12ml syringe) with an expiration date of 06/2024. 9. One (1) Heparin 50usp units/5ml (10usp units/ml) in 0.9% Sodium Chloride (5ml pre-filled in 12ml syringe) with an expiration date of 07/2024. On 02/02/2025 at 2:58 PM, S9LPN confirmed in an interview that the above Normal Saline flushes and Heparin pre-filled syringes were expired. S9LPN stated that there should not have been any expired medications available. S9LPN stated the expired Normal Saline flushes and Heparin pre-filled syringes should have been discarded. Interview of S2DON (Director of Nursing) on 02/04/2025 at 11:30 AM, confirmed that Med Room C should not have had expired medications available for usage, and should have been disposed of properly and were not.

Based on observations, and interview, the facility failed to store food in accordance with professional standards for food service, and ensure sanitary conditions were maintained in the kitchen as evidenced by: 1. opened food items in the walk in cooler not labeled with the date and time; and 2. expired foods in the dry storage area. This deficient practice had the potential to affect the 116 residents who consumed food from the kitchen. Findings: On [DATE], a review of the facility's policy titled, Food Receiving and Storage, with a last revision date of [DATE], last reviewed date of [DATE], revealed in part . Policy Statement: Foods shall be received and stored in a manner that complies with safe food handling practices. Policy Interpretation and Implementation: .6. Dry foods that are stored in bins will be removed from original packaging, labeled and dated (use by date). Such foods will be rotated using a first in-first out system. 7. All food stored in the refrigerator or freezer will be covered, labeled and dated (use by date) . On [DATE] at 8:30 AM, a tour of the facility's kitchen was conducted with S1DS (Dietary Supervisor), who stated that she was responsible for the day to day management of the kitchen. On [DATE] at 8:41 AM, an observation of the walk in cooler was conducted with S1DS and revealed the following items were opened and not labeled with the date and time they were opened nor the use by date: 1. large container of Italian dressing 2. large container of thousand island dressing 3. large container of mayonnaise 4. large container of mustard 5. large container of pickles 6. gallon of milk 7. carton of almond milk 8. carton of soy milk 9. carton of pineapple juice 10. carton of cranberry juice 11. carton of apple juice 12. container of au jus prep S1DS confirmed the food items listed above were opened, and not labeled with the date and time they were opened nor the use by date, and should have been. On [DATE] at 8:55 AM, an observation of the dry storage room was conducted with S1DS and revealed the following: a plastic gallon bag with an opened bag of powdered lemonade dated [DATE], a plastic gallon bag with an opened bag of fudge mix dated [DATE], and a plastic gallon bag with an opened bag of powdered chocolate pudding dated [DATE]. S1DS confirmed the food items were expired and should have been removed from the dry storage area and discarded.

Based on observations, interviews, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe and sanitary environment to help prevent the development and transmission of infection. The facility failed to ensure proper PPE (Personal Protective Equipment) was worn while proving care for 3 (#53, #95, #118) out of 36 sampled residents. Findings: Resident #95 On 02/04/2025, a review of the facility's policy titled, Enhanced Barrier Precautions Cheat Sheet with a last reviewed date of 10/30/2024 read in part, Examples of Enhanced-Based Precaution Residents: Wounds-includes .pressure ulcers .indwelling medical devices .feeding tubes .Enhanced-Based Precautions are indicated during: .changing briefs or assisting with toileting .Implementation: gowns and gloves are used during high-contact sessions . Review of Resident #95's electronic health record revealed she was admitted to the facility on [DATE] with diagnoses that included in part, congestive heart failure, cirrhosis of liver, and pressure ulcer of sacral region, stage 3. Review of Resident #95's physician's orders revealed an order dated 01/22/2025 that read, Nursing Intervention: Implement and maintain enhanced barrier precautions when performing high contact care activities. On 02/03/2025 08:08 AM An observation was made of a sign posted on Resident #95's room door indicating she was EBP and staff should wear a gown as a part of their PPE. On 02/03/2025 at 08:22 AM, a concurrent observation and interview was conducted with S11CNA (Certified Nursing Assistant). S11CNA was observed not wearing a gown while changing the Resident #95's incontinence brief. S11CNA confirmed that Resident #95 was on EBP and failed to wear a gown while providing resident care. On 02/03/2025 at 9:22 AM, an interview was conducted with S2DON (Director of Nursing). She confirmed a gown and gloves must be donned when providing high contact activities such as changing a resident's incontinence brief if a resident is indicated for EBP. Resident # 118 Review of Resident #118's electronic health record revealed he was admitted to the facility on [DATE] with diagnoses that included in part, muscle wasting and atrophy, severe protein calorie malnutrition, and gastrostomy status. Review of Resident #118's physician's orders revealed an order dated 04/04/2025 that read, Nursing Intervention: Implement and maintain enhanced barrier precautions when performing high contact care activities. On 02/03/2025 at 3:41 PM, a concurrent observation and interview was conducted with S12LPN (Licensed Practical Nurse). S12LPN arrived in Resident #118's room to change his incontinence brief. S12LPN left Resident #118's room and obtained an incontinence brief and gloves and returned to Resident #118's room to provide care. S12LPN was not wearing a gown when she changed Resident #118's incontinence brief. An observation was made of a sign posted on Resident #118's room door indicating he was EBP and staff should wear a gown as a part of their PPE. S12LPN confirmed she was aware the resident was on EBP and failed to wear a gown while providing resident care. On 02/04/2025 at 08:50 AM, an interview was conducted with S2DON (Director of Nursing). She confirmed a gown and gloves must be donned when providing high contact activities such as changing a resident's incontinence brief if a resident is indicated for EBP. 51503 Resident #53 Findings: Review of Resident #53's medical record revealed diagnoses that included in part . Multiple Sclerosis, Encounter for Palliative Care, Polyneuropathy in Diseases Classified Elsewhere, and Depression. Review of Resident #53's Annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/29/2024, revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated Resident #53 was cognitively intact. Review of resident #53's physician orders revealed an order to implement and maintain Enhanced Barrier Precautions when performing high contact care activities every shift, with a start date 01/14/2025. Observation on 02/02/2025 at 9:35 AM., revealed Enhanced Barrier Precautions (EBP) signage was posted on a wall next to Resident #53's door, and prior to entering the resident's room. Two (2) Certified Nursing Assistants (CNAs) were observed to enter Resident 53's room with a mechanical lift to transfer Resident #53. The 2 CNAs did not donned gowns prior to the transfer of Resident #53 with the mechanical lift, and proceeded with transferring the resident. Observation and interview of Resident #53 on 02/02/2025 at 11:03 AM, revealed Resident #53 sitting up in her geri-chair in her room. Resident #53 stated she had a pressure sore on her bottom, and that the 2 CNAs who transferred her from the bed to geri-chair wore gloves during the transfer. On 02/02/2025 at 12:22 PM, an interview with S4CNA confirmed that an EPB sign was posted on the wall next to Resident #53's door, and prior to entering the resident's room. S4CNA confirmed the EBP sign indicated she (S4CNA) should wear a gown and gloves when caring for Resident #53. Observation at that time with S4CNA revealed EBP signage was posted on the wall next to Resident #53's door. S4CNA confirmed that Resident #53 required gown and gloves during Activities of Daily Living (ADL) care, such as transferring. S4CNA confirmed that she did not wear a gown when she transferred Resident #53 on 02/02/2025 at 9:35 AM. On 02/04/2025 at 11:20 AM, S2DON revealed in an interview that staff are required to wear gown and gloves when caring for a resident who has EBP. S2DON confirmed that staff should have worn a gown and gloves when Resident #53 was transferred this morning with the mechanical lift. Unable to contact other CNA for interview.

