Every finding on record at Clyde E Lassen State Veterans Nursing Home

Based on observations, interviews, record review, and a review of the facility's policies and procedures, the facility failed to ensure that residents who required respiratory care, received such care, consistent with professional standards of practice for one (Resident #91) of seven residents receiving respiratory care from a total survey sample of 26 residents. The findings include: On 8/18/25 at 1:05 PM, Resident #91 was observed dressed and sitting in his electric wheelchair outside of his doorway. He was wearing a nasal cannula connected to a green, portable oxygen tank on the back of his wheelchair. The oxygen flow rate setting was for one Liter per minute (L/min). (Photographic evidence obtained) On 8/19/25 at 11:27 AM, Resident #91 was observed in bed. He was receiving oxygen via nasal cannula from a bedside concentrator with an oxygen flow rate set at 2.5 L/min. (Photographic evidence obtained) On 8/20/25 at 10:20 AM, Resident # 91 was observed in bed. He was receiving oxygen via nasal cannula from a bedside concentrator with an oxygen flow rate set at 2.5 L/min. (Photographic evidence obtained) A review of the resident's active oxygen orders revealed: Oxygen at 2 liters per min via nasal cannula as needed to maintain an oxygen saturation greater than 90% (1/8/2025) Monitor oxygen saturation every shift, may apply as needed oxygen if less than 90% (1/8/2025) A review of the resident's medical record revealed that Resident #91 was admitted to the facility on [DATE]. Pertinent diagnoses included chronic obstructive pulmonary disease (COPD), chronic respiratory failure with hypoxia (bodily tissues do not receive enough oxygen), and obesity. A review of the minimum data set (MDS) assessment with an assessment reference date (ARD) of 7/8/25 revealed that during the facility's interview with the resident, conducted on 7/8/25, it was identified that Resident #91 wore oxygen continuously throughout the day. A recommendation was made for oxygen to be changed from as needed to routine per the resident's preference. As of 8/20/25, this recommendation had not been carried out. A review of the Care Plan focuses and goals, dated 7/10/25, revealed: Monitor oxygen saturation every shift; may apply as needed oxygen if less than 90%. Resident #91 will be maintained at their respiratory baseline with a patent airway and unlabored respirations through completion of treatment. Approach: Oxygen treatment as needed per medical doctor orders. If oxygen saturation drops below 88%, send to ER, If AMS, send to ER, if shortness of breath occurs, send to ER.Target Date: 10/10/25 (Short Term Goal). A review of the August 2025 Medication Administration Record (MAR) revealed that nursing had signed off daily indicating that oxygen was provided as ordered by the physician. (Copy obtained) A Provider Care Note dated 8/5/25 by the Advanced Registered Nurse Practitioner (ARNP) revealed: Requires supplemental oxygen. Provider noted: Using supplemental oxygen as needed for dyspnea. On 8/20/25 at 4:00 PM, Licensed Practical Nurse (LPN) A confirmed that Resident #91's oxygen flow rate order was for 2L/minute and stated the oxygen settings should have been set to 2L/minute. All staff provided ongoing monitoring of the resident's oxygen therapy. We monitor every 2-3 hours to check the tank and also use the finger machine (pulse oximeter) to monitor oxygen levels. We check oxygen levels every two hours. Nursing is responsible for assuring that the resident is receiving the correct oxygen flow rate per the order. The doctor prescribes the order and nurses check levels. LPN A stated the correct oxygen settings were identified by checking the physician's order and looking for the number on the cylinder/concentrator gauge to verify the correct flow rate. Nursing staff on the night shift were responsible for changing the resident's oxygen tubing every 48 hours. Correct settings were communicated from one nurse to the next using nursing report sheets and reviewing the Medication Administration Record (MAR). LPN A stated Resident #91 did not refuse his oxygen therapy. On 8/20/25 at 4:35 PM, the Director of Nursing (DON) confirmed that the physician wrote the order and then the nurse checked the gauge on the oxygen tank or concentrator to verify flow rate accuracy. A review of the facility's policy and procedure titled Medication Administration (effective date: 12/31/2021) revealed: 1. Standard: The facility will ensure that medications are administered in a safe and timely manner, and as prescribed. Ll. Procedures: . Medications must be administered in accordance with the orders, including any required time frame. (Copy obtained)

Based on observations and staff interviews, the facility failed to ensure a fully functioning resident call light system in one (House 3) of six resident care units in the facility. This failure potentially affected 15 of 78 residents residing in the facility. The findings include: On November 1, 2021 at 11:07 a.m., the bedside call light in room 306 (House 3) was triggered. No sound emitted in the room, hallway or on the unit. A second bedside call light was then triggered in room 308 as well as the bathroom call light. No sound emitted on the unit. In an interview with Certified Nursing Assistant (CNA) D at 11:12 a.m. on November 1, 2021, he was asked if the call light had a volume alert such as dinging or chiming. He stated, Yes, it usually does. I don't know why it's not making any sound now. We tried turning up the volume just now, but there's still no volume. He stated he would call maintenance to check it. He was asked if he was aware how long the system was not sounding. He stated, Most of the residents over here don't use the call lights, so I'm really not sure. The light is coming on outside the door, and I can see on the handset at the nurse's desk that you triggered the call light, but I don't know why there's no noise. On November 1, 2021 at 1:53 p.m., call lights in House 3 remained without volume for staff to be alerted by sound for a call light. CNA A stated maintenance came to the unit and checked the call light system and told them it was working. She further stated she told maintenance there was no volume, only the lights above the door and at the nursing station illuminated. She stated he told her to turn the volume up. She stated she told him it was all the way up. She stated he left the unit and she wasn't sure if he was coming back. Throughout the day on November 1, 2021, call lights in other Houses/Units were noted to be both sounding and illuminating when triggered. On November 1, 2021 at 3:43 p.m., an observation was made in House 3 of room 308's bathroom call light and bed call light. They were still not sounding when triggered. At the time of the observation, Licensed Practical Nurse (LPN) F stated maintenance had come to the House/Unit today and did something to check the call lights. She stated she did hear call lights working when maintenance was working on the issue. She stated she was not sure whether they were finished or coming back. She was advised that the call lights for room 308 were still not sounding (both bathroom and bedside call light). On November 1, 2021 at 3:53 p.m., during an interview with the Administrator, he was asked if he was aware that the call lights in House/Unit 3 were not sounding when triggered, but only illuminating above the door and at the nursing station. He stated he was not aware and said the system was checked about a month ago. He stated he would go there now and check with maintenance to see whether they had checked and fixed the issue. On November 1, 2021 at 4:10 p.m., an observation in House/Unit 3 was made of the Maintenance Director testing call lights. He stated they were now working. The Administrator was also on the unit and stated they replaced the handset box unit at the nursing station that controlled the volume. Room 308's bathroom call light was triggered and it illuminated outside the room door, but the sound had a lag of 40 seconds. The Maintenance Director then triggered room 310's bedside call light and there was a lag of 20 seconds for sound. The Administrator stated they were submitting a PR (requisition) right now to have the system completely checked. He was asked what staff would do in the meantime to ensure residents were able to summon staff. He stated he considered using bells for them to ring at the bedside, but due to the low cognition of the residents on this unit, he decided to instruct staff to increase rounding of all residents on the unit. On November 2, 2021 at 9:50 a.m., an outside company was observed in House/Unit 3 working on the call light system. On November 2, 2021 at 4:00 p.m., in an interview with the Administrator, he stated, The call light system is now fully functioning and there is no lag time when activated. It has volume and lights are both working. On November 3, 2021 at 9:06 a.m., the call light system in House/Unit 3 was tested by triggering room 308's bathroom and bedside call lights. Each call light lit up outside room when activated and sounded immediately in the at nurse's station, which was audible in the hallway and common areas on the unit. On November 3, 2021 at 3:30 p.m., in an interview with the Administrator, he was asked how often the call light system was tested and whether audits were done to ensure proper function on both illumination and sound. He stated, That's a maintenance issue. I don't have an answer to that. On November 3, 2021 at 4:00 p.m. in an interview with the Maintenance Director, he was asked if he conducted call light testing and whether call light audits were done to ensure proper function on both illumination and sound. He stated Nursing will put in an order to maintenance if there is an issue with a call light not working. He was asked if there was a monitoring system in place for the entire facility to identify issues prior to finding out from nursing staff that there was a breakdown. He stated, That's what I've been working on with the company who services our call light system. I submitted a PM (preventative maintenance) order to them. We've been talking about it since March 2021, and I'm waiting on a quote for a scope of work, which would put a system in place where they'd come out quarterly and test the whole system. Us going in and testing each call light in the building manually wouldn't be effective, but they could diagnose the whole system at certain intervals, like quarterly. The system is new from March 2021, so it's still under warranty until March 2022, and that's why I've been talking to them about about putting the preventative system in place. He was asked if he had a written work order that he could provide. He stated No, it's mainly just been talking back and forth, and figuring it out. He was asked if all the call lights were currently in working order for both illumination and sound with no lag time. He stated, Yes, it looks like what happened in House/Unit 3 was someone must have dropped the desk unit for the call light system that dings at the nurses desk and damaged the speaker. It wasn't reported, so we didn't know. We replaced that unit so now it works, and the lag was because we first replaced it with the main unit, and that caused the unit to relay all the call lights in the building, causing a lag for 20 to 50 seconds as it searched for the correct house to send the ding sound to. But we replaced that with a regular unit, so now it's in real time with no lag. He was asked again if the facility had a system to audit all resident call lights on a regular basis in order to monitor for possible issues. He stated, No, like I said, it just wouldn't be effective for us to go and test every call light. .

