Every finding on record at Continuing Care at Eagles Trace

Based on observations, interviews, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for food procurement. 2-Staff were observed without hair restrains. 1 small transparent square container was observed in the dry storage room which held multiple (unable to count)insects. 1 live insect was observed in the dry storage room. These failures could place residents at risk of foodborne illness and disease. Findings Included: On 9/17/25 at 11:51 AM a delivery driver was observed in the kitchen preparation area; there was no hair restraint donned (worn).Observation and interview on 9/17/25 at 11:54 AM of Chef A in the food preparation area, there was no hair restraints donned. Chef A said he was aware of the importance of donning (wearing) hair restraints to avoid cross contamination and for infection control. He said that the negative outcome could be someone getting sick. On 9/17/25 at 11:55 AM, observation and interview with the General Manager of Dietary Services, she said that Everyone that is in the kitchen should have on a hairnet/hair restraint to prevent cross contamination and for infection control, to prevent residents of getting sick. Chef A was then observed placing a hair restraint on. The General Manager of Dietary Services said she also explained to the delivery driver the requirements of wearing a hair restraint. Interview on 9/18/2025 at 12:20 PM with the DON regarding hair restraints and pest control in the kitchen while preparing foods all staff in the kitchen were responsible to avoid cross contamination and follow infection control practices, a negative outcome could be foodborne illness. On 9/18/25 at 2:30 PM, observation and interview with the Dietary Services Manager of the facility policies Uniform Dress Code, Department: Dining Services dated 06/2025 and Food Handlers - Employee Health policy dated 01/2020, she said that the purpose of wearing hair restraints/coverings was to prevent cross contamination and for infection control. She said that the facility followed the guidelines of the Texas Food Code. Interview on 9/18/25 at 3:43 PM with the Administrator, her expectations were for all staff to wear hair restraints to avoid any cross contamination and for infection control to prevent illness. All staff were responsible for wearing hair restraints when in the kitchen.Record review of the facility policy entitled Uniform Dress Code, Department: Dining Services dated 06/2025 revealed in part. Company approved hair covering: baseball cap, hair net or skull cap.Beard guard must be worn if beard is visible. Record review of the facility policy entitled Food Handlers - Employee Health dated, 01/2020, revealed in part. Purpose / Scope: Prevention of transmission of disease-carrying organisms and food borne illness. Personal Hygiene 1. The dress code policy will be enforced, including the following. hair nets and caps worn at all times.

Based on observation and interview the facility failed to ensure the residents' rights to privacy for 1 (Resident #17) of 7 residents reviewed for personal privacy. The facility failed to ensure that certified nursing assistant (C.N.A.) A and Program Assistant (PA) A maintained Resident #17's privacy while resident received a shower from private caregiver. This failure place residents at risk of having their bodies exposed to the public, resulting in low self-esteem and a diminished quality of life.The findings included: Record review of Resident 17's Facesheet dated 09/17/2025 reflected resident was an [AGE] year-old female who admitted to the facility on [DATE] with diagnosis that included but were not limited to dementia, severe behavioral psychosis mood disorder, obsessive compulsive disorder, muscle weakness, unspecified lack of coordination, and anorexia. Record review of Resident #17's Care Plan undated had not revealed that the resident required her bathroom door open while receiving Activities of Daily Living (ADL) care, specifically showers. Record review of Resident #17's Minimum Data Set Assessment (MDS) dated [DATE] revealed that Resident #17 had a Brief Interview for Mental Status (BIMS) of 13 suggesting that the resident's cognition was intact. Further review revealed for Shower/bathe self: The ability to bathe self, including washing, rinsing, and drying self (excludes washing of back and hair). Does not include transferring in/out of tub/shower, resident required partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs, but provides less thanhalf the effort. During an observation on 09/16/2025 at 9:46 a.m. PA A was observed knocking, opening the room door of Resident #17's room, quickly closing the door giving only enough space for her to reach her arm into the room and placed a piece of paper on a dresser near the entrance of the room door before closing the resident's door. During an observation on 09/16/2025 at 9:47 a.m. C.N.A. A was observed knocking, entering, and exiting Resident #17's room. During an observation on 09/16/2025 at 9:48 a.m. Resident #17 was observed in the shower of her room fully unclothed while receiving a shower by resident's personal caregiver. During an interview on 09/16/2025 at 2:01 p.m. C.N.A. A stated that she had entered Resident #17's room earlier in the day while the resident was receiving a shower. She stated that she knocked at the resident's door, poked her head into the room, and the resident told her to come in. She stated that she observed the resident nude being given a shower by the resident's personal caregiver. She stated that she believed the resident had a bathroom door, but that there was a clear view from the entrance of the resident's room to the resident inside her shower. She stated she does not know why she did not close the bathroom door. She stated that the bathroom door should have been closed so that the resident's dignity and respect would be maintained while the resident was receiving a shower. She stated that the resident had a high mental cognitive function and should have understood her nakedness was exposed and visible from the door entrance but did not know why she did not close the door. She stated from her experience; the resident would tell anyone who knocked at the door to come inside whether she was in the shower or not. She stated that the facility received ongoing training in-services on maintaining a resident's privacy, dignity and respect. She stated that it had been her responsibility to ensure that the resident's nakedness was not exposed during showers. During an interview on 09/16/2025 at 2:24 p.m. PA A stated that morning while passing out the facilities in-house newsletter, she knocked at the door of Resident #17. She stated when she did not hear anything, she opened the door to announce herself when she immediately seen the resident naked in the shower receiving ADL care from the resident's C.N.A. She stated when she seen that the resident's nakedness had been exposed, she immediately closed the door leaving only enough space to place the newsletter on a table near the door entrance and quickly closed the door. She stated that the resident should have been covered with at least a towel to cover the top part of the resident's body to allow the resident to maintain some level of privacy while receiving her shower. She stated that the simple solution would have been to close the resident's bathroom door while giving the resident a shower but did not know why she did not close the door. She stated that she received training on maintaining a resident's privacy and dignity during her onboarding training 3 months ago. During an interview on 09/16/2025 at 03:26 p.m. Registered Nurse, RN A stated Resident #17 received private home health support for showers and on shower days, the private C.N.A. provided the resident with a shower. She stated that it was her expectation that no matter if a private staff or a facility staff assisted the resident with a shower that the resident was not exposed during showers. She stated it had been the facility's privacy issue protocol that all resident doors were to remain closed to a resident's room during ADL care to maintain privacy and dignity. She stated if it had been the resident's preference to keep the bathroom door open during showers, that should have been care planned and an additional measure should have been in place to ensure that the resident's nakedness was not exposed simply upon opening their resident's room door during shower times. She reviewed the resident's care plan and found no indication that the resident was care planned to keep her bathroom door open during showers, and by not care planning, the facility was allowing an invasion of the resident's privacy. She stated that it was all staff members responsibility to ensure that the private caregiver practiced and promoted privacy and ensured that the caregiver practice closed the resident's bathroom door during ADL care. She stated that she would create a sign for the private caregiver to place on the outside of the resident's room door during shower times to ensure the resident received privacy. She stated that the facility staff received on-going in-service training on maintaining a resident's privacy, dignity, and respect and she received said training during her onboarding 6 months ago. During an interview on 09/18/2025 at 12:31 pm, the Director of Nursing (DON) stated that Resident #17's bathroom door should be closed during ADL care such as during showering. She stated if the resident had chosen not to keep the bathroom door closed and it had not allowed for privacy in the room; it should have been care planned. She stated if that incident was a one-time occurrence, care planning was not needed. She stated when C.N.A. A and PA A entered the resident's room, they could have offered to close the resident's bathroom door to preserve the resident's privacy. She stated that training on privacy/dignity was provided at a staff members on-boarding during after hire, as needed if they feel like there had been a pattern, and during the facilities annual skills training fair. During an interview on 09/19/2025 at 3:43 pm. The Administrator (ADM) stated that it had been her expectation that staff provided Resident #17 with privacy and ensured that the resident's dignity was preserved based on the resident's preferences especially if there would be any compromised activities going on in the room. She stated that it had been her expectation that the bathroom door would remain closed while the resident was provided a shower but again deferred to the resident preferences. She stated that staff received on-going and as needed in-service training on resident's privacy, dignity, and respect. Resident was unavailable for an interview. Record review of training dated 02/13/2025 reflected showers and ADL documentation in-service had been provided. Record review of training dated 03/04/2025 reflected compliance in-service had been provided in the area of showers. Record review of training dated 03/06/2025 reflected completing showers and completing shower sheet in-service was provided. Record review of in-service training dated 09/17/2024 unsigned reflected: Showering/Bathing follow resident preferences from care plan. Honor Privacy & Dignity. - Ensure privacy (close doors/curtains), - Limit body exposure. Record review of undated Policy titled Activities of Daily Living reflected Identifying The Residents' Functional Abilities Through Measurements of Their Activities of Daily Living. The 11th Activities of Daily Living. Bathing - How the resident - Takes a full body bath/shower or sponge bath. Policy on Resident Rights was asked for and not received.