Based on interview and record review the facility failed to ensure the MDS (Minimum Data Set) was coded accurately for use of Bipap (Bilevel Positive Airway Pressure) for 1 (#19) resident of 5 (#19, #41, #78, #95 and #112) residents investigated for respiratory care. Resident #19 Review of Resident #19's electronic medical record revealed she was admitted to the facility on [DATE] with diagnoses that included in part, Type 2 Diabetes Mellitus with unspecified complications, Major Depressive Disorder and other, Sleep Apnea. Review of Resident #19's current physician's orders read, RCU (Respiratory Care Unit): Bipap (Bilevel Positive Airway Pressure) S/T (Spontaneous/Timed) 16/12 RR (Respiration Rate) = 12 @ 21% at HS (Hour of Sleep) six times a day. Review of Resident #19's care plan read in part, Focus: The resident has Bipap related to sleep apnea. Review of Resident #19's MAR/TAR (Medication Administration Record/Treatment Administration Record) for November 2024 revealed Resident #19 used a Bipap nightly as ordered. Review of Resident #19's MDS with an ARD (Assessment Reference Date) of 11/27/2024 revealed Resident #19 did not use a Bipap. On 02/03/2025 at 4:11 PM, an interview and record review was conducted with S6MDS (Minimum Data Set). She confirmed that Resident #19 had a current order for use of a BiPAP at night and she used it nightly for the entire month of November 2024 according to the MAR/TAR. S6MDS confirmed that Resident #19's Quarterly MDS with an ARD of 11/27/2024 was not coded for use of a Bipap and should have.

Based on record review, observations and interviews, the facility failed to provide appropriate and sufficient services, treatment, and care according to standards of professional practice for 1 (#3) of 4 (#3, #38, #62, and #78) residents that were reviewed for urinary catheter or UTI (urinary tract infection). The facility failed to ensure Resident #3's urinary catheter drainage tubing was properly secured off of the floor. Findings: Resident #3 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, Obstructive and Reflux Uropathy, Bladder Neck Obstruction. Review of Resident #3 Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed in Section GG Chair/bed-to-chair transfer that Resident #3 was coded as 3, indicating that the resident required partial/moderate assistance. On 02/02/2025 at 9:55 AM, an observation was conducted of Resident #3 in his room. The resident had a urinary catheter drainage bag laying on the floor roughly one foot away from the right side of his bed. The drainage bag was connected by tubing to Resident #3's suprapubic catheter. On 02/02/2025 at 12:54 PM, and observation and interview was conducted S11LPN (Licensed Practical Nurse). S11LPN stated that Resident #3 does not transfer himself and that staff assists him with transfers. She confirmed that the urinary catheter drainage bag was laying on the floor and should not have been.

Based on observation, interview, and record review the facility failed to ensure the resident's respiratory equipment was stored properly for 2 (Resident #19 and Resident #41) out of 5 (Resident #19, #41, #78, #95 and #112) 36 sampled residents reviewed for respiratory care. On 02/04/2025 review of the facility's policy titled Departmental (Respiratory Therapy) - Prevention Infection with a review date of 10/30/2024 read in part, Infection Control Considerations Related to Medication Nebulizers/Continuous Aerosol: 7. Store the circuit in plastic bag marked with date and resident's name, between uses. On 02/04/2025 at 4:17 PM, S2DON (Director of Nursing) confirmed that this is the policy used for proper storage of all respiratory equipment. Resident #19 Review of Resident #19's electronic medical record revealed she was admitted to the facility on [DATE] with diagnoses that included in part, Type 2 Diabetes Mellitus with Unspecified Complications, Major Depressive Disorder and Other, Sleep Apnea. Review of Resident #19's current physician's orders that read, RCU (Respiratory Care Unit): Bipap (Bilevel Positive Airway Pressure) S/T (Spontaneous/Timed) 16/12 RR (Respiration Rate) = 12 @ 21% at HS (Hour of Sleep) six times a day. Review of Resident #19's care plan read in part, Focus: The resident has Bipap related to sleep apnea. On 02/02/2025 at 11:31 AM, an observation was made of Resident #19's Bipap mask on her bedside table opened to air. Resident #19 stated that her Bipap mask should be in a bag, but she did not have one. On 02/02/2025 at 11:35 AM, an observation and interview with S5LPN (Licensed Practical Nurse) was conducted. She confirmed that Resident #19's BiPAP mask was on her bedside table opened to air and not stored properly. She confirmed that the Bipap mask should have been in a bag labeled with the date and her name and there was no bag available. 50950 Resident #41 Review of Resident #41's EHR (Electronic Health Record) revealed an admitted [DATE] with diagnoses which included, but were not limited to, congestive heart failure, chronic obstructive pulmonary disease, and obstructive sleep apnea. Review of Resident #41's most recent Minimum Data Set (MDS) dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) of 15, indicating his cognition was intact. Section O: Special Treatments, Procedures and Programs checked for oxygen therapy and CPAP use. On 02/02/2025 at 10:52 AM, an observation was made of Resident #41's CPAP (continuous positive airway pressure) machine at the bedside. The CPAP mask was in the machine's basket, open to air making contact with the basket. The CPAP mask was not stored in a storage bag. Further observation revealed a nasal cannula on the seat of Resident #41's motorized wheelchair, open to air with the nose piece of the tubing making contact with the seat of the wheelchair. The nasal cannula was not stored in storage bag. Resident #41 confirmed the staff assists him with applying and removing both his CPAP mask and oxygen tubing. On 02/02/2025 at 11:03 AM, a concurrent observation and interview was conducted with S8LPN (Licensed Practical Nurse) in Resident #41's room. S8LPN viewed CPAP mask and nasal cannula and confirmed the CPAP mask and nasal cannula were not stored properly and should be stored in a plastic bag when not in use. S8LPN also confirmed it is the nurses' responsibility to make sure nasal cannulas and CPAP masks are stored properly when not in use. On 02/04/25 at 08:50 AM, an interview was conducted with S2DON (Director of Nursing). S2DON confirmed oxygen tubing such as nasal cannulas and CPAP masks should be stored in a plastic storage bag when not in use and confirmed that the nursing staff is ultimately responsible for proper storage of respiratory equipment when not in use.

