Every finding on record at Collierville Nursing And Rehabilitation, Llc

Based on facility policy review, observation, and interview, the facility failed to maintain a clean and sanitary environment in the kitchen when food debris was noted on top of and inside the deep fryer, the floor around the stove, and deep fryer, crumbs and debris in the silverware tray and on metal food prep tables, the deep fryer had oil drippings down its front casing, oil and debris build up and was dripping oil onto the floor, there was a greasy substance on the metal shield between the grill and the deep fryer, the floor was slippery, the wall behind the two-compartment sink and the viewing glass around the steam table had splatter marks, 2 metal prep carts with thick greasy buildup and food debris, and storage bins had food debris and a sticky substance, unsanitary handling of food and food equipment at the steamtable, and when staff was unable to accurately test the chemical level in the 3-compartment sink. The facility's census was 83 and 79 residents received food trays from the kitchen. The findings include: 1. Review of the facility policy titled, Environment, dated 10/2019, revealed .It is the center policy that all food preparation areas, food service areas, and dining areas will be maintained in a clean and sanitary environment.Dining Service Director will insure [ensure] that the physical plant is maintained in a clean and sanitary manner, including floors, walls.will insure [ensure] that all employees are knowledgeable in the proper procedures for cleaning all food services equipment and surfaces. 2. Review of the facility policy titled Food: Preparation, dated 10/2019, revealed .Dining Services Director or Cook(s) are responsible for food preparation procedures that avoid contamination by potentially harmful physical, biological, and chemical contamination.is responsible to ensure that all.food contact equipment are cleaned and sanitized after every use . 3. Observations in the kitchen on 6/8/2026 at 9:30 AM, and 6/9/2026 at 2:15 PM, revealed the following: a. The deep fryer had food debris on the top and inside of the fryer, oil drippings down the front of the fryer, and oil and greasy debris build up on the floor beside the fryer. There was thick yellowish brown greasy buildup on the metal shield between the grill and the deep fryer. b. The floor in front of the stove and deep fryer had food debris and an oily substance that made it slippery to walk on. c. There were brown colored splatter marks all over the wall behind the two-compartment sink and the tea maker. d. Metal prep cart #1 had sticky brownish/yellow colored debris build up in the corners and sides of its surfaces. The bottom shelf had a large, sticky, yellowish colored stain that covered much of the shelf. There was a gray silverware tray that had a mixture of silverware, condiments, and food debris. d. The viewing glass on the steam table was covered with sticky liquid like splatters and drip marks. e. Three standing storage bins containing flour, sugar, and cornmeal had a sticky buildup present on the viewing lids and tops of the containers. f. The lower shelf of the metal prep table next to the fryer had food debris, crumbs, and greasy buildup. g. The lower shelf of the metal prep table by the microwave had food debris, crumbs, and a spilled white powdery substance . During observation and interview in the kitchen on 6/9/2026 at 2:30 PM, the Dining Services Manager (DSM) was shown the thick greasy build up on the shield between the stove and the deep fryer. The DSM stated, .That is a result of months and maybe years of buildup.We have called in an extra person to come and help with getting this place cleaned up.I walked through here this morning and I can tell you exactly what you saw before you even tell me. The DSM was shown the metal prep tables and stated .it definitely needs cleaned up . During observation and interview in the kitchen on 6/9/2026 at 2:40 PM, the DSM was shown the wall behind the tea maker and the two-compartment sink and confirmed that it would need to be cleaned. During observation and interview in the kitchen on 6/9/2026 at 2:45 PM, the DSM was shown the metal food prep carts and confirmed they needed to be cleaned. When shown the viewing glass on the steamtable the DSM stated .I am going to make sure that gets cleaned today . During observation and interview in the kitchen on 6/9/2026 at 2:48, the DSM was shown the standing storage bins containing flour, sugar, and cornmeal, and confirmed that all three lids needed to be cleaned. Observations in the kitchen on 6/10/2026 at 12:12 PM, revealed [NAME] E used his gloved hands multiple times to pull the stringy melted cheese completely onto the plate or pull the melted cheese apart and drop it back into the food pans. Observation in the kitchen on 6/10/2026 at 12:34 PM and 12:44 PM revealed [NAME] E used his plastic apron to wipe food off the edge of the resident's lunch plate. Observations in the kitchen during lunch-time steamtable temperature checks on 6/10/2026 at 12:50 PM, revealed [NAME] E wiped the thermometer on his plastic apron twice to clean the probe off before going to the next food. [NAME] E did not use alcohol wipes to disinfect the thermometer probe until he was prompted by the DSM. Observation in the kitchen on 6/10/2026 at 2:30 PM, revealed [NAME] E used the chemical testing strips from the dishwasher unit to test the chemicals in the 3-compartment sink, which showed no results when placed in the water. [NAME] E asked Dishwasher F if she knew what to use to test the water. Dishwasher F stated, I don't know.I've never been trained on that. [NAME] E had to ask the Kitchen Director of Operations to show him how to check the chemical level in the 3-compartment sink. During an interview in the Dining Room on 6/10/2026 at 2:40 PM, the Kitchen Director of Operations and the DSM confirmed that the kitchen needed to be cleaned and that a better system needed to be in place to educate the staff on kitchen sanitation and food preparation. The DSM stated that the staff did not know they were supposed to be keeping track of the 3-compartment sink's chemical levels and that she had made a chart that morning to hang up beside the sinks for staff to document the chemical levels, and would need to inservice them. The DSM confirmed the staff needed education on how to test the chemicals in the 3-compartment sink. The DSM confirmed [NAME] E should not have used his apron to clean off the plates or the thermometer probe while working at the steam table. The Kitchen Director of Operations stated .the staff really just needs a lot more education.They have had no one really train them and they need more help in there.

Based on policy review, medical record review, observation, and interview, the facility failed to maintain the prevention and spread of infection during catheter care and during Percutaneous Endoscopic Gastrostomy (PEG) medication administration for 2 of 2 (Resident #8 and Resident #80) sampled residents reviewed for the use of an indwelling urinary catheter and medication administration. The findings include: 1. Review of the facility policy titled, Indwelling Catheter Use and Removal, dated 4/2026, revealed .If an indwelling catheter is in use, the facility will provide appropriate care for the catheter in accordance with current professional standards . Review of the facility policy titled, Infection Prevention and Control Program, dated 4/2026, revealed .All staff shall use personal protective equipment (PPE) according to established facility policy governing the use of PPE. Review of the facility policy titled, Care and Treatment of Feeding Tubes, dated 4/20/2026, revealed .It is a policy of this facility to utilize feeding tubes in accordance with current clinical standards of practice, with interventions to prevent complications to the extent possible.In accordance with facility protocol, licensed nurses will monitor and check that the feeding tube is in the right location.Tube placement will be verified before beginning a feeding and before administering medications. Review of the facility policy titled, Enhanced Barrier Precautions, dated 4/1/2026, revealed It is policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms.Enhanced Barrier Precautions [EBP] refer to an infection control intervention designed to reduce transmission of multi-drug organisms that employs targeted gown and gloves use during high contact resident care activities.Enhanced barrier precautions will be utilized for residents with any of the following.indwelling medical devices.feeding tubes. Review of the facility policy titled, Hand Hygiene, dated 4/2026, revealed .All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents and visitors. Review of the facility policy titled, Enhanced Barrier Precautions, dated 1/2026, revealed .Enhanced barrier precautions will be utilized for residents with any of the following.indwelling medical devices (e.g.[example].urinary catheters.PPE for enhanced barrier precautions is only necessary when performing high contact care.High-contact resident care activities include.Device care or use: central lines, urinary catheters. 2. Review of medical record revealed Resident #8 was admitted on [DATE], with diagnoses including Chronic Kidney Disease Stage 4 and Neuromuscular Dysfunction of Bladder (Nerve damage to the bladder). Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #8 scored a 5 on the Brief Interview for Mental Status (BIMS) assessment, which indicated she was severely cognitively impaired. Resident #8 was dependent on staff to perform activities of daily living (ADLs) and had a foley catheter. Review of the Physician's Order dated 1/16/2026, revealed .Catheter Care Every Shift . Review of the Physician's Order dated 3/27/2026, revealed .Enhanced Barrier Precautions: Chronic Foley [indwelling urinary catheter] Catheter . Random observation in the resident's room on 6/9/2026 at 7:27 AM and 8:56 AM, revealed Resident #8's indwelling urinary catheter bag touching the floor. Observation and interview in the resident's room, on 6/9/2026 at 9:47 AM, revealed Resident #8's indwelling urinary catheter bag touching the floor. Licensed Practical Nurse (LPN) A was asked if any part of the urinary catheter should touch the floor. LPN A stated, .No it shouldn't . During an interview on 6/10/2026 at 8:11 AM, the Unit Manager LPN B was asked if the urinary catheter bag should be touching the floor. The Unit Manager LPN B stated, Never. The Unit Manager LPN B was asked what the complications of the urinary catheter bag touching the floor were. The Unit Manager LPN B stated, Infection. During an interview on 6/10/2026 at 8:45 AM, the Director of Nursing (DON) was asked, if a urinary catheter bag should ever be touching the floor. The DON stated, No. During an observation and interview in the resident's room on 6/10/2026 at 11:06 AM, Certified Nursing Aide (CNA) C was performing urinary catheter care. CNA C entered Resident #8's room, performed hand hygiene, applied gloves, and performed urinary catheter care. CNA C then removed her gloves and performed hand hygiene. CNA C was asked if Resident #8 was in Enhanced Barrier Precautions (EBP). CNA C asked, What is that. CNA C was shown EBP signage on the resident's door and was asked if the signage indicated Resident #8 was in EBP. CNA C stated, .Yes. CNA C was asked according to the EBP signage, should a gown have been worn during the urinary catheter care. CNA C stated, Yes. During an interview on 6/10/2026 at 11:42 AM, the DON was asked if she would expect her staff to know what Enhanced Barrier Precautions were and what to wear with Enhanced Barrier Precautions. The DON stated, Yes. The DON was asked if she would expect her staff to wear the proper PPE during urinary catheter care. The DON stated, I would. The DON was asked what she expected the staff to wear while performing urinary catheter care. The DON stated, Gown and gloves. 3. Review of the Medical Record revealed Resident #80 was admitted to the facility on [DATE], with diagnosis including Gastrostomy Status, Traumatic Brain Injury, Heart Failure, and Dysphagia. Review of the annual Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #80 scored a 13 on the Brief Interview for Mental Status (BIMS) assessment, which indicated she was cognitively intact. Review of a Physicians Order dated 2/12/2026, revealed .levetiracetam solution [used to treat seizures] 100 mg [milligram].Administer 10ml [milliliter] via [route] peg tube two times a day.metoclopramide [used to treat slow stomach emptying].5mg.1 TABLET po [by mouth] THREE TIMES A DAY. Review of the Physician Order dated 2/16/2026, revealed .Residuals [the amount of fluid/food remaining in the stomach].Check and record residuals and contact provider if residual exceeds 100 ml [milliliters]. Review of the Physician Order dated 2/20/2026, revealed .valproic acid [used to treat seizures].250 mg/5ml.gastric tube.Administer 10 ml by mouth three times a day. Review of the Physician Order dated 3/9/2026, revealed .Enteral Jevity [therapeutic nutrition] 1.5 @ [at] 30 cc/hr [cubic centimeters]/[hour] x [times] 12 hours. Observation outside of Resident #80's room during medication administration on 06/09/2026 at 2:15 PM, revealed Licensed Practical Nurse (LPN) D prepared Levetiracetam 10 ml, Metoclopramide 5 mg, and Valproic Acid 10 ml for administration and put gloves on at the medication cart, went to Resident #80's room, knocked on the door and entered. LPN D placed the medication on the bedside table. LPN D told Resident #80 he was going to give her medication, and she (Resident #80) requested him to put it through her peg tube. LPN D did not put a gown on before the administration of medication. LPN D started with a syringe containing 15-20 cc of water and flushed the peg tube. LPN D did not check placement or residual prior to the medication administration. LPN D then proceeded to administer the levetiracetam 10 ml via tube per syringe push, followed by a 15-20 ml water flush, next the valproic acid 10 ml via syringe push was administered, followed by a 15-20 ml water flush, lastly the metoclopramide crushed tablet in water via syringe push was administered with a 15-20 ml water flush. When LPN D completed administration of the medications he walked into Resident #80's bathroom, washed the syringe out and put it back in the plastic sleeve holder, walked to the resident's bedside and hung it on the pole. LPN D walked outside of room, to the medication cart with gloved hands and took off his gloves at the medication cart and threw them away. LPN D failed to wear the appropriate Personal Protective Equipment for EBP, failed to remove his gloves in Resident #80's room, and failed to perform hand hygiene. During an interview on 6/10/2026 at 8:47 AM, the Director of Nurses (DON) was asked if she would expect a staff member to check residual and placement on a peg tube before administration of medication and water. The DON stated, Yes. The DON was asked if she would expect staff to wear PPE with medication administration with a peg tube. The DON stated. Yes. The DON was asked should a staff member wear dirty gloves in the hallway. The DON stated, No, you should take them off in the room and use hand sanitizer.

Based on policy review, medical record review, facility investigation review, and interview, the facility failed to report allegations of abuse to Adult Protective Service (APS), the Long- Term Care Ombudsman, local law enforcement, and state survey agency, and failed to complete a 5-day follow-up for the state agency for 1 of 4 (Resident #1) sampled residents reviewed for abuse. The findings include: 1. Review of the facility's policy Abuse, Neglect and Exploitation, dated 6/2025, revealed .It is the policy of this facility to provide protections for health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect.Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish, which can include staff to resident abuse.The facility will designate an Abuse Prevention Coordinator in the facility who is responsible for reporting allegations of suspected abuse, neglect, or exploitation to the state survey agency and other officials in accordance with state law.Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies.within specified timeframes.Immediately, but no later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or.Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury.The administrator will follow up with government agencies, during business hours, to confirm the initial report was received, and to report the results of the investigation when final within 5 working days of the incident, as required by state agencies. 2. Review of the medical record revealed Resident #1 was admitted to the facility on [DATE], with diagnoses including Diabetes, Hypertension, Sepsis, and Post-Traumatic Stress Disorder. Review of the admission Minimum Data Set, dated [DATE], revealed Resident #1 scored a 13 on the Brief Interview for Mental Status, which indicated she was cognitively intact. Review of the facility's Investigation Report dated 2/2/2026, revealed the Administrator and Director of Nursing were notified via (by way of) telephone by the Unit Manager (UM) on 2/2/2026 that Resident #1 reported that she was tapped on her inner thigh and left arm by a blonde Caucasian CNA (Certified Nursing Assistant) that worked the night shift on 2/1/2026. There was no documentation the incident was reported to the appropriate regulatory authorities including Adult Protective Service (APS), the Long- Term Care Ombudsman, local law enforcement, and the state survey agency. During an interview on 2/12/2026 at 10:26 AM, Resident #1 stated on 2/1/2026 a blonde Caucasian CNA came in and jerked her diaper off. During her diaper change the CNA raised her right leg up and slapped on her inner thigh and right arm. Resident stated she does not know why the CNA slapped her thigh and arm her. Resident #1 was asked if she reported the incident. Resident #1 stated, Yes, I told the PTA [Physical Therapy Assistant] . During an interview on 2/12/2026 at 1:20 PM, the PTA stated that Resident #1 was in the therapy gym on 2/2/2026 at 6:30 AM, and he asked Resident #1 how her weekend was. Resident #1 told the PTA that a blonde Caucasian CNA on the night shift was mean to her the night before. The PTA stated that Resident #1 told him the CNA slapped her on her left leg and arm when the CNA was changing her. PTA said he looked at Resident #1's arm and did not observe any bruising. The PTA stated Resident #1 voiced that she did not feel safe. The PTA stated that he immediately notified the UM. During an interview on 2/12/2026 at 3:16 PM, the UM confirmed that she was notified on 2/2/2026 by the PTA that Resident #1 alleged that she was tapped on her thigh and arm by a blonde CNA. The UM stated that she immediately reported the allegation of abuse to the Administrator and Director of Nursing (DON) and immediately implemented an investigation. During a telephone interview on 2/12/2026 at 5:27 PM, the former DON confirmed she was the DON at the facility on 2/2/2026 when Resident #1 reported the abuse allegation involving being tapped on the left arm and thigh by a night shift CNA and was involved in the investigation. The former DON confirmed she was notified of the alleged incident by the UM. The former DON was asked what she was told occurred on that night. The former DON confirmed that she was told by the UM, Resident #1 stated she was tapped on the right thigh and right arm by a blonde Caucasian on the night shift. When asked if the allegation was reported to the state agency. The former DON stated, I thought the Administrator reported it. The former DON was asked should an alleged abuse allegation be reported to the state. The former DON stated, Yes, it should be reported. During an interview on 2/1/32026 at 11:10 AM, the Administrator was asked if the allegation was reported to the state agency. The administrator stated, No, it was not . The Administrator was asked according to federal regulations, should an allegation of abuse be reported he stated, Yes, absolutely it should have been. The administrator was asked when should an allegation of abuse be reported. The Administrator stated, Allegation of abuse should be reported within 2 hours of the facility knowledge.

Based on policy review, medical record review, and interview, the facility failed to report an injury of unknown origin for 1 of 3 (Resident #1) sampled residents reviewed for abuse. The findings include: 1. Review of the facility policy titled, Abuse, Neglect and Exploitation, dated 6/2025, revealed . Serious Bodily Injury means an injury involving .impairment of the of the function of a bodily member .requiring medical intervention such as .hospitalization .Abuse Prevention Coordinator in the facility .is responsible for reporting .suspected abuse, neglect .to the state survey agency and other officials in accordance with state law .Reporting .of all alleged violation to the Administrator, state agency, adult protective services .Immediately, but no later than 2 hours after the allegation is made, if the events that cause the allegation involve .serious bodily injury .The Administrator will follow up with government agencies, during business hours, to confirm the initial report was received, and to report the results of the investigation when final within 5 working days of the incident, as required by state agencies . 2. Review of the medical record revealed Resident #1 was admitted to the facility on [DATE], with diagnoses including Cerebral Infarction, Muscle Weakness, Lack of Coordination, and Fall. Review of the discharge Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #1 was severely cognitively impaired for Daily Decision Making and a Brief Interview for Mental Status (BIMS) score was unable to be completed. Resident used a wheelchair and was dependent on staff for all Activities of Daily Living (ADLs). Resident #1 had 1 fall with a major injury. Review of the Nursing progress note dated 2/7/2025, revealed .During morning care, the aide observed a knot on the resident's right thigh. When touched, the resident indicated pain by shaking her head. The leg was elevated .plan of care will continue . Review of the Nurse Practitioner's progress note dated 2/7/2025, revealed .Chief Complaint/Reason for this Visit Knot to right thigh .Patient being seen today per staff request for knot to right thigh .Rating of pain was assessed patient nodding head in agreement, level of pain 3/10. No aggravating factors noted .Pain: Severity 3 Location right thigh.Pain in right thigh: Continue pain assessment per facility protocol. Review of the nursing progress note dated 2/7/2025, revealed .X-ray [imaging for picture inside the body] requested by Rp [Responsible Party] d/t [due to] knot to right thigh . Review of the nursing progress note dated 2/8/2025, revealed .Res. [Resident] received x-ray today .revealed abnormal x-ray .Resident being sent to hospital . Review of the Radiology Report dated 2/9/2025, revealed .Findings .Comminuted and displaced fracture [a severe type of bone fracture where the bone is broken into multiple pieces and the fragments are misaligned] .to the .femoral diaphysis [shaft of the femur] . Review of the nursing progress note dated 2/12/2025, revealed .Resident transported to the facility .admitted with diagnosis of Acute R [Right] Tibial/fibular [bones on the upper leg] fracture . Review of the Nurse Practitioner progress note dated 2/13/2025, revealed .seen for readmission .after an x-ray was completed on her right leg where it was noted she had a knot and the results reflected a right femur fracture . Review of the Facility's Investigation revealed, staff completed online abuse training from 2/8/2025 through 2/12/2025 after the knot and fracture were discovered on Resident #1. Resident interviews were conducted by the social worker on 2/8/2025 asking if the Residents on the hall felt safe, were treated well, witnessed anyone being mistreated and if the Residents suffered any injuries. Skin Audits were completed on 2/8/2025 on Residents located on the hall that Resident #1 was on. Staff interviews were conducted on 2/8/2025 related to any witnessed abuse or falls for Resident #1. During an interview on 10/7/2025 at 11:50 AM the Director of Nursing [DON] was asked about the knot on Resident #1's thigh. She stated, .she [Resident #1] had a raised area or knot on her leg .The family .wanted an x-ray and it noted a fracture .We [Administrator and DON] did an investigation on the fracture .no other falls, no transfer issues, family was asked about a bruising or anything out of the norm [normal]. We interviewed all the staff, talked with other residents about anything that hadn't been reported that might have happened . During an interview on 10/7/2025 at 1:28 PM, the DON was asked why she did an investigation, abuse education with staff, skin audits and staff interviews. She stated, .I didn't know what happened [how the knot and femur fracture occurred] . The facility failed to report the Injury of Unknown Origin to the State Agency.