Based on observation, interview, and record review, the facility failed to ensure residents who were unable to carry out activities of daily living received necessary services to maintain grooming and personal hygiene for one (Resident#3) out of 4 residents reviewed for ADLs. The facility failed to provide timely incontinent care for Resident #3 which resulted in the resident's brief, towel on top the drawsheet, draw sheets and bed linen to be soaked with urine. This deficient practice could place residents at risk of skin breakdown and reduced feelings of self-worth.Findings included: Record review of Resident #3's face sheet revealed a [AGE] year-old female resident who was admitted to the facility on [DATE]. Resident #3 had diagnoses which included diabetes mellitus (high blood sugar), cerebral infraction (brain stroke), and dysphagia (difficulty swallowing).Record review of Resident #3's quarterly MDS assessment, dated 8/27/25, revealed a BIMS score of 4 out of 15 indicating severely impaired cognition. Resident #3 was totally dependent on staff for all ADL care with one to two staff assist.Record review of Resident #3's care plan dated 08/19/25 revealed in part . resident was incontinent of bowel and dependent on one staff for care. interventions: to pull up and down my garment, to manage garments, and or continence products .During an observation on 09/17/25 at 2:05 p.m., revealed Resident #3 was lying in bed in her room on her back. Resident #3's pants, the draw sheet, and a towel on top of the draw sheet and bed linen were wet with urine, and the bed linen had a ring on it. When CNA K opened Resident #3's incontinent brief, the inside of the incontinent brief was brown, and the wet indicator on the incontinent brief was completely faded out. During an interview on 09/17/25 at 2:56 p.m., LNV B said CNA K was supposed to make rounds every two hours for incontinent care for Resident #3. She said she monitored the aides to see if they had made their rounds every two hours. LVN B said she did not ask CNA K today if she had made her rounds because she was busy, and CNA K knew to make her rounds every two hours to check and change Resident #3. LVN B said Resident #3 was up in the wheelchair by the nursing station when she came to work this morning at 7:00 a.m. LVN B stated if CNA K did not change Resident #3's wet incontinent brief for an extended time, the resident's skin would break down. LVN B said she had training on incontinent care, and the trainer said the staff should check the residents every two hours and change the residents' incontinent briefs to prevent rashes, skin breakdown, and infection.During an interview on 09/17/25 at 3:18 p.m., CNA K said Resident #3 was already up when she came to work today at 7:00 a.m., and she was sitting at the nurse's station. CNA K said she changed Resident #3 after breakfast before she went to lunch. CNA K said she went to lunch between 11:00 and 11:30 a.m. She said Resident #3 was a heavy wetter and her brief was always wet. CNA K said Resident #3's pants were soaked, the brief had a brown color, and the wet indicator was faded entirely, and she said Resident #3's brief was always wet. She said she had in-service training on how to make rounds and provide incontinent care. She said she was supposed to make rounds every two hours but sometimes would not be able to check on residents every two hours because the morning shift was fast-paced, and she was kind of behind today. CNA K said if Resident #3 was left in a wet incontinent brief for an extended period, then Resident #3's skin could break down. She said she had an in-service on making rounds every two hours.During an interview on 08/18/24 at 11:31 a.m., the DON said CNA K was supposed to have made rounds on Resident #3 when she came in at the start of her shift, before and after each meal for incontinent care. She said CNA K should have checked Resident #3 more often since she knew Resident #3 was a heavy wetter. She said if Resident #3 was left on a wet incontinent brief, the resident's skin could break down. The DON said if Resident #3's incontinent brief was brown, and the wet indicator faded out it could mean CNA K did not change Resident #3 in over 2 hours. She was not aware Resident #3 refused the aides to change her. The DON said the aides had a checklist which the aide completed upon hire, and it had ADL rounding. During an interview on 09/18/25 at 3:45 p.m., the Administrator said CNA K was supposed to make rounds according to Resident #3's plan of care. The Administrator said CNA K should make rounds upon the start of shifts and at different intervals throughout the shift. The Administrator said if Resident #3 was left on a wet incontinent brief for an extended period of time, the resident's skin could break down.Record review of the facility undated urinary incontinence management revealed in part .maintenance Program is utilized whenever a resident cannot benefit from or is unable to participate in toileting programs. The goal is to maintain the residents' dignity and to prevent any skin breakdown or other negative consequence related to UI. The Maintenance program includes; Pad and brief change every 2-4 hours, more frequently as needed cleansing, rinsing, and drying of skin during pad/brief change. skin inspection for areas of redness, excoriation, infection, skin breakdown.

Based on interview, and record review the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 (Resident #25) out of 7 residents reviewed for adequate supervision. The facility failed to ensure Resident #25 who required supervision and assistance while receiving a shower was left unattended. This deficiency exposed residents living in the facility to potential harm, injury or death due to not being adequately monitored.Record review of Resident 25's Facesheet dated 09/16/2025 reflected she was an [AGE] year-old female who admitted to the facility on [DATE] with diagnosis that were limited to muscle weakness, other abnormalities of gait and mobility, hereditary and idiopathic neuropathy (disorder affecting nervous system causing discomfort from pain, tinging and numbness of limbs or extremities), unspecified Poly osteoarthritis (arthritis in the joints causing pain, stiffness, inflammation, and limited motion), unspecified lack of coordination, anemia (not having enough health blood cells to carry an adequate amount of blood to the lungs resulting in fatigue, shortness of breath, and lightheadedness), and cognitive communication deficit (impaired cognitive functions, such as attention, memory, reasoning, and problem-solving). Record review of Resident #25's Care Plan dated 06/24/2025 3h. Bathing - Functional Status. Goals: I may need assistance with - Bathing. Getting in and out of shower/tube washing my hair. Washing my back. Washing my legs/feet. Putting on cream/lotion, drying myself. I require the following support: one-person physical assistance. My preferred days Tuesday, Thursday, Saturday. I need the following devices to be as independent as possible: Shower chair/stool. Record review of Resident #25's Minimum Data Set Assessment (MDS) dated [DATE] reflected that Resident #25 had a Brief Interview for Mental Status (BIMS) of 09 suggesting that the resident's cognition was moderately impaired. Further review revealed for Shower/bathe self: The ability to bathe self, including washing, rinsing, and drying self (excludes washing of back and hair). Does not include transferring in/out of tub/shower. Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort. During an interview on 09/16/2025 at 10:43 a.m. Resident #25 stated that she was left alone in the shower earlier in the day by C.N.A. B and was ready to come out of the shower and called for the C.N.A. who did not respond. She stated she called out several times and then yelled out, Help, Help, but no one came, so she pushed the call light and Registered Nurse (RN) A came into the room and C.N.A. B followed thereafter. She stated she told the two staff that she was ready to get out of the shower. She stated that she could not get herself in and out of the shower alone and had not wanted to be left alone and that had not made her feel safe. She stated if she happened to fall while in the shower, it would be difficult for her to crawl over to the call light cord to summon help. During an interview on 09/16/2025 at 02:59 p.m. Certified Nursing Assistant (C.N.A.) B stated that she had given Resident #25 a shower on that day and while the resident showered herself, she had changed out the resident's bed sheets and made-up the resident's bed. She stated that she only washed the resident's back, as the resident was able to wash all other parts of her body. She stated that she would not consider the resident being left alone in the shower, because she was right in the room at the resident's bed. She stated that while the resident was in the shower, RNA came into the resident's room and turned off the resident's call light that C.N.A. stated she had forgotten to turn off when the resident had let her know earlier that she was ready for her shower. She stated that the resident had not made any concern to her or RN A about being left alone in the shower. During an interview on 09/16/2025 at 03:09 p.m. LVN C stated that this morning she entered Resident #25's room because the call light had been going off and seen that resident was in the shower. She stated that C.N.A. B was in the room and stated that she must have forgotten the light was on. Resident did not make any complaints or mention that she was left alone in the shower area or felt afraid. She stated that the resident was able to wash certain parts of her own body, and she was encouraged to wash other parts but had some limited mobility due to arthritis in her right knee. She stated it would have been her expectations that while residents were in the shower, that staff should be right there at the resident's side as a safety precaution. She also stated that it would not be her professional experience to make a resident's bed while they were in the shower and that C.N.A. B should have waited until the shower was complete to make the resident's bed to keep an observation and make sure that the resident's care needs were met. She stated that the resident made no complaints or comments about being left alone in the shower. She stated that C.N.A. B should receive in-service training because the resident had not felt safe without C.N.A. B present. During an interview on 09/19/2025 at 3:43pm. The Administrator (ADM) stated that it had been her expectation that staff provided Resident #25 with adequate supervision to ensure that the resident had been safe and felt safe while receiving ADL assistance. Record review of training dated 02/13/2025 reflected showers and ADL documentation in-service had been provided. Record review of training dated 03/04/2025 reflected compliance training for providing showers. Record review of training dated 03/06/2025 reflected completing shower sheet and completing showers in-service was provided. Record review of in-service training dated 09/17/2024 unsigned reflected: Showering/Bathing follow resident preferences from care plan. Honor Privacy & Dignity . - Do with, not for - Be present, engaged - not task focused. Record review of undated Policy titled Activities of Daily Living reflected Identifying The Residents' Functional Abilities Through Measurements of Their Activities of Daily Living 11 Activities of Daily Living. Key activities important to self-care include 1st - Measuring Self Performance. - What is the residents' participation in this activity? - Measured from the perspective of how much the staff person assists the resident with the activity. The 11th Activities of Daily Living. Bathing - How the resident - Takes a full body bath/shower or sponge bath - Transfers in/out of the bath/shower. Step 2 - Measuring support Provided - Self Performance - Measures the resident's level of involvement in completing the task - Support Provided - Measures the stat person's level f support provided to the resident so they could complete the task - Did you participate? If so, what did the participation look like? - Did you arrange items (set-up) so the resident could complete the task? - Did you provide physical assistance of any type? If so, how many staff persons were involved.