Based on observations and interview, the facility failed to ensure staffing information posted daily was current and in a prominent place readily accessible to residents and visitors. The facility's census was 133. Findings: On 02/04/2025 at 2:00 PM, an observation was made of staffing data sheets filed in a closed binder. The binder was set in a window at the nurses' station directly across the hall from the administrative offices. The hall was not in a pathway frequently used by residents or visitors. The staffing sheets for 02/03/2025 and 02/04/2025 were not in the binder. On 02/04/2025 at 2:09 PM, an interview was conducted with S7ASADMIN (Assistant Administrator). She confirmed that staffing data sheets for 02/03/2025 and 02/04/2025 were not in the binder and staffing sheets that are in a closed binder are not readily accessible to residents or visitors.

Based on observation and interview the facility failed to ensure hallway hand rails were securely affixed to the walls on 1 (Hall W) of 6 (Hall U, Hall V, Hall W, Hall X, Hall Y, and Hall Z) hallways observed in the facility. This failed practice had the potential to affect all mobile residents that reside on Hall W. Findings: Review of a facility policy on 02/04/2025 at 12:38 PM titled, Maintenance Service with a revision date of 12/2009 revealed the following in part . 1. The maintenance department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times. 2. Functions of the maintenance personnel include . a. Maintaining the building in compliance with current federal, state, and local laws, regulations, and guidelines. b. Maintaining the building in good repair and free from hazards. 9. Maintenance personnel shall follow established safety regulations to ensure the safety and well-being of all concerned . Observations made on 02/02/2025 at 9:52 AM, 02/02/2025 at 11:20 AM, 02/02/2025 at 12:10 PM, and 02/02/2025 at 12:15 PM revealed a hand rail was broken outside of Room A on Hall W. The handrail was observed with one end detached from the wall and pointing outward into Hall W. A screw was exposed and pointing out of the end of the detached portion of the hand rail. On 02/02/2025 at 12:15 p.m., an interview with S3 Maintenance Supervisor confirmed the hand rail on Hall W was broken and detached from the wall. S3 Maintenance Supervisor stated the broken hand rail was unsafe and should have been fixed.

Based on interviews and record reviews the facility failed to provide the necessary respiratory care consistent with professional standards of practice for 1 (#3) out of 5 (#1, #2, #3, #4 and #5) sampled residents who required mechanical ventilation by the staff failing to: 1. Respond to Resident #3's ventilator alarm in a timely manner and 2. Adequately assess Resident #3 for a change in her condition. This failed practice resulted in an Immediate Jeopardy on 03/15/2023 at 3:44 p.m., when Resident # 3, who was cognitively impaired and ventilator dependent, became disconnected from the ventilator, when turned on her side, while facility staff performed incontinent care and wound care. The ventilator machine alarmed and flashed for over 5 minutes while S6CNA and S7CNA provided incontinent care and positioning, and S9LPN/wound care nurse provided wound care. S6CNA, S7CNA and S9LPN/wound care nurse failed to timely alert S5RT (Respiratory Therapist) or S3LPN/unit nurse of the alarm. S9LPN/wound care nurse, who went into the room two separate times to conduct wound care, failed to adequately assess the resident and address the alarm. S5RT on the unit, who was across the hall from the resident's room, failed to respond to the ventilator alarm until she was alerted by S7CNA. The ventilator machine continued to alarm and flash for over five minutes until S6CNA observed a change in the resident's condition and alerted S7CNA to get the nurse and respiratory therapist. S5RT found the resident blue in color and disconnected from the ventilator. The resident required manual respiratory resuscitation until her oxygen saturation and skin color returned to normal. The Administrator was notified of the Immediate Jeopardy on 03/24/2023 at 3:51 p.m. The Immediate Jeopardy was removed on 03/27/2023 at 3:55 p.m. when the facility presented an acceptable Plan of Removal. Through observation, interview and record review, the following components of the plan of removal was initiated and/or implemented prior to exit. Components: 1. At approximately 3:49 p.m. on 03/15/2023 Resident #3 who was identified as the resident affected by alleged deficient practice was stabilized by the respiratory therapist. Resident #3 is ventilator dependent. At that time there were 8 other residents who were ventilator dependent in the facility for a total of 9. Immediately, the designated nurse on the floor and respiratory therapist confirmed no other alarms were sounding once Resident #3 was determined stable, thus ensuring the 8 other residents were safe and without distress. Family practitioner, Pulmonologist and family were notified of event for Resident #3. 03/15/2023 at 4:35 p.m., the facility assistant Administrator rounded on the floor to ensure stability of the 9 total ventilator dependent residents. 03/15/2023 at 4:40 p.m. the facility nursing director rounded on Resident #3 and the ventilator unit to ensure stability of the 9 total ventilator dependent residents. 2. On 03/15/2023 at 4:40 p.m., the facility DON (Director of Nursing) identified 8 other residents at risk for alleged deficient practice of failure to respond to ventilator alarms timely. The facility DON ensured all safety needs were being net for the 8 total other residents identified at risk for the alleged deficient practice. 3. On 3/25/2023 at 4:10 p.m., the respiratory therapist and designed floor nurse, verbally educated CNAs who provided care for Resident #3 during the event on providing care with ventilator tubing (including disconnection) and ventilator alarms. 03/16/2023 Respiratory Therapist and Wound Care nurse involved in situation educated on assessing for disconnected tubing and caring for residents with tubing. On 03/24/2023 these 2 employees were also educated (including disconnection) on recognizing ventilator emergency alarms, how to handle a disconnected ventilator circuit and signs and symptoms of respiratory distress. 03/16/2023 at 6:00 a.m. (name of unit) staff in-serviced initiated by DON designee, including contract nursing staff. In-service topic was: General Care for (name of unit) Resident Safety-included specifics on how to address ventilator tubing becoming disconnected. On 03/16/2023 at 8:00 a.m. DON/Administrative Nurse designee began monitoring of (name of hall) ventilator unit for safely repositioning and care for residents with ventilator tubing. During the monitoring efforts, no negative findings were identified. On 03/23/2023 at 11:00 a.m., vent unit competency form added to the new hire orientation packet for (name of hall)/ventilator unit CNA and nursing staff, including contract nursing staff. In addition to adding to orientation packet, any staff working ventilator unit will receive training prior to working ventilator unit On 3/24/2023 at 4:30 p.m. additional in-services were initiated for (name of hall)/ventilator unit staff including contract nursing staff by DON/designee. Topics included: How to recognize ventilator emergency alarms, reconnecting ventilator circuits, signs and symptoms of respiratory distress On 03/24/2023 at 7:28 p.m. additional monitoring initiated by NFA (Nursing Facility Administrator)/DON of (name of hall)/ventilator unit alarm response times. This will be performed 3 x week x 4 weeks and then weekly by the Respiratory Therapy Director. 