Based on policy review, medical record review, and interview, the facility failed to monitor for medication side effects for 2 of 4 sampled residents (Resident #1 and #2) reviewed for the use of an antipsychotic and anticoagulant medications. The findings include: 1. Review of the facility's policy titled, Use of Psychotropic Medication, dated 1/2/2020, revealed, .Residents are not give psychotropic drugs unless .the medication is beneficial .as demonstrated by monitoring and documentation of resident's response to the medication(s) .Psychotropic drugs include .antipsychotics .The indication for use of any psychotropic drug will be documented in the medical record .The resident's response to the medication(s) .presence/absence of adverse consequences, shall be documented in the resident's medical record . Review of the facility's policy titled, High Risk Medications Anticoagulants, .Examples include .heparin, lovenox .treatment of deep vein thrombosis [blood clots] .Staff shall observe resident for adverse consequences . 2. Review of the medical record revealed Resident #1 was admitted to the facility on [DATE], with diagnoses of Fracture of Right Tibia, Intracranial Injury, Motorcycle Collision, and Nontraumatic Intracranial Hemorrhage. Review of the medical record revealed no Minimum Data Set (MDS) was completed for Resident #1 due to discharge date of [DATE]. Review of the Care Plan initiated on 9/7/2022, revealed, .this resident is on anticoagulant therapy .monitor for side effects and effectiveness Q [every]-shift . Review of the facility's Order Summary Report dated 9/8/2022, revealed .Enoxaparin [Lovenox (anticoagulant medication to prevent blood clots)] .60mg [milligrams] .subcutaneously two times a day .for 12 weeks .start date .9/8/2022 .QUEtiapine [antipsychotic medication] .50mg .three times day for anxiety .start date .9/8/2022 . Review of the Medication Administration Record (MAR) for 9/2022, revealed the facility failed to monitor for side effects for the use of the antipsychotic medication and the anticoagulant medication. 3. Review of the medical record revealed Resident #2 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses of Fall on Same Level, Nontraumatic Intercranial Hemorrhage, Acute and Chronic Respiratory Failure, Hypertension, Anemia, Dysphagia and Speech/Language Deficit. Review of the admission MDS dated [DATE], revealed Resident #2 was not assessed for the use of anticoagulant or antipsychotic medications. Review of the Care Plan initiated 7/4/2022, revealed, .The resident is on anticoagulant therapy (Heparin) [a medication used to prevent blood clots] .Monitor for side effects and effectiveness Q-shift . Review of the [Named Hospital] Physician Discharge Order Sheet dated 6/27/2022, revealed Resident #2 was released from the hospital on 6/27/2022, and was admitted to the facility on QUEtiapine at bedtime. Review of the 6/2022 MAR revealed Resident #2 received an anticoagulant medication from 6/27/2022 to 6/30/2022 with no behavior or side effects monitoring. Review of the facility's July 2022 Order Review History Report, revealed Resident #2 was ordered Heparin 5000 Units injection 1 ml [milliliter] subcutaneously three times a day for DVT [deep vein thrombosis] until 7/27/2022. Review of the 7/2022 MAR revealed the resident received an anticoagulant medication from 7/1/2022 to 7/18/2022, with no behavior or side effects monitoring. Review of the September 2022 Order Review History Report, revealed, .QUEtiapine Fumarate .100 MG .at bedtime for insomnia .Order Date of 9/28/2022 .Start Date .9/28/2022 . Review of the 9/2022 MAR revealed Resident #2 received an antipsychotic medication from 9/28/2022 to 9/30/2022, and from 10/1/2022 to 10/2/2022, with no behavior or side effects monitoring. 4. During an interview on 10/25/2022 at 3:51 PM, the Director of Nursing (DON) confirmed monitoring was not documented for the use of the antipsychotic and the anticoagulant medications. The DON confirmed that if any resident is on an antipsychotic or an anticoagulant, they should be monitored for side effects. During an interview on 12/9/2022 at 12:29 PM, the Administrator confirmed that if a medication requires specific monitoring, that nursing staff should conduct the monitoring for that medication, and that all residents should be monitored for side effects of any medication.

Based on policy review, medical record review, and interview, the facility failed to provide timely laboratory services to meet the needs of 1 of 4 sampled residents (Resident #2) reviewed for laboratory services. The findings include: Review of the facility's policy titled, High Risk Medications-Anticoagulants [medications used to prevent blood clots] revealed, .Examples include .heparin .treatment of deep vein thrombosis [blood clots] .Results shall be communicated to the physician in a timely manner .Lab [laboratory] results that are outside the normal limits or target range .shall be communicated to the physician within 24 hours . Review of the medical record revealed Resident #2 was admitted to the facility on [DATE], and readmitted on [DATE], with Nontraumatic Intercranial Hemorrhage, and Dysphagia following Nontraumatic Subarachnoid Hemorrhage. Review of the admission Minimum Data Set (MDS) dated [DATE], revealed Resident #2 had long-term memory problems and severe cognition impairment. Review of the Care Plan initiated 7/4/2022, revealed, .The resident is on anticoagulant therapy (Heparin) .Monitor for side effects and effectiveness Q [every]-shift . Review of the facility's Order Review History Report, revealed Resident #2 was ordered Heparin 5000 Units injection 1 milliliter subcutaneously three times a day for DVT (deep vein thrombosis) until 7/27/2022. Review of a Physician's Order dated 7/1/2022, revealed, .Repeat CBC [complete blood count] .STAT [immediately] for low H & H [hemoglobin and hematocrit] . Review of the Lab Results Report dated 7/4/2022 revealed, .Collection Date .7/3/2022 .Received 7/4/2022 .Reviewed by the [Named Nurse Practitioner (NP)] on 7/7/2022 . The facility failed to ensure STAT labs were obtained and reported to the ordering provider in a timely manner. During an interview on 11/28/2022 at 10:03 AM, the Director of Nursing (DON) confirmed that STAT labs should be obtained within 1-3 hours from the outside laboratory vendor, and results should be returned immediately for the provider's review. The DON confirmed that the labs were not obtained timely, and that the staff should have followed up to ensure it was obtained and immediately reported to the provider. During an interview on 12/9/2022 at 12:29 PM, the Administrator confirmed that labs should be obtained as ordered by the provider.

Based on policy review, record review, observation, and interview, the facility failed to implement interventions to prevent an accident resulting in a facial laceration requiring sutures for 1 of 6 (Resident #1) total care residents reviewed. The facility's failure resulted in Harm for Resident #1. The findings included: 1. Review of the facility policy titled Accidents and Supervision dated 1/2/2022 and revised 3/23/2022, revealed .The resident environment will remain as free of accident hazards as possible. Each resident will receive adequate supervision and assistive devices to prevent accidents .Definitions: Accident refers to any unexpected or unintentional incident, which results in injury or illness to a resident .Policy Explanation and Compliance Guidelines: The facility shall establish and utilize a systematic approach to address resident risk and environmental hazards to minimize the likelihood of accidents .The facility should make a reasonable effort to identify hazards and risk factors for each resident .This information is to be documented and communicated across all disciplines .Resident-directed approach may include: 1. Implementing specific interventions as part of the plan of care 2. Supervising staff and residents, etc. 3. Facility records document the implementation of these interventions . Review of the facility's policy titled Turning and Repositioning dated 1/2/2020, revealed .This policy establishes responsibilities and protocols for turning and repositioning .Turning and repositioning is a primary result of nursing assistants. However, all nursing staff are expected to assist with turning and repositioning .Use the appropriate number of staff to perform the task .When turning to side lying position, do not tilt more than 30 degrees . Review of the facility's policy titled Safe Resident Handling/Transfers dated 1/20/2020, revealed .It is the policy of this facility to ensure that residents are handled and transferred safely to prevent or minimize risks for injury and promote a safe, secure and comfortable experience for the resident while keeping the employees safe in accordance with current standards and guidelines .Compliance Guidelines: 1. The interdisciplinary team or designee will evaluate each resident's individual mobility needs, taking into account other factors as well, such as weight and cognitive status . 2. Review of the medical record revealed Resident #1 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Anoxic Brain Injury, Intracranial Injury, Contracture of Right Hand and Left Hand, Contracture of Right Wrist, Anxiety, and Gastrostomy Status. Review of the quarterly Minimum Data Set assessment dated [DATE], revealed Resident #1 was cognitively impaired and required extensive assist of 2 people for bed mobility and dressing. Review of the Certified Nursing Assistant (CNA) Kardex plan of care revealed Resident #1 was totally dependent on staff for bed mobility for repositioning and turning. Review of the Care Plan revised 4/23/2018 revealed Resident #1 was totally dependent on staff to complete activities of daily living (ADLs). Resident #1 was at risk for falls related to impaired mobility and assistance needed with ADLs with an intervention to educate staff to use 2 persons with turning and repositioning with revision dated 11/16/2022. Review of the Event/Incident documentation dated 11/3/2022 and timed 12:31 AM, revealed .Called to room by CNA. Patient [Resident #1] noted laying on left shoulder with head noted laying on floor. Upon examining resident laceration noted to bridge of nose. CNA stated she was rolling resident and resident went over the other side of the bed .Educated CNA on resident plan of care which requires to be two person assist . Review of a Physician's Telemedicine/Virtual Visit Note dated 11/3/2022 and timed 12:25 AM, revealed .Patient [Resident #1] .with history TBI [Traumatic Brain Injury] was being cleaned and patient was rolled by the aide who pushed her too hard and she rolled off the bed hitting her face and had [hand] on the railings and landing on the floor; she sustained laceration to the bridge of her nose and has periocular swelling on the right .Transfer to ER to suture laceration and evaluate for head injury . Review of a Nurse's Note dated 11/3/2022 and timed 12:44 AM, revealed .CNA stated she was rolling the resident and resident went over the other side of the bed. CNA [educated] on resident plan of care which requires resident to be two person assist . Review of a Nurse's Note dated 11/3/2022 and timed 7:02 PM, revealed Resident #1 was noted to swing right leg out of bed continuously. Observations in the resident's room on 11/16/2022 at 1:10 PM, revealed the resident was lying in bed leaning toward her right side, awake and alert. She was nonverbal and did not follow voice sounds or movement with eye focus. There were sutures across the bridge of her nose covered with a xeroform dressing. Some discoloring to the skin surrounding the sutures was noted. During an interview on 11/16/2022 at 12:18 PM, when asked what the intervention was following Resident #1's fall on 11/2/2022, the Director of Nursing (DON) stated, Started education on if a resident is 2-person assist they [staff] call for someone, an aide or a nurse, to help. She didn't ask for help. When asked if Resident #1 was a 2-person assist prior to the fall incident, the DON stated Yes, she was. During a telephone interview on 11/17/2022 at 9:06 AM, when asked what happened when Resident #1 had a fall, CNA #3 stated, I was changing her. I was on the left side and turned her on her right side. Her legs are stiff, and she swung her leg off the side and fell off the right side. There was no one on the other side. Now they saying should always be 2 people for any type of care. I was not aware of it before. The DON said I should have known she needed 2 people . During a telephone interview on 11/21/2022 at 8:20 AM, when asked what happened when Resident #1 had the fall, Registered Nurse #1 confirmed Resident #1 fell from the bed when turned by the CNA. When asked if the resident needed 2-person assist for turning and repositioning in the bed, RN #1 stated, Yes, most of these total care residents need 2 people to turn, clean and dress them in bed for safety for the resident and the aide .I have told the supervisor we needed another CNA to work on this floor because most of these residents are total care and need 2 people . During an interview on 11/21/2022 at 1:30 PM, when asked if Resident #1 was a 2-person assist for turning and repositioning in bed, Licensed Practical Nurse #1 stated, I don't know if she was a 2-person assist before [the fall]. She should have been . When asked how staff was monitored to ensure the interventions are implemented, LPN #1 stated, They would let me know if help needed. I'm not sure which ones need 2-person assist. I could maybe look at the resident and tell you. When asked how the CNAs would know, LPN #1 stated, I'm not sure. They would call for assist if they needed it. During an interview on 11/21/2022 at 1:44 PM, CNA #2 (employed since March 2022) was asked if Resident #1 was a 2-person assist for turning and repositioning. CNA #2 stated, She is total dependent times 2 assist for showers. Told me in orientation by the aide that she was 2-person assist for turning . During an interview on 11/21/2022 at 2:10 PM LPN #2 was asked what residents needed 2-person assist for turning and repositioning in bed. LPN #2 stated, Good question. I would have to ask the nurse or the unit manager. I guess I could look in the computer. Not sure how I would find out. During an interview on 11/21/2022 at 2:47 PM, when asked if Resident #1 was a 2-person assist for bed mobility, CNA #1 looked at the Kardex plan of care and stated, She is 1 person assist for bed mobility and 2 for showers. During an interview on 11/21/2022 at 3:25 PM, when asked what determines if a resident needs a 2-person assist with bed mobility, the DON stated, It's up to their [CNA's] discretion. One [CNA] may need assist at a particular time and ask for help. It depends on that person [CNA] at the time. When asked if there was any resident other than Resident #1 that needed a 2-person assist for bed mobility for turning and repositioning, the DON shook her head no.

Based on policy review, facility staffing schedule review, medical record review, and interview, the facility failed to ensure adequate certified staff to provide care for the residents for 2 of 2 months ( and 8/2022) reviewed. The facility had an average census of 77 residents during this time. The findings include: Review of the facility's undated policy titled, Staffing, revealed .Our facility provides adequate staffing to meet needed care and services for our resident population .Our facility maintains adequate staffing on each shift to ensure our resident's needs and services are met .Certified Nursing Assistants (CNAs) are available on each shift to provide the needed care and services for each resident . 1. Review of the 1st floor facility staffing schedule revealed the following: a. 7/21/2022 with a census of 25 residents on the 1st floor, there were 2 CNAs scheduled from 7 AM- 7 PM (dayshift) b. 7/22/2022 with a census of 25 residents on the first floor, there were 2 CNAs scheduled from 7 AM- 7 PM c. 7/25/2022 with a census of 25 residents on the 1st floor, there were 2 CNAs scheduled from 7 AM- 7 PM d. 7/26/2022 with a census of 25 residents on the 1st floor, there were 2 CNAs scheduled from 7 AM- 7 PM e. 7/27/2022 with a census of 25 residents on the 1st floor, there were 2 CNAs scheduled from 7 AM- 7 PM f. 8/4/2022 with a census of 25 residents on the 1st floor, there were 2 CNAs scheduled from 7 AM- 7 PM g. 8/5/2022 with a census of 25 residents on the 1st floor, there were 2 CNAs scheduled from 7 AM- 7 PM h. 8/6/2022 with a census of 25 residents on the 1st floor, there were 2 CNAs scheduled from 7 AM- 7 PM i. 8/9/2022 with a census of 26 residents on the 1st floor, there were 2 CNAs scheduled from 7 AM - 7 PM j. 8/10/2022 with a census of 26 residents on the 1st floor, there were 2 CNAs scheduled from 7 AM - 7 PM k. 8/11/2022 with a census of 26 residents on the first floor, there were 2 CNAs scheduled from 7 AM - 7 PM l. 8/12/2022 with a census of 25 residents on the 1st floor, there were 2 CNAs scheduled from 7 AM- 7 PM Review of the 2nd floor facility staffing schedule revealed the following: a. 7/18/2022 with a census of 26 residents on the 2nd floor, there were 0 CNAs scheduled from 10:30 PM - 7AM b. 7/29/2022 with a census of 29 residents on the 2nd floor, there were 2 CNAs scheduled from 7 AM - 7 PM 3. Review of the 3rd floor staffing schedule revealed the following: a. 7/22/2022 with a census of 25 residents on the 3rd floor, there were 2 CNAs scheduled from 7 AM- 7 PM b. 8/7/2022 with a census of 24 residents on the 3rd floor, there were 2 CNAs scheduled from 7 AM- 7 PM Review of the medical record, revealed Resident #1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #1 scored a 15 on the Brief Interview of Mental Status (BIMS), which indicated the resident was cognitively intact for daily decision making. Resident #1 was dependent on others for care and two-person physical assist for bathing. Review of the Shower Schedule revealed Resident #1 was to be provided a shower on Tuesday, Thursday, and Saturday on day shift each week. Review of the Documentation Survey Report dated 8/2022, revealed Resident #1 was not provided a shower from 8/1/2022 - 8/15/2022. Review of the medical record, revealed Resident #4 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Care Plan dated 7/22/2022, revealed .The resident has an ADL [Activities of Daily Living] self-care performance deficit r/t [related to] [CONDITION(S)] .BATHING/SHOWERING: The resident is dependent on staff for bathing on scheduled days and prn [as needed] . Review of the admission MDS assessment dated [DATE], revealed Resident #4 scored a 15 on the BIMS assessment which indicated no cognitive impairment for daily decision-making tasks. The resident was dependent upon staff for bathing/showers. Review of the Shower Schedule revealed Resident #4 was to be provided a shower on Tuesday, Thursday, and Saturday on evening shift each week. Review of the Documentation Survey Report dated 8/2022, revealed Resident #4 was provided one shower from 8/1/2022 - 8/15/2022. Review of the medical record, revealed Resident #8 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the admission MDS assessment dated [DATE], revealed Resident #8 scored a 10 on the BIMS assessment, which indicated the resident had moderate cognitive impairment for daily decision-making tasks. Resident #8 needed extensive assistance with Activities of Daily Living. Review of the Care Plan dated 8/4/2022, revealed .The resident has an ADL self-care performance deficit r/t impaired mobility .BATHING/SHOWERING: The resident requires extensive to max [maximum] assistance by staff with (bathing/showering) as scheduled and as necessary Date Initiated: 7/31/2022 . Review of the Shower Schedule revealed Resident #8 was to be provided a shower on Tuesday, Thursday, and Saturday on evening shift each week. Review of the Documentation Survey Report dated 8/2022, revealed Resident #8 was provided one shower from 8/1/2022 - 8/15/2022. Review of the medical record, revealed Resident #10 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly MDS assessment dated [DATE], revealed the resident scored a 4 on the BIMS assessment, which indicated the resident had severe cognitive impairment for daily decision-making tasks. Resident #10 needed limited to extensive assistance for ADLs. Review of the Care Plan dated 8/7/2022, revealed .The resident has an ADL self-care performance deficit r/t [CONDITION(S)] [[CONDITION(S)]] with (L) [left] side weakness .BATHING/SHOWERING: The resident requires extensive assistance by staff with (bathing/showering) as scheduled and as necessary Date Initiated: 7/27/2022 . Review of the Shower Schedule revealed Resident #10 was to be provided a shower on Tuesday, Thursday, and Saturday on evening shift each week. Review of the Documentation Survey Report dated 8/2022, revealed Resident #10 was not provided a shower from 8/1/2022 - 8/15/2022. Review of the medical record, revealed Resident #11 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the admission MDS assessment dated [DATE], revealed Resident #11 scored a 15 on the BIMS assessment, which indicated the resident had no cognitive impairment for daily decision-making tasks. Resident #11 needed limited assistance with ADLs. Review of the Care Plan dated 8/7/2022, revealed .The resident has an ADL self-care performance deficit r/t [CONDITION(S)] [[CONDITION(S)]] with (L) side weakness .BATHING/SHOWERING: The resident requires extensive assistance by staff with (bathing/showering) as scheduled and as necessary Date Initiated: 7/27/2022 . Review of the Shower Schedule revealed Resident #11 was to be provided a shower on Tuesday, Thursday, and Saturday on dayshift each week. Review of the Documentation Survey Report dated 8/2022, revealed Resident #11 was not provided a shower from 8/1/2022 - 8/15/2022. Review of the medical record, revealed Resident #27 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the admission MDS assessment dated [DATE], revealed Resident #27 scored a 15 on the BIMS assessment, which indicated the resident had no cognitive impairment for daily decision-making tasks. Resident #27 needed limited assistance with one staff for bathing /showers. Review of the Care Plan dated 7/20/2022, revealed .The resident has an ADL self-care performance deficit r/t car accident .BATHING/SHOWERING: The resident requires limited assistance by one staff with bathing 2x [times] week and as necessary Date Initiated: 7/20/2022 . Review of the Shower Schedule revealed Resident #27 was to be provided a shower on Monday, Wednesday, and Friday on dayshift each week Review of the Documentation Survey Report dated 8/2022, revealed Resident #27 was provided one shower from 8/1/2022 - 8/15/2022. During an interview on 8/12/2022 at 4:06 PM, when asked if showers were scheduled, Resident #27 stated, .I've had one shower with help .I would like one more often, but I don't know how they offer them here. I've had one . Resident #27 had been at the facility for four weeks. Review of the medical record, revealed Resident #31 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Nursing Progress Note dated 8/3/2022, revealed Resident #31 was alert and oriented. Review of the Care Plan dated 8/4/2022, revealed .The resident has an ADL self-care performance deficit r/t .BATHING/SHOWERING: The resident is totally dependent on staff to provide (SPECIFY bath/shower) Date Initiated: 8/4/2022 . Review of the admission MDS assessment dated [DATE], revealed the resident needed assistance of one staff with ADLs. Review of the Shower Schedule revealed Resident #31 was to be provided a shower on Tuesday, Thursday, and Saturday on night shift each week. Review of the Documentation Survey Report dated 8/2022, revealed Resident #31 was not provided a shower from 8/3/2022 - 8/15/2022. During an interview on 8/15/2022 at 3:40 PM, when asked if she received a bath or shower, Resident #31 stated, I've not had a full bath or a shower . A visiting family member confirmed the resident had not been provided a shower. Resident #31 had been in the facility 12 days. Review of the medical record, revealed Resident #32 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Initial Care Plan dated 8/3/2022, revealed .The resident will maintain or develop clean and intact skin . Review of the admission MDS assessment dated [DATE], revealed Resident #32 scored a 15 on the BIMS assessment which indicated no cognitive impairment for daily decision-making tasks. Resident #32 needed extensive assistance with bathing/showers. Review of the Shower Schedule revealed Resident #32 was to be provided a shower on Tuesday, Thursday, and Saturday on dayshift each week. Review of the Documentation Survey Report dated 8/2022, revealed Resident #32 was not provided a shower from 8/3/2022 - 8/15/2022. Resident #32 confirmed she had not been given a shower since admission on 8/3/2022. During an interview on 8/12/2022 at 1:35 PM, when asked how many residents she was assigned to provide care, Certified Nursing Assistant (CNA) #4 stated, 13. When asked if she could provide care for each of the 13 as each needed, CNA #4 stated, No, I can't. Can't get all the ones up today . When asked if she offered showers or baths, CNA #4 stated, .Not sure who gets a shower. I only have time to give a partial bath. You know like pericare . During an interview on 8/12/2022 at 2:20 PM, when asked if she could provide care to residents as each one needed, CNA #3 stated, With lunches and breakfast and getting these people up I can't get to all of them. We have too many most days . During an interview on 8/15/2022 at 3:40 PM, when asked what residents were offered or given a shower, CNA #1 stated, .I haven't given any today or offered any [showers]. Not time with all the other tasks I do. During an interview on 8/15/2022 at 4:07 PM, when asked what residents had received a shower, CNA #2 stated, I haven't given any showers today. I don't usually give showers. Not sure who is on the list today. I give bed baths or partials. During an interview on 8/15/2022 at 4:15 PM, when asked if each CNA provides showers as scheduled for each resident, the Director of Nursing stated, .Not sure. I assume showers are by schedule. The Unit Manager on the 2nd floor has the schedule. Staffing is a problem. We rely on agency at this point to fill positions .We don't have a shower schedule book .