Based on observation, interview, and record review, the facility failed to ensure residents who were incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 of 4 residents (Resident #3) reviewed for incontinent care. The facility failed to ensure CNA K properly cleaned Resident #3 during incontinent care. This failure could place residents at risk for pain, infection, injury, and hospitalization. Findings included: Record review of Resident #3's face sheet revealed a [AGE] year-old female resident who was admitted to the facility on [DATE].Resident #3 had diagnoses which included diabetes mellitus (high blood sugar), cerebral infraction (brain stroke), and dysphagia (difficulty swallowing). Record review of Resident #3's quarterly MDS assessment, dated 8/27/25, revealed a BIMS score of 4 out of 15 indicating severely impaired cognition. Resident #3 resident was totally dependent on staff for all ADL care with one to two staff assist.Record review of Resident #3's care plan dated 08/19/25 revealed in part . resident was incontinent of bowel and dependent on one staff for care. interventions: to pull up and down my garment, to manage garments, and or continence products .During an observation on 09/17/25 at 2:10 p.m., revealed incontinent care for Resident #3 was provided by CNA K. CNA K did not separate Resident #3's labia when she cleaned the resident's peri area. CNA K also wiped from back to front while she provided care. CNA K was about to apply barrier cream on Resident #3's private area, and the surveyor intervened. CNA K separated Resident #3's labia and wiped the area three times, and the wipes had a significant amount of yellow substance.During an interview on 9/17/25 at 3:08 p.m., LVN B said CNA K should not have wiped Resident #3 from back to front to prevent contaminating the peri with germs or bowel movement. LVN B said when CNA K cleaned Resident #3's peri area, CNA K was supposed to separate the labia and clean each side and middle from front to back. LVN B said the labia should be separated and cleaned to prevent infection. LVN B said she had in-service training, and the aides, too, had in-service training on incontinent care for a female resident, and they were educated to separate the labia.During an interview on 9/17/25 at 3:33 p.m., CNA K said she wiped Resident 3's buttocks from back to front, but she was supposed to wipe from front to back. CNA K said the resident should not be wiped from back to front to prevent infection or mistakenly transfer germs from the buttocks to the peri area. CNA K said she was supposed to wipe Resident #3's labia by separating the area and wiping to prevent infection and irritation, but she forgot to separate the labia. CNA K said she did not separate the labia when she wiped Resident #3, but when she wanted to apply the barrier cream, the surveyor intervened, and she separated Resident#3's labia and wiped three times, and she wiped out a substantial amount of yellow substance. CNA K said she had in-service training on how to provide incontinent care for a female resident, and the trainer stated the female labia should be separated and wiped.During an interview on09/18/25 at 11:42 a.m., the DON said the aides had a skills -check off upon hire, and it included peri care. The DON said CNA K should have wiped from front to back and opened Resident #3's labia and wiped side to side, then middle, also inspect the area for any skin impairment, and ensure she cleaned the area properly to prevent infection. The DON said CNA K should have wiped from front to back, which meant CNA K should have cleaned from the cleanest to the dirtiest area. That would prevent any bowel movement from contaminating the front (peri area), thereby preventing infection. Record review of the facility undated urinary incontinence management revealed in part .maintenance Program is utilized whenever a resident cannot benefit from or is unable to participate in toileting programs. The goal is to maintain the residents' dignity and to prevent any skin breakdown or other negative consequence related to UI. The Maintenance program includes; Pad and brief change every 2-4 hours, more frequently as needed cleansing, rinsing, and drying of skin during pad/brief change. skin inspection for areas of redness, excoriation, infection, skin breakdown.

Based on observation, interviews and record review, the facility failed to maintain an effective pest control program so that the facility is free of for rooms in 1 of 1 kitchen reviewed for environment.1 small transparent square container was observed in the dry storage room which held multiple fruit flies. 1 live insect was observed in the dry storage room. These failures could place residents at risk of foodborne illness and disease. Findings included: On 9/16/25 at 8:35 AM an observation and interview with the Director of Dietary Services, revealed inside of the dry storage room was a small, a clear square container that had a clear light brown liquid inside and several, (unable to count), small insects. The Director identified the liquid as apple cider vinegar and the insects as fruit flies. He said it was a fruit fly contraption and that it was not supposed to be there. He said the contraption would cause no harm, but it was just not the best look. He said the Chef would be in later to discuss who placed the contraption there. One live insect flew away from the container when the Director of Dietary Services removed the container. On 9/16/25 at 12:12 PM, interview with the General Manager of Dietary Services, she said she was made aware of the container with vinegar and fruit flies and that the fruit flies came with the summer heat. She said that the contraption should not have been there at all. She said all staff were aware of cross-contamination and infection control. On 9/17/25 at 1:40 PM an interview with the Maintenance Director, he said that pest control came to the facility every Wednesday and as needed by request. He said that the facility had not had any major issues with fruit flies. He said that pest control was important to prevent residents from getting sick and could cause cross contamination if a fruit fly landed on food. Interview on 9/18/25 at 3:43 PM with the Administrator, regarding pests, any pest around food could cause contamination. She said as the Administrator she was responsible while general services managed pest control contracts and made sure they were effective to prevent illness. Record review of the facility policy entitled Integrated Pest Management, dated 3/17/2025 revealed in part.Purpose: The purpose of this policy is to establish guidelines for the prevention, monitoring, and control of pests in a manner that protects the health and safety of residents, staff, and visitors.our approach will include monitoring, prevention strategies, and control methods that align with health, safety, and sustainability standards. Objectives: Prevention: Prevent the introduction of pests by eliminating favorable conditions. Monitoring: Conduct regular inspections to detect pest activity early. Control: Implement non-toxic, environmentally safe measures for managing pests when necessary. Education: Educate staff, residents, and contractors on pest prevention and management.

Based on observation, interview, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 kitchen reviewed for food procurement. 1. The facility failed to ensure foods were dated as opened/preparation discarded after 72 hours. 3. The facility failed to keep food off the floor. 4. The facility failed to keep scoops in a separate holder from bulk food bin. These failures could place residents at risk of food borne illness and disease. Findings Include: Observation of the facility's kitchen on 08/13/24 at 8:15 AM revealed the following. 1. A plastic container of Blue Cheese had No Label and No use by Date. 2. A Plastic container of sliced Swiss Cheese in the walk-in cooler had a used by date of 8/10/24. 3. A cs of fresh sliced mushroom in the walk-in cooler had a use by date of 8/09/24 4. 2cs. Of wheat bread in the walk-in freezer were stored on the floor. 5. 1cs. Of breaded chicken in the walk-in freezer was stored on the floor 6. 4 cs. Of ice cream individual cups in the walk-in freezer were stored on the floor. 7. 2 cs. Sausage in the walk-in freezer were stored on the floor. 8. Scoops were left in cornbread, flour, and sugar bins In an interview with the General Manager of Dining on 08/13/24 at 8:30 AM; she stated the leftover food stored in the refrigerator should have been used or discarded prior to use by date. She stated the Cases of food should be off the floor and the scoops were stored. She said she would be re-in-service dietary staff on labeling & dating. She said the tray aides are responsible for checking the food in the walk in and to discard food prior to the used by date. Record review of facility's policies and procedures for Food Safety, dated 05/2012 read in part .potentially hazardous leftover foods are properly covered, labeled, dated, and refrigerated immediately. They are discarded after 72 hours unless otherwise indicated. Record review of facility's policies and procedures for Food Storage, dated 04/2016 read in part '' .All food and supplies will be stored six (6) Inches above floor. 6.Scoops for dispensing dry bulk foods these items will be stored separately in a holder.

Based on observation, interview, and record review the facility failed to dispose of garbage and refuse properly for 1 of 2 dumpsters dumpster A and dumpster B reviewed for Food and nutrition services. -The facility failed to ensure all garbage was dispose properly in the dumpster and not left outside of dumpster. This failure could place residents at risk of infection from improperly disposed garbage. Findings include: Observation on 08-13-24 at 8:45 am, revealed the facility's dumpster area, which was in the lot behind the dietary department had a commercial -size dumpster 3/4 full of garbage and a bag full of garbage was left on top of the dumpster lid. In an interview on 08-13-24 at 8:45 am, with the General Manager of Dining Services, she stated the bag full of garbage should have been put in the dumpster and not left on top of the dumpster. She also stated the dumpster doors must always be closed to keep vermin, pests, and insects out of the dumpster and from entering the facility. She further stated housekeeping, and nursing also discarded their waste garbage in the dumpster. It was the responsibility of dietary staff, nursing and housekeeping to ensure the dumpster doors were kept closed and all garbage should be put in the dumpster. Record review of facility's Policies and Procedures on waste disposal, dated 6/ 2023, reflected trash containers liners are secured, collected, and deposited in the designated dumpster.