Based on observations, staff and resident interviews, and record reviews, the facility failed to promote and facilitate resident self-determination through support of resident choice, by not allowing the resident to make choices about aspects of his/her life in the facility that were significant to the resident for one (Resident #21) out of a total sample of 24 residents. The findings include: A tour of House 5, including the lunch meal observation, was on conducted at 12:00 p.m. on 11/1/2021. Resident #21 was observed rejecting his lunch tray. Certified Nursing Assistant (CNA) H delivered the facility-provided meal the to resident. When the resident saw what was offered, he declined the meal. CNA H set the food to the side and stated, I guess you are not eating today. and left the room. CNA H was interviewed at the time of the observation, but stated he didn;t know much about Resident #21 because he didn't normally work in House 5. The resident was also interviewed at the time of the observation, and during the interview, the resident stated he did not want a pureed meal, he wanted food. Licensed Practical Nurse (LPN) G entered the room at 12:16 p.m. and asked the resident what he would like to eat. The resident stated he wanted a quarter-[NAME] with cheese. LPN G explained that she couldn't get him a quarter-[NAME] with cheese, but she would request a cheeseburger. She told the resident the cheeseburger would be pureed. During an interview with LPN G on 11/1/2021 at 12:19 p.m., she stated the resident was on hospice. The family signed a waiver for comfort foods/regular texture but the resident choked on it. When asked about whether a mechanical-soft textured diet had been considered, LPN G stated she was unsure why the resident was not prescribed a mechanical soft diet. LPN G was interviewed again on 11/3/2021 at 2:00 p.m. During the interview she stated she spoke with the Dietician and Certified Dietary Manager (CDM) on 11/2/2021. She said all agreed to upgrade the resident's diet from a pureed consistency to mechanical soft. She stated the resident ate his lunch meal today without resistance and drank a Dr. Pepper instead of the thickened liquid he always spit out. A follow-up observation/interview was conducted with Resident #21 on 11/3/2021 at 2:15 p.m. When he was asked about his lunch meal, he replied It was good. An interview with the CDM was conducted on 11/4/2021 at 10:15 a.m. The CDM stated the resident was still on a regular diet with a pureed texture. When asked about the resident having received a mechanical soft meal for lunch on 11/3/2021, the CDM was not aware of the meal having been provided to the resident. The CDM acknowledged that the resident was able to receive comfort foods and could get items he requested. The CDM stated the kitchen staff sent out a pureed meal based on the meal ticket, unless hospice staff came in and requested a mechanical soft meal. The lunch meal was observed on 11/4/2021 at 12:22 p.m. Resident #21 was served a tray of pureed soup, carrots, ham, mashed potatoes, and bread. The resident requested mechanical soft meat (ground ham). The nurse provided the resident with mechanical soft meat per the resident's request. A review of the resident's record revealed that a Refusal of Medication or Treatment form for the pureed diet and honey-thickened liquids was signed by the resident's spouse/legal representative on 9/29/2021 at 3:55 p.m. and the resident's physician on 9/30/2021. The only dietary order available for review was dated 9/3/2021. The order communicated a diet change to a pureed texture and honey-thickened liquids. There was no updated diet order reflecting the resident's signed refusal of the 9/3/2021 diet order on 9/29/2021.

Based on record review and interviews, the facility failed to provide appropriate treatment and services to maintain or improve a resident's ability to carry out activities of daily living for one (Resident #32) of 24 residents sampled. The findings include: A medical record review was conducted for Resident #32, revealing an admitted [DATE], and diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Minimum Data Set (MDS) assessment was completed on 9/2/2021 due to a significant change (decline) in status. The resident's Brief Interview for Mental Status (BIMS) score was 00 out of a possible 15 points, indicating severe cognitive impairment. His activities of daily living needs ranged from limited assistance of one person to extensive assistance of one person. His assistive devices were listed as a walker and a wheelchair. A review of the resident's current orders revealed he was on a Restorative Nursing program, and was to be seen one to three times a week for 60 days, starting on 9/23/2021 and ending on 11/21/2021. An interview with Certified Nursing Assistant (CNA) I was conducted on 11/04/2021 at 9:37 a.m. CNA I was asked if Resident #32 received restorative therapy. He stated, Occasionally they will walk him [Resident #32] to therapy or take him for a walk in the hall. CNA I was asked about the resident's recent decline in function, and he reported he had a decline two or three months ago. An interview was attempted with CNA J, Restorative CNA, on 11/4/2021 at 3:00 p.m. After stating she needed to check her restorative therapy book, she never returned to finish the interview. An interview with the Director of Nursing (DON) was conducted on 11/4/2021 at 4:00 p.m. She stated she could only find one time (on 10/8/2021) where restorative nursing was provided for Resident #32. On that day, the resident refused to participate. No other documentation was found indicating restorative nursing had been provided as ordered. (Copy obtained) A review of Resident #32's Restorative Program form, revealed the goal for Resident #32 was that he maintain the ability to perform safe, functional mobility. The plan included the following: May use 2 pounds /Thera-ban active range of motion 15 reps times two sets Nu-step times 15 minutes Ambulation (stand-by assist) times 1 utilizing front-wheeled walker for a distance of 100 to 150 feet. This order was for 1 to 3 times a week.

Based on record review, observations and staff interviews, the facility failed to provide appropriate treatment and services to prevent potential complications of enteral feeding, by failing to adhere to physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The findings include: A record review for Resident #70 revealed an [AGE] year-old male admitted on [DATE]. His diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . He required total assistance with all activities of daily living and tube feeding for nutrition and hydration. He was unable to take any nutrition by mouth. A review of Resident #70's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During an 11:50 a.m. observation on 11/1/21, the [MEDICATION(S)] 1.5 feeding and bag of water for flush were not running. The [MEDICATION(S)] feeding and water bag were dated 11/1/2021 and were hung at 5:00 a.m. The feeding pump was turned off and the tubing was disconnected from Resident #70. There was approximately 700 ml in the water bag. Further review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 11/2/2021 at 9:50 a.m., Resident #70's [MEDICATION(S)] 1.5 was observed hanging and was dated it was hung on 11/2/2021 at 5:00 a.m. to run at 75 cc/hr (cubic centimeters per hour). The water bag was dated 11/1/2021 at 5:00 a.m. and there was approximately 700 cc left in the bag. The water bag was dated from the previous day and contained the same amount of water. An interview was conducted with Licensed Practical Nurse (LPN) C on 11/2/2021 at 9:55 a.m. She was asked what time she turned off the tube feeding and water and disconnected the tubing from Resident #70. She stated at 9:00 a.m. She was asked how she knew when the water flush was due. She replied that there was an alert in the MAR (medication administration record). She went to the resident's record in the computer and pointed out the water flush. She said he received a 200 cc water flush every four hours. The water infused from the bag for each flush except for the 2:00 p.m. flush, which was done manually since he was off the pump from 9:00 a.m. through 5:00 p.m. The record indicated the water flush had not been signed off as having been provided. At 10:05 a.m., Resident #70 was given personal care, dressed and assisted into his wheelchair and taken to an activity. The nurse was not observed going into the room, connecting the water flush or administering the scheduled 10:00 a.m. flush. Certified Nursing Assistant (CNA) A was asked on 11/2/2021 at 10:40 a.m. whether LPN C had come into the room to administer the water flush while she was providing resident care. She stated no. An observation was made on 11/3/2021 at 9:42 a.m. of the [MEDICATION(S)] tube feeding and water bag for Resident #70. The [MEDICATION(S)] container was dated 11/3/2021 at 7:00 a.m. and was hung by the night nurse. The water bag was not dated nor did it identify the time it was hung. The water bag was filled above the fill line. The hours for the water flush were 6:00 a.m., 10:00 a.m., 2:00 p.m., 6:00 p.m., 10:00 p.m., and 2:00 a.m. It could not be determined whether the 6:00 a.m. water flush had been administered. Resident #70 was observed at 10:00 a.m. He was in bed, his feeding tube was not connected, and the pump was off for the 10:00 a.m. flush. An observation at 10:30 a.m., found the water flush bag was not connected to the tube feeding site and the pump was not running. Resident #70 was provided personal care, dressed and placed in his wheelchair between 10 :00 a.m. and 10:30 a.m. An interview was conducted with LPN C on 11/3/2021 at 10:45 a.m. She was asked if the feeding pump had the capability of providing the amount of feeding and water that was dispensed in the 24 hours. She demonstrated on the pump how the rate was set, however, she was unable to find the amount that had run in the 24 hours for feeding and water. She was asked how she knew how much water and tube feeding the resident received over 24 hours, and she replied that she did not know how to get that information from the pump. She was asked if Resident #70 received the 10:00 a.m. water flush via the pump, and she said no the pump was off at 9:00 a.m. When asked how the resident received his 10:00 a.m. water flush, she said she gave him the flush manually. She was asked where she documented the flush was manual and not by pump. She said she documented on the MAR. Upon review of the MAR, the order for the 10:00 a.m. water flush indicated the water flush was given via pump. Only the 2:00 p.m. water flush was to be administered manually via syringe. LPN C stated she would change the order to include a manual flush at 10:00 a.m. An observation on 11/4/2021 at 8:30 a.m., found the pump was running at 75 cc of [MEDICATION(S)] 1.5. The container of tube feeding was hung at 7:00 am and 96 cc had been infused. The water bag was not dated and was full. The water bag was not running. During an interview with the Director of Nursing (DON) on 11/4/2021 at 10:30 a.m., she was asked for the tube feeding policy including documentation and instructions regarding the tube feeding pump (Kangaroo pump). She was asked if the pumps could be programmed to automatically dispense a water flush at designated times. She said, Yes, both feeding and water are programmed. When asked whether a pump could indicate the amount of feeding and water provided for 24 hours, she said yes, she was made aware by one of the nurses yesterday that she did not know how to obtain the the amounts infused via the pump. The DON stated she had an in-service with all of the nurses last evening regarding pump function. She was asked where the nurses documented the amount of water and feeding consumed in 24 hours, and she replied that the amount was not recorded, as the nurses documented on the MAR when feedings and water were administered.

Based on record review and staff interview, the facility failed to follow physician's orders related to reporting weight gain due to fluid overload while receiving diuretic therapy for a cardiac condition for one (Resident #1) of three sampled residents receiving diuretics. The findings include: A record review for Resident #1 revealed a [AGE] year old male admitted on [DATE] with [DIAGNOSES REDACTED]. He was alert and oriented x 2 (oriented to self and place), required extensive assistance with activities of daily living, and was independent with eating. He used a wheelchair for mobility. On 3/5/20, orders were given to weigh the resident daily, then document and notify the physician if there was 3-4 pound weight gain. On 3/18/20, a new order was received for [MEDICATION NAME] (diuretic) 1 mg (milligram) daily with an end date of 4/17/20. A review of the resident's weights revealed the following: 4/11/20 180 pounds 4/13/20 185 pounds 4/17/20 183.2 pounds 4/19/20 184.4 pounds 4/20/20 186.4 pounds 4/21/20 191.2 pounds A review of the Advanced Practice Registered Nurse's (APRN) progress note, dated 3/19/20, revealed Resident #1 had been recently hospitalized for [REDACTED]. A review of the nursing progress notes for 4/13/20 found no documentation that the physician had been notified of a five pound weight gain. The Medication Administration Record [REDACTED]. A review of the weights between 4/17 and 4/21/20, indicated an eight pound weight gain. There was no documentation indicating the physician had been notified of the weight gain. On 4/23/20, the nurse documented that Resident #1 was escorted to his room for assessment of current condition due to family concerns related to weight gain and cardiac status. He complained of intermittent pain to head, neck tenderness, and had 1+ [MEDICAL CONDITION] to both legs. There was no documentation indicating the physician had been notified. On 4/24/20, a new order was received instructing the nursing staff to administer [MEDICATION NAME] 1 mg now and then give daily. A review of the APRN's progress note dated 5/29/20 included: patient recently hospitalized for [REDACTED]. Review of the nursing note dated 10/15/20, revealed Resident #1's daughter called regarding vital signs and weights. The daughter voiced that there was a huge jump in weight from Sunday and wanted to know if the physician had been called. The nurse informed her that she would contact the APRN. Weights: Thursday 10/8/2020 at 7:52 AM 184.6 Friday 10/9/2020 at 9:42 AM 183.4 Saturday 10/10/2020 at 7:27 AM 184.4 Sunday 10/11/2020-No weight recorded Monday 10/12/2020 at 12:47 PM 186.0 Tuesday 10/13/2020 at 7:35 AM 186.0 Wednesday 10/14/2020 at 7:41 AM 189.4 Thursday 10/15/2020 at 7:15 AM 189.2 Further review of the nursing notes found no documentation that the physician had been made aware of the resident's increasing weight, even though the order instructed nursing to call the physician of more than a 3-4 pound weight gain. Resident #1 had been hospitalized in March and May 2020 for worsening [MEDICAL CONDITION] and weight gain, contributing to exacerbation of [MEDICAL CONDITION]. During an interview with Registered Nurse A on 10/15/20 at 3:10 pm, she was asked if she had provided care to Resident #1. She said yes. She was asked if Resident #1 had an order for [REDACTED]. She confirmed there was an eight-pound weight gain. When asked if there was documentation verifying the physician had been notified, she said none was found. She was asked who was responsible for monitoring the resident's weight and reporting weight gain to the physician. She replied that the nurse who was on duty was responsible for monitoring the resident's weight and making the physician aware of weight gain. RN A was asked to review the weights recorded between 10/8 and 10/15/20. She was asked if there had been weight gain of more than four pounds. After a review of the record, she said there was a five-pound weight gain. She was asked if the physician had been notified, and she said the APRN was contacted on 10/15/20 due to the resident's daughter's concern.