Based on policy review, medical record review, and interview, the facility failed to ensure that a resident who requires respiratory equipment received physician's orders and indication for the use of the Airvo (a flow based therapy that the flow rate can be adjusted and a humidifier with integrated flow generator that delivers high flow warmed and humidified fully saturated breathing respiratory gases to spontaneously breathing patients) tubing, chamber changes, and ventilator circuit changes (the ventilator circuit is the tubing that connects the ventilator to a patient, as well as any device that is connected to the circuit tubing. The ventilator circuit is used to deliver gas from a positive pressure ventilator to the patient.) for 5 of 10 sampled residents (Resident #14, #15, #16, #17, and #18) requiring AIRVO and mechanical ventilator use. The findings include: Review of the facility's undated policy titled, Order Guide [Named Electronic Medical Record] orders for AIRVO PATIENTS, revealed .13. Change airvo tubing and chamber - Monthly & PRN [as needed] Day shift . Review of the facility's undated policy titled, Order Guide [Named Electronic Medical Record] orders for VENTILATOR PATIENTS, revealed .15. Change vent [ventilator] circuit - Monthly & PRN - Day shift . Review of the medical record, revealed Resident #14 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #14 scored a 15 on the Brief Interview of Mental Status (BIMS), which indicated the resident was cognitively intact for daily decision making. Resident #14 needed extensive assistance and two plus person physical assist for bathing and set up only for feeding. Special treatments and procedures included oxygen, suctioning, and [CONDITION(S)] care. Review of Resident #14's Physician's Order dated 5/25/2022, revealed .Initial Airvo settings - 10L [liters]/30% [percent] Titrate as needed every 4 hours . Review of Resident #14's Physician's Orders dated 7/2022 and 8/2022, revealed there were no orders documented to change the Airvo tubing and chamber as required per the facility's policy. Review of the medical record, revealed Resident #15 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the admission MDS assessment dated [DATE], revealed Resident #15 scored a 15 on the BIMS, which indicated intact cognition. Resident #15 needed limited assistance with one-person physical assist for bathing and set up only for feeding. Special treatments and procedures included oxygen, suctioning, and [CONDITION(S)] care. Review of Resident #15's Physician's Order dated 7/2022, revealed .Airvo @ [at] 35, 10l [10 liters]/m [minute], 70% - titrate as needed two times a day . Review of Resident #15's Physician's Order dated 8/1/2022, revealed .Initial airvo settings: 31/30/39 - titrate as needed . Review of Resident #15's Physician's Orders dated 7/2022 and 8/2022, revealed there were no orders documented to change the Airvo tubing and chamber as required per the facility's policy Review of the medical record, revealed Resident #16 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the admission MDS assessment dated [DATE], revealed Resident #16 scored a 12 on the BIMS, which indicated cognitively intact for daily decision making. Resident #16 needed extensive assistance with two-person physical assist for bathing. Special treatments and procedures included oxygen, suctioning, and [CONDITION(S)] care. Review of Resident #16's Physician's Order dated 7/22/2022 and 8/2022, revealed .Initial oxygen settings [Airvo 37/30L/min/30%] titrate as needed . Review of Resident #16's Physician's Orders dated 7/2022 and 8/2022, revealed there were no orders documented to change the Airvo tubing and chamber as required per the facility's policy. Review of the medical record, revealed Resident #17 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the admission MDS assessment dated [DATE], revealed Resident #17 scored a 0 on the BIMS, which indicated severely cognitively impaired for daily decision making. Resident #17 needed extensive assistance with two-person physical assist for bathing. Special treatments and procedures included oxygen, suctioning, and [CONDITION(S)] care. Review of Resident #17's Physician's Order dated 7/20/2022 and 8/2022, revealed .Initial Airvo settings [32%/35L] titrate as needed . Review of Resident #17's Physician's Orders dated 7/2022 and 8/2022, revealed there were no orders documented to change the Airvo tubing and chamber as required per the facility's policy. Review of the medical record, revealed Resident #18 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the admission MDS assessment dated [DATE], revealed Resident #18 scored a 3 on the BIMS, which indicated severely cognitively impaired for daily decision making. Resident #18 needed extensive assistance with one-person physical assist for bathing. Special treatments and procedures included oxygen, suctioning, [CONDITION(S)] care, and invasive mechanical ventilator. Review of Resident #18's Physician's Order dated 7/27/2022 and 8/2022, revealed, .PSV [pressure support ventilation] 18/+5 @ bedtime Titrate as needed .PSV 18/+5 @ bedtime Titrate as needed every night shift . Review of Resident #18's Physician's Orders dated 7/2022 and 8/2022, revealed there were no orders documented to change the vent [ventilator] circuit as required per the facility's policy. During an interview on 8/10/2022 at 2:39 PM, the Respiratory Therapy Director confirmed Resident #14, #15, #16, #17 had no physician's order documented to change the Airvo tubing, and chamber as required every 30 days per the facility's policy and Resident #18 had no physician's order documented to change the vent circuit as required every 30 days per the facility's policy. She stated, .the Airvo tubing and chamber and the vent circuit are required to be changed every thirty days for infection control purposes .these residents [records] need an actual order for the Airvo tubing and chamber, and vent circuit to be changed .the expectation is the Respiratory Therapist that admits the patient is to write those orders .due to no order being written it will not fire on the MAR [Medication Administration Record] for the therapist to change it out .

Based on daily staffing postings, facility staffing schedule, and interview, the facility failed to document the total number of hours worked by licensed and unlicensed nursing staff directly responsible for resident care on every shift for 43 of 43 days (7/1/2022, 7/2/2022, 7/3/2022, 7/4/2022, 7/5/2022, 7/6/2022, 7/7/2022, 7/8/2022, 7/9/2022, 7/10/2022, 7/11/2022, 7/12/2022, 7/13/2022, 7/14/2022, 7/15/2022, 7/16/2022, 7/17/2022, 7/18/2022, 7/19/2022, 7/20/2022, 7/21/2022, 7/22/2022. 7/23/2022, 7/24/2022, 7/25/2022, 7/26/2022, 7/27/2022. 7/28/2022, 7/29/2022, 7/30/2022, 7/31/2022, 8/1/2022, 8/2/2022, 8/3/2022, 8/4/2022, 8/5/2022, 8/6/2022, 8/7/2022, 8/8/2022, 8/9/2022, 8/10/2022, 8/11/2022, and 8/12/2022) of staffing postings reviewed. The findings include: Review of the daily staffing postings from 7/1/2022 through 8/12/2022, revealed the facility did not document actual hours worked by a Registered Nurse (RN), Licensed Practical Nurse (LPN), and a Certified Nursing Assistant (CNA) on each shift. Review of the daily staffing postings for 7/1/2022 through 7/31/2022, revealed the facility documented no actual hours for an RN. Review of the actual Employee Punch Report revealed an RN had worked 14 hours on 7/1/2022, 8.5 hours on 7/2/2022, 1.5 hours on 7/3/2022, 24 hours on 7/4/2022, 12 hours on 7/5/2022, 14.75 hours on 7/6/2022, 24 hours on 7/7/2022, 23.75 hours on 7/8/2022, 12 hours on 7/9/2022, 12 hours on 7/10/2022, 21 hours on 7/11/2022, 4.5 hours on 7/12/2022, 9.5 hours on 7/13/2022, 12 hours on 7/14/2022, 30.5 hours on 7/15/2022, 4 hours on 7/16/2022, 36 hours on 7/17/2022, 36 hours on 7/18/2022, 24 hours on 7/19/2022, 17.25 hours on 7/20/2022, 24 hours on 7/21/2022, 24 hours on 7/22/2022, 12 hours on 7/23/2022, 24 hours on 7/25/2022, 24 hours on 7/26/2022, 12 hours on 7/28/2022, 12 hours on 7/29/2022, 24 hours on 7/30/2022, and 24 hours on 7/31/2022. Review of the daily staffing postings 7/1/2022 through 8/12/2022, revealed the facility documented no actual hours for an LPN or CNA. The postings revealed the projected scheduled hours per shift to be worked instead of actual hours worked. During an interview on 8/12/2022 at 5:12 PM, when asked if the documentation on the daily staffing postings was actual hours worked for direct care, the Director of Nursing stated, Not sure, but this is the number we try to schedule . During an interview on 8/15/2022 at 1:55 PM, when asked if the documentation on the daily staffing postings was actual hours worked for direct care, the Administrator stated, .These are what they are scheduled to work .Should be updated each shift . During an interview on 8/15/2022 at 2:05 PM, when asked if the documentation on the daily staffing postings for July and August 2022 was updated as actual hours worked, the DON stated, It is projected daily staffing .This number is not actual hours .

Based on policy review, medical record review, observation, and interview, the facility failed to provide functioning call lights for 6 of 70 (Resident #1, #5, #11, #13, #14, and #24) call lights observed in resident's rooms. The findings include: Review of the facility's undated policy titled, Call Lights: Accessibility and Timely Response, revealed .The purpose of this policy is to assure the facility is adequately equipped with a call light at each residents' bedside, toilet, and bathing facility to allow residents to call for assistance. Call lights will directly relay to a staff member or centralized location to ensure appropriate response. 1. All staff will be educated on the proper use of the resident call system, including how the system works and ensuring resident access to the call light .3. Special accommodations will be identified and provided accordingly. [Examples include touch pads, larger buttons, bright colors, etc.] 4. Staff will ensure the call light is within reach of resident and secured, as needed. 5. The call system will be accessible to residents while in their bed or other sleeping accommodations within the resident's room .7. Ensure the call system alerts staff members directly or goes to a centralized staff work area. 8. All staff members who see or hear an activated call light are responsible for responding. If the staff member cannot provide what the resident desires, the appropriate personnel should be notified . Review of the medical record, revealed Resident #1 was admitted to the facility on [DATE] with diagnoses [CONDITION(S)], Acute and Chronic [CONDITION(S)], [CONDITION(S)], and [CONDITION(S)]. Review of the admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #1 scored a 15 on the Brief Interview of Mental Status (BIMS), which indicated the resident was cognitively intact for daily decision making. Resident #1 was dependent on others for care and was two plus person physical assist for bathing. Special treatments and procedures included suctioning and [CONDITION(S)] care. Observation on the 300 Hall on 8/10/2022 at 12:30 PM, revealed Resident #1's room had a non-working call light with no visual or audible alarm. Review of the medical record revealed Resident #5 was admitted to the facility on [DATE] with diagnoses of Sacral Pressure Ulcer Unstageable, Low Back Pain, Elevated White Blood Cell Count, and Need for Assistance with Personal Care. Review of the admission MDS assessment dated [DATE], revealed Resident #5 scored 13 on the BIMS assessment, which indicted the resident had no cognitive impairment for daily decision-making tasks. Resident #5 needed limited to extensive assistance with Activities of Daily Living (ADLs). Observation on the 200 Hall on 8/10/2022 at 1:30 PM and 8/12/2022 at 11:15 AM, revealed Resident #5's room had a non-working call light with no visual or audible alarm. Review of the medical record, revealed Resident #11 was admitted to the facility on [DATE] with diagnoses of Cerebral Infarction, [CONDITION(S)], Repeated Falls, and Need for Assistance with Personal Care. Review of the admission MDS assessment dated [DATE], revealed Resident #11 scored 15 on the BIMS assessment, which indicated the resident had no cognitive impairment for daily decision-making tasks. Resident #11 needed limited assistance with ADLs. Observation on the 100 Hall on 8/10/2022 at 3:05 PM and 8/15/2022 at 2:23 PM, revealed Resident #11's room had a non-working call light with no visual or audible alarm. Review of the medical record, revealed Resident #13 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of [CONDITION(S)], Type 2 Diabetes, Acute [CONDITION(S)] Infarction, Convulsions, Bacteremia, and Need for Assistance with Personal Care. Review of the admission MDS assessment dated [DATE], revealed Resident #13 scored 13 on the BIMS assessment, which indicated the resident had no cognitive impairment for daily decision-making tasks. Resident #13 needed limited assistance with ADLs. Observation on the 100 Hall on 8/10/2022 at 3:05 PM and 8/15/2022 at 2:23 PM, revealed Resident #13's room had a non-working call light with no visual or audible alarm. Review of the medical record, revealed Resident #14 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of [CONDITION(S)], [CONDITION(S)], Chronic Obstructive Pulmonary Disease, Heart Failure, Hypertension and Diabetes. Review of the quarterly MDS assessment dated [DATE], revealed Resident #14 scored a 15 on the BIMS, which indicated the resident was cognitively intact for daily decision making. Resident #14 needed extensive assistance and two plus person physical assist for bathing and set up only for feeding. Special treatments and procedures included oxygen, suctioning, and [CONDITION(S)] care. Observation on the 300 Hall on 8/10/2022 at 12:30 PM, revealed Resident #14's room had a non-working call light with no visual or audible alarm. Review of medical record, revealed Resident #24 was admitted to the facility on [DATE] with diagnoses of [CONDITION(S)] requiring Mechanical Ventilator, [CONDITION(S)], Gastrostomy tube, Hit/Run over Motor Vehicle Accident with Multiple Rib Fractures, and Neck, Scapula, Arm Humerus, Forearm and Left Femur Fracture. Special treatments and procedures included oxygen, suctioning, [CONDITION(S)] care, and mechanical ventilator. Review of Physician's Note dated 8/8/2022 at 3:16 PM, revealed Resident #24 was alert and oriented to self, and answered questions appropriately. Observation on the 300 Hall on 8/10/2022 at 12:30 PM, revealed Resident #24's room had a non-working call light with no visual or audible alarm. Review of maintenance logs dated June, July, and August 2022, revealed no documentation of call light system maintenance or interventions. Observations in 300 hall on 8/10/2022 at 12:30 PM, revealed if the call light alert light located high up on the wall outside the room did light up, the staff would have to see it to know it. There was no audible alarm to alert staff of a call light being activated. The control panel at the Nurses' Station had no audible alarm alerting staff of a resident in need. The staff would have to be at the Nurses' Station looking at the panel on the desktop to see it. During an interview on 8/10/2022 at 12:30 PM, Resident #14 stated, .My call light has not worked in weeks. They gave me this small bell to ring, but they don't come when I ring it .I don't think they can hear it at the Nurses' Station. I just have to wait and hope someone checks on me . During an interview on 8/10/2022 at 1:17 PM, Resident #1 stated, .My call light does not work .It hasn't worked since I was admitted [5/2/2022] .I have to call my mom and ask her to call the facility to tell them I need help .just the other night I was alone, my family had left and because my call light does not work, I had no way to get help . During an interview on 8/10/2022 at 1:40 PM, Resident #16 pushed his call light button and the light at the box in the room and the light outside the room did not come on. He stated, .I don't think it works .They don't come . During an interview on 8/10/2022 at 2:06 PM, the Maintenance Director confirmed there was no documentation on the June, July, and August 2022 maintenance logs concerning call lights or the call light system. He stated, .No, there is none . During an interview on 8/10/2022 at 4:13 PM, Certified Nursing Assistant (CNA) #1 stated, .There is no audible alarm if a call light has been activated .The only way we know would be if we happen to be in the hallway and look up to see it .No, that light does not really get our attention. We would intentionally have to look up to see it .I was not aware there were any call lights that did not work . During an interview on 8/10/2022 at 4:30 PM, Licensed Practical Nurse (LPN) Unit Manager for the 300 Hall was asked if the facility had call lights that did not work. She stated, .Yes, we gave her [Resident #14] a bell . When asked what about the other residents whose call lights did not work, she shook her head and did not answer. She was asked if there was an audible alarm to alert staff if a resident has activated their call light. She stated, .No . During a telephone interview on 8/11/2022 at 11:52 PM, when asked if the call lights worked in all the rooms on the 200 Hall, LPN #1 stated, .Several call lights don't work. There is no sound to the lights. They [call lights] light up above the door, but you have to be in the hall to see if a light is on. Some [call lights] don't light up in the hall . During an interview on 8/12/2022 at 11:15 AM, when asked how the staff are alerted when a resident activates a call light, Registered Nurse (RN) #1 stated, .I wouldn't know the call light was on unless I am in the hall and look up. There is [are] no sounds or alerts. They are supposed to fix the sound I was told. Guess not yet . During a telephone interview on 8/15/2022 at 3:42 PM, a family member stated, .I tried to call in the afternoons till about 7:00 [PM]. Phones didn't work half the time. They never returned my calls .Not sure call lights were working .A nurse told me the call light was out .I called 911 to come [to the facility] .