Based on observation, interview, and record review the facility failed to ensured that residents who are incontinent of bladder receives appropriate treatment and services to prevent urinary trat infections and restore continence to the extent possible in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 of 6 (Resident #13) residents reviewed for quality of care. The NF failed to secure Resident #13 suprapubic catheter tubing to prevent from dislodging. This failure could place residents at risk for injury, hospitalization , and decrease in quality of life. Findings include: Record review of Resident #13's face sheet, dated 08/15/2024, reflected a 90- year-old male who was admitted to the facility on [DATE]. Resident #13 had diagnoses which included the following: hemiplegia (paralysis on one side of the body), dysarthria (slow or slurred speech) following a cerebral infarct (when blood flow to the brain is blocked), and benign (tumor, or growth that is not cancerous) and prostatic hyperplasia (enlarge prostate gland that can cause difficulty in urinating). Record review of Resident #13's annual MDS, dated [DATE] , reflected that the resident had a BIMS score of 2, indicating which indicated resident cognition was severely impaired. Section H (bladder and bowel) was coded 9 (not rated, resident had a catheter [(indwelling, condom]), urinary ostomy, or no urine output for entire the 7 days. Record review of Resident #13's care plan, dated 08/13/2024, revealed reflected the that resident was being care planned for having a 16 fr suprapubic catheter (surgically placed tube into the bladder through a small incision in the lower abdomen [(stomach]) with intervention to manage protective garment and/or continence products to empty catheter bag to measure urinary output. Record review of Resident #13's physician orders for the month of August 2024 revealed reflected the following order: -Indwelling urinary Foley, change suprapubic Foley q month, dated 07/15/2024. Observation on 08/15/2024 at 9:07 AM of Resident #13 revealed the resident in bed with a suprapubic catheter draining cloudy yellow urine. The resident tubing was not secured to prevent pulling on the tubing. The site at the suprapubic catheter was clean without drainage or redness. Interview on 08/15/2024 at 9:10 AM, CNA B said he had been working at the NF for 5 years and 3 months. CNA B said he received an in-service on making sure Foley catheters were draining well, keeping the site clean and dry, and securing the tubing by using a statlock (catheter stabilization device) to prevent pulling. CNA B said he believed it was the nurses who placed the statlock on resident's that had an indwelling Foley catheter. CNA B said he was not aware Resident #13 did not have a statlock to secure the tubing from pulling. Interview on 08/15/2024 at 9:18 AM, RN A said she was the nurse for Resident #13. RN A said it was the NF policy any resident who had an indwelling Foley catheter to place a statlock on the tubing to prevent pulling on the tubing, injuring the resident, and dislodging the tube. RN A said it was the nurse's responsibility to ensure that a statlock was placed on the resident (s) who had indwelling Foley catheters. RN A said it was the CNA's responsibility to report to the nurse if the statlock came off the resident . Interview on 08/15/2024 at 2:04 PM, the DON said the nursing staff should be securing the tubing for any resident who had a Foley catheter to prevent injury to the resident. Record review of the facility's policy on Urinary Catheters, dated 07/2021, reflected in part: .Secure suprapubic catheter to the abdomen to prevent accidental dislodgement or removal-allow room and do not pull catheter taut (tight)

Based on observation, interview, and record review, the facility failed to ensure drugs and biologicals used in the facility must be labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable for standards in 1 of 1 medication (Resident #83) rooms reviewed for medication storage. -The facility failed to discard Resident #83 medication IV antibiotic cefepime that expired on 08/14/2024. This failure could place residents at risk for not receiving adequate antibiotic therapy to treat infection. Findings include: Record review of Resident #83's face sheet reflected an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #83 had diagnoses which included cellulitis (bacterial skin infection) of right lower limb (arm or leg) and lymphedema (swelling that that occurs in an arm or leg). Record review of Resident #83's face sheet reflected an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #83 had diagnoses which included cellulitis (bacterial skin infection) of right lower limb (arm or leg) and lymphedema (swelling that that occurs in an arm or leg). Record review of Resident #83 admission MDS, dated [DATE], reflected the resident had a BIMS score of 15, which indicated the resident's cognition was intact. The resident received antibiotic therapy. Record review of Resident #83's care plan, dated 08/06/2024, reflected the resident was being care planned for receiving cefepime 1 gram intravenous every 8 hours for 21 days (till 08/22/2024) for cellulitis. Record review of Resident #83's Physician orders reflected the following order: Cefepime 1 gram solution for intravenous for cellulitis every 8 hours for 21 days, dated 08/02/2024. Record review of Resident #83's MAR for the month of August 2024 reflected the resident was receiving the medication cefepime every 8 hours at 6AM, 2PM, and 10PM. Observation on 08/15/2024 at 8:45 AM revealed the medication room fridge had two 50ml bags of normal saline mixed with cefepime 1gm for Resident #83. The expiration date on the bags read 08/14/2024. Interview on 08/15/2024 at 8:46AM, the ADON said all the nurses should be checking for expired medications prior to placing in the fridge and before administering the medication. Interview on 08/15/2024 at 2:04 PM, the DON said she would have to looked at the expired medication cefepime for Resident #83 to see what may have happened. The DON said audits were done in the medication room by herself, the ADON, and pharmacy for expired medications. Record review of the facility's policy on Medication Administration, Receipt, Storage & Disposal, dated 10/2023, reflected in part: .Medication management in Continuing Care will include ordering, transcribing, receiving, proper storage, accurate documentation and safe administration of residents' medications by authorized staff, consistent with state requirements .

Based observation, interview and record review the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 2 storage rooms (Room A and Room B) reviewed for infection control. -The facility failed to keep infection control gowns and pillows off the floor in the storage rooms. This failure could place residents at risk of cross-contamination and development of infection. Finding include: Observation of the laundry room and linen closets on 08/15/2024 at 2:00 PM revealed 2 yellow gowns on the floor of Room A and 3 blue plastic resident pillows on the floor of Room B. Interview with the Facility Manager and the Director of HK on 08/15/2024 at 2:02 PM, they said they did not know if it should be on the floor. They did not know why the items were on the floor. Interview with the Administrator and DON on 08/15/2024 at 2:40 PM, the Administrator said the items might have fallen from the shelves. The DON said the pillows and gowns should not have been on the floor as everything should be elevated off the floor due to infection control. Record review of the facility's Housekeeping, Maintenance and Laundry Services Policy, dated May 2021, reflected the facility will provide sufficient housekeeping, maintenance, and laundry personnel to maintain interior and exterior of the facility in a safe, clean, orderly and attractive manner. Interior walls and floors will be of a character to permit frequent and easy cleaning.

Based on interview, and record review, the facility failed to immediately assess the resident, consult with the physician, and immediately transport the resident to the hospital when a change in condition occurred for 1 of 1 resident (CR #6) was reviewed for a change of condition: 1. The facility failed to assessed CR #6 for more than 3.5 hours after the CA identified a change in resident's condition to include slurred speech and elevated blood pressure. 2. The facility failed to notified CR #6's physician for more than 4 hours after CA identified a change in condition. The noncompliance was identified as past noncompliance (PNC). The Immediate Jeopardy (IJ) began on 08/06/2023 and ended on 08/06/2023. The facility corrected the noncompliance before the investigation began. These failures resulted in an IJ on 11/17/2023. While the IJ was past non-compliance, this failure could affect all residents who dependent on staff to assess them and report changes in condition to physicians. Findings included: Review of the Face Sheet for CR #6 reflected an [AGE] year-old female admitted to the facility on [DATE] and discharged on [DATE] with the following diagnoses: dysarthria following other cerebrovascular disease, malignant neoplasm of connective and soft tissue of abdomen, secondary maligneoplasm of liver and intrahepatic bile duct, and chronic diastolic (congestive) heart failure. Review of Resident CR #6 Minimum Data Set (MDS) assessment, dated 09/07/2023, reflected a Brief Interview for Mental Status (BIMS) score of 08 out of 15. The MDS reflected CR #6's primary medical condition category that best describes the primary reason for admission: stroke. Review of CR #6 Care Plan dated 08/04/2023, reflected the following: Resident had a history of recent falls, was noted that resident was alert and oriented and able to make needs known. Resident required one-person extensive assistance with activities of daily living. Record review of CR #6's nursing note dated 08/06/2023 at 05:27 PM written by Registered Nurse (RN) revealed: Resident was sent to the ER for evaluation following Medical Director's (MD) orders due to right side generalized weakness. BP vitals 173/93 (systolic/diastolic pressure in arteries), HR: 79, and BG 236. Witness #2 concerned of possible stroke or UTI and MD was notified hence the orders. Review of CR #6 hospital records dated 08/14/2023 revealed discharge diagnoses as: acute ischemic left middle cerebral artery stroke. Paroxysmal atrial fibrillation. Hypertension. History of stroke in adulthood. Diabetes mellitus, type 2, with complications. Obesity. Primary sarcoma of intraabdominal site. Hyponatremia. Cerebral infarction due to embolism of left middle cerebral artery. Record review of a timely of events from CM's interviews with CA dated 09/08/2023 revealed the morning of 08/06/2023 Care Associate (CA) assisted CR #6 in dining area and resident's speech was clear. RN checked CR #6 while visiting with Witness #1 with no concerns. After breakfast, CA reported to RN that CR #6 had an elevated BP. RN indicated she would recheck CR #6's BP. During transport to the dinning for lunch, RN asked CA to place TED hose (compression socks) on CR #6. CR #6 was checked after lunch with no concerns. At 1:00 PM, CA reported slurred speech to the RN after CR #6 dropped her glasses to the floor. Witness #2 reported CR #6 had difficulty finishing her sentences and did not seem like herself. RN assessed and CR #6 seemed fine. RN text MD with performing an assessment with Licensed Vocational Nurse (LVN). MD sent a text that CR #6 could be sent out for evaluation. EMS arrived and CR #6 was transported to the local ER. Record review of CR #6 Progress Note dated 09/12/2023 at 09:50 a.m. written by Social Worker (SW) revealed CR #6 discharged on [DATE] on stretcher with EMT in stable condition. Record review of the facility's provider investigation report dated 09/18/2023 signed by NHA revealed on 8/6/23, RN provided a delay in care, and a delay in notifying MD for CR #6 change in condition. There was also no documentation pertaining to reported elevated BP by CA. The RN also did not complete any documentation/assessment of the change in condition for CR #6 having had a difficulty forming words at 01:00 PM reported to RN by CA. The NHA, DON and CM meet with the CR #6's family informing that an investigation that was done. It was found that RN did not assess CR #6 properly and was terminated. Resident return to facility on 08/28/2023 after having a stay at an acute care facility from 8/14/2023 to 08/28/2023. Record review of RN's Counseling Reason dated 9/19/2023 at 09:52 AM revealed RN's work performance and behavior did not meet expectation and did not exhibit the facility's Mission, Vision, and Values. The events of 08/06/2023 revealed that RN presented a delay in care, delay in notifying the doctor, she did not provide clinical/nursing assessment. No documentation pertaining to reported elevated blood pressure escalated to her by CA. No documentation /assessment of the change in condition in resident having difficulty forming words at 1 pm reported to her by CA. RN did not report events to Manager on Call, instead called the NHA. The policy to notify provider for change of condition was not performed by RN The series of events by RN lead to a delay in care to the resident. Record of policy Physician Notification of Change in Condition, origination date of 5/2023 revealed, Policy: When there is a sudden change of condition, the clinical team is responsible to perform a complete assessment, to include obtaining a full set of vital signs and the concern and notify the provider /attending physician. Procedure: 1. Significant changes in resident medical or psychosocial condition may include but are not limited to: Change in Vital Signs. 