4. On 03/24/2023 at 6:30 p.m. all additional in-services, audits and education completed for the (name of hall) ventilator staff resident safety. 5. The education regarding safety and care for all ventilator dependent residents were initiated 03/15/2023. Additional education for ventilator unit staff implemented specifically for alarming systems and was completed on 03/24/2023 at 6:30 p.m. thus removing the likelihood of serious injury. This deficient practice had the potential to affect eight other residents who are ventilator dependent that reside in the nursing home. Findings: Review of Resident #3's clinical record revealed she was admitted to the facility on [DATE]. The resident had diagnoses and conditions including Chronic Respiratory Failure, Dependence On Respirator [ventilator] Status; Gastrostomy, Tracheostomy (trach), Aphasia, Quadriplegia, Amyotrophic Lateral Sclerosis (ALS), Sepsis (2/27/23) Ventilator Associated Pneumonia (2/27/23), and Personal History Of Transient Ischemic Attack (TIA) and Cerebral Infarction. Review of the resident's quarterly MDS (Minimum Data Set), dated 03/03/23, revealed the resident had a BIMS (brief Interview for Mental Status) score of 99 indicating resident was unable to complete the BIMS. The resident was totally dependent on two or more persons to physically assist her with bed mobility, transfer, dressing, toilet, bathing. Further review revealed she had trouble breathing/short of breath when lying flat. The resident required treatments including oxygen therapy, suction, tracheostomy care, and a mechanical ventilator. Review of the resident's care plan revealed in part that the resident was at risk for alteration in respiratory function and required mechanical ventilation d/t (due to) respiratory status r/t (related to) dx (diagnosis) of Chronic Respiratory Failure, ALS and History Of Hypoxemia. Interventions included: adjust ventilator settings as appropriate for resident, assess for changes in level of consciousness, assess for comfort and ability to cooperate while on mechanical ventilator, assess skin color, examine lips and nail beds for cyanosis, notify respiratory therapist as needed, suction as needed, trach care as ordered/needed. Review of video footage, with audio, dated 03/15/2023 provided by the Resident #3's family, revealed the following: Video 1: Start time: 15:44:28 (3:44 p.m.) with a run-time of 2:59 (2 minutes, 59 seconds). At 19 secs (15:44:47), S6CNA and S7CNA turned Resident #3 on her left side to perform incontinent and wound care. At 5 seconds (15:44:52) on her left side the resident's ventilator machine started alarming and flashing. S6CNA and S7CNA continued to conduct incontinent care without informing the unit nurse or the respiratory therapist of alarm. After, 1 minute and 37 seconds (15:46:05), the wound care nurse (S9LPN) entered the room. The ventilator machine was still alarming and flashing. The wound care nurse performed wound care and left the room at 2:13 (15:46:41) without addressing the alarm or assessing the resident. According to the run time, the resident's ventilator had been alarming for 2 minutes and 8 seconds. S6CNA was left in room still holding the resident on her left side. Ventilator machine still alarming. She didn't check the resident but instead looked towards the television. At 2:33 minutes (15:47:03) the wound care nurse returned to the resident's room and conducted more wound care. She looked over the resident's shoulder towards the head of the bed, looked at the ventilator machine, and proceeded to provide wound care. Video 2: Start time 15:47:28 (3:47 p.m.); run-time 2:59 (2 minutes and 59 seconds). At 15:47:31 (3:47 p.m.), the wound care nurse and S7CNA left the resident's room. Resident still on her left side and the ventilator machine was still alarming. S6CNA turned and looked at the resident 7 seconds into the video, continued to look at the resident for 25 seconds, then looked at the ventilator machine but did not respond. At 37 seconds into the video (15:48:08), the wound care nurse returned back to the room to conduct wound care. Ventilator alarm was still sounding and flashing. At 53 seconds into the video, the CNA (S6CNA) holding the resident reached for tissue on the bedside table and the wound care nurse walked out of the room. After one minute into the video, S6CNA placed the resident on her back, looked at the resident and then told (audible) S7CNA to call for the nurse (1:10). At 1:27 the respiratory therapist (S5RT) entered the resident's room, picked up something in the resident's bed stated (audible) We have to make sure it's connected. At 2:30 (15:50:01) the respiratory therapist connected an Ambu bag to resident then squeezed bag. Resident's chest was observed rising and falling. The respiratory therapist stated, If the alarm (inaudible) more than a few times ya'll have to come get somebody (inaudible) have to make sure its connected at all times. Respiratory therapist continued bagging resident until video ended at 2:49. Video 3: 15:50:28; run-time 2:59 Respiratory Therapist (S5RT) continued to give the resident manual ventilation via Ambu bag. Sixteen seconds into the video, the respiratory therapist removed the Ambu bag and connected the vent tubing to the resident. Review of the resident's progress notes revealed that on 03/15/23 at 4:43 p.m., S5RT wrote I was called to resident's room by CNA due to vent (ventilator) alarming and CNA states resident was turning blue. Upon arrival at bedside I found resident disconnected from ventilator with mild cyanosis (skin blue in color). I then reconnected the vent to resident and gave 100% oxygen while connecting Ambu (artificial manual breathing unit) bag to the wall flow meter. I told the CNA to get the nurse and a pulse ox (oximetry) on the resident's finger. I connected the Ambu bag to 100% oxygen from the wall flow meter at 15 LPM (liters per minute) and started to bag the resident until she fully recovered . On 03/23/23 at 12:55 p.m., an interview and observation was conducted with S4RTDirector. S4RTDirector provided demonstration of the Trilogy EV3000 ventilator's alarm in room located next door to Resident #3's room. She stated that this model was not commercial and was frequently used in nursing homes. She turned it on and after a few seconds of blowing air out a port on the left side of the monitor, the monitor began flashing red, alarmed loudly with message on screen in red that said Circuit disconnect Alarm. S4RTDirector stated that this message