Based on policy review, medical record review, observation, and interview, the facility failed to provide accommodating equipment and accessibility to call lights for 2 of 70 sampled residents (Resident #24 and #30) reviewed with call lights. The findings include: Review of the facility's undated policy titled, Call Lights: Accessibility and Timely Response, revealed .The purpose of this policy is to assure the facility is adequately equipped with a call light at each residents' bedside, toilet, and bathing facility to allow residents to call for assistance. Call lights will directly relay to a staff member or centralized location to ensure appropriate response. 1. All staff will be educated on the proper use of the resident call system, including how the system works and ensuring resident access to the call light .3. Special accommodations will be identified and provided accordingly. [Examples include touch pads, larger buttons, bright colors, etc.] 4. Staff will ensure the call light is within reach of resident and secured, as needed. 5. The call system will be accessible to residents while in their bed or other sleeping accommodations within the resident's room .7. Ensure the call system alerts staff members directly or goes to a centralized staff work area. 8. All staff members who see or hear an activated call light are responsible for responding. If the staff member cannot provide what the resident desires, the appropriate personnel should be notified . Review of medical record, revealed Resident #24 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Physician's Note dated 8/8/2022 at 3:16 PM, revealed Resident #24 was alert and oriented to self, and answered questions appropriately. Observation of Resident #24's room on 8/10/2022 at 12:30 PM, revealed the call light activation system was a handheld push button. The resident was unable to push the button and needed a touch pad to activate the call light system. During an interview on 8/10/2022 at 1:50 PM, Licensed Practical Nurse (LPN) Unit Manager of the 300 Hall confirmed Resident #24's call light did not accommodate their needs. She stated, .No .can't push the button on the call light .Yes .need a push pad in order to activate the call light system . Review of medical record, revealed Resident #30 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The admission Minimum Data Set (MDS) assessment dated [DATE], revealed the resident scored a 13 on the Brief Interview for mental Status (BIMS), which indicated Resident #30 was cognitively intact for daily decision making. Resident #30 was totally dependent and one-person physical assist for bathing. Special treatments and procedures included oxygen, suctioning, [CONDITION(S)] care, and invasive mechanical ventilator. Observation in the resident's room on 8/10/2022 at 1:45 PM, revealed the call light cord was wrapped around the bed frame under the mattress at the top of the head frame. Resident #30 could not gain access to the call light to activate the call system. During an interview on 8/10/2022 at 1:45 PM, LPN Unit Manager of the 300 Hall confirmed the call light cord in Resident #30's room was wrapped around the bed frame at the top of the head, and she did not have access to the call button. She stated, .Her cord is tangled in the bed frame way up here .She couldn't reach it even if she wanted to .

Based on the Centers for Disease Control and Prevention (CDC) guidelines, policy review, Employee Time Punch Reports, Employee Screening Logs, and interview, the facility failed to implement policies to properly prevent and/or contain COVID-19 when 17 of 110 staff members (Licensed Practical Nurse (LPN) #1, #2, #3, #4, Certified Nursing Assistant (CNA) #1, #2, #3, #4, #5, and #6, Respiratory Therapist (RT) #1, #2, #3, #4, #5, and #6, and Maintenance Staff #1) failed to complete screenings for COVID-19 prior to working on 11 of 34 days (2/12/2022, 2/13/2022, 2/14/2022, 2/15/2022, 2/16/2022, 2/18/2022, 2/19/2022, 2/20/2022, 2/21/2022, 2/22/2022, and 2/23/2022) reviewed. This had the potential to affect the 54 residents residing in the facility. The findings include: Review of the Centers for Disease Control and Prevention (CDC) document titled, Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, updated 9/10/2021, revealed .Establish a process to identify anyone entering the facility, regardless of their vaccination status .so that they can be properly managed .Options could include .individual screening on arrival at the facility .before entering the facility. Review of the facility's policy titled, Coronavirus Testing, revised 2/6/2022, revealed .The facility will screen all staff each shift .for signs and symptoms of COVID-19 . Review of the Employee Time Punch Reports and Employee Screening Logs from 1/24/2022 to 2/26/2022, revealed the following employees worked on the following days and failed to screen for signs and symptoms of COVID-19: a. 2/12/2022 - CNA #1 b. 2/13/2022 - LPN #1, LPN #2, and RT #1 c. 2/14/2022 - RT #2, RT #3, and Maintenance Staff #1 d. 2/15/2022 - RT #1 and RT #3 e. 2/16/2022 - CNA #1 and RT #4 f. 2/18/2022 - Maintenance Staff #1 g. 2/19/2022 - CNA #2, LPN #3, RT #5, and RT #6 h. 2/20/2022 - CNA #3, LPN #2, RT #1, and RT #3 i. 2/21/2022 - CNA #4, LPN #4, RT #2, and RT #4 j. 2/22/2022 - CNA #5 and CNA #6 k. 2/23/2022 - LPN #3 and Maintenance Staff #1 During an interview on 2/25/2022 at 8:00 PM, during review of the Employee Time Punch Reports and the Employee Screening Logs, the Scheduler and the Social Services Director confirmed there was no documentation of the employees screening prior to working on those days. During an interview on 2/25/2022 at 8:45 PM, the Director of Nursing confirmed all staff should be screened for COVID-19 upon entering the facility.

Based on policy review, employee file review, and interview, the facility failed to implement a written policy to ensure employees were screened for a history of abuse, neglect, exploitation, or misappropriation of resident property prior to being hired for 4 of 8 sampled employees (Respiratory Therapist (RT) #1, the Social Services Director, the Activity Director, and the Medication Aide) reviewed. The findings include: Review of the facility's policy titled, Abuse, Neglect and Exploitation, dated 9/3/2021, revealed .Abuse, Neglect and Exploitation .The facility will develop and implement written policies and procedures that: a. Prohibit and prevent abuse, neglect, and exploitation .and misappropriation .Potential employees will be screened for a history of abuse, neglect, exploitation or misappropriation .Background, reference, and credentials' checks shall be conducted on potential employees . Review of RT #1's employee file, revealed there were no reference checks, abuse registry check or criminal background check included in the file. The facility was unable to provide reference checks, an abuse registry check or a criminal background check was conducted prior to RT #1 being employed. Review of the Social Services Director's employee, file revealed there were no reference checks, abuse registry check, or criminal background check included in the file. The facility was unable to provide reference checks, an abuse registry check, or a criminal background check conducted prior to employment for the Social Services Director. Review of the Activity Director's employee file, revealed there were no reference checks, abuse registry check or criminal background check included in the file. The facility was unable to provide reference checks, an abuse registry check or a criminal background check conducted prior to employment for the Activity Director. Review of the Medication Aide's employee file revealed there were no reference checks, abuse registry check, or criminal background check included in the file. The facility was unable to provide reference checks, an abuse registry check, or a criminal background check conducted prior to employment for the Medication Aide. During an interview on 2/25/2022 at 7:40 PM, the Business Office Manager confirmed all employees should have background checks including reference checks, abuse registry checks, and criminal background checks completed prior to working in the facility.

Based on policy review, medical record review, observation, and interview, the facility failed to ensure dental services were provided for 2 of 2 residents (Resident #11 and #24) reviewed for dental services. The findings include: Review of the facility's policy titled, Dental Examination/Assessment, dated 12/2013, revealed .Each resident shall undergo a dental assessment prior to or within ninety .days of admission . Review of the medical record, revealed Resident #11 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly Minimum Data Set (MDS) dated [DATE], revealed the resident had moderate cognitive impairment, was dependent on staff for oral hygiene and had her own natural teeth. Medical record review revealed there was no documentation that Resident #11 had received a dental consult. Observation in the resident's room on 2/22/2022 at 10:10 AM and 2:46 PM, Resident #11 had her own natural teeth, dark brown areas were noted on her upper teeth, and a white filmy substance was observed in her mouth and on her teeth. Observation and interview in the resident's room on 2/23/2022 at 7:57 AM, revealed Resident #11 had her own natural teeth, had dark brown areas noted on her upper teeth, and a white filmy substance was in her mouth and on her teeth. Resident #11 confirmed staff did not help her brush her teeth daily. During an interview on 2/25/2022 at 4:34 PM, the Social Worker confirmed it was her responsibility to ensure residents were scheduled for dental care. The Social Worker confirmed that Resident #11 had not previously seen the dentist. Resident #11 had resided in the facility since 6/14/2019. Review of the medical record, revealed Resident #24 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the annual MDS dated [DATE], revealed Resident #24 was cognitively intact, dependent on staff for oral hygiene and had her own natural teeth. Medical record review revealed there was no documentation that Resident #24 had received a dental consult. Observation on 2/22/2022 at 2:38 PM, revealed Resident #24 had her own natural teeth. During an interview on 2/22/2022 at 2:43 PM, Resident #24 stated she had not been seen by a dentist and she needed to see one. During an interview on 2/25/2022 at 4:45 PM, the Social Worker confirmed the facility did not have documentation that Resident #24 had received dental services. The Social Worker confirmed that residents' who have their own teeth should be checked on for dental needs.

Based on medical record review, observation, and interview the facility failed to ensure care and services were provided to maintain an indwelling urinary catheter for 1 of 1 resident (Resident #157) reviewed for catheters. The findings include: Review of the medical record, revealed Resident #157 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Treatment Administration Record (TAR) dated 2/2022, revealed there was no documentation Resident #157 received care for the indwelling urinary catheter. Observation in the resident's room on 2/23/2022 at 7:44 AM and 12:02 PM, and on 2/24/2022 at 12:11 PM, revealed Resident #157 had an indwelling urinary catheter. During a telephone interview on 2/25/2022 at 2:50 PM, the interim Minimum Data set (MDS) Coordinator confirmed Resident #157 should have an order for [MEDICAL RECORD OR PHYSICIAN ORDER] During an interview on 2/25/2022 at 5:38 PM, the Regional Director of Clinical Services confirmed residents with an indwelling urinary catheter should have an order for [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on policy review, medical record review, and interview the facility failed to follow physician's orders for medication administration for 1 of 5 sampled residents (Resident #4) reviewed for unnecessary medications. The findings include: The facility's policy titled, Medication Administration, dated 1/1/2021, revealed .Administer medication as ordered . Review of the medical record, revealed Resident #4 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Physician's Order dated 11/20/2021, revealed .Lomotil Tablet 2.5-0.025 MG [milligram] .Give 1 tablet via PEG [Percutaneous [NAME]-gastric] -Tube two times a day for Diarrhea . Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 2/25/2022 at 3:28 PM, the Director of Nursing (DON) confirmed staff had not documented Lomotil was administered as ordered. The DON stated, .I should have been notified, and the doctor should have been notified and asked to change the order to something else if the pharmacy could not get it here. Also, pharmacy should have been notified that the med [medication] had not been delivered. Upon further investigation, the med [medication] was placed in the tote on 11/18/2021 to be delivered. I think she ran out and never got a hard script to renew the med .

Based on policy review, medical record review, observation, and interview the facility failed to ensure residents were assisted with Activities of Daily Living (ADLs) for brushing teeth for 1 of 2 residents (Resident #11) reviewed for dental services. The findings include: Review of the facility's policy titled, Mouth Care, dated 10/ , revealed .The purposes of this procedure are to keep the resident's lips and oral tissues moist, to cleanse and freshen the resident's mouth, and to prevent infections of the mouth .The following equipment and supplies will be necessary .Toothbrush .Toothpaste .The following information should be recorded in the resident's medical record .The date and time mouth care was provided . Review of the medical record, revealed Resident #11 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly Minimum Data Set (MDS) dated [DATE], revealed the resident had moderate cognitive impairment, was dependent on staff for oral hygiene and had her own natural teeth. Review of the comprehensive Care Plan revised 9/2/2021, revealed .I have an ADL self-care performance deficit .assist needed with ADLs, I am legally blind .ORAL CARE .I am dependent on staff for oral care BID [two times a day] and prn [as needed] . Review of the Documentation Survey Report dated 11/2021, revealed personal hygiene was not documented on 11/2/2021, 11/3/2021, 11/4/2021, 11/8/2021, 11/9/2021, 11/12/2021, 11/13/2021, 11/14/2021, 11/16/ , 11/17/2021, 11/18/2021, 11/19/2021, 11/20/2021, 11/22/2021, 11/23/2021, 11/25/2021, 11/26/2021, 11/27/2021, 11/28/2021, 11/29/2021, and 11/20/2021. The facility failed to document personal hygiene on 21 of 30 days in November. Review of the Documentation Survey Report dated 12/2021, revealed personal hygiene was not documented 12/1/2021-12/20/2021, 12/23/2021 - 12/25/2021, 12/28/2021, and 12/30/2021. The facility failed to document personal hygiene on 25 of 31 days in December. Review of the Documentation Survey Report dated 1/2022, revealed personal hygiene was not documented on 1/2/2022, 1/4/2022, 1/16/2022, 1/17/ 2022, and 1/22/2022. The facility failed to document personal hygiene on 5 of 31 days in January. Observation in the resident's room on 2/22/2022 at 10:10 AM and 2:46 PM, Resident #11 had her own natural teeth, dark brown areas were noted on her upper teeth, and a white filmy substance was observed in her mouth and on her teeth. Observation and interview in the resident's room on 2/23/2022 at 7:57 AM, revealed Resident #11 had her own natural teeth, had dark brown areas noted on her upper teeth, and a white filmy substance was in her mouth and on her teeth. Resident #11 confirmed staff did not help her brush her teeth daily. During an interview on 2/24/2022 at 2:50 PM, Resident #11 was asked if staff assisted her with brushing her teeth. Resident #11 confirmed that staff brought her a toothbrush and toothpaste on 2/23/2022 and helped her brush her teeth. Resident #11 confirmed that was the first time in about 3 months since her teeth had been brushed. Resident #11 stated, .I was saying yesterday I wish you would come back because they brought me [NAME] stick and a toothbrush . During an interview on 2/24/2022 at 3:04 PM, Certified Nursing Assistant (CNA) #1 confirmed she had frequently worked with Resident #11. CNA #1 confirmed that Resident #11 required assistance to perform oral care. CNA #1 confirmed that she had assisted Resident #11 to brush her teeth with a toothbrush for the first time on 2/23/2022. CNA #1 stated, .I usually take the swabs and go around her mouth that way .

Based on review of the Centers for Medicare & Medicaid Services (CMS) Long-Term Care (LTC) Facility Resident Assessment Instrument (RAI) 3.0 dated October 2019, medical record review, and interview the facility failed to ensure residents were accurately assessed for antipsychotic medication use, Activities of Daily Living (ADLs), and weight loss for 3 of 19 sampled residents (Resident #2, #21, and #35) reviewed. The findings include: Review of the CMS LTC Facility RAI 3.0 User's Manual Version 1.17.1 dated October 2019, pages G-4 and K-4 revealed, .In order to be able to promote the highest level of functioning among residents, clinical staff must first identify what the resident actually does for himself or herself, noting when assistance is received and clarifying the type .and level of assistance .provided by all disciplines .Weight loss can result in debility and adversely affect health, safety, and quality of life .Weight loss may be an important indicator of a change in the resident's health status or environment . Review of the medical record, revealed Resident #2 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #2 was coded as receiving antipsychotic medications on 7 of the 7 days of the look back period, but Resident #2 was coded as not receiving antipsychotis since the MDS assessment. Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . During a telephone interview on 2/25/2022 at 3:07 PM, the Interim MDS Coordinator confirmed Resident #2's MDS dated [DATE] should have been coded as receiving antipsychotic medication on a regular basis. Review of the medical record revealed Resident #21 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the admission MDS dated [DATE], revealed Resident #21 was coded as bed mobility did not occur, transfers did not occur, dressing activity occurred only once or twice, toileting occurred only once or twice, personal hygiene activity occurred only once or twice, and bathing did not occur in the 7 day look back period. Review of the Care Plan dated 10/3/2021, revealed .The resident has an ADL self-care performance deficit r/t impaired mobility and disease process . During a telephone interview on 2/25/2022 at 3:10 PM, the Interim MDS Coordinator confirmed Resident #21 should have been coded as receiving some type of assistance with bed mobility, dressing, toileting, personal hygiene and bathing daily during the 7 day look back period that ended on 9/28/2021. Review of the medical record revealed, Resident #35 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly MDS dated [DATE], revealed Resident #35 was coded as weighing 168 pounds and as had no weight loss. Review of the Registered Dietician notes dated 1/31/2022, revealed Resident #35 had a significant weight loss of 10.8 percent (%) in 6 months. During a telephone interview on 2/25/2022 at 3:04 PM, the Interim MDS Coordinator confirmed Resident #35's MDS dated [DATE] should have been coded for a significant weight loss.

Based on policy review, observation, and interview, the facility failed to ensure the environment was clean, comfortable, and sanitary when fans were covered in a thick layer of gray dust and were in disrepair in 3 of 29 resident rooms (Room #302, #305, and #307) observed. The findings include: Review of the facility's policy titled, Cleaning and Disinfection of Resident-Care Equipment, dated 9/20/2021, revealed .Resident-care equipment can be a source of indirect transmission of pathogens .Reusable resident-care equipment will be cleaned and disinfected Cleaning .is the removal of visible soil from objects and surfaces and normally is accomplished manually or mechanically . Observation in Room #302 on 2/22/2022 at 11:02 AM and 3:06 PM, and on 2/23/2022 at 7:42 AM and 12:05 PM, revealed a rotating fan with a layer of thick gray dust on the casing. Observation in Room #305 on 2/22/2022 at 11:12 AM, 2/23/2022 at 7:36 AM and 11:58 AM, and on 2/24/2022 at 11:50 AM and 3:27 PM, revealed a fan on the bedside table covered in a thick layer of gray dust and dust hanging from the fan openings. Observation in Room #307 on 2/22/2022 at 12:22 PM and 2:21 PM, 2/23/2022 at 9:15 AM and 11:53 AM, and on 2/24/2022 at 2:35 PM, revealed a standing fan with the front part of the casing missing and the remaining casing covered in a thick layer of gray dust. During an interview on 2/24/2022 at 2:39 PM, the Director of Nursing confirmed the fans should not be covered in dust, needed cleaning, and should not be in disrepair.