2. If after the nurse evaluates/assesses a resident and a change in condition is noted, the nurse will promptly notify provider and provides recent vital signs, and physical assessment. 3. Review identified change(s) with resident and document evaluation/assessment in electronic medical record. Procedure: 6. Nurse documents assessment of change of condition, time & conversation of physician & responsible party conversation and transcribes any new orders received in resident's electronic medical record (EMR). Record of policy Physician Notification for Change in Condition - SOP. Origination date of 8/2020. Purpose: Regulatory Requirements mandate that the resident's provider and healthcare representative will be notified of changes in a resident's condition that affect health. When there is a change of condition, the clinician is responsible to perform a complete assessment of vital signs and assessment of the basic problem, and to notify the provider. The following are examples of times when the provider must be immediately notified of a change in condition. After the provider is notified and the resident is stabilized the clinical team are responsible to notify the healthcare representative of the change in condition. Signs and symptoms of an impending stroke. Sudden decline in cognitive status and vital signs outside of parameter. Documents and follow up: Notifying clinician documents in electronic medical records: assessment completed of change of condition. Record review policy Abuse Prevention originated date 12/2006. Neglect. The failure of facility, its employees or service provider to provide goods and/or services necessary to avoid physical harm or mental anguish. Neglect is the failure to provide the necessary treatment, rehabilitation, care, attention, food, clothing, shelter, supervision, or medical services by a caregiver. Neglect could include instances where competent resident's wishes are not honored, restricting contact with family, ignoring the resident's need for verbal and emotional contact. Interview on 11/03/2023 at 12:34 PM NHA stated that on 08/06/2023 CA was assisting CR #6 did not have clear speech and did not eat breakfast. She stated at 01:00 PM, CA reported to RN that CR #6 had difficulty with word finding and to have an elevated BP. The RN did not check on resident at this time but did report she had checked on resident before lunch and did not notice any changes. At 02:00 PM Witness #2 reported to CA that resident had slurred speech. She stated that CA told witness #2 that RN had been made aware. She stated the RN reported she assess resident after Witness #2 reported that resident appeared frustrated, and that resident's son was finishing the resident's sentences. She stated the RN notified MD at approximately 03:43 PM to inform MD that Witness #2 was upset with resident's change in condition. She stated the MD called back within 15 minutes of notification and informed the RN to send resident out to the hospital. She stated that CR #6 was transported to the ER at 04:43 PM and was later admitted with a diagnosis of acute ischemic left middle cerebral artery stroke. She stated at the time of transport, resident's BP was 173/93. Interview on 11/03/2023 at 01:15 PM Witness #3 stated that Resident #3 was doing fine. He stated that the facility was short staffed. He stated he had to visit with the resident everyday all day long to ensure that the resident was receiving adequate care. He stated he had not issue to no concerns to presently report. Interview on 11/03/2023 at 01:23 PM Resident #2 stated said he had no issues with care or delay in care. no staff were abusive to him. that he was on his way to watch a moving and was in a hurry. Interview on 11/03/2023 at 01:29 PM Resident #4 stated he believed he was doing fine and had no issues with care or a lack of care. Interview on 11/03/2023 at 01:34 PM Resident #1 stated he had no issues with care or a lack of care. Interview on 11/03/2023 at 02:56 PM DON stated on 10/31/2023 between 11:30 AM and 12:30 PM CR #6 ate lunch with Witness #1 with no reports of concern. She stated on or about the same time Witness #2 called to speak to resident and reported to Witness #1 that resident was not easily understood as speech was slurred. She stated that CA checked on resident between 12:00 PM and 1:00 PM and resident had slurred speech and an elevated BP. She stated that CA immediately reported the resident's change of condition to the RN who told CA she would be to assess CR #6 shortly. She stated at 02:00 PM witness #2 arrived at the facility and report to both CA and RN that CR was not looking good and had slurred speech. She stated RN told witness #2 that when she finished with another resident, she would be in to assess CR. She stated RN spoke with resident but did not take resident's vitals. She stated that Witness #2 told RN that CR had previous stroke history. She stated that RN felt that the CR was stable. She stated that witness #2 was adamant that MD come to the facility and assess CR. She stated (exact time unknown) RN sent a message regarding CR's change in condition. She stated at that time, the Administrator called her stating RN had called MD regarding CR's slurred speech and positioning in chair. She stated that she told Administrator if RN had not heard back from the MD or if MD cannot triage CR in-house, to send CR to the hospital. She stated that there was a lap in time between the MD was contacted and when CR was sent to the hospital. She stated that RN failure to take heed to witness #2's keen history of CR's previous stroke history and did not possess a sense of urgency to CR's change in condition. She stated that RN could not provide her a reason for not assessing CR #6. She stated that as an experienced RN with several years of experience RN had not followed protocol for assessing and reporting to the MD a change in resident's condition. Interview on 11/03/2023 at 05:00 PM MD stated he had been the MD at the facility for [AGE] years. He stated on 08/06/23 he received a text message from RN that CR #6 had a change in condition with signs and symptoms of slurred speech which indicated that CR #6 may had experienced a stroke. He stated he could not recall the specific time of day that he received the message from RN. He stated he ordered RN to send CR #6 to the hospital. He stated it was confirmed by the hospital that CR #6 had experienced a stroke. Interview on 11/07/2023 at 04:43 PM CA stated that on 08/06/2023 during breakfast Witness # 1 ate breakfast with the CR #6 in the dining room. She stated after breakfast, exact time unknown she took the resident back to her room and performed vitals checks. She stated that the resident's BP was elevated, and she wrote down the BP and gave it to RN. She stated that Witness #2 came in at 2:00 PM and reported that the resident had slugged speech and was unable to finish her sentences. She stated again she reported the resident's BP reading and slurred speech to the RN also explaining Witness #2 was concerned. She stated RN came to assess the resident after Witness #2 insisted CR #6 be assessed. She stated thereafter she did not assist resident because the resident as transferred to the hospital. It was determined these failures placed CR #6 in an Immediate Jeopardy (IJ) situation on 08/06/2023. The NHA was notified and provided with the IJ template on 11/16/2023 at 02:28 PM. The facility took the following action to correct the non-compliance on 08/07/23. Record review of the facility's Inservice Chain of Command meeting dated 08/07/2023 revealed 13 staff and on 08/15/2023 revealed 14 staff were trained on Care protocol in an emergency situation: After the nurse evaluates/assesses the resident and a change in condition is noted, the nurse will promptly notify the provider and provide the provider with the resident's vital signs, physical assessment, lab results, etc. The nurse will notify the resident's responsible party (if appropriate) of the findings and any new orders and document. Chain of command when reporting: In the event of a change in condition, the team member is to immediately notify the nurse of the findings. If the nurse is unavailable, the team member should then, immediately notify the clinical manager. In the event the clinical manager is unavailable, the team member should then notify the on-call manager. Record review of the facility's Inservice meeting dated 08/07/2023 revealed 13 staff were trained on Change in Condition/Provider Notification and Quality Insurance Performance Plan. A review of all change in conditions in daily clinical meeting, check documentation completed, who noted the change in condition, timely notification to the provider, and follow-up with family/POA/resident. Record review of RN's Notice of Employee Separation dated 08/10/2023. She was terminated for unsatisfactory performance. It was determined that her actions constituted a violation of facility values, standards of conduct and other polices. Record review of the facility's Inservice meeting dated 08/15/2023 revealed 14 staff were trained on Change in Condition/Provider Notification. Quality Insurance Performance Plan. A review of all change in conditions in daily clinical meeting, check documentation completed, who noted the change in condition, timely notification to the provider, and follow-up with family/POA/resident. Record review of the facility's Quality Insurance Performance Plan begun on 10/01/2323 after all education was initiated. The Staff Development Coordinator conduct random weekly audits of 3-staff members that consisted of RNs/LVNs and CAs on what they would have done in a situation where there was a change in condition. Interview on 11/17/2023 at 01:55 PM LVN B stated she received training on reporting changes of condition, reporting change in condition: chain of command, abuse prevention, and abuse reporting. in-service medication administration and watched pass meds. Last weekend. And one during the week Interview on 11/17/2023 at 02:14 PM RN B stated she received training on reporting changes of condition, reporting change in condition: chain of command, abuse prevention, and abuse reporting. Attempts to contact RN were made on 11/03/2023 at 12:04 PM, 11/07/2023 at 03:59 PM, 11/07/2023 at 04:24 PM, and 11/16/2023 at 11:18 AM no answer and voice mail messages left.