Based on record reviews and interviews, the facility failed to protect the resident's right to be free from abuse for three (Resident #2, Resident #3, Resident #4) of three residents reviewed for abuse. The findings include: A record review for Resident #1 revealed an admission date of [DATE] with a primary medical [DIAGNOSES REDACTED]. The resident required extensive assistance with activities of daily living and his cognition was impaired. A record review for Resident #2 revealed an admission date of [DATE] with a primary medical [DIAGNOSES REDACTED]. The resident required extensive assistance with activities of daily living and his cognition was impaired. A record review for Resident #3 revealed an admission date of [DATE] with a primary medical [DIAGNOSES REDACTED]. Secondary [DIAGNOSES REDACTED]. The resident required extensive assistance with activities of daily living and his cognition was impaired. A record review for Resident #4 revealed an admission date of [DATE] with a primary medical [DIAGNOSES REDACTED]. Secondary [DIAGNOSES REDACTED]. The resident required supervision to limited assistance with activities of daily living and his cognition was impaired. A review of the facility's federal reports was conducted on 7/7/20. An incident occurring on 5/12/20 indicated that the alleged perpetrator (Resident #1) took a cane belonging to Resident #3 and struck Resident #3 repeatedly on his head, left arm and left side before staff intervened. An interview was conducted with the Interim Administrator and the facility Risk Manager on 7/7/20 at 1:20 PM regarding this incident. The Interim Administrator, referencing the facility's investigation file, explained that Resident #1 and Resident #3 were eventually separated and that all remaining residents were removed from the unit due to safety concerns. She further explained that the resident was transferred to the hospital under the Baker Act. The Interim Administrator confirmed that, upon return from the hospital, Resident #1 was not placed under direct supervision until a determination could be made as to whether he was a continuing risk to others. Continued review of the facility's federal reports revealed an incident occurring on 6/6/20 indicating that Resident #1 struck Resident #3 on the head with a wash cloth. The facility indicated that a review of each resident's care plan was conducted and that the care plans were found to accurately reflect the needs of each resident. This event was discussed with the Interim Administrator and the facility Risk Manager during the interview conducted on 7/7/20 at 1:20 PM. The Interim Administrator, again referencing the facility's investigation file, explained that all residents were again removed from the unit due to safety concerns. She confirmed that Resident #1 was not placed under direct supervision despite the resident's now repetitive physical aggression toward other residents. An incident occurring on 6/9/20 indicated that Resident #1, during a period of increased agitation, threw a spoon which hit Resident #4's middle finger causing an injury. The facility indicated that direct supervision would be provided as needed. This event was discussed with the Interim Administrator and the facility Risk Manager during the interview conducted on 7/7/20 at 1:20 PM. The Interim Administrator explained that the facility continued close supervision following the incident but confirmed that Resident #1 was not placed under direct supervision despite a pattern of physical aggression toward other residents. An incident occurring on 6/24/20 indicated that Resident #1 approached Resident #2 and grabbed Resident #2's groin while he was asleep in a reclining chart. As a result, Resident #2 suffered redness and swelling to the area. Resident #1 was again transferred to the hospital under the Baker Act. This event was discussed with the Interim Administrator and the facility Risk Manager during the interview conducted on 7/7/20 at 1:20 PM. The Administrator acknowledged the concern about Resident #1's repeated episodes of physical aggression and the facility's lack of appropriate interventions to prevent resident to resident altercations. The Administrator explained that she hadn't yet taken over the administrative role during the first three incidents but acknowledged that, given the resident's aggressive history, it would have been appropriate to have Resident #1 supervised directly. A review of the resident's nursing progress notes revealed a significant and repeating history of behaviors and aggression. The resident's care plans did not include interventions that were effective in ensuring the safety of the resident or others. -A note dated 4/26/20 at 4:50 PM indicated Resident #1 entered the room of another resident and laid down in the resident's bed. -A note dated 4/27/20 at 10:13 PM indicated Resident #1 was walking into other resident's rooms and waking them up. -A note dated 5/2/20 at 10:00 PM indicated Resident #1 was again walking into other resident's rooms and waking them up. -A note dated 5/8/20 at 10:19 PM indicated Resident #1 became aggressive when trying to redirect him away from another resident he was attempting to push. -A note dated 5/21/20 at 9:40 PM indicated Resident #1 was unable to be redirected and was displaying aggressive behavior when staff were attempting to assist him to bed. -A note dated 5/28/20 at 2:26 PM indicated Resident #1 walked into another resident's room and sat on the resident's bed refusing to get up. Once the resident was out of the room he became agitated and kicked a certified nursing assistant (CNA). -A note dated 5/30/20 at 10:24 PM indicated Resident #1 entered another resident's room and the staff were not able to redirect him. -A note dated 6/5/20 at 6:43 AM indicated Resident #1 was agitated and was swinging a dustpan at staff. -A note dated 6/9/20 at 6:35 AM indicated Resident #1 chased a CNA around the nurse's station and tore a door off it's hinges. -A note dated 6/13/20 at 3:14 AM indicated Resident #1 came out of his room and overturned a table. -A note dated 6/14/20 at 4:47 AM indicated Resident #1 was wandering around and trying to get into other resident's rooms. A review of Residident #1's care plans revealed a behavior care plan with a revision date of 7/7/20 at 2:38 PM. The goal was that behaviors would be controlled by staff approach and redirection through the next review date on 8/19/20. Interventions included the following: Maintain other residents at a safe distance - start date: 9/27/19 Do not crowd resident - start date: 9/18/19 Do not touch until attention is focused on you - start date: 9/18/19 May need to remove resident to quieter surroundings - start date: 9/18/19 A review of the facility's abuse policy titled Abuse, Neglect, and Exploitation/Misappropriation of Resident Property revealed in the section titled Protection, If the abuse involves another resident, the accused resident' representative and attending physician will be informed of the alleged abuse incident and there may be closer supervision and/or restrictions on the accused resident's interactions with other residents.