would show on screen if the ventilator hose was completely disconnected from resident. The alarm message would change to Low minvent after 5 seconds of alarming due to the vent tube being disconnected. At this time, S4RTDirector was asked to continue to let the alarm sound. Surveyor exited the room, closed the room door and stood behind nursing station desk. The alarm could be heard with the room door closed across the hall. An interview was conducted on 03/24/2023 at 11:15 a.m. with S5RT, who stated that on 03/15/2023, she was in a resident's room across the hall from Resident #3's room. She stated that she was not able to hear the alarm because she was suctioning the resident, his television was very loud and the CNAs (S6CNA and S7CNA) had Resident #3's room door closed. She stated she did not know how long the resident's alarm had been sounding before S8CNA came to inform her that they needed assistance in Resident #3's room. When she walked into the room, the ventilator machine alarm was sounding. The resident was blue in color and the ventilator tubing was disconnected. She noticed that the clip on the resident's ventilator machine that holds the vent tubing in place was closed around the tubing which should have been opened to allow the tubing to move when the CNAs turned the resident away from the ventilator machine. She stated that because the clamp was not opened, this caused the tubing to disconnect. She stated that she immediately reconnected the ventilator tubing back to the resident's tracheal tube. She then connected the Ambu bag in the room to the oxygen flow meter at 100%, unconnected to ventilator tubing, and started giving the resident manual ventilations with the Ambu bag. She confirmed Resident #3 had a Triology ventilator and that the ventilator will display on the screen a message Circuit disconnected alarm letting you know the ventilator tubing was disconnected. She stated the CNAs should know that when the machine alarms, they need to get the nurse or the respiratory therapist immediately. On 03/23/33 at 2:44 p.m., a phone interview was conducted with S6CNA. She stated that this was her first time working the vent unit and she had not been trained prior nor had anyone told her anything about what to do or about any alarms prior going on the unit on 03/15/2023. S6CNA stated on 03/15/2023, she and an agency CNA were assigned the vent unit and were making their last rounds. Resident #3 needed to have her brief changed. She stated that they turned the resident on her side and that at some point while they were getting her cleaned up, an alarm sounded. She was then asked if she had any idea what the alarm was for and she stated No. She stated the alarm kept sounding but she and the agency CNA (S7CNA) did not know what the alarm was for. She stated that the treatment nurse came and checked the monitor but said nothing was wrong. At some point later, she looked and saw the resident's face was discolored and called for the nurse. An interview was conducted with S7CNA on 03/23/23 at 4:06 p.m. S7CNA stated that she was employed as a full time CNA at this nursing home before she began to work as an agency CNA and was familiar with the vent unit. She stated that she seldom worked the vent unit and would be assigned to different areas of the nursing home. When asked if she received any training prior to being assigned the unit, she stated she could not recall. She confirmed that she worked with Resident #3 on 03/15/2023. When asked to explain the events of the incident, S7CNA stated that she and the other CNA (S6CNA) went into Resident #3's room to clean her and change her brief. She stated that the other CNA told her get the nurse because she noticed something was wrong with the resident. S7CNA stated that she could not recall how long the resident's ventilator alarm had been sounding before she left to get the nurse. S7CNA was asked if she knew what the ventilator alarm sounds like, she replied, I don't know what the vent alarm sounds like. On 03/24/2023 at 1:45 p.m., an interview was conducted with S9LPN. S9LPN stated that on 03/15/23 she was the wound care nurse and she went into Resident #3's room to conduct wound care on the resident's bottom. She confirmed that when she entered the room, she heard the resident's ventilator machine alarming. She stated she assumed that the alarm was sounding because the resident had been turned on her side. She confirmed that she left the resident's room because she forgot something on her cart and did not address why the ventilator was alarming. She also confirmed that she returned to the resident's room to finish the wound care. When asked if she heard the ventilator machine alarm still sounding when she returned to the room, she replied, I cannot recall. When asked if she assessed the ventilator machine and/or the resident at that time. She replied, Yes, I'm sure I did, but I don't remember. I am pretty sure that I did. I didn't see anything wrong. When asked if the CNAs voiced concern about the ventilator machine alarm she replied, No. On 03/24/2023 at 2:30 p.m., a phone interview was conducted with S3LPN who stated that she was an agency nurse. S3LPN stated that on 03/15/23, she was in another resident's room administering medication when someone (can't remember who) came and told her that she was needed in Resident #3's room. She stated she asked what had happened and the person told her that the resident's tube had disconnected. She stated that when she walked in the resident's room, the respiratory therapist was bagging the resident. She denied hearing Resident #3's ventilator machine alarming. On 03/27/2023 at 11:40 a.m., an interview was conducted with S2DON and the facility's Corporate Nurse. S2DON and the Corporate Nurse agreed that the facility's protocol regarding vent patients was that the CNAs should know when a ventilator alarms sounds, to inform the respiratory therapist and/or the nurse immediately; they should know the proper way to position/turn a resident on a ventilator to avoid disconnecting that resident's ventilator tube; and they are not to touch the ventilator equipment. On 03/27/2023 at 3:50 p.m., an interview was conducted with S1ADM. S1ADM stated before a CNA is allowed to work on the vent unit they must have training. S1ADM was asked if the CNAs involved in the incident on 03/15/2023 exhibited competency by allowing Resident #3's ventilator machine to alarm for five minutes and not immediately informing the nurse or the respiratory therapist until after the resident had a change in condition. S1ADM stated he could not answer because he was not aware of what exactly happened because the family refused to provide this video that apparently has leaked out. The facility did not provide requested documentation of training and competencies for any CNA or nursing staff working on the vent unit regarding responding to ventilator alarms and respiratory care for a resident on a ventilator. The facility did not provide requested policy/procedure for training and competencies of staff working on the vent unit before the survey exit.