Based on policy review, job description review, record review, medical record review, observation, and interview, the Quality Assurance Performance Improvement (QAPI) committee failed to ensure systems and processes were in place and consistently followed by staff to address quality concerns related to safe individualized resident care when the staff failed to conduct a timely Ad Hoc (as needed) committee meeting and corrective action plan after Resident #1 arrived at the facility to be admitted and the facility did not have a ventilator available for the resident. The facility failed to ensure the QAPI committee met to determine a corrective action plan, identified and validated systemic problems, and determined a system was in place to ensure adequate supplies were available for the mechanical ventilators (a machine used to assist or replace spontaneous breathing), ensure respiratory therapy staff and licensed agency nurses had the competencies, knowledge and skill sets needed to provide care for residents with respiratory care needs and mechanical ventilation (mechanical means to assist or replace breathing to a person that is unable to breathe on their own), had a written training program for staff providing care for residents requiring respiratory care and mechanical ventilation, had a written mechanical ventilator weaning (gradually reduce the use of the ventilator to assess the tolerance of the resident without it's use) program, had an external ventilator alarming system for all residents on a mechanical ventilator, provided mechanical ventilator resident monitoring of the resident's condition utilizing pulse oximetry (Assessing Blood Oxygen Saturation) and/or end tidal [MEDICATION(S)] (ETCO) (a noninvasive measurement of exhaled [MEDICATION(S)] (CO2) and provides a breath by breath analysis and a continuous recording of ventilatory status) in order to identify a resident's change in condition and adverse events. These failures resulted in Immediate Jeopardy for 4 of 8 sampled residents (Resident #1, #2, #3, and #4) with respiratory care needs and on invasive mechanical ventilation and had the potential to affect all 8 residents on the respiratory care unit requiring mechanical ventilation. Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury harm, impairment, or death to a resident. The Administrator, Director of Nursing (DON), and Regional Director of Clinical Services were notified of the Immediate Jeopardy (IJ) for F-867 on 9/17/2021 at 3:45 PM, in the DON office. The facility was cited Immediate Jeopardy at F-695, F-726, F-835, and F-867. The facility was cited F-695 at a scope and severity of K, which is Substandard Quality of Care. The Immediate Jeopardy was effective from 9/9/2021 through 9/17/2021. An acceptable Removal Plan for F-867, which removed the immediacy of the jeopardy, was received on 9/18/2021 at 1:45 PM, and was validated onsite by the surveyor on 9/18/2021 through observation, review of audits, record review, and staff interviews. The findings include: Review of the facility's undated policy Quality Assurance & Performance Improvement (QAPI) Plan, revealed, .The purpose of QAPI in our organization is to take a proactive approach to continually improve the way we care for and engage with our residents, caregivers, and other partners so that we may realize our vision to create an environment where people are loved, valued and at peace. To do this, all employees will participate in ongoing QAPI efforts which support our mission by enhancing quality of life by nurturing individuality and independence .The QAPI program at [Named Management Company] will aim for safety and high quality with all clinical interventions while emphasizing autonomy and choice in daily life for residents (or resident's agents), by ensuring our data collection tools and monitoring systems are in place and are consistent for a proactive analysis .The governing body assures adequate resources exist to conduct QAPI efforts .The QAPI plan will guide your facility's performance improvement efforts. This is a living document that you will continue to refine and revisit .[Named Management Company] company's facilities governing body is ultimately responsible for overseeing the QAPI Committee. The president has direct oversight responsibility for all functions of the QAPI Committee and reports directly to the governing body. The QAPI Committee, which includes the medical director, is ultimately responsible for assuring compliance with federal and state requirements and continuous improvement in quality of care and customer satisfaction .Feedback systems will actively incorporate input from staff, residents, families, and others as appropriate. It will include using performance indicators to monitor a wide range of care processes and outcomes and reviewing findings against benchmarks and/or goals the facility has established for performance. It also includes tracking, investigating, and monitoring adverse events/medical errors every time they occur, and action plans implemented through the Plan Do Study Act (PDSA) and Root Cause Analysis to prevent recurrences .The QAPI team at [Named Management Company] facilities will review our sources of information to determine if gaps or patterns exist in our systems of care that could result in quality problems; or if there are opportunities to make improvements .[Named Management Company] facilities use a systematic approach to determine when in-depth analysis is needed to fully understand the problem, its causes, and implications of a change .[Named Management Company] facilities approach comprehensively assesses all involved systems to prevent future events and promote sustained improvement . Review of the facility's Administrator job description dated 12/2018, revealed .Lead and direct the overall operations of the facility in accordance with customer needs, government regulations and company policies, with focus on maintaining excellent care for the residents while achieving the facility's business objectives .Identify and participate in process improvement initiatives that improve the customer experience, enhance workflow, and/or improve the work environment. Management duties including, but not limited to .training and developing, coaching and counseling .department staff, as deemed necessary .Oversee regular rounds to monitor delivery of nursing care, operation of support departments .and ensure resident needs are being addressed .Responsible for the QA [Quality Assurance] program .ensure state and federal regulations are met and adhered to . Review of the Enhanced Respiratory Care (ERC) Operations Manual dated 12/1/2019, revealed .Standards of Care for Ventilator Services .A written training program, including an annual demonstration of competencies, for nursing staff (including nurses' aides, registered nurses, and licensed practical nurses) and respiratory therapy staff providing direct care services for residents receiving Enhanced Respiratory Care. Required Supporting Documentation: 1. Written training program/plan. 2. Documentation of annual demonstration of staff competencies for all staff caring for ERC residents . Review of the medical record, revealed Resident #1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's Emergency Medical Services (EMS) trip ticket dated 9/9/2021 at 7:00 PM, revealed the patient was breathing on her own with ventilator support. When the EMS personnel arrived at the facility with the patient they were told by the respiratory therapist (RT) and nurse they were not expecting a patient on a ventilator and did not have the equipment to place the patient on a ventilator. Attempts to connect the resident to a ventilator were unsuccessful and the EMS personnel had to use a manual method to provide ventilation for the resident. The RT informed the EMS personnel they did not have any ventilator circuits (a device for portable ventilators with an exhalation valve near the patient, the expiratory valve is closed during the inspiratory phase to prevent loss of delivered tidal volume, and the ventilator will be inoperable without this device) on the ventilator hall to provide and manage appropriate care of the patient and would be unable to accept the patient. EMS personnel had been informed by the transferring hospital the facility was expecting the patient on the ventilator. EMS and the RT were unable to attach the EMS ventilator circuit to the facility ventilator even though the EMS personnel had attempted to adapt their equipment to fit the facility ventilator. The EMT [Emergency Medical Technician]s continued to provide manual ventilatory support for the resident. The RT and the charge Registered Nurse (RN) informed the EMTs the facility would be unable to accept the patient as they did not have any available ventilator circuits. The EMS personnel were instructed by their office to transport the patient back to the acute care hospital emergency department. During an interview on 9/13/2021 at 12:00 PM, RT #1 stated, .Yes I was working 9/9/2021 7:00 AM to 7:00 PM shift and I was still here when Ms. [Named Resident #1] arrived. We had no idea she was coming. I was trying to help the oncoming therapist for night shift before I left for the evening .When [Named Resident #1] came in I went into the closet to get the vent [ventilator] circuit and there wasn't one .Because we didn't have one the EMS was in agreement, we could try to make theirs [EMS] fit our ventilator. I cut the tubing to fit the exhalation port and it didn't work .we couldn't make it fit .EMS went back to their truck to get another vent circuit for their machine but did not have one .I know when start trying to makeshift things to work it is dangerous .When we know a patient is coming, we have the room set up with the ventilator, vent circuit, suction, neb [nebulizer] all the supplies. We did not know she was coming .I don't order supplies usually the manager is responsible to order . During an interview on 9/13/2021 at 12:05 PM, the Interim Director of Respiratory Therapy stated, .I knew when I left [9/9/2021], we had one vent [ventilator] circuit left .Ms. [Named Resident #5] admitted and got that one .I did not know about another resident coming .We had no more vent circuits in the building .I had no idea we had no more .I just got in this position 9/7/2021 and have been working at the bedside every day and not as manager . During an interview on 9/13/2021 at 12:10 PM, the Administrator stated, .I had asked [Interim Director of Respiratory Therapy] what supplies she needed on Wednesday [9/8/2021] .drain sponges, suction catheters but we did not say vent circuits. We had a box, but it was the wrong kind [circuits]. That is my fault thought they were the correct one. I'm ignorant to what a [CONDITION(S)] [[CONDITION(S)]] circuit is, and I didn't probably stress to her [Interim Director of Respiratory Therapy] .No, I had no idea how long we had just one vent circuit in the building [prior to 9/9/2021] .I didn't communicate properly with her the number of admissions. I didn't know how many vents were to come in .No, RT is not included in the text thread [notification of staff] of admissions .In regard to supplies I don't have par levels [minimum amount of supplies that should be on hand to meet the demand]. I don't know how much of what is needed. I didn't even know who to order respiratory supplies from. I had to get on the internet and find someone . During a telephone interview on 9/13/2021 at 4:55 PM, RN #1 stated, .I just got to work at 7:00 PM on 9/9/2021 and I was doing admissions and assessments. We were not told ahead of time who was coming. We don't know till they get here .I was just told two vent [ventilator] patients were coming and one had already got here [Resident #5] .I had the paperwork for Ms. [Named Resident #1] but didn't know if had vent hook up .that is respiratory .When she [Resident #1] got here RT had no vent circuit so we could not transfer her from EMS vent to our vent. We could not admit her and had to send her back to the hospital. I assisted EMS back down the elevator to the ambulance for them to return her to the hospital . During an interview on 9/13/2021 at 5:00 PM, the Interim Director of Respiratory Therapy stated, .The vent circuits are changed out every 30 days .Yes, we do have to change them prn [as needed] if the line leaks, pops, stretches or the patient pulls on it and pops it off we have to change it .Yes, we should have had more vent circuits in stock in case of prn needing changed .those other patients on the vents could have needed one .yes, the ventilators are inoperable without the vent circuits .I had no idea how long we had just one vent circuit in the building [prior to 9/9/2021] . Observation on in the resident's room [ROOM NUMBER]/16/2021 at 10:26 AM, revealed Resident #1's ventilator alarm was sounding in the room. There was no external audible or visual alert outside her room of the ventilator alarming. During an interview on 9/16/2021 at 11:00 AM, the Administrator confirmed no external audible or visual alarm alert was outside Resident #1's room to signal when the ventilator was alarming. She stated, .It should be hooked up to the call light system and beeper system but in that room the door [side bed] does not have that capability. We have to get that fixed . Observation in the resident's room on 9/15/2021 at 9:10 AM and 9/16/2021 at 10:15 AM, revealed Resident #2 had a mechanical vent in use and no continuous pulse oximetry was in use or ETCO2 monitor was in use. Review of Resident #2's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Respiratory Administration Record dated August 2021, revealed no documentation that the vent circuit was changed. During an interview on 9/14/2021 at 12:00 PM, the Interim Director of Respiratory Therapy stated, .I don't know if her [Resident #2] vent circuit was changed. It should have been changed 8/26/2021. I will have to check on that . The Interim Director of Respiratory Therapy confirmed Resident #2's vent circuit had not been changed in August. During an interview on 9/15/2021 at 9:10 AM, the Interim Director of Respiratory Therapy confirmed Resident #2 did not have a continuous pulse oximetry monitor or an end tidal [MEDICATION(S)] (ETCO) continuous monitor. Observation in the resident's room on 9/15/2021 at 9:00 AM and 9/16/2021 at 10:20 AM, revealed Resident #3 had a mechanical vent in use and no continuous pulse oximetry was in use or ETCO monitor was in use. During an interview on 9/15/2021 at 9:00 AM, the Interim Director of Respiratory Therapy confirmed Resident #3 did not have a continuous pulse oximetry or an ETCO continuous monitor. During an interview on 9/17/2021 at 9:53 AM, the Administrator stated, .No we did not do an Ad Hoc QA on the incident [Resident #1] .I didn't see it as an incident like you do. I see it now .No, we haven't tracked or trended all incidents and no action plan .I see we need organization and standardization .No, we have no documentation of the MD [Medical Doctor] reviewed and signed or documented their input about incidents. Just the signature of attendance of the meeting . During an interview on 9/18/2021 at 4:30 PM, the Administrator stated, .I did not know about that wireless external alarm system for the vents. We have a box here of not working alarm boxes. The system is programmed exclusively for either door bed or window bed of the room it is in. Therefore, you cannot move the wireless alarms from room to room. That is why we had to move [Named Resident #1] .I did not know that until you found that on her and it was [Named room number] door [side] .We have to get a guy in here as soon as possible to fix that .That is the only one missing . While looking at the equipment in the RT Director's office, the Interim Director of Respiratory Therapy stated, .We have no more inline continuous ETCO cables. I believe they are all broken . The Administrator stated, .We need to order more . The Administrator confirmed have capability for 20 vent residents but only 8 were in service now. Upon review of the pulse oximetry machines and supplies, there were a total of 10 with 9 in use leaving 1 machine not in use. The Interim Director of Respiratory Therapy stated, .There are no extra pulse oximetry cables .All those in the bag are broken . The Administrator stated, .We need to order more machines and cables . The Interim Director of Respiratory Therapy stated, .I would like to order the inline [connects to vent while vent in use] pulse oximetry . Refer to F-695, F-726, and F-835. The surveyor verified the Removal Plan by: 1. Education was provided to the Nursing Home Administrator on 9/15/2021 by the Regional Director of Operations regarding QAPI resources, how to analyze and self-identify potential issues, tools, and programming available to assist in self-identifying issues in the facility that require a root cause analysis, thorough investigation, and process changes with ongoing monitoring. Education was provided regarding communicating issues to the Regional support team to ensure the full range of resources are accessed and available to the facility team and education on how to identify what constitutes a potential adverse incident. The surveyor confirmed this through interview and review of the education sign in sheet. 2. An Ad Hoc QAPI meeting was conducted on 9/16/2021 at 9:00 PM with the Administrator, DON, Unit Managers, other Interdisciplinary (IDT) team members, the Regional Director of Operations, and the Regional Director of Clinical Services to discuss the identified respiratory events, the supply concern, the alarm concern, to conduct the root cause analyses and initiate a thorough investigation that led to process changes, monitoring, and correction. The surveyor confirmed this through interview and review of the sign in sheet. 3. The root cause of the occurrence of the supply incident was discussed and the findings were: a. The respiratory manager quit without notice and the task of reordering supplies had not been delegated. Therefore, supplies were not immediately available when a new patient arrived. b. A process was put in place to ensure manager tasks are immediately delegated, to include ordering supplies in the event the position becomes vacant. Backups will be trained to ensure ordering stays on track and supplies are always available. c. A model of Director and lead will be established to ensure processes stay in place if one person is not available. d. As the facility works toward that model, the Administrator and DON will be trained on ordering the needed supplies, as well as backup personnel in the respiratory department. The surveyor confirmed this through interview and review of the inventory sheet. 4. Due to the facility not having a respiratory manager, the monitoring of the external alarm systems was not occurring timely. If a vacancy occurs in the future, there will be a backup staff member trained to ensure monitoring of the alarms happens timely and to ensure all alarms are validated to be in working order daily. The system of a Director and Lead RT manager will be implemented to ensure there is always someone available that is aware of the required alarm checks. As another backup, the facility Administrator and DON will be trained to validate, check, and ensure alarms are in working order and an audit schedule will be created to review in the monthly QAPI meeting and for additional recommendations and changes. The surveyor confirmed this through interview and review of the audit tool. 5. Ongoing audits were implemented to check the alarms with the results discussed at the QAPI committee meetings. The surveyor confirmed this through interview and record review. 6. The plan to bring in consultant respiratory assistance to help with the overall operation of the unit to ensure operations are in top operational order was initiated. The surveyor confirmed this through interview. 7. Education and a written training program will be established for all respiratory staff, the Director of Nursing, and the Administrator that have interactions with the facility written training program for residents with respiratory diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The surveyor confirmed by interview. 8. Educational overview was provided on 9/17/2021 to include resources, where to obtain assistance, how to identify potential adverse issues and identification of Interim Director of Respiratory Therapy and communication tree. The surveyor confirmed by interview and sign in sheet. 9. The (Named) Supervising company identified three Respiratory Therapy resources and they were contacted. The facility will engage in a QAPI process with them. One of the consultants to contact was a Respiratory Consultant, who will come to the facility on [DATE] to assist in developing strengthened processes on the respiratory unit and to reiterate education on QAPI, competencies, supply management, alarm monitoring, root cause analysis and overall mechanical ventilation programming. These respiratory expert consultants will assist in the quality review and operations of the unit. This intervention was identified in the root cause analysis completed on 9/17/2021. The surveyor confirmed this through interview. 10. On 9/17/2021, education was provided by the Regional Director of Operations and Regional Director of Clinical Services to the Respiratory team, Administrator and DON regarding the comprehensive QAPI policies and processes in place for the full range of care and services the facility provides. The surveyor confirmed this through interview and review of the sign in sheet. 11. The Administrator, DON and Interdisciplinary team were educated on 9/17/2021 by the Regional Director of Operations and Regional Director of Clinical Services on the process to self-identify and report issues within the facility. Once self-identification of an issue occurs, the facility is to immediately identify root causes of such issues and complete a thorough investigation that will ultimately lead to correcting process issues and broken systems, monitoring such issues and continually reviewing to ensure continued compliance. The surveyor confirmed this through interview and review of the sign in sheet. The facility's noncompliance at F-867 continues at a scope and severity of E for monitoring the effectiveness of the corrective actions. The facility is required to submit a Plan of Correction.

Based on policy review, personnel file review, observation, and interview, the facility failed to ensure 3 of 3 agency Licensed Practical Nurses (LPN #1, #2, and #3) were competent to provide [CONDITION(S)] (an opening in the front of the neck with a tube inserted into the windpipe to help you breathe) Care and Suctioning, the necessary knowledge and skills to provide care for residents with respiratory care needs, and mechanical ventilation (a machine to assist or replace spontaneous breathing with a machine). This lack of knowledge and skills had the potential to cause serious injury or harm to 8 of 8 residents (Resident #1, #2, #3, #4, #5, #6, #7, and #8) with tracheostomies and mechanical ventilators, which resulted in Immediate Jeopardy. Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury harm, impairment, or death to a resident. The Administrator, Director of Nursing (DON), and Regional Director of Clinical Services were notified of the Immediate Jeopardy (IJ) for F-726 on 9/16/2021 at 4:05 PM, in the DON office. The facility was cited Immediate Jeopardy at F-726. The Immediate Jeopardy was effective from 9/9/2021 through 9/17/2021. An acceptable Removal Plan for F-726, which removed the immediacy of the jeopardy, was received on 9/17/2021 at 11:00 AM, and was validated onsite by the surveyor on 9/18/2021 through observations, record review, review of audits, and staff interviews. The findings include: Review of the facility's policy titled, Provision of Invasive Mechanical Ventilation Services, dated 12/28/2018, revealed .A Respiratory Therapist [RT] shall be present at the facility twenty-four [24] hours per day, seven [7] days a week to provide: Ventilator Care, Administration of Medical Gases, Administration of aerosol medications, Diagnostic Testing and monitoring of life support systems, Assist in initial, routine and as needed assessment of residents requiring invasive mechanical ventilation .Pre-admission assessment is reviewed by the Nurse Liaison, Director of Nursing and/or Respiratory Manager with experience in the care of the ventilator-dependent patient. This review will determine the appropriateness of admitting resident to the facility . Review of the facility's policy titled, Mechanical Ventilation: Setup and Monitoring, dated 10/2010, revealed .The purpose of this procedure is to provide assisted or controlled ventilation to a resident with acute or chronic respiratory insufficiency. Verify that there is a physician's order for this procedure .Adjust the remote and ventilator alarms so that they can be heard by staff responsible for monitoring the resident . Review of the facility's undated procedure titled, New Admit Checklist, revealed .New Admit Checklist .date all equipment once patient admits, concentrator .and oxygen tubing, Ambu-bag [a hand held device used to provide positive pressure ventilation to patients that are not breathing] with filter, full tank of oxygen, back-up trachs [tracheostomies] [same size and size smaller of the tube to keep the airway open], 10 ml [milliliters] syringe, saline bullets [packets of saline to clean the [CONDITION(S)] tube], gauzes, suction with suction set-up & [MEDICATION(S)] [An oral suctioning tool to suction secretions to prevent aspiration], neb [nebulizer] cup & nebulizer [a drug delivery device used to administer medication in the form of a mist into the lungs] machine, pulse-ox machine [measures the amount of oxygen in the blood] . Review of the facility's Licensed Practical Nurse (LPN) job description dated 12/2018, revealed .Responsible for supervision of the delivery of care to residents. Accommodate resident needs, develop care plans, administer nursing care, evaluate nursing care, and supervise CNA's [Certified Nursing Assistant] and other personnel in the delivery of nursing care .Collect information and assist to complete evaluations of residents at admission and discharge .Document services rendered to resident .Identify and prioritize primary nursing problems .Make daily rounds to monitor resident care and status of residents. Implement care plans for residents in compliance with physician's orders. Implement established nursing policies and procedures .Document in resident's chart pertinent information about significant change in resident's condition .Inform Central Supply of any supplies that are needed . Review of the facility's competency on [CONDITION(S)] Care dated 12/2019, revealed .The purpose of this procedure is to guide [CONDITION(S)] care and the cleaning of reusable [CONDITION(S)] cannulas [a plastic tube] . Review of the facility's competency for Suctioning the Lower Airway (Endotracheal (ET) or [CONDITION(S)] Tube) dated 10/2010, revealed .The purpose of this procedure is to remove secretions, maintain a patent airway and prevent infection of the lower respiratory tract . Review of the Enhanced Respiratory Care (ERC) Operations Manual dated 12/1/2019, revealed .Standards of Care for Ventilator Services .A written training program, including an annual demonstration of competencies, for nursing staff (including nurses' aides, registered nurses, and licensed practical nurses) .staff providing direct care services for residents receiving Enhanced Respiratory Care. Required Supporting Documentation: 1. Written training program/plan. 2. Documentation of annual demonstration of staff competencies for all staff caring for ERC residents . Review of the facility's schedule for the licensed nursing staff on the 300 Hall which was the ventilator unit dated September 2021, revealed three agency Licensed Practical Nurses (LPN #1, #2, and #3) worked 9/13/2021 and 9/14/2021. Review of the licensed nursing staff competencies revealed there was no documentation of competencies recorded for these agency nursing staff. During an interview on 9/15/2021 at 3:30 PM, the Administrator was asked if the facility had competencies documented for the licensed agency nurses working in the facility. She stated, .We don't do competencies on agency nurses . The Administrator was asked how the facility would know the agency nurses were competent to provide care for patients with tracheostomies and mechanical ventilation. She stated, .Oh, I see. We don't . During an interview on 9/16/2021 at 1:20 PM, the Administrator was asked if the facility had a written training program for the Respiratory Care Unit as required in the Enhanced Respiratory Care Operations Manual dated 12/1/2019. The Administrator stated, .No . During an interview on 9/16/2021 at 2:30 PM, the Interim Director of Respiratory Therapy stated, .I have never seen a training program here for the unit . Refer to F-695, F-835, and F-867. The Surveyors verified the Removal Plan by: 1. In-services were immediately conducted regarding the care of residents with respiratory mechanical ventilation set up and monitoring and competencies were performed for the three agency licensed nursing staff reviewed on 9/16/2021 during the survey. Any staff not in-serviced will not be allowed to work until the competencies are completed by the Interim Director of Respiratory Therapy or designee. The surveyor confirmed this through record review and interview. 2. A 100 percent (%) audit of all licensed nursing files was conducted by the DON to ensure all licensed staff, including agency staff, that work on the ventilator unit have the competencies completed in their files. This was completed by 9/17/2021. The surveyor confirmed this through record review. 3. No licensed or registered nursing staff will be allowed to work on the ventilator unit without competencies on providing care for residents with mechanical ventilation in their file. The surveyor confirmed this through record review and interview. 4. All licensed and registered nurses working on the ventilator unit will have competencies completed by the Interim Director of Respiratory Therapy by 9/17/2021. No staff will be allowed to work the ventilator unit without having competencies completed. The surveyor confirmed this through record review and interview. 5. The Administrator/Designee will audit 5 files of licensed and registered nurses every week to ensure competencies are in place for four weeks, then 3 files every week for four weeks, then three files monthly for three months and/or until substantial compliance is achieved. The surveyor confirmed this through record review and interview. 6. The Administrator and DON will provide oversight of the continued monitoring of all areas of the respiratory unit with additional oversight by the Regional Director of Operations, The Regional Director of Clinical Services, and Area Director of Clinical Services. The surveyor confirmed this through interview. The facility's noncompliance at F-726 continues at a scope and severity of E for monitoring the effectiveness of the corrective actions. The facility is required to submit a Plan of Correction.