Based on observations, resident and facility record reviews and staff interviews, the facility failed to ensure residents who received [MEDICAL CONDITION] drugs received appropriate behavioral interventions and clinical monitoring for three (Residents #1, #3 and #4) of four residents reviewed who received [MEDICAL CONDITION] medications, from a total of nine residents in the sample. The findings include: 1. An observation of Resident #1 was conducted in the locked unit on 7/7/20 at 10:20 a.m. Resident #1 was closely followed by Certified Nursing Assistant (CNA) A, and walked about slowly with a shuffling gait and forward-bent posture. An attempted greeting was met with refusal to visually engage or verbally respond. An interview was conducted with CNA B on 7/7/20 at 10:34 a.m. She stated Resident #1 exhibited many behaviors including resistance to care and fighting with residents and staff. He recently had a big problem, so now someone had to be near him around the clock. An interview was conducted with CNA A on 7/7/20 at 10:45 a.m. She explained she was assigned to provide 1:1 supervision today for Resident #1. CNA A stated the biggest trigger of Resident #1's unwanted behavior was when staff attempted to change his brief. Resident #1 did not like that at all and did not like to be touched. A record review for Resident #1 found he was admitted to the facility on [DATE] and was [AGE] years old. Resident #1 was recently discharged to a psychiatric hospital under a Baker Act on 6/24/20 and returned to the facility on [DATE]. A Discharge Return Anticipated Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 6/24/20, noted Resident #1 had an unplanned discharge to a psychiatric hospital the same day. He had memory problems and moderately impaired cognitive skills for daily decision making. Inattention and disorganized thought fluctuated. He exhibited physical and verbal behaviors directed toward others, rejection of care and wandering behavior during 1-3 days over the assessment period. He ambulated independently and required limited assistance with activities of daily living. Resident #1 was frequently incontinent. His [DIAGNOSES REDACTED]. He also experienced hallucinations. Resident #1 was care planned on 6/26/20 for periods of negative behavior that potentially result in injury to self and others, which included hitting staff, resisting care, urinating in others rooms, picking up random objects, hallucinations, and running to chase his target. A review of the physician's order history revealed that on 6/23/20, Resident #1 began treatment with [MEDICATION NAME] ([MEDICATION NAME], an antipsychotic medication), one 5 milligram (mg) tablet twice daily. The dose was increased to three times daily on 6/26/20. A single-dose order was also obtained on 6/26/20 for 1 mg of [MEDICATION NAME] intramuscularly (injection). On 6/27/20 the physician again increased the dose and changed the medication to [MEDICATION NAME] liquid concentrate 2 mg/milliliter (ml), give 2.5 ml three times daily and 5 ml at bedtime. On 7/2/20 the dose was reduced to 2.5 mg twice daily. A history and physical examination [REDACTED]. He had been sent out under Baker Acts three times since May. Resident #1 was described with known behavior of sudden changes of personality and character, a strong tendency to get hostile, and the ability to physically assault other patients or staff. His medications were adjusted and appropriate. [DIAGNOSES REDACTED]. A subsequent visit on 6/29/20 noted that due to violent weekend behavior, Resident #1 received intramuscular (IM) [MEDICATION NAME] and an increase to three times daily. Sleepiness was noted, as was poor appetite due to increased sleep. On 7/2/20 the physician again noted increased sleepiness and readjusted Resident #1's [MEDICATION NAME] back to twice daily. The physician expressed concern over poor nutrition should the sedation linger. Further review of the clinical and medication administration records found there was no monitoring in place for the use of [MEDICATION NAME] for the treatment of [REDACTED]. There was no indication as to what associated behaviors should be monitored, no specific side effects or special instructions for monitoring those side-effects, and no intervention codes to note what non-pharmacological interventions were attempted when behavioral outbursts occurred. 2. A record review for Resident #3 revealed he was admitted to the facility on [DATE] and was [AGE] years old. His quarterly MDS assessment with an ARD of 4/16/20, noted he was sometimes able to make himself understood and sometimes understood others. He had a brief interview for mental status (BIMS) score of 3, indicating severely impaired cognition. Inattention and disorganized thought fluctuated. Resident #3 required extensive assistance with walking, dressing, and activities of daily living. [DIAGNOSES REDACTED]. Resident #3 was care planned on 4/22/20 for elopement behaviors (attempting to leave facility unaccompanied and without authorization) and for his cognition and communication deficits. He was care planned for resisting care during periods of paranoid beliefs related to his [MEDICAL CONDITION] and for delusional behaviors related to the use of his personal vehicle. There was no mention of aggressive behaviors in the care plan. Resident #3 was last seen by a psychiatrist on 11/22/19, who noted a [DIAGNOSES REDACTED]. He recommended the resident continue with his use of [MEDICATION NAME] ([MEDICATION NAME] - an antipsychotic medication) and [MEDICATION NAME] ([MEDICATION NAME] - an antianxiety medication). He was last seen by the Advanced Registered Nurse Practitioner (ARNP) on 6/5/20 for review of his medications. Resident #3 had a physician's order for [MEDICATION NAME] ([MEDICATION NAME] - an antipsychotic medication) 0.25 mg twice daily. Behavioral monitoring was in place for the use of this medication and associated behaviors of yelling, swinging his cane at staff and his inability to be redirected. Further review of the clinical and medication administration records found no care plan for the aggressive behaviors being monitored in relation to the use of [MEDICATION NAME]. There were no instructions for how to intervene when these behaviors occurred, and no non-pharmacological interventions to redirect aggressive or resistive behaviors. 3. A record review for Resident #4 revealed he was admitted to the facility on [DATE] and was [AGE] years old. A quarterly MDS assessment with an ARD of 5/11/20 revealed the resident was sometimes able to understand others and to make himself understood. He had a BIMS score of 4, indicating severe cognitive impairment, with fluctuating inattention and disorganized thought. He required supervision with mobility and limited assistance with activities of daily living. [DIAGNOSES REDACTED]. Resident #4 had a physician's order for [MEDICATION NAME] (an antipsychotic medication) 50 mg every night at bedtime, with instructions to monitor for aggressive behavior related to the indication for use of [MEDICATION NAME]. Resident #4 was care planned on 5/13/20 for occasional confusion, disorientation and urinating in a trash can due to his slowly advancing dementia. He was also care planned for a history of delusions, suspiciousness and paranoia, and for frequent requests to call his wife. Further review found no care plan for aggressive behaviors that were ordered to be monitored in relation to the [MEDICATION NAME]. 4. An interview was conducted with the Interim Administrator at 3:00 p.m. on 7/7/20. She confirmed there should be care plans to address resident behavior and [MEDICAL CONDITION] medication use. She confirmed behavioral symptoms, side-effects and interventions should be monitored for all residents on [MEDICAL CONDITION] medication. She and the Consulting Nurse searched for care plans for Residents #3 and #4 and [MEDICATION NAME] monitoring for Resident #1, but found none. 5. A review of the facility policy and procedure [MEDICAL CONDITION] Medication Clinical Guidelines effective 4/30/17 and revised 10/6/17, found under section 1 (Standard): Residents who use [MEDICAL CONDITION] drugs should receive gradual dose reductions and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs. Section II. Procedures specified: Nursing 1. Daily monitoring of the resident for presence of target behaviors and any adverse effects of the medication (charting behavior/adverse effects when present) . .3. (Nursing) assists in the development of behavioral care plans . Social Services: .2. Coordinates the development of behavioral care plans. Photocopy was obtained. The Informed Consent for Antipsychotic Medications form included with the policy, listed multiple medications including [MEDICATION NAME] and the following possible side effects: Sedation, lethargy, dry mouth, constipation, enlarged breast, disturbed gait, blurred vision, weight gain, movement disorders, [MEDICAL CONDITIONS], tremors, [MEDICAL CONDITIONS], cardiovascular events, increased risk for [MEDICAL CONDITION]. stroke, drooling and skin reactions.

Based on a review of facility records and interviews with staff, the facility failed to notify the resident and/or the resident's representative(s) of their hospital transfer(s) in writing for two (Residents #2 and and #3) of three residents whose records were reviewed, from a total of nine residents in the sample. The findings include: 1. An electronic record review for Resident #2 found he was admitted to the facility on [DATE]. A Discharge Return Anticipated Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 5/31/20, noted Resident #2 had an unplanned discharge to an acute care hospital on [DATE]. He was assessed with [REDACTED]. [DIAGNOSES REDACTED]. Active discharge planning for his return to the community was not occurring at the time of the assessment. The record indicated a family member was designated as the resident's representative and power of attorney (POA). A review of the progress notes in his clinical record revealed he was sent to the emergency room (ER) on 5/31/20 with a fever and tremors. He returned to the facility and was sent back out to the emergency roiagnom on [DATE]. He was admitted for treatment at that time. Further review of the record found there was no written notification to the resident or his representative informing them of the reason or effective date for either of the hospital transfers, the location the resident was being transferred to, or any statement of the resident's appeal rights. 2. An electronic record review for Resident #3 found he was admitted to the facility on [DATE]. A Discharge Return Anticipated MDS assessment with an ARD of 12/17/19, found Resident #3 had an unplanned discharge to an acute care hospital the same day. He had moderately impaired cognitive skills and [DIAGNOSES REDACTED]. Active discharge planning to the community was not occurring during the time of the assessment. The record indicated a family member was designated as the resident's representative and POA. A review of the progress notes in his clinical record confirmed Resident #3 was transferred to the emergency room and admitted to the hospital for treatment on 12/17/19. Further review of the record found there was no written notification to the resident or his representative informing them of the reason or effective date of the transfer, the location he would be transferred to, or any statement of the resident's appeal rights. A review of the facility's Policy titled Resident Transfer to Hospital or Therapeutic Leave (Number 1602 and last revised on 11/1/17) noted the following: . 5. When a discharge or transfer is initiated by the nursing home (NH), the NH administrator . or designee . must sign the notice of discharge or transfer . (photocopy obtained) An interview was conducted with the Deputy Director of Service Operations (DDSO) at 2:05 p.m. on 6/19/20. She was asked for the written notifications for Residents #2 and #3 related to their transfers to the hospital. The DDSO stated she thought the written notification form was required only for discharges. She was unaware the written notice was also required for transfers. The DDSO confirmed the missing written notification for Resident #2 and #3's transfers. The regulation was reviewed with her and she voiced understanding of the requirements. She telephoned the Administrator at 2:10 p.m. on 6/19/20, relaying that the Administrator confirmed she had not completed the forms for Residents #2 or #3. In a second interview on 6/19/20 at 3:15 p.m., she reviewed the policy and confirmed it referenced written notification for transfers.

Based on observation, record review and record review the facility failed to ensure qualified staff assess residents with change in respiratory status and to properly perform [MEDICATION NAME] maneuver during a choking episode resulting in death of 2 of 2 sampled residents. (Resident #2, 3) The findings include: Professional Standard of Care is defined in Chapter 766.102 as the prevailing professional standard of care for a given health care provider shall be that level of care, skill, and treatment which in light of all relevant surrounding circumstances is recognized as acceptable and appropriate by reasonably prudent similar health care providers. The Florida Nurse Practice Act, Chapter 464.003 defines the practice of professional nursing as the performance of those acts requiring substantial specialized knowledge, judgment, and nursing skill based upon applied principles of psychological, biological, physical, and social sciences which shall include, but not limited to: the administration of medications and treatments as prescribed or authorized by a duly licensed practitioner ' practice of practical nursing as the performance of selected acts, including the administration of treatments and medications, in the care of the ill, injured or infirmed and the promotion of wellness, maintenance or health, and the prevention of illness of others under the direction of a registered nurse, a licensed physician, a licensed osteopathic physician or a licensed dentist. Review of the records for Resident #2 revealed a choking episode on [DATE]. Record review for Resident #3 revealed a choking incident on [DATE]. Employee A, (Registered Nurse) was involved in both incidents, the incident on [DATE] she was directly involved and the other on [DATE] she was the RN supervisor who oversaw Employee B (Licensed Practical Nurse) attempting to perform [MEDICATION NAME] maneuver and offered no assistance. On [DATE] Employee A did not appropriately assess Res #2's respiratory status, perform [MEDICATION NAME] maneuver properly and instead of immediately contacting 911 and notifying the physician she waited and called family for direction. The family requested he be sent to the hospital. Res #2 was transferred to the hospital but died shortly after arriving. On [DATE], Employee A did not participate in attempts to help Res #3 when he was choking, nor did she offer any guidance to Employee B, LPN, who did not assess respiratory status, failed to ensure [MEDICATION NAME] maneuver was executed properly, notify the physician and immediately summons EMS when choking could not be resolved. Resident #3 died at the facility. Per Mayo Foundation of Medical Evaluation and Research ,[DATE] (Mayo Clinic) Mayo.org: Choking occurs when a foreign object lodges in the throat or windpipe, blocking the flow of air. In adults, a piece of food often is the culprit. Young children often swallow small objects. Because choking cuts off oxygen to the brain, give first aid as quickly as possible. The universal sign for choking is hands clutched to the throat. If the person doesn't give the signal, look for these indications: · Inability to talk · Difficulty breathing or noisy breathing · Squeaky sounds when trying to breathe · Cough, which may either be weak or forceful · Skin, lips and nails turning blue or dusky · Skin that is flushed, then turns pale or bluish in color · Loss of consciousness If the person is able to cough forcefully, the person should keep coughing. If the person is choking and can't talk, cry or laugh forcefully, a five-and-five approach to delivering first aid: · Give 5 back blows. Stand to the side and just behind a choking adult. Place one arm across the person's chest for support. Bend the person over at the waist so that the upper body is parallel with the ground. Deliver five separate back blows between the person's shoulder blades with the heel of your hand. · Give 5 abdominal thrusts. Perform five abdominal thrusts (also known as the [MEDICATION NAME] maneuver). · Alternate between 5 blows and 5 thrusts until the blockage is dislodged. To perform abdominal thrusts ([MEDICATION NAME] maneuver) on someone else: · Stand behind the person. Place one foot slightly in front of the other for balance. Wrap your arms around the waist. Tip the person forward slightly. · Make a fist with one hand. Position it slightly above the person's navel. · Grasp the fist with the other hand. Press hard into the abdomen with a quick, upward thrust - as if trying to lift the person up. · Perform between six and 10 abdominal thrusts until the blockage is dislodged. If you're the only rescuer, perform back blows and abdominal thrusts before calling 911 or your local emergency number for help. If another person is available, have that person call for help while you perform first aid. To clear the airway of a pregnant woman or obese person: · Position your hands a little bit higher than with a normal [MEDICATION NAME] maneuver, at the base of the breastbone, just above the joining of the lowest ribs. · Proceed as with the [MEDICATION NAME] maneuver, pressing hard into the chest, with a quick thrust. · Repeat until the food or other blockage is dislodged. If the person becomes unconscious, follow the next steps. To clear the airway of an unconscious person: · Lower the person on his or her back onto the floor, arms to the side. · Clear the airway. If a blockage is visible at the back of the throat or high in the throat, reach a finger into the mouth and sweep out the cause of the blockage. Don't try a finger sweep if you can't see the object. Be careful not to push the food or object deeper into the airway.