Based on interview and record review, the facility failed to ensure staff were trained and deemed competent with the appropriate skill set to adequately assess for changes in resident condition and respond to ventilator alarms in order to assure a resident maintain the highest practicable physical, mental, and psychosocial well-being for 1(#3) out of 5 (#1, #2, #3, #4 and #5) sampled residents who required mechanical ventilation. This failed practice resulted in an Immediate Jeopardy on 03/15/2023 at 3:44 p.m., when Resident # 3, who was cognitively impaired and ventilator dependent, became disconnected from the ventilator, when turned on her side, while facility staff performed incontinent care and wound care. The ventilator machine alarmed and flashed for over 5 minutes while S6CNA and S7CNA provided incontinent care and positioning, and S9LPN/wound care nurse provided wound care. S6CNA, S7CNA and S9LPN/wound care nurse failed to timely alert S5RT (Respiratory Therapist) or S3LPN/unit nurse of the alarm. S9LPN/wound care nurse, who went into the room two separate times to conduct wound care, failed to adequately assess the resident and address the alarm. S5RT on the unit, who was across the hall from the resident's room, failed to respond to the ventilator alarm until she was alerted by S7CNA. The ventilator machine continued to alarm and flash for over five minutes until S6CNA observed a change in the resident's condition and alerted S7CNA to get the nurse and respiratory therapist. S5RT found the resident blue in color and disconnected from the ventilator. The resident required manual respiratory resuscitation until her oxygen saturation and skin color returned to normal. The Administrator was notified of the Immediate Jeopardy on 03/24/2023 at 3:51 p.m. The Immediate Jeopardy was removed on 03/27/2023 at 3:55 p.m. when the facility presented an acceptable Plan of Removal. Through observation, interview and record review, the following components of the plan of removal was initiated and/or implemented prior to exit. Components: 1. At approximately 3:49 p.m. on 03/15/2023 Resident #3 who was identified as the resident affected by alleged deficient practice was stabilized by the respiratory therapist. Resident #3 is ventilator dependent. At that time there were 8 other residents who were ventilator dependent in the facility for a total of 9. Immediately, the designated nurse on the floor and respiratory therapist confirmed no other alarms were sounding once Resident #3 was determined stable, thus ensuring the 8 other residents were safe and without distress. Family practitioner, Pulmonologist and family were notified of event for Resident #3. 03/15/2023 at 4:35 p.m., the facility assistant Administrator rounded on the floor to ensure stability of the 9 total ventilator dependent residents. 03/15/2023 at 4:40 p.m. the facility nursing director rounded on Resident #3 and the ventilator unit to ensure stability of the 9 total ventilator dependent residents. 2. 03/15/2023 at 4:40 p.m., the facility DON (Director of Nursing) identified 8 other residents at risk for alleged deficient practice of failure to respond to ventilator alarms timely. The facility DON ensured all safety needs were being net for the 8 total other residents identified at risk for the alleged deficient practice. 3. 3/15/2023 at 4:10 p.m., the respiratory therapist and designed floor nurse, verbally educated CNAs who provided care for Resident #3 during the event on providing care with ventilator tubing (including disconnection) and ventilator alarms. 03/16/2023 Respiratory Therapist and Wound Care nurse involved in situation educated on assessing for disconnected tubing and caring for residents with tubing. On 03/24/2023 these 2 employees were also educated (including disconnection) on recognizing ventilator emergency alarms, how to handle a disconnected ventilator circuit and signs and symptoms of respiratory distress. 03/16/2023 at 6:00 a.m. (name of unit) staff in-serviced initiated by DON designee, including contract nursing staff. In-service topic was: General Care for (name of unit) Resident Safety-included specifics on how to address ventilator tubing becoming disconnected. 03/16/2023 at 8:00 a.m. DON/Administrative Nurse designee began monitoring of (name of hall) ventilator unit for safely repositioning and care for residents with ventilator tubing. During the monitoring efforts, no negative findings were identified. 03/23/2023 at 11:00 a.m., vent unit competency form added to the new hire orientation packet for (name of hall)/ventilator unit CNA and nursing staff, including contract nursing staff. In addition to adding to orientation packet, any staff working ventilator unit will receive training prior to working ventilator unit 03/24/2023 at 4:30 p.m. additional in-services were initiated for (name of hall)/ventilator unit staff including contract nursing staff by DON/designee. Topics included: How to recognize ventilator emergency alarms, reconnecting ventilator circuits, signs and symptoms of respiratory distress 03/24/2023 at 7:28 p.m. additional monitoring initiated by NFA (Nursing Facility Administrator)/DON of (name of hall)/ventilator unit alarm response times. This will be performed 3 x week x 4 weeks and then weekly by the Respiratory Therapy Director. 4. 03/24/2023 at 6:30 p.m. all additional in-services, audits and education completed for the (name of hall) ventilator staff resident safety. 5. The education regarding safety and care for all ventilator dependent residents were initiated 03/15/2023. Additional education for ventilator unit staff implemented specifically for alarming systems and was completed on 03/24/2023 at 6:30 p.m. thus removing the likelihood of serious injury. This deficient practice had the potential to affect eight other residents who are ventilator dependent that reside in the nursing home. Findings: Review of Resident #3's clinical record revealed she was admitted the facility on 11/29/22. The resident had diagnoses and conditions including Chronic Respiratory Failure, Dependence On Respirator [ventilator] Status; Gastrostomy, Tracheostomy (trach), Aphasia, Quadriplegia, Amyotrophic Lateral Sclerosis (ALS), Sepsis (2/27/23) Ventilator Associated Pneumonia (2/27/23), and Personal History Of Transient Ischemic Attack (TIA) and Cerebral Infarction. Review of the resident's quarterly MDS (Minimum Data Set) dated 03/03/2023, revealed the resident had a BIMS (Brief Interview for Mental Status) score of 99 indicating resident was unable to complete the BIMS. The resident was totally dependent on two or more persons to physically assist her with bed mobility, transfer, dressing, toilet, bathing. Further review revealed she had trouble breathing/short of breath when lying flat. The resident required treatments including oxygen therapy, suction, tracheostomy care, and a mechanical ventilator. Review of the resident's care plan revealed the resident was at risk for alteration in respiratory function and required mechanical ventilation d/t (due to) respiratory status r/t (related to) dx (diagnosis) of Chronic Respiratory Failure, ALS and History Of Hypoxemia. Interventions included: adjust ventilator settings as appropriate for resident, assess for changes in level of consciousness, assess for comfort and ability to cooperate while on mechanical ventilator, assess skin color, examine lips and nail beds for cyanosis, notify respiratory therapist as needed, suction as needed, trach care as ordered/needed. Review of the resident's progress notes revealed that on 03/15/23 at 4:43 p.m., S5RT wrote I was called to resident's room by CNA due to vent (ventilator) alarming and CNA states resident was turning blue. Upon arrival at bedside I found resident disconnected from ventilator with mild cyanosis (skin blue in color). I then reconnected the vent to resident and gave 100% oxygen while connecting Ambu (artificial manual breathing unit) bag to the wall flow meter. I told the CNA to get the nurse and a pulse ox (oximetry) on the resident's finger. I connected the Ambu bag to 100% oxygen from the wall flow meter at 15 LPM (liters per minute) and started to bag the resident until she fully recovered. On 03/23/23 at 12:55 p.m., an interview was conducted with S4RTDirector. S4RTDirector stated that she did not