Based on observation, interview, and record review the facility failed to provide pharmaceutical services including procedures that assure the accurate administering of all drugs to meet the needs for 5 of 5 Residents (#1, #2, #3, #4 and CR #5) reviewed for pharmacy services in that: Medication Aide (MA) failed to follow medication administration policies resulting in Resident #1, #2, #3, #4 and CR #5 receiving double doses of medication. MA failed to follow the posted medication administration schedule for Resident #1, #2, #3, #4 and CR #5. MA failed to document the start date for Resident #1, #2, #3, #4 and CR #5's medications. MA failed to monitor medication administration as CR#5 was discovered deceased with medications in his mouth. These failures could place all residents at risk of drug diversion, health decline, and/or death. The noncompliance was identified as PNC. The IJ began on [DATE] and ended on [DATE]. The facility corrected the noncompliance before the investigation began. These failures resulted in an IJ on [DATE]. While the IJ was past non-compliance, this failure could affect all residents who dependent on staff to administer medication. Findings included: Review of the Face Sheet for Resident #1 reflected a [AGE] year-old male admitted to the facility on [DATE] with diagnoses of essential (primary) hypertension (high blood pressure), atherosclerotic heart disease of native coronary artery without angina pectoris (thickening of heart arteries), insomnia, unspecified pain, peptic ulcer (sore on lining of stomach, intestines, or esophagus), acute or chronic, without hemorrhage or perforation. Record review of Resident #2's Face Sheet reflected a [AGE] year-old male admitted to the facility on [DATE] with diagnoses of Parkinson's disease (nerve disorder), hereditary and idiopathic neuropathy (disfunction of motor nerves), urge incontinence (frequent urination), atrial fibrillation (irregular heartbeat), and atherosclerotic heart disease of native coronary artery without angina pectoris (fat build up in arteries causing difficult blood passage). Record review of Resident #3's Face Sheet reflected an [AGE] year-old female admitted to the facility on [DATE] with diagnoses of Poly osteoarthritis (5 or more locations of arthritis), hyperlipidemia (hardening of arteries), gastro-esophageal reflux disease without esophagitis (stomach acid flows into the food pipe) , dizziness and giddiness, and repeated falls. Record review of Resident #4's Face Sheet reflected an [AGE] year-old male admitted to the facility on [DATE] with diagnoses of heart failure, hypertensive heart disease with heart failure paroxysmal atrial fibrillation (rapid heart rate associated with blood clots), gout (inflammation and crystallization of joints), and chronic obstructive pulmonary disease (airflow blockage). Record review of CR #5's Face Sheet reflected an [AGE] year-old male admitted to the facility admitted to the facility on [DATE] and deceased on [DATE] with diagnoses of acute on chronic systolic (congestive) heart failure, hypertensive heart disease with heart failure (high blood pressure). Review of Resident #1's Care Plan dated [DATE], reflected the following: Resident had a history of oxygen therapy, pacemaker/defibrillator, and diabetes. Resident received diuretics and to be monitored for dry mouth, constipation, low BP, and increased heart rate, spontaneous nose and diabetic bleeds, bleeding of gums, blood in sweat and urine, lethargy, paleness, and cold and clammy skin. Resident received psychotropics and to be monitored for sleepiness, drooling, increased confusion, restlessness, and change in posture, actions and expressions. Record review of Resident #2's Care Plan dated [DATE], reflected the following: Resident had a history seizure and required seizure precautions, shortness of breath, and complications with cardiac status. Resident was on anticoagulant therapy and needed assistance with bleeding precautions, administer medications per order, monitor for side effects to medications: blood shot eyes, red enlarged tongue. Resident took psychotropic drugs and was to be monitored for sleepiness, drooling, increased confusion, restlessness, and change in posture, actions and expressions and monitor resident's sleep patterns and report insomnia. Record review of Resident #3's Care Plan dated [DATE], reflected that resident had a history of seizures and required seizure precautions, with shortness of breath, and complications with cardiac status. Administer medications per orders. Resident on anticoagulant monitor for blood in my urine and stool, black stools, blood shot eyes, enlarged red tongue and monitor resident's sleep pattern and report insomnia. Record review of Resident #4's Care Plan dated [DATE], reflected that resident had a pacemaker, history with complications with cardiac status. Resident was on anticoagulant therapy and needed assistance with bleeding precautions, administer medications per order, monitor for side effects to medications: blood shot eyes and red enlarged tongue. Record review of CR #5's Care Plan dated [DATE], reflected that resident had a fatigue defibrillator. Monitor resident for side effect and interactions of medications and report spontaneous nose bleeds, bleeding of gums or blood in urine to nurse promptly. Administer medications per orders and monitor resident's sleep pattern and report insomnia. Review of Resident #1's MDS assessment, dated [DATE], reflected a BIMS score of 08 out of 15. The MDS reflected Resident's 1's primary medical condition category that best describes the primary reason for admission: Debility, cardiorespiratory condition. Review of Resident #2's MDS assessment, dated [DATE] reflected a BIMS score of 08 out of 15. The MDS reflected Resident #2's primary medical condition/reason for admission: Progressive neurological condition. Review of Resident #3's MDS assessment, dated [DATE] reflected a BIMS score of 04 out of 15. The MDS reflected Resident #3's primary medical condition/reason for admission: Medically complex condition. Review of Resident #4's MDS assessment, dated [DATE] reflected a BIMS score of 11 out of 15. The MDS reflected Resident #4's primary medical condition/reason for admission: stroke. Review of CR #5's MDS assessment, dated [DATE] reflected a BIMS score of 15 out of 15. The MDS reflected CR #5's primary medical condition/reason for admission: Debility, cardiorespiratory condition. Review of Resident #1's Incident Report dated [DATE] written by DON revealed that at approximately 10:30 p.m. MA reports to LVN A that she administered prescribed 9:00 p.m. medications to resident at 10:00 p.m. However, this resulted in a medication error because resident had received his medication prior by LVNA. Review of Resident #2's Incident Report dated [DATE] written by DON revealed that at approximately 10:30 p.m. MA reports to LVN A that she administered prescribed 9:00 p.m. medications to resident at 10:00 p.m. However, this resulted in a medication error because resident had received his medication prior by LVNA. Review of Resident #3's Incident Report dated [DATE] written by DON revealed that at approximately 10:30 p.m. MA reports to LVN A that she administered prescribed 9:00 p.m. medications to resident at 10:00 p.m. However, this resulted in a medication error because resident had received his medication prior by LVNA. Review of Resident #4's Incident Report dated [DATE] written by DON revealed that at approximately 10:30 p.m. MA reports to LVN A that she administered prescribed 9:00 p.m. medications to resident at 10:00 p.m. However, this resulted in a medication error because resident had received his medication prior by LVNA. Review of Resident CR #5's Incident Report dated [DATE] written by DON revealed that at approximately 10:30 p.m. MA reports to LVN A that she administered prescribed 9:00 p.m. medications to resident at 10:00 p.m. However, this resulted in a medication error because resident had received his medication prior by LVNA. Record review of Resident #1's [DATE] MAR reflected on [DATE] during 09:00 p.m. medication pass LVN A administered the following medications: Refresh Tears 0.5 % eye drops 1- drop both eyes for dry eye syndrome of bilateral lachrymal glands. Hydralazine 50 MG 1-tablet oral for atherosclerotic heart disease of native coronary artery without angina pectoris with bp ,d+[DATE] and heart rate 70. Trazodone 50 MG tablet (,d+[DATE] tab) oral for insomnia, unspecified. Record review of Resident #2's [DATE] MAR reflected on [DATE] during 09:00 p.m. medication pass LVN A administered the following medications: Tamsulosin 0.4 MG 1-capsule oral for urge incontinence. Lisinopril 20 MG 1-tablet oral for hypertensive heart disease without heart failure. atorvastatin 10 MG 1-tablet oral for hyperlipidemia, unspecified. Metoprolol tartrate 25 MG 1-tablet (oral for unspecified atrial fibrillation. DonepeziL 10 MG 1-tablet oral for unspecified dementia with behavioral disturbances. Eliquis 5 MG 1-tablet oral for long term (current) use of anticoagulants. Valproic acid 250 MG 1-capsule oral for unspecified mood effective disorder. Myrbetriq 50 MG 1-tablet, extended release 24 hour oral for major depressive disorder, single episode, severe without psychotic features. Record review of Resident #3's [DATE] MAR reflected on [DATE] during 09:00 p.m. medication pass LVN A administered the following medications: Memantine 10 MG1-tablet oral for unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. Eliquis 2.5 MG 1-tablet oral for atrial fibrillation. CarvediloL 12.5 MG tablet (1) for hypertensive stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease. Record review of Resident #4's [DATE] MAR reflected on [DATE] during 09:00 p.m. medication pass LVN A administered the following medications: Budesonide-formoterol HFA 160 mcg-4.5 mcg/actuation aerosol inhaler (2 puffs) HFA (hydrofluoroalkane) aerosol with adapter (gram) for chronic obstructive pulmonary disease, unspecified. Flomax 0.4 MG 1-capsule oral for benign prostatic hyperplasia with lower urinary tract symptoms. Colace 100 MG capsule (1) oral for constipation, unspecified. Oxcarbazepine 300 MG tab capsule for trigeminal neuralgia. Record review of CR #5's [DATE] MAR reflected on [DATE] during 09:00 p.m. medication pass LVN A administered the following medications: Carvedilol 3.125 MG oral 1-tab for hypertensive heart disease with heart failure with a recorded BP of ,d+[DATE] and