Based on observations, record reviews and interviews, the facility failed to appropriately assess a resident's respiratory status following a choking incident, appropriately perform the [MEDICATION NAME] maneuver and promptly notify Emergency Medical Services for two residents requiring assistance by staff for meals (Resident #2 and Resident #3). On [DATE], the facility's census was 107. There were thirty-five residents identified as requiring assistance by staff with meals and were at risk. Immediate Jeopardy (IJ) at a scope of J (isolated) was identified at 5:19 PM on [DATE], which is ongoing. On [DATE] at 6:45 PM, the Administrator was notified of the IJ determination. The findings include: A review of the medical record for Resident #2 was conducted which revealed a readmission date of [DATE] with a primary medical [DIAGNOSES REDACTED]. The resident's cognition was impaired and he required assistance by staff with activities of daily living, to include meals. The resident received a mechanically altered diet for swallowing difficulties. A nursing note entry by Employee A, Registered Nurse (RN) dated [DATE] at 3:17 PM indicated that the resident was in distress by explaining that he appeared blue with wide eyes open and presented with a blood pressure of ,[DATE] and a heart rate of 87. However, the note failed to indicate whether the resident's respiratory status was assessed, whether the [MEDICATION NAME] maneuver was performed, and contained no timeline of the actions the facility took in response to the choking incident. A nursing note entry by Employee K, RN - House Supervisor dated [DATE] at 3:38 PM indicated the resident was having trouble breathing and was turning blue. The note indicated the RN supervisor proceeded to check the resident's code status and it was determined the resident was a do-not-resuscitate (DNR). The resident's wife was then called who requested the resident be transferred to the hospital. The resident's physician was then called to obtain an order to send the resident to the hospital. Finally, Emergency Medical Services (EMS) was called. The note indicated no attempts to appropriately assess the resident's respiratory status or perform the [MEDICATION NAME] maneuver but did demonstrate delays in notification to EMS. The resident expired in the facility on [DATE]. An interview was conducted with Employee A, RN on [DATE] at 4:00 PM. The nurse indicated that as she was exiting another resident's room, Resident #2's CNA summoned her from across the hall. She explained that when she entered the room the resident was lying in bed and was noted to be blue and that his eyes were wide open. She explained that she instructed the CNA to call the supervisor and applied oxygen via nasal cannula at a rate of 2 liters per minute. She explained that she did not attempt the [MEDICATION NAME] maneuver because of the resident's position in bed. She was asked whether she attempted to reposition the resident to facilitate the [MEDICATION NAME] maneuver and she stated No. The nurse was asked whether she assessed the resident's respiratory status (to include breath sounds) and she stated No. The nurse explained that the, because the resident was a DNR, the supervisor called the resident's family and the physician prior to notifying EMS as this was the facility's protocol. She then stated had it been up to me I would have called 911. When asked to expand on the answer the nurse explained that, prior to this incident, the facility's policy had been to notify the family and physician for any resident that was a DNR prior to calling EMS for emergencies. She explained that this policy was without regard to whether the resident still presented with signs of life (a blood pressure and/or pulse). The nurse acknowledged that a delay in performing the [MEDICATION NAME] maneuver and notifying EMS had the potential to result in harm or death to residents. An interview was conducted with Employee C, Certified Nursing Assistant (CNA) on [DATE] at 4:13 PM. She was asked to explain what she could recall about the incident and resident #2. The CNA explained that as she was assisting the resident with his lunch the resident's eyes got very big and that he opened his mouth as if to try and say something. She acknowledged that the resident was in bed at the time. The CNA explained that she called the nurse immediately. She stated the nurse came in and instructed her to call the supervisor so she left the room. She explained that the supervisor responded to the resident's room but that she was unable to recall whether the supervisor or the primary RN attempted the [MEDICATION NAME] maneuver. She explained that EMS arrived a little while later and pronounced the resident deceased . An interview was conducted with the risk manager on [DATE] at 4:28 PM. She acknowledged that she was responsible for conducting an internal investigation into Resident #2's choking incident and provided an investigative file. The investigative file was reviewed with the risk manager. She explained that the resident had experienced a decline in function in the weeks prior to the incident and that his needs for assistance had increased as a result. She also explained that, because the resident was a DNR, the investigation concluded the facility had followed it's policies with regard to emergency care for choking incidents. A copy of the policy/procedure was requested. Several minutes later the risk manager returned and acknowledged that no specific policy/procedure for choking incidents was available and explained that the facility would revert to professional standards of practice in that instance. During a review of Resident #2's most recent speech therapy discharge summary dated [DATE], it was noted that his discharge recommendations were to be up to his wheelchair for all meals. The resident was being assisted with his meal in bed at the incident. A review of the resident's nutritional care plan indicated interventions to assist the resident with meals as needed and encourage meals in the dining room. The care plan did not reflect the speech therapist's recommendations from the [DATE] discharge summary. An interview was conducted with Employee E, Speech Therapist on [DATE] at 11:00 AM regarding Resident #2. She explained that she evaluated the resident for weight loss and that the resident did require assistance with meals. She explained that the resident's decline in condition had progressed and that he hadn't been eating as much. The speech therapist was asked about the discharge summary dated [DATE] in which recommendations were made for the resident to be up to his wheelchair for all meals. The therapist confirmed that this was her recommendation to facilitate swallowing and confirmed that the resident may have been at a higher risk for choking if he was eating in the bed. A review of the medical record for Resident #3 was conducted which revealed a readmission date of [DATE] with a primary medical [DIAGNOSES REDACTED]. The resident's cognition was impaired and he required extensive to total assistance by staff for activities of daily living (to include meals). The resident received a mechanically altered diet for difficulties swallowing. A review of the resident's nursing notes revealed an entry by Employee B, Licensed Practical Nurse (LPN) dated [DATE] at 10:26 AM which indicated that the nurse was summoned to the dining room by the CNA at 9:20 AM. The nurse observed the resident's eyes open and he was moving his lips as if to say something. The resident was breathing but appeared pale. Two staff members assisted the resident to lean forward while the nurse attempted to perform abdominal thrusts which were unsuccessful. Subsequently, the resident's breathing stopped. He was assessed by the RN supervisor and pronounced deceased . The note did not indicate any respiratory assessments or notifications to EMS were conducted. The resident expired in the facility on [DATE]. A nursing note entry by Employee A, RN, dated [DATE] at 9:51 AM was reviewed. The nurse was functioning as the house supervisor at the time of the incident. The note indicated the nurse responded to an overhead page and upon arriving to the unit the resident was noted to be sitting in a broda chair with staff attempting abdominal thrusts. Shortly thereafter, the RN assessed the resident and was unable to obtain vital signs. The note did not indicate any respiratory assessments or notifications to EMS were conducted. An interview with Employee A, RN was conducted on [DATE] at 4:05 PM regarding Resident #3. She explained that she was functioning as the house supervisor at the time of the incident. She noted that the resident's assigned caregivers were attempting abdominal thrusts while the resident was seated in his Broda chair and that they were unsuccessful due to the resident's abdominal girth. The nurse was asked whether any attempts to perform back blows or attempts to reposition the resident were made and she stated No. The RN explained that EMS was never called and voiced concerns that the facility had not provided her with enough training or support. The nurse explained that she had been instructed to call a resident's family and physician prior to notifying EMS even in emergency incidents such as choking. An interview was conducted with Employee C, LPN on [DATE] at 9:43 AM regarding Resident #3. She explained that she assisted the resident with his morning oatmeal and left the table to administer treatment to another resident. She explained that when she returned to the dining area she observed the CNA with the resident at that the resident appeared to be choking. The resident mouthed help me but no sound came out. Staff attempted to perform abdominal thrusts in the Broda chair but they were unsuccessful. The nurse explained that the RN supervisor responded to the unit but proceeded to the nursing station to review the medical record and offered to assistance or direction during the choking incident. The nurse confirmed that no respiratory assessment was conducted and that no notification was made to EMS. An interview was conducted with Employee D, CNA on [DATE] at 10:00 AM regarding Resident #3. She explained that after assisting the resident with a bite of eggs the resident's eyes enlarged. She explained that she called the nurse thinking maybe he's choking. The CNA explained that the nurse started to perform abdominal thrusts from the front of the resident's chair. The CNA was unable to recall whether EMS was notified but confirmed that they never responded to the incident. An interview was conducted with the resident's attending physician on [DATE] at 2:28 PM. The physician also serves as the facility's medical director. During the interview the physician confirmed that Resident #3 expired from an acute choking episode and confirmed that he believed it would have been appropriate to notify EMS in this instance. The physician indicated he did recall that some remedial training had been conducted with the nurses as a result of this incident.