formally train any CNAs because they were not responsible for the vent. The former CNA Supervisor oriented the CNAs to the vent unit and communicated to them what they should do on the unit, but she was not sure what they were told or trained to do. On 03/23/23 at 2:44 p.m., a phone interview was conducted with S6CNA. S6CNA stated she told the previous CNA supervisor that she never wanted to work the vent unit because she was not comfortable with it. She stated it was her first time working the vent unit on 03/15/2023 and she had not been trained prior nor had anyone told her anything about what to do or anything about any alarms. An interview was conducted on 3/23/23 at 3:48 p.m. with S8CNASupervisor. S8CNASupervisor stated she was new to the position and that she had not trained or oriented any full time or agency CNAs prior to them working with residents on the vent unit. When asked how she ensured that all CNAs working on the vent unit were competent to work on the unit, she stated, She made rounds with them and reeducated them on the facility's protocol regarding vent residents. S8CNA Supervisor was asked to provide documentation of CNA training and competencies regarding working with residents on the vent unit. She stated, I would have to ask the DON or the Staff Coordinator. S8CNASupervisor stated she was not sure if S6CNA and S7CNA had received any training by the Respiratory Therapist Director or anyone else in the facility prior to working on the vent unit. S8CNASupervisor confirmed that the CNAs should alert the nurse or Respiratory Therapist on the unit whenever the ventilator alarm sounds. On 03/23/23 at 4:06 p.m., a phone interview was conducted with S7CNA. S7CNA stated that she was pulled to work in the vent unit on 03/15/23 but that she seldom worked the vent unit because she would be assigned different areas of the nursing home. When asked if she received any training prior to being assigned the unit, she stated she could not recall. She stated that she could not recall when or how long Resident #3's alarm sounded before she left to get the nurse. S7CNA was asked if she knew what the vent alarm sounded like and she stated that she was not sure, I don't know what the vent alarm sounds like. An interview was conducted on 3/24/23 at 10:00 a.m. with S2DON. She stated that if the ventilator machine alarmed, the CNA staff should know to get the respiratory therapist or the nurse immediately. She stated regarding turning/repositioning, the resident's ventilator machine will alarm, but if the ventilator continues to alarm, the CNAs should get the respiratory therapist or the nurse. S2DON was asked to provide training and competencies for all staff that worked on the vent unit. S2DON stated that she would provide the training and competencies. An interview was conducted on 03/24/23 at 1:45 p.m. with S9LPN who confirmed that on 03/15/23 she went into Resident #3's room to conduct wound care on the resident's bottom. She confirmed that when she entered the room, she heard the resident's ventilator machine alarm sounding. She stated she assumed that ventilator was alarming because the resident had been turned on her side. She confirmed that she went into Resident #3's room three times. When asked if she heard the ventilator machine alarming when she returned to the room, she replied, I cannot recall. When asked if she assessed the ventilator machine and/or the resident at any time, she replied, Yes, I'm sure I did, but I don't remember. I am pretty sure that I did. I didn't see anything wrong. When asked if the CNAs voiced concern about the ventilator machine alarm, she replied, No. When asked if she was aware of what the alarms represent on the ventilator machine, she replied, I know that there are yellow and red flashing alarms. S9LPN stated that she did not know what the colors meant. When asked if she had been trained to work with resident on a ventilator, she replied, Only the nurses who worked on the vent unit were trained. When asked if she ever had to work on the vent unit, she replied, No. On 03/24/23 at 3:30 p.m., a review of training and competency documents provided by S2DON was reviewed. The documents failed to contain evidence of vent unit training or competency for staff working on the vent unit. On 03/27/2023 at 10:50 a.m., S2DON was informed that the staff training and competency documents provided did not contain evidence that training or competency evaluation regarding vent patients were conducted. On 03/27/2023 at 11:40 a.m., an interview was conducted with S2DON and the facility's Corporate Nurse. The Corporate Nurse stated that she was not aware of any verbiage in the regulations that stated that a CNA had to receive specialized training to work on a vent unit. She stated that the CNAs should be able to review the plan of care for a resident on the vent unit and determine any special needs that the resident required. Another request was made to S2DON for documentation that the CNA and their preceptor were deemed competent to work on the vent unit. A review of S6CNA and S7CNA's personnel files failed to revealed documentation that had received orientation to the vent unit and failed to reveal that they were assessed for competency. The facility did not provide requested documentation of training and competencies for any CNA or nursing staff working on the vent unit regarding responding to ventilator alarms and respiratory care for a resident on a ventilator. The facility did not provide requested policy/procedure for training and competencies of staff working on the vent unit before the survey exit. .

Based on interview and record review, the facility failed to be administered in a manner that enabled its resources to be used effectively and efficiently to attain or maintain the highest practicable physical, mental and psychosocial well- being for 1 (#3) out of 9 ventilator dependent residents. The facility failed to: 1. Develop policies and procedures to ensure a. staff adequately assess and promptly respond to ventilator alarms for residents on a ventilator machine b. nurses and CNAs are trained and deemed competent to care for residents who require ventilator care, 2. Monitor and supervise services being provided by the CNAs during care of residents on a ventilator, and 3. Ensure all staff working on the vent unit were trained and competent to perform their duties in meeting the needs of residents who are ventilator dependent which included the proper response to ventilator alarms and turning/repositioning to prevent vent tubing from disconnecting. This failed practice resulted in an Immediate Jeopardy on 03/15/2023 at 3:44 p.m., when Resident # 3, who was cognitively impaired and ventilator dependent, became disconnected from the ventilator, when turned on her side, while facility staff performed incontinent care and wound care. The ventilator machine alarmed and flashed for over 5 minutes while S6CNA and S7CNA provided incontinent care and positioning, and S9LPN/wound care nurse provided wound care. S6CNA, S7CNA and S9LPN/wound care nurse failed to timely alert S5RT (Respiratory Therapist) or S3LPN/unit nurse of the alarm. S9LPN/wound care nurse, who went into the room two separate times to conduct wound care, failed to adequately assess the resident and address the alarm. S5RT on the unit, who was across the hall from the resident's room, failed to respond to the ventilator alarm until she was alerted by S7CNA. The ventilator machine continued to alarm and flash for over five minutes until S6CNA observed a change in the resident's condition and alerted S7CNA to get the nurse and respiratory therapist. S5RT found the resident blue in color and disconnected from the ventilator. The resident required manual respiratory resuscitation until her oxygen saturation and skin color returned to normal. The Administrator was notified of the Immediate Jeopardy on 03/24/2023 at 3:51 p.m. The Immediate Jeopardy was removed on 03/27/2023 at 3:55 p.m., when the facility presented an acceptable Plan of Removal. Through observation, interview and record review, the following components of the plan of removal was initiated and/or implemented prior to exit. Components: 1. At approximately 3:49 p.m. on 03/15/2023 Resident #3 who was identified as the resident affected by alleged deficient practice was stabilized by the respiratory therapist. Resident #3 is ventilator dependent. At that time there were 8 other residents who were ventilator dependent in the facility for a total of 9. Immediately, the designated nurse on the floor and respiratory therapist confirmed no other alarms were sounding once Resident #3 was determined stable, thus ensuring the 8 other residents were safe and without distress. Family practitioner, Pulmonologist and family were notified of event for Resident #3. 