Based on job description review, medical record review, observation, and interview, facility Administration failed to provide oversight of staff and facility resources effectively and efficiently to ensure necessary services for residents with respiratory care needs and mechanical ventilation (assisted breathing with a machine). The lack of oversight resulted in inadequate and lack of necessary supplies available for use in the care of residents with mechanical ventilation and respiratory care needs. Facility staff were unaware the facility had no mechanical ventilator circuits (a device for portable ventilators with an exhalation valve near the patient, the expiratory valve is closed during the inspiratory phase to prevent loss of delivered tidal volume, and the ventilator will be inoperable without this device) for a new admission (Resident #1) which resulted in Resident #1 being sent back to the hospital. Due to the lack of supplies and an inoperable mechanical ventilator, the residents could have suffered serious harm if any of the seven residents in the facility on mechanical ventilation experienced a ventilator circuit leak, a pop off, a stretched line or a resident pulled on it and popped it off. Administration failed to ensure a necessary audible, external alarm system and response process for the ventilator was located outside Resident #1's room to alert the staff of a potentially harmful event, and there was no monitoring process for continuous pulse oximetry (a method for assessing the amount of Oxygen Saturation in the blood) or end tidal [MEDICATION(S)] (CO2) (the level of [MEDICATION(S)] that is released at the end of an exhaled breath) that provides a breath by breath analysis and a continuous recording of ventilatory status in place for Resident #2 and #3 who had respiratory care needs and required mechanical ventilation. Facility Administration failed to ensure staff notified the physician to obtain Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Facility Administration failed to ensure the Respiratory Therapist (RT) and agency Licensed Practical Nurses had the specific knowledge and skills necessary to provide the care needed for residents with respiratory care concerns and mechanical ventilation. These failures resulted in Immediate Jeopardy for the 8 residents in the facility with respiratory care concerns and required invasive mechanical ventilation which had the potential to result in serious harm, injury, or death. Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury harm, impairment, or death to a resident. The Administrator, Director of Nursing (DON) and Regional Director of Clinical Services were notified of the Immediate Jeopardy (IJ) for F-835 on 9/15/2021 at 3:41 PM, in the DON office. The facility was cited Immediate Jeopardy at F-695, F-726, F-835, and F-867. The facility was cited F-695 at a scope and severity of K, which is Substandard Quality of Care. The Immediate Jeopardy was effective from 9/9/2021 through 9/17/2021. An acceptable Removal Plan for F-835, which removed the immediacy of the jeopardy, was received on 9/17/2021 at 2:59 PM, and was validated onsite by the surveyor on 9/18/2021 through observations, record reviews, audits conducted, and staff interviews. The findings include: Review of the facility's Administrator job description dated 12/2018, revealed .Lead and direct the overall operations of the facility in accordance with customer needs, government regulations and company policies, with focus on maintaining excellent care for the residents while achieving the facility's business objectives .Identify and participate in process improvement initiatives that improve the customer experience, enhance workflow, and/or improve the work environment. Management duties including, but not limited to .training and developing, coaching and counseling .Oversee regular rounds to monitor delivery of nursing care, operation of support departments, cleanliness and appearance of the facility; morale of the staff; and ensure resident needs are being addressed .Responsible for the QA [Quality Assurance] program .ensure state and federal regulations are met and adhered to . Review of the facility's DON job description dated 12/2011, revealed .To manage the overall operations of the Nursing Department in accordance with company policies, standards of nursing practices and governmental regulations so as to maintain excellent care of all resident's needs .Identify and participate in process improvement initiatives that improve the customer experience, enhance workflow, and/or improve the work environment. Management duties including, but not limited to .training and developing, coaching and counseling .as deemed necessary. In the absence of the Administrator assume responsibility of the facility .Plan develop, organize, implement, evaluate and direct the nursing services department, as well as its programs and activities, in accordance with current rules, regulations, and guidelines that govern the long-term care facility. Assume administrative authority, responsibility and accountability for all functions, activities, and training of the nursing department. Organize, develop, and direct the administration and resident care of the nursing service department. Participate in .resident care plan meetings .safety committee meetings, quality assessment and assurance committee meetings .Meet daily with Director of Admissions/Marketing, Business Office Manager and Administrator regarding admission and placement of proposed residents. Evaluate prospective residents in terms of the nursing service they need and the capability of the facility to supply the needed service .Make daily rounds of the nursing department to verify that all nursing service personnel are performing their work assignments in accordance with acceptable nursing standards .Perform nursing services and deliver resident care services in compliance with corporate policies and State and Federal regulations .Regularly inspect the facility and nursing practices for compliance with federal, state, and local standards and regulations .Monitor nursing service personnel to verify that they are following established safety regulations in the use of equipment and supplies .Assure proper handling and emergency care of residents, personnel, and visitors while on the job or in the building .Monitor stock level of medications, medical supplies, equipment .to verify they are maintained on premises at all times to adequately meet the needs of the resident .Create and implement procedures for department equipment to be operated only by trained, authorized personnel in a safe manner .Work closely with Central Supply to confirm that changes are made on a timely basis and that inventory is current and medical-surgical supplies are adequate on the nursing stations .Review and verify that documentation procedures for nursing care are met according to corporate, state and federal guidelines .Recommend to the Administrator the equipment and supply needs of the nursing department .Participate in monthly QA . Review of the facility's Respiratory Care Practitioner job description dated 10/1/2018, revealed .To provide accurate patient evaluation, testing, diagnostics and monitoring under medical direction to assure quality patient care in compliance with N.B.R.C. [National Board for Respiratory Care], AARC [American Association for Respiratory Care], State of Tennessee Respiratory Care Act, and Department policy and procedures .Implement all therapeutic aspects of respiratory care under the direction of the department medical director and in compliance with the department policy and procedures to provide safe quality care for the adult and geriatric patient population we service. Perform respiratory care assessment of patients in an accurate, thorough, and timely manner to assure the delivery of effective therapy. Monitor patient's rehabilitation goals for appropriateness and consistency of therapy. Provide ongoing care to patients requiring oxygen therapy, artificial airway management, mechanical ventilation and weaning, among others, according to N.B.R.C., AARC, and department policy and procedure .Consistently and accurately document in the patient medical records patient assessment with clinical parameters such as breath sounds, [CONDITION(S)] data, sputum [secretions] production, ventilator settings based on physician orders, weaning and tolerance, in compliance with department daily documentation records. Provide the in-coming shift with room-to-room walking detailed, verbal report on the patient condition, any change in orders and tolerance to care provided. Consistently and accurately provide information regarding SpO2 [oxygen saturation] .sputum [secretions] production, breath sounds, mode of therapy, medication administration and tolerance, among others. For patients on ventilatory support, latest ventilator settings, tolerance to weaning and Fio2 [fraction of inspired oxygen, the concentration of oxygen in the gas mixture] titration. Perform diagnostic procedures in accordance with physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] .Maintain equipment .Must be competent in the clinical performance, analysis and understanding of diagnostic procedures. Ability to recognize and understand disease processes as well as the psychological and physiological aspects and needs of the patients and families we service . Review of the facility's Licensed Practical Nurse (LPN) job description dated 12/2018, revealed .Responsible for supervision of the delivery of care to residents. Accommodate resident needs, develop care plans, administer nursing care, evaluate nursing care, and supervise CNA's [Certified Nursing Assistant] and other personnel in the delivery of nursing care .Collect information and assist to complete evaluations of residents at admission and discharge .Document services rendered to residents .Identify and prioritize primary nursing problems .Make daily rounds to monitor resident care and status of residents. Implement care plans for residents in compliance with physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .Document in resident's chart pertinent information about significant change in resident's condition .Inform Central Supply of any supplies that are needed . During an interview on 9/13/2021 at 12:00 PM, RT #1 stated, .Yes I was working 9/9/2021 7:00 AM to 7:00 PM shift and I was still here when Ms. [Named Resident #1] arrived. We had no idea she was coming. I was trying to help the oncoming therapist for night shift before I left for the evening .When [Named Resident #1] came in I went into the closet to get the vent circuit [a tube that connects the ventilator to the patient] and there wasn't one .Because we didn't have one the EMS was in agreement, we could try to make theirs [EMS] fit our ventilator. I cut the tubing to fit the exhalation port and it didn't work .we couldn't make it fit .EMS went back to their truck to get another vent circuit for their machine but did not have one .I know when start trying to makeshift things to work it is dangerous .When we know a patient is coming, we have the room set up with the ventilator, vent circuit, suction, neb [nebulizer] all the supplies. We did not know she was coming .I don't order supplies usually the manager is responsible to order . During an interview on 9/13/2021 at 12:05 PM, the Interim Director of Respiratory Therapy stated, .I knew when I left [9/9/2021], we had one vent circuit left .Ms. [Named Resident #5] admitted and got that one .I did not know about another resident coming .We had no more vent circuits in the building .I had no idea we had no more .I just got in this position 9/7/2021 and have been working at the bedside every day and not as manager . During an interview on 9/13/2021 at 12:10 PM, the Administrator stated, .I had asked [Interim Director of Respiratory Therapy] what supplies she needed on Wednesday [9/8/2021] drain sponges, suction catheters but we did not say vent circuits. We had a box, but it was the wrong kind [circuits]. That is my fault thought they were the correct one. I'm ignorant to what a [CONDITION(S)] circuit is, and I didn't probably stress to her [Interim Director of Respiratory Therapy] .No, I had no idea how long we had just one vent circuit in the building [prior to 9/9/2021] .I didn't communicate properly with her the number of admissions. I didn't know how many vents were to come in .No, RT is not included in the text thread [a system used by the facility Administration to notify staff of new admissions] of admissions .In regard to supplies I don't have par levels [the minimum amount of supplies that should be on hand to meet the demand] I don't know how much of what is needed. I didn't even know who to order respiratory supplies from. I had to get on the internet and find someone . During a telephone interview on 9/13/2021 at 4:55 PM, Registered Nurse (RN) #1 stated, .I just got to work at 7:00 PM on 9/9/2021 and I was doing admissions and assessments. We were not told ahead of time who was coming. We don't know till they get here .I was just told two vent [ventilator] patients were coming and one had already got here [Resident #5] .I had the paperwork for Ms. [Named Resident #1] but didn't know if had vent hook up that is respiratory [responsibility] .When she [Resident #1] got here RT had no vent circuit so we could not transfer her from EMS vent to our vent. We could not admit her and had to send her back to the hospital . During an interview on 9/13/2021 at 5:00 PM, the Interim Director of Respiratory Therapy stated, .The vent circuits are changed out every 30 days .Yes, we do have to change them prn [as needed] if the line leaks, pops, stretches or the patient pulls on it and pops it off we have to change it .Yes, we should have had more vent circuits in stock in case of prn needing changed .those other patients on the vents could have needed one .yes, the ventilators are inoperable without the vent circuits .I had no idea how long we had just one vent circuit in the building . Observation in the resident's room on 9/16/2021 at 10:26 AM, revealed Resident #1's ventilator alarm was sounding. There was no external audible or visual alert outside her room to alert the staff the ventilator was alarming. During an interview on 9/16/2021 at 10:26 AM, the Interim Director of Respiratory Therapy confirmed no audible or visual alarm alert was outside Resident #1's room alerting staff of the ventilator alarm. She also confirmed the beeper (a device staff carry for notification) system the RT carries was not alarming. She stated, .There is no external audible alarm or visual alarm alert outside Resident #1's room .It also did not alarm on the beeper . During an interview on 9/16/2021 at 11:00 AM, the Administrator confirmed no external audible or visual alarm alert was outside Resident #1's room to signal when the ventilator was alarming. She stated, .It should be hooked up to the call light system and beeper system but in that room the door [side bed] does not have that capability. We have to get that fixed . During an interview on 9/18/2021 at 4:30 PM, the Administrator stated, .I did not know about that wireless external alarm system for the vents. We have a box here of non working alarm boxes. The system is programmed exclusively for either door bed or window bed of the room it is in. Therefore, you cannot move the wireless alarms from room to room. That is why we had to move [Named Resident #1] .I did not know that until you found that on her and it was [Named Room Number] door .We have to get a guy in here as soon as possible to fix that .That is the only one missing . While looking at the equipment in the RT Director's office, the Interim Director of Respiratory Therapy stated, .We have no more inline continuous ETCO cables. I believe they are all broken . The Administrator stated, .We need to order more . The Administrator confirmed the facility had the capability for 20 ventilator residents but only 8 were in service at this time. Upon review of the pulse oximetry machines and supplies, the facility had a total of 10 with 9 in use, leaving 1 machine not in use. The Interim Director of Respiratory Therapy stated, .There are no extra pulse oximetry cables .All those in the bag are broken . The Administrator stated, .We need to order more machines and cables . The Interim Director of Respiratory Therapy stated, .I would like to order the inline [connects to vent while vent in use] pulse oximetry . Observation in the resident's room on 9/15/2021 at 9:10 AM and 9/16/2021 at 10:15 AM, revealed Resident #2 had a mechanical ventilator in use and there was no continuous pulse oximetry or ETCO2 monitors in use. Review of Resident #2's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Respiratory Administration Record dated August 2021, revealed no documentation that the vent circuit was changed. During an interview on 9/14/2021 at 12:00 PM, the Interim Director of Respiratory Therapy stated, .I don't know if her [Resident #2] vent circuit was changed. It should have been changed 8/26/2021. I will have to check on that . The Interim Director of Respiratory Therapy confirmed Resident #2's vent circuit had not been changed in August. During an interview on 9/15/2021 at 9:10 AM, the Interim Director of Respiratory Therapy confirmed Resident #2 did not have a continuous pulse oximetry monitor or an end tidal [MEDICATION(S)] (ETCO) continuous monitor. Observation in the resident's room on 9/15/2021 at 9:00 AM and 9/16/2021 at 10:20 AM, revealed Resident #3 had a mechanical vent in use but did not have continuous pulse oximetry or ETCO monitor in use. During an interview on 9/15/2021 at 9:00 AM, the Interim Director of Respiratory Therapy confirmed Resident #3 did not have continuous pulse oximetry or an ETCO continuous monitor. Review of Resident #4's RT Note dated 9/15/2021 at 6:39 PM, revealed Resident #4 was sent to the emergency room for a gastrostomy (a tube inserted in the belly to administer nutrition) tube replacement and was on a ventilator. Resident #4 was returned to the facility without a ventilator and on a venturi mask [a medical device to deliver a known oxygen concentration to patients on controlled oxygen therapy] 4 liters at 38 percent (%) and not on a ventilator. Review of Resident #4's RT Notes dated 9/15/2021 revealed no documentation Resident #4's physician or pulmonologist was notified to obtain new Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review revealed no documentation of continuous monitoring of pulse oximetry. Review of Resident #4's RT Note dated 9/16/2021 at 11:30 PM, revealed .Placed patient back on vent due to being in distress, pt said she was having trouble catching her breath after using bedside urinal and she was worried that she wasn't getting any better . During an interview on 9/16/2021 at 3:00 PM, the Regional Director of Clinical Services stated, .I am shocked they [facility] didn't have a weaning policy/program . When asked if the Pulmonologist should have been notified when Resident #4 returned to the facility and was not on a ventilator, she stated, Yes. Review of Resident #4's RT Note dated 9/17/2021 at 6:45 AM, revealed .When the RT came in it was reported from night shift therapist that the patient was exhibiting distress and was placed back on ventilator . Review of Resident #4's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 9/17/2021 at 9:09 AM the Administrator confirmed the facility had no ventilator weaning policy. She stated, No, we don't have a weaning policy. The Administrator confirmed the Pulmonologist should have been notified timely when Resident #4 returned to the facility and was not on a ventilator. During a telephone interview on 9/17/2021 at 11:20 AM, the Pulmonologist was asked if the facility should have notified him when Resident #4 returned to the facility and was not placed back on the ventilator. He stated, .I would expect them to notify me and to monitor the resident with a continuous pulse oximetry .They should have found out why the resident was not on the vent .I should have been informed of the resident's condition .was she maintaining her oxygen level, ventilating properly, and being monitored with a continuous pulse oximetry and a continuous end tidal CO2 measurement as well, and her physical appearance signs and symptoms of distress . The Pulmonologist was asked if the facility had a weaning policy. He stated, .They should have a weaning policy. I have never seen it and am not aware of what it is .They tell me they have a procedure they go through, but I am not aware of what it is .I think they should have a written weaning policy . Review of the facility's RT competency files on revealed, no documentation of a competency for Mechanical Ventilator Set Up and Monitoring for RT #1, #2, #3, #4, #5 and #6. During an interview on 9/15/2021 at 3:30 PM, the Administrator was asked why all RTs do not have a mechanical vent set up and monitoring competency. The Administrator stated, .I guess because difference in directors . The Administrator was asked if all RTs should have documentation of competencies. The Administrator stated, .Yes, I do . Review of the facility's schedule for the licensed nursing staff for the 300 hall (vent unit) dated September 2021 revealed, three licensed agency nursing staff worked 9/13/2021 and 9/14/2021. Review of the licensed nursing staff competencies revealed there was no documentation of competencies for agency nursing staff to work the ventilator unit. During an interview on 9/15/2021 at 3:30 PM, the Administrator was asked if the facility had a record of skill competencies for the agency licensed nurses. She stated, .We don't do competencies on agency nurses . The Administrator was asked how she would know the agency nurses are competent to care for the patient population that had tracheostomies and required mechanical ventilation. She stated, .Oh, I see. We don't . During an interview on 9/16/2021 at 1:20 PM, the Administrator was asked if the facility had a written training program for the Respiratory Care Unit as required in the Enhanced Respiratory Care Operations Manual dated 12/1/2019. The Administrator stated, .No . During an interview on 9/16/2021 at 2:30 PM, the Interim Director of Respiratory Therapy stated, .I have never seen a training program here for the unit . Refer to F-695, F-726 and F-867. The Surveyor verified the Removal Plan by: 1. On 9/15/2021 the Regional Director of Operations educated the Administrator on the administrative role, job description, tools and resources available to effectively administer nursing facility operations regarding respiratory patients and services pertaining to respiratory care needs and mechanical ventilation. The surveyor confirmed this through interview and review of the sign in sheet. 2. The Administrator was educated by the Regional Director of Clinical Services on the Respiratory Policy on 9/15/2021. The surveyor confirmed this through interview and review of the sign in sheet. 3. The Administrator was educated on the required functions and processes of the external alarm system by the Regional Director of Operations (RDO) and Regional Director of Clinical Services (RDCS) on 9/16/2021, to include the required monitoring. The surveyor confirmed this through interview and sign in sheet. 4. The Administrator was educated by the RDO and RDCS on 9/16/2021 on the resources available to provide oversight and ensure necessary services are provided regarding audible, redundant external alarm systems outside resident rooms and on monitoring processes for continuous pulse oximetry or ETCO systems. The surveyor confirmed this through interview and sign in sheet. 5. The Administrator was educated on the tools available to oversee and operate the vent/[CONDITION(S)] unit, to include ERC manuals, available personnel resources (with consultant group) and other clinical experts on 9/15/2021. The surveyor confirmed this by interview and sign in sheet. 6. On 9/15/2021 the Regional Director of Operations provided education for the Administrator on the process of ensuring supplies were available to staff and residents on the respiratory unit. The surveyor confirmed this by interview, review of the audit tool, and the sign in sheet. 7. The Administrator was educated on Quality Assessment and Performance Improvement (QAPI) as it relates to self-identifying, monitoring and correcting in-house process issues, to include bringing identified issues to the committee for review, revision, and monitoring by the Regional Director of Operations on 9/16/2021. The surveyor confirmed this by interview and sign in sheet. 8. Beginning 9/17/2021 the DON, Administrator and/or designees will round daily to ensure necessary services are being provided to residents. The surveyor confirmed this by interview. 9. The Administrator and DON will provide oversight of the continued monitoring of all areas of the respiratory unit with oversight by the Regional Director of Operations, Regional Director of Clinical Services, and the Area Director of Clinical Services. The surveyor confirmed this by interview. 10. The Regional Director of Operations will provide weekly oversight for the Administrator to ensure that all aspects of the operation of the respiratory/vent unit including supply management, alarm system management, monitoring of processes for continuous pulse oximetry and end tidal [MEDICATION(S)] and QAPI is provided. The surveyor confirmed this by interview. Noncompliance of F-835 continues at a scope and severity of E for monitoring the effectiveness of the corrective actions. The facility is required to submit a Plan of Correction.