Based on record reviews and interviews, the facility failed to ensure licensed nurses had the specific competencies and skill sets necessary to care for resident at risk of chocking by failing to ensure consistent nursing practice and provision of education/training as it related performing [MEDICATION NAME] Maneuver on chocking residents. Failure to appropriately assess the residents' respiratory status following a choking incident, appropriately perform the [MEDICATION NAME] maneuver based on a resident's size and promptly notify Emergency Medical Services, resulted in Resident #2 and #3's death. There were thirty-five residents identified as requiring assistance by staff with meals and were at risk. Immediate Jeopardy (IJ) at a scope of J (isolated) was identified at 5:19 PM on [DATE], which is ongoing. On [DATE] at 6:45 PM, the Administrator was notified of the IJ determination. The findings include: A review of the medical record for Resident #2 revealed he was admitted to the facility on [DATE] with a primary medical [DIAGNOSES REDACTED]. A review of the most recent comprehensive assessment revealed the resident required supervision with his meals. The diet order was a regular diet with a mechanical soft texture. Brief Interview of Mental Status (BIMS) score was 9. A record review of the nurses' notes for Resident #2 dated [DATE] at 3:17 PM read, Finished care with a resident and came out of room when the Certified Nursing Assistant (CNA) came out of this resident's room. Went into room and found resident appeared blue with wide eyes opened. Yelled out to staff to call supervisor, while assessing resident's mouth. There was a small amount of food noted between gum and cheek. No food noted in back of mouth or throat. Blood Pressure (BP) ,[DATE] Millimeters of Mercury (mm Hg Heart Rate (HR) 87 Oxygen at 2 Liters per minute via nasal cannula was in place. Further review of the nurses' notes revealed an entry by the registered nurse (RN) supervisor (Employee A) dated [DATE] at 3:38 PM. She wrote Writer was called STAT (immediately) to the unit. CNA (Employee C) reported Resident #2 was experiencing respiratory distress. Upon entering the room, resident was observed having difficulty breathing and turning blue, was able to make weak sound. Employee A checked resident's code status. He was a Do Not Resuscitate (DNR). Called wife/Power of Attorney (POA). POA requested to send resident to the hospital. The attending physician was called who ordered to send resident to hospital. When Emergency medical technicians (EMT) arrived and assessed Resident #2, he was pronounced deceased . An interview was conducted with Employee A, RN supervisor on [DATE] at 4:00 PM. The nurse explained that she was the supervisor on duty on [DATE]. She responded to the R2 room after being summoned by the CNA (Employee C) who was assisting the resident with lunch (lunch was delivered between 12:00 -12:10 PM). She explained that, upon entering the room, the resident was lying in bed with his head elevated and that he appeared blue. She explained that the resident's eyes were very wide. The nurse checked the resident's mouth for food and observed food pocketed between the cheek and tongue on both sides. The nurse stated she attempted the [MEDICATION NAME] maneuver but was unsuccessful due to the resident's position in bed. She explained that EMT was notified around 1:15 pm, they responded and pronounced the resident deceased in the facility. An interview on [DATE] at 4:30 pm, Employee C, Certified Nursing Assistant (CNA) stated that she was the assigned to care for Resident #2 on [DATE] when the incident happened. She explained that the he had recently been transferred to her unit and that she was assisting him with his meal. She stated, All of a sudden his eyes got very big and he opened his mouth as if he was trying to say something. She responded by calling the nurse immediately. The nurse responded and instructed the her to call the supervisor. She explained that the paramedics came in and stated, There is nothing we can do. He probably had a [MEDICAL CONDITION] or a stroke. A review of the medical record for Resident #3 revealed he was admitted to the facility on [DATE] with a primary medical [DIAGNOSES REDACTED]. A review of the most recent comprehensive assessment, dated [DATE], revealed the resident required extensive to total assistance with activities of daily living. The diet order included a mechanical soft consistency with nectar-thickened liquids. Brief Interview of Mental Status (BIMS) of 12. A review of the nurses' progress notes for Resident #3 dated [DATE] at 10:26 AM read, Writer assisted resident with consuming oatmeal. Resident completed oatmeal. While awaiting main entrée, writer prepared and administered medication for another resident. At 9:20 AM writer was called to main dining area by CNA (Employee H). Upon arriving resident's eyes were open. Resident was chewing his food and at the same time he was moving his lips as if to say something. Resident was breathing but looked pale. Resident then stopped breathing. Two staff assisted resident in leaning forward while writer performed abdominal thrusts. Abdominal thrusts were unsuccessful. Due to resident size, a second staff member with longer arms performed abdominal thrusts. Abdominal thrusts were unsuccessful. During this time, non-rebreather at 12 liters applied to resident. Staff attempted to obtain 02 sat and blood pressure. Unable to obtain. RN supervisor assessed resident. Resident did not have a heartbeat. Notified daughter. An interview on [DATE] at 4:05 PM, Employee A, RN supervisor stated that she entered the unit dining room and observed Resident #3 seated in his Broda chair with two or three staff members positioning the resident and attempting to perform the [MEDICATION NAME] maneuver. She indicated that she then proceeded to the nurse's station to check the resident's code status and confirmed he was a DNR. When asked whether emergency medical personnel were notified the nurse indicated they were not. She stated, If it was my choice, I would have notified them. When asked to elaborate on the facility's procedures she stated, There's not enough training or support here. I've heard from one person that we have to call the family and get permission to call 911 first. I've also heard that now we can call 911 immediately if we need to. The nurse explained that she was unclear of the facility's emergency response procedures and that, in response to the death of Resident #3, the facility conducted training to clarify its procedures for notifying emergency medical personnel. Employee B stated in an interview on [DATE] at 9:55 am, that she had worked in the facility since February 2020. She added that had not received training on facility protocol for chocking She further mention that there was a recent training on [DATE]rd where she was informed to contact 911 for all emergencies. Interview on [DATE] at 10:15 am, Employee J Licensed Practical Nurse (LPN) stated that she is an Agency Nurse. She stated that she works an average of ,[DATE] days a week for the last two years. She stated that she received four-hour onboarding computer training. When asked to walk the surveyor through a chocking incident, the nurse could not mention all the appropriate steps for [MEDICATION NAME] Maneuver. Additionally, the nurse was unfamiliar with the facility chocking protocol. Interview [DATE] at 4:15 pm, Employee H, CNA that she has worked in the facility for the last 9 years. Every year during the hire month they are offered a training packet. After the training is completed the packet is handed over to the staff development specialist. She mentioned that she had not had any in-service on chocking. When asked about the competency checklist. She stated that they complete it themselves depending on the skill which one is comfortable completing. She mentioned that here is no one who checks the skills as the CNA completes the check list. Interview on [DATE] at 8:30 am revealed that Employee I LPN had worked at the facility for four years. She added that the facility provided a packet containing all he mandatory annual trainings. She stated that she had not received any training on chocking or emergency protocol. She added that recently (could not remember the exact date) she was informed about calling 911 in all emergencies and confirmed that she signed the in-service. When asked to walk the surveyor through a chocking incident, the nurse could not mention all the appropriate steps for [MEDICATION NAME] Maneuver. In addition, the nurse could not state different [MEDICATION NAME] maneuvers depending on residents' sizes. Per Mayo Foundation of Medical Evaluation and Research ,[DATE] (Mayo Clinic) Mayo.org: Choking occurs when a foreign object lodges in the throat or windpipe, blocking the flow of air. In adults, a piece of food often is the culprit. Young children often swallow small objects. Because choking cuts off oxygen to the brain, give first aid as quickly as possible. The universal sign for choking is hands clutched to the throat. If the person doesn't give the signal, look for these indications: · Inability to talk · Difficulty breathing or noisy breathing · Squeaky sounds when trying to breathe · Cough, which may either be weak or forceful · Skin, lips and nails turning blue or dusky · Skin that is flushed, then turns pale or bluish in color · Loss of consciousness If the person is able to cough forcefully, the person should keep coughing. If the person is choking and can't talk, cry or laugh forcefully, a five-and-five approach to delivering first aid: · Give 5 back blows. Stand to the side and just behind a choking adult. Place one arm across the person's chest for support. Bend the person over at the waist so that the upper body is parallel with the ground. Deliver five separate back blows between the person's shoulder blades with the heel of your hand. · Give 5 abdominal thrusts. Perform five abdominal thrusts (also known as the [MEDICATION NAME] maneuver). · Alternate between 5 blows and 5 thrusts until the blockage is dislodged. To perform abdominal thrusts ([MEDICATION NAME] maneuver) on someone else: · Stand behind the person. Place one foot slightly in front of the other for balance. Wrap your arms around the waist. Tip the person forward slightly. · Make a fist with one hand. Position it slightly above the person's navel. · Grasp the fist with the other hand. Press hard into the abdomen with a quick, upward thrust - as if trying to lift the person up. · Perform between six and 10 abdominal thrusts until the blockage is dislodged. If you're the only rescuer, perform back blows and abdominal thrusts before calling 911 or your local emergency number for help. If another person is available, have that person call for help while you perform first aid. To clear the airway of a pregnant woman or obese person: Position your hands a little bit higher than with a normal [MEDICATION NAME] maneuver, at the base of the breastbone, just above the joining of the lowest ribs. Proceed as with the [MEDICATION NAME] maneuver, pressing hard into the chest, with a quick thrust. Repeat until the food or other blockage is dislodged. If the person becomes unconscious, follow the next steps. To clear the airway of an unconscious person: Lower the person on his or her back onto the floor, arms to the side. Clear the airway. If a blockage is visible at the back of the throat or high in the throat, reach a finger into the mouth and sweep out the cause of the blockage. Don't try a finger sweep if you can't see the object. Be careful not to push the food or object deeper into the airway. An interview was conducted with Staff Development Nurse (SDN) on [DATE] at 9:55 am. She was asked if she conducted competencies including skills for the nursing staff. She stated no the house supervisors do the annual competencies and sign off the skills check lists completed by the nurses and certified nursing assistants. She stated that the facility has had a high staff turnover and it was a challenge to capture all the staff. When asked how often in-service training was provided, she stated she had not conducted any in-services for the past six months. Annually all nursing staff are given a packet that contains all mandatory in-services. The nursing staff completed the trainings including the tests and turn them in. She was asked if the supervisors had been provided any training or instruction as to how to conduct the annual competencies and monitor staff for proper skills techniques, she said not to her knowledge. She was asked if she had been made aware by nursing management or the administrator regarding how nurses were responding to choking episodes. She said she was asked by the administrator to conduct an in-service for nurses on [DATE] regarding Patient health emergency. When asked what was included in the in-service, she said calling 911 in all emergencies. She as asked if the in-service addressed choking or change in resident condition, she said no. Review of the sign in sheets dated [DATE] revealed Detailed Description of the in-service: This in service discusses the protocol for a patient health emergency. Nursing staff will be educated that all patient health emergencies require a call to 911 and evaluation from a physician. 18 out of 36 nurses in the facility had not received the inservice. In addition, 2 of the 4 nurses involved in the two choking incidences has not received the in-service. On [DATE] at 5:30 pm an interview was conducted with the administrator. She was asked about the choking incident of Resident #3 on [DATE]. She stated she was not in the facility at the time, she was out on sick leave. She was asked how the facility addressed adverse incidents. She said that all emergency incidents are discussed in the next business day clinical meeting. At that time the risk manager and the director of nursing (DON) determines what actions to take e.g. staff education. She confirmed that she was informed about the incident with R3 however, there were no measures/ training put in place since it was determined that the resident expired so quickly, and the staff did what they could keeping in mind the resident was a DNR. The DON who was present during the interview stated that he was not informed of the incidence. He added that he was the assistant director of nursing (ADON) at the time. The administrator was asked who was responsible for ensuring all nursing staff have annual competencies and skills checks, she stated SDN.