03/15/2023 at 4:35 p.m., the facility assistant Administrator rounded on the floor to ensure stability of the 9 total ventilator dependent residents. 03/15/23 at 4:40 p.m. the facility nursing director rounded on Resident #3 and the ventilator unit to ensure stability of the 9 ventilator dependent residents. 2. On 03/15/2023 at 4:40 p.m., the facility DON (Director of Nursing) identified 8 other residents at risk for alleged deficient practice of failure to respond to ventilator alarms timely. The facility DON ensured all safety needs were being net for the 8 total other residents identified at risk for the alleged deficient practice. 3. On 3/25/2023 at 4:10 p.m., the respiratory therapist and designed floor nurse, verbally educated CNAs who provided care for Resident #3 during the event on providing care with ventilator tubing (including disconnection) and ventilator alarms. 03/16/2023 Respiratory Therapist and Wound Care nurse involved in situation educated on assessing for disconnected tubing and caring for residents with tubing. On 03/24/2023 these 2 employees were also educated (including disconnection) on recognizing ventilator emergency alarms, how to handle a disconnected ventilator circuit and signs and symptoms of respiratory distress. 03/16/2023 at 6:00 a.m. (name of unit) staff in-serviced initiated by DON designee, including contract nursing staff. In-service topic was: General Care for (name of unit) Resident Safety-included specifics on how to address ventilator tubing becoming disconnected. On 03/16/2023 at 8:00 a.m. DON/Administrative Nurse designee began monitoring of (name of hall ) ventilator unit for safely repositioning and care for residents with ventilator tubing. During the monitoring efforts, no negative findings were identified. On 03/23/2023 at 11:00 a.m., vent unit competency form added to the new hire orientation packet for (name of hall)/ventilator unit CNA and nursing staff, including contract nursing staff. In addition to adding to orientation packet, any staff working ventilator unit will receive training prior to working ventilator unit. On 3/24/2023 at 4:30 p.m. additional in-services were initiated for (name of hall)/ventilator unit staff including contract nursing staff by DON/designee. Topics included: How to recognize ventilator emergency alarms, reconnecting ventilator circuits, signs and symptoms of respiratory distress. On 03/23/2023 at 7:28 p.m. additional monitoring initiated by NFA (Nursing Facility Administrator)/DON of (name of hall)/ventilator unit alarm response times. This will be performed 3 x week x 4 weeks and then weekly by the Respiratory Therapy Director. 4. On 03/24/2023 at 6:30 p.m. all additional in-services, audits and education completed for the (name of hall) ventilator staff resident safety. Corporate RN is providing oversight and monitoring of training 1 time a week for 4 weeks for continued compliance. Corporate RN educated Administrator and Director of Nursing regarding training of employees related to ventilator dependent residents. 5. The education regarding safety and care for all ventilator dependent residents was initiated 03/15/2023. Additional education for ventilator unit staff implemented specifically for alarming systems and was completed on 03/24/2023 at 6:30 p.m. thus removing the likelihood of serious injury. This deficient practice had the potential to affect eight other residents who are ventilator dependent that resided in the nursing home. Findings: Cross reference findings at F695 and F726 On 03/23/23 at 12:55 p.m., an interview was conducted with S4RTDirector. S4RTDirector stated that she was responsible for training the all respiratory therapist and nurses. They are trained for two weeks before they are allowed to care for residents on the vent unit. She stated that she did not formally train any CNAs because they were not responsible for the vent. The former CNA Supervisor oriented the CNAs to the vent unit and communicated to them what they should do on the unit, but she was not sure what they were told or trained to do. An interview was conducted on 3/23/23 at 3:48 p.m. with S8CNASupervisor. S8CNASupervisor stated she was new to the position and that she had not trained or oriented any full time or agency CNAs prior to them working with residents on the vent unit. When asked how she ensured that all CNAs working on the vent unit were competent to work on the unit, she stated, She made rounds with them and re-educated them on the facility's protocol regarding vent residents. S8CNA Supervisor was asked to provide documentation of CNA training and competencies regarding working with residents on the vent unit. She stated, I would have to ask the DON or the Staff Coordinator. S8CNASupervisor stated she was not sure if S6CNA and S7CNA had received any training by the Respiratory Therapist Director or anyone else in the facility prior to working on the vent unit. S8CNASupervisor confirmed that the CNAs should alert the nurse or Respiratory Therapist on the unit whenever the ventilator alarm sounds. On 03/24/2023 at 10:00 a.m., an interview was conducted with S2DON. S2DON was asked for the facility's policy/procedure and CNA training and competencies for ventilator alarms and turning/repositioning residents on a ventilator. S2DON stated that facility's protocol for new hire CNA training on the vent unit included putting them with a CNA with more experience working on the vent unit for a few days before they are allowed to work on the vent unit. She stated that they try to never schedule two inexperienced CNAs together but instead try to put one experienced CNA with a less experienced CNA. On 03/27/2023 at 11:40 a.m., an interview was conducted with S2DON and the facility's Corporate Nurse. The Corporate Nurse stated that she was not aware of any verbiage in the regulations that a CNA had to receive specialized training to work on a vent unit. She stated that the CNAs should be able to review the plan of care for a resident on the vent unit and determine any special needs that the resident required. When asked how the facility ensured that those CNAs received appropriate training and competency, the Corporate Nurse replied, We can pull the time cards for the CNAs that were oriented to the vent unit to show that they received 3 days training prior to working on the vent unit. S2DON and the Corporate Nurse agreed that it would be incumbent on the facility to know that the staff, nurses and CNAs, working on the vent unit were competent to work on that vent unit. Another request was made to S2DON for documentation that the CNA and their preceptor were deemed competent to work on the vent unit. On 03/27/2023 at 3:50 p.m., an interview was conducted with S1ADM. S1ADM stated before a CNA was allowed to work on the vent unit they must have training. S1ADM was asked if the CNAs involved in the incident on 03/15/2023 exhibited competency by allowing Resident #3's ventilator machine to alarm for five minutes and not immediately informing the nurse or the respiratory therapist until after the resident had a change in condition. S1ADM stated he could not answer because he was not aware of what exactly happened because the family refused to provide this video that apparently has leaked out. A review of S6CNA and S7CNA's personnel files failed to revealed documentation that they had received orientation to the vent unit and failed to reveal that they were assessed for competency. The facility did not provide requested documentation of training and competencies for any CNA or nursing staff working on the vent unit regarding responding to ventilator alarms and respiratory care for a resident on a ventilator. The facility did not provide requested policy/procedure for training and competencies of staff working on the vent unit before the survey exit.