pulse of 72. Ranolazine ER 1,000 MG tablet, extended release, 1-tab, for hypertensive heart disease with heart failure. Atorvastatin 80 MG 1-tab oral for hyperlipidemia, unspecified. ClopidogreL 75 MG 1-tab oral for atherosclerotic heart disease of native coronary artery without angina pectoris. Tamsulosin 0.4 MG capsule (1 cap) oral for benign prostatic hyperplasia without lower urinary tract symptoms. Benzonatate 100 MG capsule oral for cough. Remeron 15 MG tablet (1 tab) oral for muscle weakness (generalized)/weight loss. Interview on [DATE] at 01:15 PM Witness #3 stated that Resident #3 received a double dose of medication on [DATE]. He stated he was concerned that the resident as she was on anticoagulant blood thinners. He stated he expressed his frustration and displeased concerns with the NHA and the DON about the lack of competences in the staff who over medicated the resident. He stated the incident occurred because the facility was short staffed. He fears if a mistake was made again, the results may not be as favorable for the resident. Interview on [DATE] at 01:23 PM Resident #2 stated he had no issues from the double dose of medication. Interview on [DATE] at 01:29 PM Resident #4 stated that he could not recall receiving a double dose of medication and believes he was doing fine. Interview on [DATE] at 01:34 PM Resident #1 stated he had no issues from the double dose of medication. Interview on [DATE] at 01:43 PM DON stated that on [DATE] she received a telephone call from LVN A of drug diversion. She stated that CMA took a picture of Resident #1, #2, #3, #4 and #CR #5's MARs with her cellphone around 08:00 p.m. on [DATE]. She stated on or about 09:00 p.m. LVN A passed medication to Resident #1, #2, #3, #4, and CR #5. She stated sometime between 10:,d+[DATE]:30 p.m. CMA went to pass Resident #6 meds with the resident informed the CMA that she had already received her meds for the evening. She stated that CMA spoke to LVN A and confirmed LVN A had passed the 6 residents' medication at 09:00 p.m. She stated that LVN A called MD who requested a list of all the medications that were passed and ordered the staff to do follow-up vital checks and monitor the 5 residents for any adverse effects and bruises and bleeding. She stated that Residents #1, #2, #3, and #4 were all in stable conditions after follow-up checks by CMA and LVN A. She stated upon follow-up check of CR #5 LVN A found the resident non-responsive with no pulse, no BP, and partially undissolved medication in his mouth. She stated that CR #5 had been on a decline since admission. She stated he had weight loss, poor appetite, increased behaviors of agitation resulting in redirection, falls, and restlessness. She stated the family was scheduled to consult with hospice on [DATE]. She stated that the facility resolved the issue by terminating the CMA. She stated that the policy and procedures for med administration and reporting medication errors were reviewed by the NHA, ADON and herself and found to be effect when followed. She stated all CMAs, LVNs, and RNs were in-serviced by the ADON on med administration, medication error reporting, abuse and neglect reporting, and following floor assignments. She stated that the facility has never had any issues with staff following the medication administration, floor assignments policies in the past. She stated that the ADON and herself had implemented an on-going audit/monitoring system reviewing MARs, and observed MAs medication administration for a 3-month period and on-going as needed to ensure that the med administration and floor assignment process and procedures were followed. Interview on [DATE] at 03:35 p.m. NHA stated that on [DATE], LVN A notified the DON that a medication error occurred, and 5 residents may have received a second dose of their evening medications administered by the CMA. She stated that the DON informed staff to take vitals and monitor residents for adverse signs and symptoms. She stated that MD was immediately notified, and orders were provided to hold meds and monitor. She stated when LVN A went to perform a check on CR #5 he was found to be unresponsive and ultimately pronounced deceased . She stated that CR #5 had a pacemaker. She stated that resident's family had a consult with hospice providers prior to his passing. She stated they immediately began an investigation. She stated that CMA was suspended on [DATE] and terminated from employment on [DATE]. She stated to resolve the drug diversion the DON, ADON and herself reviewed the med administration and reporting medication errors which they found to be effect when followed. She stated all CMAs, LVNs, and RNs were in-serviced by the ADON on med administration, medication error reporting, abuse and neglect reporting, and following floor assignments. She stated that the DON and ADON had implemented an on-going audit/monitoring system reviewing MARs, observed medication administration by MAs constantly for a 3-month period and on-going as needed to ensure that the med administration and floor assignment process and procedures were followed. Interview on [DATE] at 05:00 PM MD stated he had been the MD for the facility for [AGE] years. He stated on [DATE] he received a text message from the DON stating that Resident #1, #2, #3, #4 and #CR #5 had received double doses of medication and MA B would be calling him. MD stated he instructed the facility to do immediate assessments on the 5 residents to ensure that their vitals were within range and that the resident had no adverse effects from the double doses. He stated that LVN A, and CMA began vital checks on the 5 residents. He stated he received another call back from LVN A that CR #5 was deceased and that partially consumed medication remained in his mouth. MD stated that CR #5's mediations: ranolazine, clopidogrel and benzoate were all low doses of .25 and the max doses were 3.5. He stated that the medication should not have cause the death of CR #5. He stated CR #5's cause of death was cardiac arrest. Interview on [DATE] at 02:23 PM Witness #4 stated that he learned that CR #5 received a double dose of his medication and was then found deceased . He stated that facility told him they were performing an investigation and he was waiting on the time frame from when the resident was given the medication until he passed. He stated that he had not made up his mind if he would be requesting an autopsy and he was not interested in doing that. He stated that the MD informed the facility the quantity of the medications that CR #5 received would not have killed the resident. Interview on [DATE] at 10:45 a.m. LVN A stated that on [DATE] she was scheduled from 03:00 p.m. to 11:30 p.m. and assigned to pass medication to 9 residents. She stated at 09:00 p.m. she began and completed passing medication to the 9 residents. She stated at 10:30 p.m. she saw CMA on the same hall coming out of Resident #6's room and heading into another resident's room passing medication. She stated she stopped CMA and asked what she was doing on hall and who told her to pass meds there. She stated that CMA told her, Everyone and threw her hands in the air, They told me to pass meds. She stated CMA did not given any one staff person's name as to who instructed her to pass meds on that same hall as her. She stated CMA told her she had not looked at the posted schedule. She stated she told CMA if she had looked, she would have seen that she was not assigned to that hall and informed her that meds were already passed to the resident there. She stated CMA told her that Resident #6 had just told her she had already received her meds. She stated that she immediate began comparing the MARs of the residents she passed meds to pictures CMA had on her phone of the resident's MARs. She stated it was confirmed that CMA had given a second dose of medication to Resident #1, #2, #3, #4, and CR #5. She stated CMA had taking photos of the resident's MARs sometime around 08:00 p.m. earlier in the evening with her cellphone and was working from the photos to pass medication. She stated she then called and informed the DON of the drug diversion. She stated that the DON instructed her to call the MD, immediately begin assessments on the 5 residents, and writing everything down to determine if any adverse effects occur from the double doses. She stated the MD was contacted and called back ordering residents be monitored and vitals checked. She stated Residents #1, #2, #3, and #4 were assessed and vitals checked with no adverse effects. She stated at 10:,d+[DATE]pm she entered CR #5's room she found him to have no rise in his chest and his mouth was jarred and she saw what appeared to be white and red colored medication still in the resident's mouth. She performed vitals and found the resident nonresponsive with no BP and no pulse. She stated resident received somewhere between 6 and 7 medications during med pass. She stated when she saw the resident during her 09:00 p.m. med pass, he in his bed alert with a good BP. She stated that she walked out the room, told the CMA B to assist her with end-of-life care and she called the MD and DON to relay CR #6's condition. She stated that RN B came to the room and too found the resident had no vitals and pronounced the resident deceased . She stated the CR #6's family came sometime after midnight. She stated CMA had screenshot the MARs because as they pass meds, the internet goes in and out in parts of the building and they are logged off the system. She stated they then have to go back by the nurse's station for the internet to pick back up and they are able to sign back in. She stated it was an inconvenient but not impossible. She stated management was aware of the issue and it was being addressed as far as she knows. She stated it was not an approved practice for staff to take pictures of the MAR with their phone to pass meds. She stated that she was a contact employee and [DATE] was her last scheduled shift with the facility and at 12:00 a.m. the electronic medical record system locked her out and she was unable to add notes to the system. She stated she had to handwrite her assessments from that evening and gave them to the DON. It was determined that the drug diversion/double dose of medication placed Resident #1, #2, #3, #4, CR #5 in an Immediate Jeopardy (IJ) situation on [DATE]. The NHA was notified and provided with the IJ template on [DATE] at 02:28 PM. The facility took the following action