Based on record reviews and staff interviews and the facility's policy and procedure for Quality Assurance Performance Improvement (QAPI), the facility failed to ensure quality assurance monitoring of facility processes related to adverse events and to ensure identification of potential significant problems. The lack of follow up to adverse events related to choking incidents resulted in the death of two residents. (Resident #2 , 3) Immediate Jeopardy (IJ) at a scope of J (isolated) was identified at 11:07 a.m On [DATE] at 6:45 PM, the Administrator and Director of Nursing was notified of the IJ determination. The findings include: Review of the records for Resident #2 revealed a choking episode on [DATE]. Record review for Resident #3 revealed a choking incident on [DATE]. Employee A, (Registered Nurse) was involved in both incidents, the incident on [DATE] she was directly involved and the other on [DATE] she was the RN supervisor who oversaw Employee B (Licensed Practical Nurse) attempting to perform [MEDICATION NAME] maneuver and offered no assistance. On [DATE] Employee A did not appropriately assess Res #2's respiratory status, perform [MEDICATION NAME] maneuver properly and instead of immediately contacting 911 and notifying the physician she waited and called family for direction. The family requested he be sent to the hospital. Res #2 was transferred to the hospital but died shortly after arriving. On [DATE], Employee A did not participate in attempts to help Res #3 when he was choking, nor did she offer any guidance to Employee B, LPN, who did not assess respiratory status, failed to ensure [MEDICATION NAME] maneuver was executed properly, notify the physician and immediately summons EMS when choking could not be resolved. Resident #3 died at the facility. Following the incident the facility risk manager documented a summary and submitted to Veterans affair. There was no investigation regarding the details of the incident or actions needed to be taken. During an interview with the Risk Manager (RM) on [DATE] at 11:30 am, she was asked if there had been any adverse incident reports or federal one and five day reports filed in past 3 months. She stated there were no adverse incidents, however there were some federal reports. She was asked to provide copies of the reports and facility investigations. She also added the facility reports adverse events(AE) reports to the Veterans, however those reports did not meet criteria of adverse incidents for reporting to the State agency. An interview was conducted with RM on [DATE] at 4:20pm. She was asked what was the definition of a sentinel event found in the AE reports, she said did not want to misspeak and would bring a copy of definition. Sentinel event was defined as an adverse event that results in the loss of life or limb or permanent loss of function The RM was asked why adverse incidents were not filed with State agency, she said the criteria for reporting was not the same. She was asked if the investigations of the incidents of Res #2 and Res #3 resulted in any change of practice, additional education or nursing competencies, she said no. She was asked who was responsible to determine what further actions were needed, she said administrator, director of nursing, risk manager and Veteran affairs consultants. During an interview on [DATE] at 3:35pm with the Nursing Home Administrator(NHA) and Director of Nursing (DON) (acting) they were asked what did they know about the incident on [DATE] involving Resident #2. The DON stated that at the time he was the ADON/infection control nurse and had not been involved in the investigation. The Administrator stated when a situation like this occurs we all speak about what happened, review the care plan, discuss current interventions and hold interdisciplinary team meeting for new interventions. If we felt any concerns we would implement immediate actions whether it be competency skills, corrective actions and we would begin implementing the plan that day. She said she really did not have a recollection of the event of [DATE] or anything that we did moving forward. Regarding the incident on [DATE] involving Resident #3, NHA said she was not in the facility at the time, she was quarantined due to being positive for COVID-19. She was asked who was designated as NHA when you were out on sick leave, she said the former DON was in the building at the time and was designated as in charge. Also a regional NHA came in for a week. The RM investigated the incident on [DATE] and reported findings to regional office. When asked what measures were taken. she said all nursing staff would be educated that all health emergencies require call to 911 and evaluation from a physician. When asked if nursing competencies were performed after the incident, she stated no. Review of the in-service training sign in sheet dated [DATE] revealed as of [DATE] only half of the nurses had received the training (18 of 36). At the time of the survey, the facility had no consistent monitoring/audit process for ensuring nursing staff were appropriately trained and competent to provide necessary care to the facility residents. Staff interviews revealed a packet was received annually to independently complete training. No oversight, monitoring or auditing of training completion or competency was completed by nursing management.

Based on record review and staff interviews, the facility failed to provide written notice for a change in services covered by Medicare for one (Resident #130) of three residents reviewed for beneficiary protection notification from a total of 28 residents in the sample. The findings include: A review of the Beneficiary Protection Notification Review form for Resident #130 revealed skilled services, Part A, were started on 8/8/19. The last covered date was documeted as 9/5/19. An interview was conducted with the administator on 12/3/19 at 11:15 am. When asked whether a Notice of Non-Coverage was issued for Resident #130, she replied no. An interview was conducted with the Social Worker on 12/4/19 at 9:40 am. When asked whether Resident #130 had been issued a Notice of Medicare Non-Coverage, she replied, no, she was not made aware of the issue until today. She was asked who was responsible for notifying residents and resident representatives. She stated that the therapy department communicated when a discharge from services would occur. She said she was responsible for issuing the notice of non-coverage.

Based on record reviews and interviews, the facility failed to develop and implement a comprehensive person-centered care plan for one (Resident #40) of three residents reviewed for falls, from a total 28 residents in the sample. The findings include: A record review was conducted for Resident #40, revealing a [AGE] year-old male admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Further review of the record revealed he had fallen twice on 12/2/19. Both falls were reviewed and it was noted that both falls occurred on the resident's way to the bathroom by himself. A review of his care plans revealed the following: Problem Start Date: 12/03/2014 Category: Falls Risk for falls related to: history of falls, history of weakness, and coordination deficits. Edited 11/22/2019 Goal: long-term goal target date: 01/09/2010 Risk for falls will be minimized through interventions in place thru next review date Edited: 10/10/2019 Approach: PT RNP (physical therapy restorative nursing program) 5 times a week for 60 days Created 11/22/19 Current level of function - Set up for bed mobility, transfers, ambulation, mobility. Created: 4/30/19 Shower bench for all showers. Created 3/6/19 Head end enablers on bed. Created 10/10/19 Gripper socks at all times, document noncompliance. Created 10/31/19 May keep bed room door closed as desires. Created 5/1/18 Monitor for safety and whereabouts - assist as needed. Upon further review of his care plan it was revealed that the facility failed to enter and/or document any approaches for his two falls on 12/2/19. On 12/5/19 at 2:05 PM, and interview was conducted with Employee G, Licensed Practical Nurse (LPN), regarding the fall care plan and Kardex (care card with resident information) for Resident #40. She stated that the MDS (minimum data set) assessment nurse was responsible for updating residents' care plans. The floor nurse and/or unit manager would update the Kardex. She stated the resident was placed on one to one supervision. (This information was not on the care plan or the Kardex.) She said she observed him walking back from the dining area today, he was much better and the one to one supervision would probably be discontinued tomorrow. When asked how other staff members caring for Resident #40 would be able to identify him as a fall risk and had two recent falls, she stated those individuals would receive the information during report at change of shift. She reviewed the Kardex and confirmed that it did not indicate the resident was at risk for falls. The space indicating the resident was a fall risk was not checked off on the card. She attributed the most recent falls to a slight infection, the beginning of pneumonia, but added that the infection was clearing up, so he would not have any additional falls. When asked whether they had considered a toileting plan since he had fallen twice going to the bathroom unassisted, she confirmed that had not occurred yet, but it could be considered. On 12/5/19 at 2:14 PM, an interview was conducted with Employee E, Registered Nurse (RN), regarding the care plan for Resident #40 and his two falls on 12/2/19. She stated his care plan had not been updated because no official orders had been written. She went on to say that updating a care plan relied upon a doctor's order being written, then that information is added to the care plan if applicable. She further stated that she as the MDS nurse reviewed a resident's Kardex approximately every 90 days, and she was not responsible for updating them. The unit manager and floor nurse were responsible for updating the Kardex. On 12/5/19 at 2:30 PM, an interview was conducted with Employee F, RN/Nurse Supervisor, regarding the care plan for Resident #40 and his two recent falls. She stated that any resident with falls was discussed each morning. She stated for Resident #40 they used nursing judgement to keep him on one to one supervision each shift and this was reassessed daily. She was unsure of when the one to one status would be discontinued. She was unable to state what, if any, interventions would be in place after the one to one status ended, in order to ensure that all oncoming staff were aware that this resident was at increased risk for falls. She said she believed his two recent falls were due to an acute illness. She had not considered implementing a toileting program and was unsure of whether anyone else had considered this. She states there is no system in place to alert staff that patient had a recent fall.

Based on interviews and record reviews, the facility failed to provide the physician-ordered restorative nursing program for one (Resident #71) of one resident reviewed for restorative services, from a total of 28 residents in the sample. The findings include: A record review was conducted for Resident #71, which revealed a [AGE] year-old male admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The resident had a [DIAGNOSES REDACTED]. An interview was conducted with Resident #71 on 12/2/19 at 10:33 AM, regarding the care and services he was provided by the facility. He stated the care was okay, but he was supposed to walk with restorative five times a week and they only walked with him twice a week. Further review of the clinical record revealed an order for [REDACTED]. There was no documentation in the record indicating that restorative services were being provided. An interview was conducted with the Interim Director of Nursing (IDON) and Employee A, Restorative Aide, regarding Resident #71's restorative program. The IDON stated that they had just identified while reviewing the requested paperwork that the resident had not been receiving his restorative services as ordered. Employee A stated she walked with the resident when she was on duty, but if she was off or was pulled from her restorative duties to work a floor assignment, there was no way another restorative aide would know what to do for the resident. When she was told the resident claimed he was only being walked twice a week, she confirmed that was an accurate statement. She stated that due to the time restrictions and whether a restorative aide was pulled from their duties in order to work a floor assignment, they were unable to complete residents' restorative plans as ordered. The IDON stated that the facility would have to review their system, as it was not currently working. He had not realized there was a problem until the records were requested.

Based on observations, record reviews and interviews, the facility failed to maintain a medication error rate of less than 5%. The facility had 25 medication opportunities and two medication errors, resulting in an error rate of 8%. There were thirteen residents reviewed during medication administration, and two residents were affected. (Residents #56 and #6). The findings include: A medication administration observation was conducted with Employee B, Licensed Practical Nurse (LPN), for Resident #56. He had an order for [REDACTED]. An interview was immediately conducted with Employee B, and she confirmed that the medication was not available. A medication administration observation was conducted with Employee C, Licensed Practical Nurse (LPN), for Resident #6. He had an order for [REDACTED]. On 12/4/19 at 12:51 PM, an interview was conducted with Employee C, LPN, regarding the [MEDICATION NAME] order for Resident #6. She reviewed the electronic medical record and confirmed that the order was for one and a half tablets. She looked in the cart and confirmed that he had half tablets packaged from the pharmacy and she had given the wrong dosage.