Based on policy review, medical record review, observation and interview, the facility failed to provide necessary mechanical ventilator (a machine used to assist or replace spontaneous breathing) equipment and supplies for residents with tracheostomies (an opening in the front of the neck with a tube inserted into the windpipe to help you breathe) that required mechanical ventilation and failed to provide the necessary mechanical ventilator audible, external alarm system and response processes that Resident #1 required; failed to provide monitoring processes of continuous pulse oximetry (a process to measure the oxygen level in the blood) and end tidal [MEDICATION(S)] (the level of [MEDICATION(S)] that is released at the end of an exhaled breath) when a resident had breathing problems; or end tidal [MEDICATION(S)] (CO2) monitoring for Resident #2 and #3 who required invasive mechanical ventilation. Staff provided care without obtaining orders from the Physician for Resident #4, who had required a mechanical ventilator, returned from the hospital without a ventilator; and the facility failed to ensure 6 of 9 respiratory staff (Respiratory Therapist (RT) #1, #2, #3, #4, #5, and #6) and 3 of 3 agency nurses (Licensed Practical Nurses (LPN) #1, #2, and #3) had the competencies to monitor residents on mechanical ventilation and to set up mechanical ventilation. The facility's failure resulted in Immediate Jeopardy for 4 of 8 sampled residents (Resident #1, #2, #3, and #4) on mechanical ventilators and placed all eight residents requiring invasive mechanical ventilation at risk due to the potential of serious harm, injury, or death to a resident. Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury harm, impairment, or death to a resident. The Administrator, Director of Nursing (DON) and Regional Director of Clinical Services were notified of the Immediate Jeopardy (IJ) for F-695 on 9/15/2021 at 3:41 PM, in the DON office. The facility was cited Immediate Jeopardy at F-695. The facility was cited F-695 at a scope and severity of K, which is Substandard Quality of Care. The Immediate Jeopardy was effective from 9/9/2021 through 9/17/2021. An acceptable Removal Plan for F-695, which removed the immediacy of the jeopardy, was received on 9/17/2021 at 11:00 AM, and was validated onsite by the surveyor on 9/18/2021 through observations, record review, review of audits, and staff interviews. The findings include: Review of the facility's policy titled, Provision of Invasive Mechanical Ventilation Services, dated 12/28/2018, revealed .A Respiratory Therapist shall be present at the facility twenty-four [24] hours per day, seven [7] days a week to provide: Ventilator Care, Administration of Medical Gases, Administration of aerosol medications, Diagnostic Testing and monitoring of life support systems, Assist in initial, routine and as needed assessment of residents requiring invasive mechanical ventilation .Pre-admission assessment is reviewed by the Nurse Liaison, Director of Nursing and/or Respiratory Manager with experience in the care of the ventilator-dependent patient. This review will determine the appropriateness of admitting resident to the facility .An appropriate, individualized plan of care is prepared for each resident requiring ventilator services. The plan of care shall be developed with input and participation from a pulmonologist or a physician with experience in ventilator-dependent care. The facility will ensure that the following monitoring processes are in place for the resident requiring invasive mechanical ventilation: continuous pulse oximetry or access of arterial blood gases [ABG] or end tidal [MEDICATION(S)] [ETCO monitoring]. Each ventilator is equipped with an alarm. An audible, redundant external alarm system is located outside each ventilator-dependent resident's room for alerting caregivers of resident disconnection, ventilator disconnection or ventilator failure. Ventilator alarms are to be answered within 30 seconds. Pulse-Oximetry alarms are to be answered within 60 seconds . Review of the facility's policy titled, Mechanical Ventilation: Setup and Monitoring, dated 10/2010, revealed .The purpose of this procedure is to provide assisted or controlled ventilation to a resident with acute or chronic respiratory insufficiency. Verify that there is a physician's order for this procedure. Review the physician's orders, including instructions for: tidal volume [the air moved between one normal inhaled breath and one normal exhaled breath], ventilatory rate, peak flow rate [a test using a small device to detect the expiration], pressure limit [control variable for the breathing cycle], sensitivity, oxygen concentration, mode (assist control or rate control) and special parameters such as positive and expiratory pressure (PEEP) settings .assemble the equipment and supplies as needed. Obtain and use the written instructions specific for the ventilator to be used .The following equipment and supplies will be necessary when performing this procedure: mechanical ventilator, oxygen source, [CONDITION(S)] tube connector, spirometer or respirometer [measures the volume of air breathed in or out of the lungs], humidification system, remote ventilator alarms, oxygen analyzer and personal protective equipment .while the resident is on mechanical ventilation, assess for the following: signs and symptoms of [CONDITION(S)] [a below normal level of oxygen in the blood], including: restlessness, increased pulse rate, increased rate and depth of respirations, diminished lung sounds, cyanosis, fatigue, pallor [pale skin]and/or confusion, airway obstruction [suction as indicated], arterial blood gases or oxygen saturation, vital signs and cardiac rhythm. Steps in the Procedure: 3. Check for proper functioning of lights, alarms, filters, fittings, and the humidifier. 4. Start the ventilator following instructions for the ventilator being used .8. Check the ventilator pressure. 9. Connect the ventilator to the resident. 10. Adjust the remote and ventilator alarms so that they can be heard by staff responsible for monitoring the resident . Review of the facility's policy titled, Pulse Oximetry, dated 10/2010, revealed .The purpose of this procedure is to monitor arterial blood oxygen saturation .without the use of invasive devices .General Guidelines: The pulse oximeter is a probe .connected to an oximeter .Normally SpO2 [the measurement determined by pulse oximetry] is between 90 and 100 percent; SpO2 below 70 percent is life threatening . Review of the facility's undated procedure titled, New Admit Checklist, revealed .New Admit Checklist .date all equipment once patient admits, concentrator .and oxygen tubing, Ambu-bag [a hand held device used to provide positive pressure ventilation to patients that are not breathing] with filter, full tank of oxygen, back-up trachs [tracheostomies] [same size and size smaller of the tube to keep the airway open], 10 ml [milliliters] syringe, saline bullets [packets of saline to clean the [CONDITION(S)] tube], gauzes, suction with suction set-up & [MEDICATION(S)] [An oral suctioning tool to suction secretions to prevent aspiration], neb [nebulizer] cup & nebulizer [a drug delivery device used to administer medication in the form of a mist into the lungs] machine, pulse-ox machine [measures the amount of oxygen in the blood on ventilator patients] ETCO [end tidal [MEDICATION(S)] that is in each exhaled breath] connector [yellow connector for ventilator patients and clear tubing for patients on AIRVO, an air flow delivery system], HME [heat and moisture exchange for ventilator patients] . Review of the facility's Respiratory Care Practitioner job description dated 10/1/2018, revealed .To provide accurate patient evaluation, testing, diagnostics and monitoring under medical direction to assure quality patient care in compliance with N.B.R.C. [National Board for Respiratory Care], AARC [American Association for Respiratory Care], State of Tennessee Respiratory Care Act, and Department policy and procedures .Implement all therapeutic aspects of respiratory care under the direction of the department medical director and in compliance with the department policy and procedures to provide safe quality care for the adult and geriatric patient population we service. Perform respiratory care assessment of patients in an accurate, thorough, and timely manner to assure the delivery of effective therapy. Monitor patient's rehabilitation goals for appropriateness and consistency of therapy. Provide ongoing care to patients requiring oxygen therapy, artificial airway management, mechanical ventilation and weaning, among others, according to N.B.R.C., AARC, and department policy and procedure .Consistently and accurately document in the patient medical records patient assessment with clinical parameters such as breath sounds, [CONDITION(S)] tube data, sputum [secretions] production, ventilator settings based on physician orders, weaning and tolerance, in compliance with department daily documentation records. Provide the in-coming shift with room-to-room walking detailed, verbal report on the patient condition, any change in orders and tolerance to care provided. Consistently and accurately provide information regarding Spo2 [oxygen saturation] .sputum production, breath sounds, mode of therapy, medication administration and tolerance, among others. For patients on ventilatory support, latest ventilator settings, tolerance to weaning and Fio2 [fraction of inspired oxygen, the concentration of oxygen in the gas mixture] titration. Perform diagnostic procedures in accordance with physician orders .and department policy and procedures .Maintain equipment .Must be competent in the clinical performance, analysis and understanding of diagnostic procedures. Ability to recognize and understand disease processes as well as the psychological and physiological aspects and needs of the patients and families we service . Review of the facility's policy titled, Notification of Changes, dated 3/22/2021, revealed .The purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician; and notifies, consistent with his or her authority, resident's representative when there is a change requiring notification .Circumstances requiring notification include: Significant change in the resident's physical, mental, psychosocial condition such as deterioration in health, mental or psychosocial status. Circumstances that require a need to alter treatment. This may include new treatment or discontinuation of current treatment due to adverse consequences, acute condition, exacerbation [worsening] of a chronic condition . Review of the Enhanced Respiratory Care (ERC) Operations Manual dated 12/1/2019, revealed .Standards of Care for Ventilator Services .A written training program, including an annual demonstration of competencies, for nursing staff (including nurses' aides, registered nurses, and licensed practical nurses) and respiratory therapy staff providing direct care services for residents receiving Enhanced Respiratory Care. Required Supporting Documentation: 1. Written training program/plan. 2. Documentation of annual demonstration of staff competencies for all staff caring for ERC residents . Review of the medical record, revealed Resident #1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's Emergency Medical Services (EMS) trip ticket dated 9/9/2021 at 7:00 PM, revealed .Patient is breathing on her own with ventilator and pressure support. Switched from hospital ventilator to EMS with no issues along with ETCO2 for waveform capnography [continuous, noninvasive measurement and graphical display of partial concentration of [MEDICATION(S)]] monitoring with success .Vent circuit [a device for portable ventilators with an exhalation valve near the patient, the expiratory valve is closed during the inspiratory phase to prevent loss of delivered tidal volume, and the ventilator will be inoperable without this device] and ETCO2 confirmation made and at every PT [patient] movement and loading .Arrival at [Named Skilled Nursing Facility]. Pt safely loaded off the ambulance and brought into facility. EMS crew was met by the RT [Respiratory Therapist] team and charge nurse. The RTs stated to EMS crew that they were not expecting EMS crew to arrive with a PT on ventilator when they arrived into the PT room where EMS crew had brought the PT. The RT stated to EMS crew that they did not have any vent circuits on their ventilator hall to appropriately manage care of the PT and that they may not be able to accept the PT. EMS crew was informed by [Named Hospital] that report was called to [Named Skilled Nursing Facility] and they will be expecting the PT. EMS crew offered the RT to see if the EMS crew ventilator circuit could occupy the facility ventilator. The RT advised the EMS crew that his [Resident #1] ventilator settings were in place and attached to O2 [oxygen] and is ready for transfer. The RT took the end connections of the ventilator and attempted to attach the EMS ventilator circuit to the facility ventilator without success. The RT took scissors and had cut the end of the pressure and O2 hoses of the EMS ventilator circuit in attempt allow the circuit to fit into the facility ventilator and no success of transfer. This action rendered the EMS ventilator circuit inoperable forcing the EMS crew to utilize a BVM [bag valve mask] on 15 LPM [liters per minute of oxygen] to give ventilation to the PT and the RT and the charge RN [Registered Nurse] nurse responded with I am sorry we will be unable to accept this PT since we do not have any ventilator circuits. EMS crew continued to breathe for the PT using a BVM on O2 and contacted MOD [dispatch] for direction and was instructed to transport the PT back to [Named Hospital]. EMS crew safely loaded the PT back into the ambulance and prepared for transport. EMS crew continued to use a BVM on the PT during transport and no issues or incidents during transport. Arrival at [Named Hospital] PT safely loaded off the ambulance and brought into ER [emergency room ] dept. PT safely loaded from stretcher to PT bed by EMS crew .Report given to RT and RN at [Named Hospital] . Review of Resident #1's Skilled Nursing Facility (SNF) Nurse's Note dated 9/10/2021 at 6:21 AM, revealed, resident returned to the facility, VS [vital signs] 122/74 [blood pressure], 76 [heart rate], 20 [respiratory rate], 97.5 [temperature], 99% [SaO2] Vent. [Ventilator] Res [Resident] arrived to facility at 12:20 AM to RM [room] .assist to bed by EMT [Emergency Medical Technician] x 2. HOB [head of bed] elevated, call light @ [at] reach, NAD [no acute distress] noted. Review of Resident #1's RT Note dated 9/10/2021 at 7:36 AM, revealed, .@ [at] 1230 am [12:30 AM] 9/10/21 [2021], pt arrives on vent .Pt is alert and anxious. rt [RT] and staff had to calm pt down multiple times. pt has 6 .size [CONDITION(S)], [CONDITION(S)] area is red, and it appears that the area is also lumpy. pt was placed on 400/16/5 [vent settings] on 40% [percent] oxygen. pt is tolerating at this time 97% [oxygen saturation], 138 hr [heart rate], 49 co2 [CO2]. rt will continue to monitor. During an interview on 9/13/2021 at 12:00 PM, RT #1 stated, .Yes I was working 9/9/2021, 7:00 AM to 7:00 PM shift and I was still here when Ms. [Named Resident #1] arrived. We had no idea she was coming. I was trying to help the oncoming therapist for night shift before I left for the evening .When [Named Resident #1] came in I went into the closet to get the vent circuit and there wasn't one .Because we didn't have one the EMS was in agreement, we could try to make theirs [EMS] fit our ventilator. I cut the tubing to fit the exhalation port and it didn't work .we couldn't make it fit .EMS went back to their truck to get another vent circuit for their machine but did not have one .I know when start trying to makeshift things to work it is dangerous .When we know a patient is coming, we have the room set up with the ventilator, vent circuit, suction, neb [nebulizer], all the supplies. We did not know she was coming .I don't order supplies usually the manager is responsible to order . During an interview on 9/13/2021 at 12:05 PM, the Interim Director of Respiratory Therapy stated, .I knew when I left [9/9/2021], we had one vent circuit left .Ms. [Named Resident #5] admitted and got that one .I did not know about another resident coming .We had no more vent circuits in the building .I had no idea we had no more .I just got in this position 9/7/2021 and have been working at the bedside every day and not as manager . During an interview on 9/13/2021 at 12:10 PM, the Administrator stated, .I had asked [Interim Director of Respiratory Therapy] what supplies she needed on Wednesday [9/8/2021] drain sponges, suction catheters but we did not say vent circuits. We had a box, but it was the wrong kind [circuits]. That is my fault thought they were the correct one. I'm ignorant to what a [CONDITION(S)] circuit is, and I didn't probably stress to her [Interim Director of Respiratory Therapy] .No, I had no idea how long we had just one vent circuit in the building [prior to 9/9/2021] .I didn't communicate properly with her the number of admissions. I didn't know how many vents [ventilators] were to come in .No, RT is not included in the text thread [notification to staff] of admissions .In regard to supplies I don't have par levels [the minimum amount of a product the facility should have on hand]. I don't know how much of what is needed. I didn't even know who to order respiratory supplies from. I had to get on the Internet and find someone . During a telephone interview on 9/13/2021 at 4:55 PM, RN #1 stated, .I just got to work at 7:00 PM on 9/9/2021 and I was doing admissions and assessments. We were not told ahead of time who was coming. We don't know till they get here .I was just told two vent [ventilator] patients were coming and one had already got here [Resident #5] .I had the paperwork for Ms. [Named Resident #1] but didn't know if had vent hook up that is respiratory .When she [Resident #1] got here RT had no vent circuit so we could not transfer her from EMS vent to our vent. We could not admit her and had to send her back to the hospital. I assisted EMS back down the elevator to the ambulance for them to return her to the hospital . During an interview on 9/13/2021 at 5:00 PM, the Interim Director of Respiratory Therapy stated, .The vent circuits are changed out every 30 days .Yes, we do have to change them prn [as needed] if the line leaks, pops, stretches or the patient pulls on it and pops it off we have to change it .Yes, we should have had more vent circuits in stock in case of prn needing changed .those other patients on the vents could have needed one .yes, the ventilators are inoperable without the vent circuits .I had no idea how long we had just one vent circuit in the building . Observation in the resident's room on 9/16/2021 at 10:26 AM, revealed Resident #1's ventilator alarm was sounding in the room only. There was no external audible or visual alarm alert outside the resident's room that the ventilator was alarming. During an interview on 9/16/2021 at 10:26 AM, the Interim Director of Respiratory Therapy confirmed no audible or visual alarm alert was outside Resident #1's room alerting staff of the ventilator alarm. She also confirmed the beeper system the RT carries was not alarming. She stated, .There is no external audible alarm or visual alarm alert outside Resident #1's room .It also did not alarm on the beeper . During an interview on 9/16/2021 at 11:00 AM, the Administrator confirmed no audible or visual alarm alert was outside Resident #1's room to signal staff when the ventilator was alarming. She stated, .It should be hooked up to the call light system and beeper system but in that room the door [side bed] does not have that capability. We have to get that fixed. We moved her [Resident #1] to another room . Review of the medical record, revealed Resident #2 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation in the resident's room on 9/15/2021 at 9:10 AM and 9/16/2021 at 10:15 AM, revealed Resident #2 had a mechanical ventilator in use. There was no continuous pulse oximetry or ETCO2 monitor in use. Review of Resident #2's Physician's Orders dated August and September 2021, revealed the vent circuit was to be changed monthly and prn. Review of the Respiratory Administration Record dated August 2021, revealed no documentation that the vent circuit was changed. During an interview on 9/14/2021 at 12:00 PM, the Interim Director of Respiratory Therapy stated, .I don't know if her [Resident #2] vent circuit was changed. It should have been changed 8/26/2021. I will have to check on that . The Interim Director of Respiratory Therapy confirmed Resident #2's vent circuit had not been changed in August. During an interview on 9/15/2021 at 9:10 AM, the Interim Director of Respiratory Therapy confirmed Resident #2 did not have a continuous pulse oximetry monitor or an ETCO continuous monitor. Review of the medical record, revealed Resident #3 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation in the resident's room on 9/15/2021 at 9:00 AM and 9/16/2021 at 10:20 AM, revealed Resident #3 had a mechanical ventilator in use. There was no continuous pulse oximetry or ETCO monitor in use. During an interview on 9/15/2021 at 9:00 AM, the Interim Director of Respiratory Therapy confirmed Resident #3 did not have a continuous pulse oximetry or an ETCO continuous monitor. Review of the medical record, revealed Resident #4 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #4's ER Physician's Note dated 9/15/2021 at 2:30 PM, revealed .Patient sent from a nursing home for PEG [Percutaneous Endoscopic Gastrostomy, a tube in the abdomen to deliver nutrition directly to the stomach] tube replacement. Accidentally the patient has pulled her PEG tube out. Patient is on a [CONDITION(S)] collar with vent dependent .Physical exam neck: [CONDITION(S)] in place attached to vent . Record review revealed no documentation the ventilator was removed by the physician or new orders for discontinuation of the ventilator upon discharge from the ER and return to the facility. Review of Resident #4's ER visit RT Note dated 9/15/2021 at 2:40 PM, revealed .Pt presents to ER needing peg tube replaced. EMT [Emergency Medical Technician] stated she was on ventilator at [Named Skilled Nursing Facility] but would take herself off multiple times. EMT stated staff says she does that often. EMT transported pt to bed off of ventilator. Pt alert and oriented and stating she does not want to be on ventilator that she breathes easier without. Placed pt on 8 liters [of oxygen] [CONDITION(S)] mask. SPO2 100%. Pt respirations unlabored. Pt begging not to go back to [Named Skilled Nursing Facility] and wants her daughter and son called. Informed RN of patient's request . Resident #4 was returned to the facility without a ventilator and was on a Venturi mask (a medical device to deliver oxygen concentration to patients on controlled oxygen therapy) on 4 liters a minute of oxygen. Review of Resident #4's Skilled Nursing Facility RT Notes dated 9/15/2021, revealed no documentation Resident #4's facility physician or pulmonologist was notified to obtain new Physician Orders when Resident #4 returned to the facility and was not on the ventilator. Review of Resident #4's facility RT Note dated 9/15/2021 at 6:39 PM, revealed .Sent out [to hospital] .no distress on transport. Resident returned from hospital [ER for PEG change] on venturi mask [a medical device to deliver a known oxygen concentration to patients on controlled oxygen therapy] 4 liters at 38%. Resident shows no sign of distress. Resting comfortably in bed .continue to monitor . The resident was not on the ventilaor when returned from the hospital. Medical record review, revealed no documentation of continuous monitoring of pulse oximetry for Resident #4. Review of Resident #4's RT Note dated 9/15/2021 at 8:30 PM, revealed .O2 sat 99% [CONDITION(S)] care, oral care, resident suctioned .thick moderate yellow secretions, coarse breath sounds, ETCO 27 [normal is 35-45 range] . Review of Resident #4's RT Note dated 9/16/2021 at 12:25 AM, revealed .ETCO 40, O2 sat 100% .venturi mask Oxygen 4 liters, thick small yellow secretions, coarse breath sounds . Review of Resident #4's Pulmonologist Orders dated 9/16/2021 at 4:45 PM, revealed Initial [CONDITION(S)] collar settings (40% ATC [automatic tube compensation]) wean as needed. The Interim Director of Respiratory Therapy confirmed the Pulmonologist should have been notified on 9/15/2021 of the resident's change in condition/treatment when the resident returned from the ER without the ventilator and for the CO2 of 27. Review of Resident #4's RT Note dated 9/16/2021 at 11:30 PM, revealed Placed patient back on vent due to being in distress, pt said she was having trouble catching her breath after using bedside urinal and she was worried that she wasn't getting any better. I assured her that she was, will continue to monitor . Review of Resident #4's RT Note dated 9/17/2021 at 6:45 AM revealed, When the RT came in it was reported from night shift therapist that the patient was exhibiting distress and was placed back on ventilator. I noticed no distress from the pt upon further evaluation pt had a spo2 [SpO2 of 98 [%] hr 78 co2 [CO2] 35. Review of Resident #4's Physician's Orders dated 9/17/2021, revealed there were no orders to place Resident #4 back on the ventilator or documentation the doctor was notified of the change in treatment or condition. During an interview on 9/16/2021 at 1:20 PM, the Administrator was asked if the facility had a written training program for the Respiratory Care Unit as required in the Enhanced Respiratory Care Operations Manual dated 12/1/2019. The Administrator stated, .No . During an interview on 9/16/2021 at 2:30 PM, the Interim Director of Respiratory Therapy stated, .I have never seen a training program here for the unit . During an interview on 9/17/2021 at 9:09 AM, the Administrator confirmed the facility had no ventilator weaning policy. She stated, No, we don't have a weaning policy. The Administrator confirmed the Pulmonologist should have been notified timely of Resident #4's change in treatment per policy. During a telephone interview on 9/17/2021 at 11:20 AM, the Pulmonologist was asked if the facility should have notified him of Resident #4's change in treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . He stated, .I would expect them to notify me and to monitor the resident with a continuous pulse oximetry .They should have found out why the resident was not on the vent .I should have been informed of the resident's condition .was she maintaining her oxygen level, ventilating properly, and being monitored with a continuous pulse oximetry and a continuous end tidal CO2 measurement as well, and her physical appearance signs and symptoms of distress . The Pulmonologist was asked if the facility had a weaning policy. He stated, .They should have a weaning policy. I have never seen it and am not aware of what it is .They tell me they have a procedure they go through, but I am not aware of what it is .I think they should have a written weaning policy . Review of the facility's schedule for the licensed nursing staff on the 300 Hall which was the ventilator unit dated September 2021, revealed that three licensed agency nursing staff (LPN #1, #2, and #3) worked 9/13/2021 and 9/14/2021. Review of the agency licensed staff competencies revealed there was no documentation of competencies recorded for the agency nursing staff. During an interview on 9/15/2021 at 3:30 PM, the Administrator was asked if the facility had skill competencies documented for the licensed agency nurses working in the facility. She stated, .We don't do competencies on agency nurses . The Administrator was asked how the facility would know the agency nurses were competent to provide care for patients with tracheostomies and mechanical ventilation. She stated, .Oh, I see. We don't . Review of the facility's RT competency files revealed, no documentation of a competency for Mechanical Ventilator Set up and monitoring for RT #1, #2, #3, #4, #5 and #6. During an interview on 9/15/2021 at 3:30 PM, the Administrator was asked why all RTs did not have a mechanical vent set up and monitoring competency documented. The Administrator stated, .I guess because difference in directors . The Administrator was asked if she thought this should be a competency that all RTs should have. The Administrator stated, .Yes, I do . The Surveyor verified the Removal Plan by: 1. The facility Administrator obtained two circuit vents on 9/9/2021 for Resident #1 (a new admission) and the resident was admitted the following day on 9/10/2021. The surveyor confirmed this through staff interviews. 2. The facility Administrator ordered additional circuit vents on 9/10/2021 and two boxes were delivered to the facility. The boxes contained 15 circuit vents per box to be available for the six residents on mechanical ventilation. The surveyor confirmed this through staff interviews and observation of supplies. 3. All respiratory orders for the circuit vent to be changed every 30 days and PRN were corrected and verified by the DON, Interim Respiratory Therapy Manager & Regional Director of Clinical Services. The surveyor confirmed this through record review, observation, and staff interviews. 4. The order for the circuit vents to be changed were placed on the Respiratory Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The surveyor confirmed this through record review and interviews. 5. The Respiratory Therapist will date the circuit vent when changed and sign the respiratory MAR. The surveyor confirmed this through observation, record review, and interview. 6. The resident who did not have the audible alarm was moved to another room and connected to an audible, redundant external alarm system on 9/16/2021 at 11:00 AM. The surveyor confirmed this through observation, record review, and interview. 7. Resident #2 was immediately connected to continuous pulse oximetry and Resident #3 was connected to continuous end tidal [MEDICATION(S)] (ETCO) by the Interim Respiratory Manager at 11:00 AM on 9/16/2021. The surveyor confirmed this through observation, record review, and interview. 8. A 100% audit was done on 9/14/2021 by the Interim Director of Respiratory Therapy to check all ventilators and circuit vents and any that needed to be changed was completed. Each resident on a ventilator had one additional back up circuit available. The surveyor confirmed this by observation, record review, and interview. 9. A 100% audit was completed on 9/16/2021 by the Interim Director of Respiratory Therapy to check all external alarm systems to ensure continuous pulse oximetry or end tidal [MEDICATION(S)]. No other residents were found to be affected. The surveyor confirmed this through observation, record