Based on observations and interviews, the facility failed to maintain infection control prevention practices, and provide a safe, sanitary and comfortable environment to help prevent the development and transmission of communicable diseases and infections for four (Residents #42, #93, #27 and #48) of a total of 28 residents in the sample. The findings include: 1. During dining observations on 12/04/19 at 12:22 PM, Employee D, Certified Nursing Assistant (CNA), was observed using her bare hands to cut Resident #42's hot dog in half. On 12/5/19 at 12:42 PM, an interview was conducted with Employee D regarding the handling of Resident #42's hotdog during the lunch observation on 12/4/19. She stated she should not have touched it with her bare hands, and the facility had to in-service them again regarding not touching residents' food. She was asked about handwashing and she confirmed that the staff should wash their hands between residents. 2. A medication administration observation was conducted on 12/4/19 at 4:31 PM with Employee J, Registered Nurse (RN), for Resident #93. Employee J performed blood glucose testing for the resident and returned to her cart wearing the same gloves she had worn to obtain the blood sample. She donned gloves, obtained the resident's blood glucose reading and returned to the cart with all of her supplies, while wearing the same gloves. She then removed two bleach wipes and cleansed the glucometer. She then placed it in the top drawer of the medication cart with all of the other glucometers. Next, she removed the gloves and continued on to the next resident without washing/santizing her hands. On 12/4/19 at 4:38 PM, an interview was conducted with Employee J regarding the break in infection control related to not changing her gloves or washing/sanitizing her hands. She confirmed that she failed to remove the gloves, and stated she would remove the glucometer from the medication cart and clean it again. When asked about washing and/or sanitizing her hands between residents, she confirmed that she should have been washing her hands between each resident. 3. An observation of Resident #27 on 12/02/19 at 12:41 PM, found him in his room with Employee H, Certified Nursing Assistant (CNA). Employee H stated she had just finished providing incontinence care, and was observed holding a clear plastic bag containing an adult undergarment. She was wearing gloves. Employee H disposed of the bag and its contents in the trash, then without removing her gloves, touched the controls on the device at the foot of the bed to adjust the setting on his air mattress. Wearing the same gloves, she then adjusted the head of Resident #27's bed to approximately 30 degrees. An interview with Employee H at this time confirmed she had neglected to remove the soiled gloves and wash her hands following the provision of incontinence care, and prior to touching surfaces in Resident #27's room. 4. Resident #48's room was observed on 12/03/19 at 9:45 AM. A nebulizer was observed on the small dresser. The face mask of the device was not encased in a bag or covered to protect dust or debris from entering the mask, and neither the mask nor the tubing was dated. Resident #48's room was observed again on 12/04/19 at 9:40 AM. The nebulizer mask was not covered, and there was no date on the mask or the tubing. An interview was conducted with Employee I, Agency Nurse, on 12/05/19 at 3:54 PM. She stated that after each use, the nebulizer mask should be cleaned and bagged. It should not be stored un-bagged at any time. An interview was conducted with the facility's Infection Preventionist on 12/05/19 at 4:26 PM. When told of the observations with Employee H's gloving practice, he confirmed the aide should have removed her gloves and washed her hands following incontinence care and prior to touching any surfaces. He stated nebulizer masks should be bagged as soon as possible following use. A review of the facility's policy and procedure titled Scheduled Change of Respiratory Equipment (revised 10/1/12), found instructions for the Hand Held Nebulizer mouthpiece: 1. Date and time. 2. After each use, rinse with hot tap water. Dry with clean paper towel. Store in paper bag. 3. After last treatment of [REDACTED]. Wash with warm soapy water rinse, dry, and store as above.

Based on observations, a review of posted daily staffing reports and staff interview, the facility failed to include actual hours worked by registered nurses, licensed practical nurses, and certified nursing assistants directly responsible for resident care per shift. The findings include: On 9/11/19 at 10:10 am, the posted daily staffing sheet was observed in the front lobby. A review of the staffing sheet did not include actual hours worked by registered nurses, licensed practical nurses, and certified nursing assistants directly responsible for resident care. The form did not include a line item to enter the actual hours worked. A Review of the POS [REDACTED]. An interview was conducted with the Administrator on 9/11/19 at 2:15 pm, and she confirmed the posted daily staffing did not include actual hours worked.

Based on observations, resident and facility record reviews, and staff interviews, the facility failed to ensure nursing staff had the appropriate skills to provide respiratory services to maintain the highest practicable physical well-being for two (Residents #1 and #2) of three sampled residents reviewed for respiratory care, out of a total of five residents in the sample. The findings include: 1. During an interview with the Administrator on 11/8/18 at 10:20 am, she stated there were three residents in the facility who received continuous oxygen; Residents #1, #2, and #3. A record review for Resident #1 revealed a quarterly minimum data set (MDS) assessment with an assessment reference date (ARD) of 8/30/18. Resident #1 was usually able to make himself understood, and was able to understand others. He had a brief interview for mental status (BIMS) score of 15, indicating that he was cognitively intact. He required extensive assistance of two staff members with activities of daily living (ADLs), and used a wheelchair as a mobility aide. Active [DIAGNOSES REDACTED]. Shortness of breath was noted to occur with exertion and when lying flat. Resident #1 received oxygen therapy while a resident. Resident #1 was care planned on 9/6/18 for oxygen therapy for low oxygen saturation rates. The goal was not to exhibit signs of [MEDICAL CONDITION] (not enough oxygen). Approaches included oxygen per the physician's orders [REDACTED]. Resident #1 had a physician's orders [REDACTED].>) 88%. If unable to keep O2 sat >88%, use a rebreather mask. A separate physician's orders [REDACTED]. A history and physical examination [REDACTED]. The physician indicated Resident #1 was dependent on supplemental oxygen. He had spoken with a family member regarding this resident's condition, to make sure that the facility was aware of the importance of supplemental O2. Discontinuation of this treatment at this time would cause the patient possible respiratory problems. The physician indicated family reported (Resident #1) had an episode of not receiving supplemental oxygen the day before the visit, therefore felt weak. An electronic nursing progress note dated 9/8/18 indicated Resident #1 complained he felt like an elephant was sitting on his chest, and was having difficulty breathing. His oxygen saturation rates were 72% on 2 liters of oxygen. He was wheezing, and 911 was called. An entry on 11/3/18 indicated Resident #1's O2 saturation rates had dropped to 89% on 2 liters of oxygen earlier in the shift. The resident had complained to the nurse, I don't feel any air coming out of this. An observation and interview was conducted with Resident #1 at 2:25 PM on 11/8/18 in his unit, House 5. He was in bed, and was receiving humidified oxygen via nasal cannula (NC) at 2.5 liters per minute (LPM) from a room concentrator. A small portable oxygen concentrator was observed hanging from the back of his wheelchair. Resident #1 stated he received continuous oxygen, and had a new unit for when he was up in his wheelchair. He believed the staff knew how to operate the new portable concentrator. A second observation on 11/9/18 at 9:15 am revealed oxygen delivery via nasal cannula and room concentrator at 2 LPM. 2. A clinical record review for Resident #2 revealed an annual MDS assessment with an ARD of 8/15/18. Resident #2 was assessed with [REDACTED]. Resident #2 had a BIMS score of 14, indicating good cognitive skills. He required limited assistance with ADLs and used a walker or a wheelchair for locomotion. Active [DIAGNOSES REDACTED]. Resident #2 had shortness of breath with exertion and when lying flat. He received oxygen therapy while a resident. Resident #2 was care planned for potential for difficulty breathing related to shortness of breath (SOB) and [MEDICAL CONDITION], with a goal to be maintained at his respiratory baseline with a patent airway and unlabored respirations through completion of treatment. Interventions included oxygen as ordered around the clock. Resident #2 had a physician's orders [REDACTED]. A History and Physical dated 7/24/18 revealed Resident #2 recently returned from the hospital due to aspiration pneumonia [MEDICAL CONDITION] (a potentially life threatening complication of an infection) secondary to the pneumonia. The resident was noted with a history of [MEDICAL CONDITION] with acute-on-chronic hypoxic [MEDICAL CONDITION]. Oxygen use via nasal cannula was documented at 2 liters per minute. An observation was conducted of Resident #2's room in House 5 at 11:18 am on 11/8/18. His wheelchair was in the room just outside the bathroom, and the bathroom door was closed. The wheelchair had a portable oxygen concentrator (a small battery powered device that converts room air to highly [MEDICATION NAME] air) hanging from the back of the chair. Closer inspection of the unit found the digital display was instructing Shut down, no breath detected. A yellow light on the face of the machine was illuminated. Observation of the posted staffing assignment for House 5 at 11:26 am on 11/8/18 revealed LPN C was the only nurse assigned to this unit on the first shift. An interview was conducted at this time with Licensed Practical Nurse (LPN) C. When asked about the device on the back of Resident #2's chair in his room, she stated she was not sure what the machine was called, or how it operated. She was unable to explain how to program the unit to set the flow of oxygen. At approximately 11:28 am, Resident #2 exited his bathroom and sat in his wheelchair. He independently placed the nasal cannula back in. He explained the machine was set at 2% and was automatic. It did not have to be changed out like a portable oxygen tank did. When asked how the concentrator worked, and what the display message Shut down, no breath detected meant, he did not know. Resident #2 stated the nurses were responsible for programming the machine to deliver the oxygen. He stated he received oxygen continuously. After several minutes of interview, Resident #2 was asked if he was having any difficulty breathing, as the unit did not appear to turn on when he resumed breathing. The display still indicated no breath was detected. Resident #2 replied Yes, and said it was starting to be difficult to breathe. LPN C was located again at 11:32 am, and notified of the situation. She was asked how she assisted with the portable oxygen concentrator, who was responsible for the device, and how the flow rate was set. She explained she normally did not work in House 5, so was not sure how to operate the machine. She knew how to turn it on and off, and to check the display for the setting. She accompanied the surveyors to Resident #2's room. She was asked to read the display on the machine, and interpret its meaning. She did so, and read the display warning out loud. LPN C then began pressing the button to the left of the display, but nothing happened. She never pushed the on/off button despite the display warning instructing her to do so. An aide walked over at this time, and instructed LPN C to turn the unit off and back on again. She did, and the unit immediately made an audible noise and appeared to resume operation. An interview with the Registered Nurse (RN) in House 5 at 1:58 pm on 11/8/18 revealed she had worked in the facility for six years. She was not on this unit all the time. She did not know of any residents who used the portable oxygen concentrators, and did not know how they operated. Observation of the posted staffing assignment for House 5 on 11/8/18 at 2:40 pm revealed LPN A was the only nurse assigned to this unit on the second shift. LPN A was interviewed at this time. She stated she did not usually work on this unit and had no awareness at all of the portable oxygen concentrators. She had never been in-serviced, and did not know how they operated. She stated she felt she should have been trained on the use of the units. Observation of House 5's posted staffing assignment on 11/9/18 at 9:18 am found LPN B was the only nurse assigned to this unit on the first shift. LPN B was interviewed at this time, and asked if she knew how to operate the portable oxygen concentrators that were in use for residents on the unit. She said she was usually here on the night shift, when the room concentrators were in use. She did not know how to operate the portable concentrators, and had not been shown how they operated. She then asked Certified Nursing Assistant (CNA) A if she knew anything about the machines. CNA A stated the machines were to be programmed by the nurses. During the interview, an un-sampled resident wheeled himself across the unit. CNA A pointed to him, and stated he also used one of the portable oxygen concentrators on an as-needed basis. In an interview with the Director of Nursing (DON) at 11:58 am on 11/9/18, he was asked if the nurses had received any training on the use of the portable oxygen concentrators that were in use for Residents #1, #2 and the un-sampled resident in House 5. He stated he went to the unit, and did a hands-on training with CNAs and the nurse on duty on the first day. He provided instruction on how to turn it on, the meaning of the indicator lights, and charging the device. He stated two additional nurses had been trained, and his intention was for a train the trainer continuation of the education. When told none of the House 5 nurses interviewed by the survey team over the past two days were aware of, or trained on its operation, he replied there was no excuse for that. He would think the nurses would say something if they did not know how to use the devices. The DON was not aware the only way Resident #2 knew his unit was off was to become short of breath. He was asked for the in-service training sign-in sheets for the education on the portable concentrators. Upon review of the records, only two LPNs had signed as having been trained in the operation of the portable oxygen concentrators. The DON acknowledged the training oversight for nurses assigned to work on the unit.