Based on policy review, medical record review, and interview, the facility failed to follow up on the Registered Dietician's (RD) recommendations to prevent significant weight loss for 1 of 1 (Resident #36) sampled residents receiving an enteral feeding. The failure to prevent a significant weight loss for Resident #36 resulted in actual harm. The findings included: Review of the facility's weight change procedures policy documented, .Residents with significant, unplanned weight change will be monitored and appropriate intervention initiated . Medical record review revealed Resident #36 was admitted to the facility on [DATE] and re-admitted on [DATE] with [DIAGNOSES REDACTED]. Review of a significant change Minimum Data Set ((MDS) dated [DATE] revealed a staff assessment for cognitive skills for daily decision making was severely impaired - never/rarely made decisions. Weight 161 (pounds), no weight loss or weight gain. Nutrition approach: feeding tube. A care plan dated 9/15/15 documented, .Problem . I require a PEG (Percutaneous Endoscopy Gastrostomy) tube for adequate nutritional intake . Goal . I will maintain my current weight . Approaches . Dietician to evaluate my current nutritional status . The Weight Change History documented the following weights for Resident #36: a. 6/9/15 - 164 pounds (lbs). b. 7/6/15 - 165 lbs. c. 8/10/15 - 161 lbs. d. 8/11/15 - 161 lbs. e. No weights for 9/15. f. 10/27/15 - 148 lbs. g. 11/6/15 - 148 lbs. Review of a Nutrition Services Progress Note dated 7/23/15 documented, .Continues to receive 100% (percent) needs in a peg of [MEDICATION NAME] 1.2 @ (at) 85cc/hr (cubic centimeters per hour) x (for) 22 hr . Resident #36 was receiving [MEDICATION NAME] 1.2 at a rate of 85 cc/hr prior to his hospital admission on 8/1/15. Resident #36 was admitted to the hospital from 8/1/15 to 8/5/15 for replacement of a PEG tube. A physician order [REDACTED].Tube Feeding (TF) . [MEDICATION NAME] 1.2 at 30 cc/hr . An enteral administration record dated August, 2015 documented, .Tube Feeding (TF) Continuous . [MEDICATION NAME] 1.2 at 30cc/hr x 22 hours . 8A (AM) on . 6A off . August 5, 6, 7, 8, 9, 10, 11, 12, 17, 18, 19, 21, 22, 23, 24, 25, 26, 27, 28, 29 and 31, 2015 were blank for the 8A and the 6A boxes, indicating Resident #36 did not receive any enteral nutrition on those dates. Review of a Medical Nutritional Assessment - Enteral assessment dated [DATE] documented, .DIET / NUTRITION PLAN . [MEDICATION NAME] 1.2 @ 85cc/hr . signed by the RD. The RD incorrectly documented what Resident #36 was receiving 6 days after re-admission. (Resident #36 was actually receiving [MEDICATION NAME] 1.2 @ 30 cc/hr). Review of a Nutrition Services Progress Note dated 9/22/15 documented, .TF review: CBW (Current Body Weight) 161# (pounds) on 8/11/15 - 0 wt (weight) this month obtained - unable to assess TF order states [MEDICATION NAME] 1.2 @ 30cc/hour. Error made to nutrition assessment, to receive previous TF orders of [MEDICATION NAME] 1.2 @ 85cc/hr. Will recommend (arrow up) (increase) TF to [MEDICATION NAME] 1.2 @ 70 cc/hr x 22 . No additional RD notes were provided regarding the missing monthly weight, nor any RD notes documenting any follow-up or monitoring between 8/11/15 and 9/22/15 (43 days) A RD monitoring note dated 9/22/15 documented, .TF Review . (arrow up) (increase) TF to [MEDICATION NAME] 1.2 @ 70cc/hr x 22 hr . No order was written to increase the TF rate to 70cc/hr on 9/22/15. There was no documentation of RD follow-up or monitoring until the order was written on 10/13/15. Resident #36 continued to receive the TF at 30cc/hr until 10/13/15. (70 days after re-admission). A RD monitoring note dated 10/13/15 documented, .[MEDICATION NAME] 1.2 @70cc/hr x 22 hr . A physician's telephone order dated 10/15/15 documented, .[MEDICATION NAME] 1.2@70cc/hr x 22 hr . Review of a Nutrition Services Progress Note dated 10/26/15 documented, .CBW 147.6#, (arrow down) (decreased) 8.3% x ~ (approximately) 60 d. (days) 0 wt obtained last month. Receives [MEDICATION NAME] 1.2 @ 70cc/hr x 22 hr . will rec (recommend) to (arrow up) (increase) to 80cc/hr x 22 . No order was written to increase the TF rate to 80cc/hr. There was no documentation of RD follow-up or monitoring until 11/17/15. Resident #36 continued to receive the TF at 70cc/hr until 11/17/15. Review of a Nutrition Services Progress Note dated 11/17/15 documented, .CBW 147.8, (arrow down) (decreased) 10.0% (percent) x 180 d .continues NPO (nothing by mouth), tolerating current TF well of [MEDICATION NAME] 1.2 @ 70cc/hr x 22 hr .will rec to (arrow up) (increase) TF to [MEDICATION NAME] 1.2 to 85cc/hr x 22 hr . A telephone interview with the RD on 12/3/15 at 4:14 PM, the RD was asked about Resident #36's weight loss. The RD stated, I actually have several documentation entries on it, his usual weight was 160. There was a time there was missing weights, he came back from the hospital on 30 cc's. I thought he was getting 85cc's, what he was getting before he went out. When I followed up and I realized he was not getting that, I asked them to get the weights and when they finally got one, he had lost to 140's. The RD was asked if she brought her concerns to nursing. The RD stated, From my memory, I brought the issue to the Director of Nursing (DON). There have been several DON's and I would bring my recommendations to the DON and she would distribute the recommendation. The RD was then asked which DON she brought her concerns to about Resident #36's missing weight. The RD stated, This one, I believe I told (named current DON). Actually, I brought it to her that he hadn't been weighed. I see them monthly anyway, so I documented on him every month. Until this month, he has had consistent weights. The RD was asked if there was a problem getting her recommendations processed. The RD stated, Yes, I have to be honest sometimes they don't get done. All of my recommendations are copied and given to dietary, the DON, and I keep a copy. A lot of times my recommendations are not done and I rewrite them again. The RD was then asked how she would follow up or monitor whether her recommendations were completed. The RD stated, As far as I know my recommendations went to the corporate interims (DON's). I was doing my best and giving them (the facility) the benefit of the doubt. I don't always see if they have been done in a timely manner. Dietary is supposed to keep them (copies of the recommendations) in the office. The DON distributes my recommendations to the nurse supervisors. At some time I realized that someone told me that what was recommended wasn't always followed through. Interview with the DON on 12/3/15 at 4:45 PM, in the theatre room, the DON was asked when she became aware of Resident #36's weight loss. The DON stated, Let's see, October (2015), no November (2015). The DON was asked how recommendations from the RD are completed or processed. The DON stated, I give them out to the unit manager to carry them out, then I get them back and file them in the binder. The DON was asked for a copy of the 9/22/15 RD recommendation. The DON stated, I don't have a recommendation for September (2015). The DON was shown the enteral administration record dated August, 2015 for the TF administration, and asked if the blanks were acceptable. The DON stated, Absolutely not. Interview with the Regional Vice President (RVP) on 12/4/15 at 5:25 PM, in the theatre room, the RVP was asked about Resident #36's significant weight loss. The RVP stated, We find that the dietary notes are inconsistent. This does not meet our expectations. The facility's failure to follow up on the RD's recommendations to increase the tube feeding resulted in a significant weight loss and caused actual harm to Resident #36.

A. Based on review of the "Centers for Disease Control and Prevention" (CDC) guidelines, policy review, medical record review, observation and interview, it was determined 2 of 5 (Nurse #1 and 4) nurses failed to maintain infection control practices in 2 of 3 locations (200 and 300 Hall) in the facility to prevent the possible cross-contamination between residents by taking the accu-check machine from resident to resident without cleaning the accu-check machine before and after each use. The facility used the same accu-check machine for 3 (Resident #13, Random Resident (RR) #1 and 2) residents on the 200 Hall, and 1 (Resident #11) resident on the 300 hall. Observations on the upper 300 Hall on 7/25/11 at 4:40 PM, revealed Nurse #4 performed an accu-check on Resident #11, then went to another room on the 300 hall to perform another accu-check. Nurse #4 was stopped by the surveyor at 4:40 PM prior to the accu-check procedure being done. Observation of one of the residents that had an accu-check performed had a [DIAGNOSES REDACTED]. In the Social Services office on 7/25/11 at 4:15 PM, the Administrator and Director of Nursing (DON) were informed of the findings that placed the residents receiving accu-checks in Immediate Jeopardy with an effective date of 7/25/11. The facility put corrective actions in place on 7/25/11 and 7/26/11 to remove the IJ, resulting in a decrease in the scope and severity for F 441 to an E. The findings included: 1. Review of the "Centers for Disease Control (CDC) and Prevention" guidelines documented, "...Infection Prevention during Blood Glucose Monitoring and Insulin Meters...Whenever possible, blood glucose meters should be assigned to an individual person and not be shared. If blood glucose meters must be shared, the device should be cleaned and disinfected after every use..." 2. Review of the facility's "CLEANING AND DISINFECTING DIAGNOSTIC EQUIPMENT" policy documented, "...1. After completing the test, wipe the blood glucose meter with a bleach based wipe ...4. Wipe machine with the bleach based wipe until it is completely wet ...5. Allow to remain wet for 1 minute at room temperature ...6. Wipe dry or allow to air dry ...8. Repeat this procedure between each resident usage and at the end of each shift..." 3. Medical record review for Resident #11 documented an admission date of [DATE] and a readmission date of [DATE] with [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. Observations during medication administration on the upper 300 Hall on 7/25/11 at 4:30 PM, revealed Nurse #4 entered Resident #11's room and obtained an accu-check on Resident #11. Nurse #4 obtained supplies for another accu-check and started to enter another room on the 300 hall to perform an accu-check on another resident without cleaning the accu-check machine. Nurse #4 was stopped at that time by the surveyor, prior to performing the procedure. 4. Medical record review for Resident #13 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. Observations during medication administration in Resident #13's room on 7/25/11 at 3:45 PM, revealed Nurse #1 entered the room and obtained an accu-check on Resident #13. Nurse #1 entered Random Resident (RR) #1's room at 3:55 PM and obtained an accu-check on RR #1. Nurse #1 entered RR #2's room at 4:00 PM and obtained an accu-check on RR#2. Nurse #1 did not clean the accu-check machine at any time during this observation. 5. Medical record review for Resident #15 documented an admission date of [DATE] with a readmission date of [DATE] with [DIAGNOSES REDACTED]. This resident had a [DIAGNOSES REDACTED]. 6. There were 28 residents in the facility that received accu-checks. Each resident did not have their own accu-check machine. Each resident that had orders for a finger stick blood glucose had a finger stuck with a lancet to obtain a blood glucose reading. The test strip is placed in the accu-check machine. The resident will then have a finger stick and a blood droplet will be dropped onto the strip. The blood could drop on the accu-check machine. When squeezing the finger for the drop of blood the nurse could get non-visible blood on the glove and carry it to the instrument. Nurse #1 and 4 did not clean the accu-check machines prior to use nor between each resident use, placing all residents that have accu-checks performed at risk of a blood borne illness. 7. During an interview on the lower 200 Hall on 7/25/11 at 5:50 PM, when asked if Nurse #1 had been inserviced on procedure for cleaning the accu-check machine, Nurse #1 stated, "...between residents and at the end of the shift and let it air dry. I was trained during orientation and again tonight." 8. During an interview on the upper 300 hall at 7/25/11 at 5:55 PM, Nurse #4 stated, "I thought it was a general thing to clean it before the shift and after. I didn't know it had to be cleaned between residents. I have been inserviced tonight." 9. During an interview in the Social Services office on 7/25/11 at 6:00 PM, the DON stated, " The previous DON said she inserviced the nurses for cleaning the glucometer (accu-check machine), but as for me I have not inserviced them since I've been here." When asked if Nurse #4 and Nurse #1 had received any training on accu-checks the DON stated, "...I'm unaware of any. They are both new nurses..." When asked if pharmacy had inserviced any nurses on accu-checks the DON stated,"...The pharmacist is on vacation and she is unaware, but she had observed a medication pass..." When the DON was asked what is used to clean the accu-check machine, the DON said that Dispatch wipes (bleach wipes) are used. The DON stated, "It should be cleaned before and after each resident." 10. During an interview in the Social Services office on 7/25/11 at 6:25 PM, the DON said that all of the 3 to 11 nurses had been inserviced, and that she (DON) would be back at 11:00 PM to inservice the 11 to 7 shift. 11. During an interview on the 100 Hall on 7/25/11 at 6:33 PM, Nurse #2 stated she had received training at 5:00 PM on 7/25/11. 12. During an interview on the 300 Hall on 7/25/11 at 6:40 PM, Nurse #4 was asked if she had an inservice on cleaning the accu-check machine. Nurse #4 stated, "A little while ago, about 1 hour ago". Nurse #4 stated she was told to clean before the machine is used and after. 13. During an interview with the Medical Director in the conference room on 7/25/11 at 7:00 PM, it was explained that there was an accu-check performed on a resident that evening that had Chronic Hepatitis and that the accu-check machine had not been cleaned between residents. When asked what her expectations are regarding accu-checks, the Medical Director stated, "I expect them to go by facility protocol and manufacturer's instructions." B. Based on review of the "Geriatric Medication Handbook", policy review, observation, and interview, it was determined the facility failed to ensure 2 of 11 (Nurse #3 and 4) nurses failed to prevent the potential spread of infection by not washing hands during medication administration observations. The findings included: 1. Review of the "Geriatric Medication Handbook". Tenth Addition, from the American Society of Consultant Pharmacists, page 60, "Eyedrop Administration" documented "...6. Wash hands thoroughly. 7. Put on examination gloves..." 2. Review of the facility's "HANDWASHING" policy documented, "...Handwashing is generally considered the most important single procedure for preventing nosocomial infections...Hands should be washed before and after resident care...personal care and after contact with a resident's mucous membranes and body fluids or excretions...Hands should be washed before and after performing invasive procedures..." 3. Observations in Random Resident (RR) #3's room on 7/25/11 at 4:25 PM, revealed Nurse #3 applied gloves and performed an accu-check on the resident. Nurse #3 did not wash her hands prior to applying gloves or performing the accu-check. Observations in RR #4's room on 7/25/11 at 4:40 PM, revealed Nurse #4 applied gloves and obtained an accu-check on the resident. Nurse #4 did not wash her hands prior to applying gloves and obtaining accu-check or after removing gloves. Observations in Resident #3's room on 7/25/11 at 5:15 PM, revealed Nurse #3 applied gloves, administered 1 eyedrop to Resident #3's right eye, then to Resident #3's left eye. Nurse #3 did not wash her hands prior to applying the gloves and administering the eyedrops, and did not change her gloves or wash her hands in between each eyedrop administration. 4. During an interview in the Social Services office on 7/27/11 at 4:00 PM, the DON was asked what her expectation was for handwashing during medication administration. The DON stated, "...I want them (nurses) to wash their hands before and after resident contact...between accu-checks...when applying eyedrops...and in between eyedrops..."