to correct the non-compliance on [DATE]: Record review of Resident #1's Nursing Note dated [DATE] written by NP revealed resident seen following-up with medication review as unfortunately resident had receive 2 doses of his 9 PM meds which were trazodone and hydralazine. Resident was seen earlier today in bed however at baseline resident usually does sleep later during the day. Reading his newspaper without any difficulties and denies any complication. Notes: Medication reconciled, and resident was monitored closely. At that time vital signs were normal, and he was eating without any difficulties. Resident continued with all of his medications as ordered. Follow-up in the a.m. Follow-up: 2 - 3 days. Record review of Resident #1's Nursing Note dated [DATE] written by NP revealed resident seen following up with overall status due to resident receiving a double dose of his p.m. meds 48 hours ago. Resident is up in his wheelchair without any complication. Noted eating without any difficulty. Notes: No adverse effects noted with medication error per staff. Resident is on hospice and will continue his hospice orders as written. Vital signs reviewed with staff and all within normal limits. We will continue to monitor closely. Notes: Not experiencing any adverse effects of the medication ever. Resident monitored closely and resident at baseline stayed in bed the majority of his day. Eat well and was without pain. Record review of Resident #2's Nursing Note dated [DATE] written by NP revealed resident seen following up with medication review. Unfortunately, there was a possible med error in which resident received 2 doses of his neck medication. At that time resident noted with difficulties but was wanting to sleep after his breakfast. Notes: Due to the med error, Eliquis was held that a.m. and p.m. donepezil, metoprolol, lisinopril, valproic acid and Myrbetriq's were held times 1 dose since resident received double dose in the [DATE] PM. Also, will be ordering a CBC, CMP along with valproic acid level. Staff ensured that resident received gabapentin only at midnight thus medication request he will that was double dose was his 9:00 meds. Resident monitored closely and vital signs were stable. Follow-up: 2 - 3 days. Record review of Resident #3's NP Nursing Note dated [DATE] revealed resident seen following up with medication review. Evidently staff and did give resident her 9:00 p.m. meds twice [DATE]: Namenda, Coreg and Eliquis were given. Resident was up in wheelchair doing therapy without any difficulty. Witness #3 reports of no complication. Resident was in good spirits. Notes: Again, resident without any complication after medication error. Eliquis was held. Follow Up: 2 - 3 days. Record review of Resident #3's NP Nursing Note dated [DATE] revealed resident seen following up with medication error per staff as it was noted that resident received a double dose of her 9:00 PM meds on [DATE]. Resident was seen up in her wheelchair without any complication. Eating much better. Witness #3 at bedside and also was accompanying resident throughout her stay during the day. Notes: No adverse effects noted. Vital signs reviewed with staff extensively and all are within normal limits. Follow-up: prn. Record review of Resident #4's NP Nursing Note dated [DATE] revealed resident received a double dose last night of budesonide, Eliquis, Colace, Flomax, Norco, nystatin, and oxcarbazepine. Eliquis was held this [DATE] a.m. Resident had no complications with the extra dose of medication given. Resident was stable and will resume all his meds this [DATE] p.m. Hospice notified, and resident continued to be monitored by the hospice team and continue with comfort and palliative care. Follow-up: 2 - 3 days. Record review of Resident #4's NP Nursing Note dated [DATE] revealed resident seen following double dose of his p.m. meds 48 hours ago. Resident was up in his wheelchair without any complication. Noted eating without any difficulties. No adverse effects noted with medication error per staff. Resident was on hospice and continued his hospice orders as written. Vital signs reviewed with staff and all within normal limits and resident was monitored closely. Follow-up: prn. Record review of Resident CR #5's handwritten Nursing Note dated [DATE] at 07:19 p.m. created by the LVN A. Resident returned from appointment with Witness #1. Assisted to dining room to eat with poor appetite. Resident put to bed 30 minutes later and tried to climb out of bed. Resident remained confused. LVN A walked resident around hall to calm. NP notified, incident report created, and resident monitored. Record review of Resident CR #5's handwritten Nursing Note dated [DATE] created by the LVN A revealed resident seen by cardiologist early in day with no new orders given. Resident viewed sitting up in his wheelchair the remaining of the day. At 10:50 p.m., LVA A entered resident's room to find resident without pulse, BP, or respiration. Resident code: DNR. The CMA last observed resident between 10:00 p.m. and 10:15 p.m. when he received his medications. RN B pronounced CR #5 deceased on [DATE] at 11:30 p.m. DON, MD, and family contacted. Record review of CR #5's Nursing Note dated [DATE] at 01:21 a.m. created by the DON. Resident had a change in condition. Refer to handwritten LVN A notes. Record review of CR #5's Nursing Note late entry dated [DATE] at 04:30 a.m. created by the LVN A. Head to toe assessment completed and vitals taken. No chest rise and respiration was zero. DON, MD, and family arrived. Family left before mortician picked up CR #5's remains at 03:14 a.m. Record review of CR #5's Nursing Note dated [DATE] at 04:54 p.m. created by the NHA. Family informed by NHA and DON facility performing an investigation due to medication error reported by LVN A after CR #5 received a double dose of medication on [DATE]. Review of Progress Note dated [DATE] written by MD B revealed Resident #1's Medical History: Bisacodyl 10 MG Suppository 1 suppository as needed, rectal once a day. Acetaminophen 650 MG Suppository 1 suppository as needed rectal every 6-hrs. Levsin (Hyoscyamine Sulfate) 0.125 MG tablet 1 tablet as needed orally every 4-hrs. Ondansetron Hydrochloric acid (HCI) 4 MG tablet 1 tablet orally every 4-hrs as needed. Morphine Sulfate (Concentrate) 20 MG/ML solution 1 ML as needed orally every 4-hrs. LORazepam 0.5 MG tablet 1 tablet orally every 6-hrs as needed. Taking Dutasteride 0.5 MG capsule 1 capsule orally once a day. Colace (Docusate Sodium) 100 MG capsule 1 capsule as needed orally once a day. Budesonide-Formoterol Fumarate ,d+[DATE].5 microgram/actuation (mcg/act) Aerosol 2 puffs Inhalation Twice a day. GenTeal Tears 0XXX,d+[DATE].3 % Solution as directed Ophthalmic. Miralax 17 GM Packet 1 packet mixed with 8 ounces of fluid Orally once a day. OXcarbazepine 150 MG Tablet 2 tablets at breakfast, lunch and bedtime, 1 tab before dinner oral as directed. Allopurinol 100 MG Tablet take 2 tablets by mouth daily oral. Eliquis (apixaban) 5 MG tablet 1 (one) tablet by mouth 2 times daily oral. Tamsulosin HCI 0.4 MG capsule take 1 capsule by mouth at bedtime oral. Ppantoprazole sodium 40 MG tablet delayed release take 1 tablet by mouth every day oral. HYDROcodone-Acetaminophen ,d+[DATE] MG tablet 1 tablet scheduled 5 x day and quaque (q) 6 needed as orally every 6 hrs. Review of Progress Note dated [DATE] written by MD B revealed Resident #2's Medical History: HYDROcodone-Acetaminophen ,d+[DATE] MG Tablet 1 tablet as needed orally every 12-hrs. Salonpas Lidocaine Plus (Lidocaine HCI-Benzyl Alcohol) ,d+[DATE] % cream patch externally daily. Melatonin 3 MG Tablet 1 tablet at bedtime orally once a day. Gabapentin 600 MG Tablet 2 tablet Orally nightly. Pepcid (Famotidine) 20 MG tablet 1 tablet orally once a day. Carbidopa-Levodopa ,d+[DATE] MG tablet 1 tablet orally 3 times a day. Taking Eliquis (Apixaban) 5 MG Tablet 1 tablet orally 2 times a day. Donepezil HCI 10 MG Tablet 2 tablet at bedtime orally once a day. Multi Complete (Multiple Vitamins-Minerals) - Capsule as directed orally. Metoprolol Tartrate 25 MG Tablet 1 tablet with food orally twice a day. Aspir-81 81 MG tablet delayed release 1 tablet Orally Once a day. Cholecalciferol 25 MCG (1000 international units) (UT) capsule 1 capsule orally once a day. Tylenol (Acetaminophen) 325 MG capsule 1 capsule as needed orally every 6-hrs. Preparation H (Phenylephrine-Mineral Oil-Pet) 0XXX[DATE].9 % ointment as directed rectal. Atorvastatin Calcium 10 MG tablet 1 tablet orally once a day. MiraLax (Polyethylene Glycol 3350) 17 GM/SCOOP powder 1 scoop mixed with 8 ounces of fluid orally once a day. Lisinopril 20 MG tablet 1 tablet orally once a day. Tamsulosin HCI 0.4 MG capsule 1 capsule orally twice a day. Azelastine HCI 137 MCG/SPRAY Solution 1 puff in each nostril nasally twice a day. Abilify (ARIPiprazole) 20 MG tablet 1 tablet orally once a day Lexapro (Escitalopram Oxalate) 20 MG Tablet 1 tablet orally once a day. Valproic Acid 250 MG capsule 1 capsule orally nightly. Myrbetriq (Mirabegron ER) 50 MG Tablet extended release 24-hr 1 tablet rally take in evening. Review of Progress Note dated [DATE] written by MD B revealed Resident #3's Medical History: Medical History: traMADol HCI 50 MG Tablet 1 tablet as needed orally once a day. Sennosides Docusate Sodium 8XXX,d+[DATE] MG Tablet 1 tablet orally once a day. Memantine HCI 10 MG Tablet 1 Tablet orally twice a day. Ferrex 150 (Polysaccharide Iron Complex) 150 MG Capsule 1 capsule orally twice a day. Carvedilol 12.5 MG Tablet 1 Tablet orally twice a day. Hydroxyurea 500 mg Capsule 1 tablet orally daily. Esomeprazole Magnesium 20 MG Capsule Delayed Release take 1 capsule orally daily. Losartan Potassium 100 mg Tablet 1 tablet Orally Daily. Apixaban 5 MG Tablet 1 tablet orally twice a day. amLODIPine Besylate 5 MG Tablet 1 tablet orally once a day. Escitalopram Oxalate 20 MG Tablet 1 tablet orally daily. Solifenacin Succinate 5 MG Tablet 1 tablet orally once a day. Review of Progress Note dated [DATE] written by MD B revealed Resident #4's Medical History: Bisacodyl 10 MG Suppository 1 suppository as needed rectal once a day. Acetaminophen 650 MG Suppository 1 suppository as needed rectal every 6-hrs. Levsin (Hyoscyamine Sulfate) 0.125 MG Tablet 1 tablet as needed orally every 4-hrs. Ondansetron HCI 4 MG Tablet 1 tablet orally every 4-hrs as needed. Morphine Sulfate (Concentrate [TRUNCATED]

Based on observation, interview and record review, the facility failed to ensure garbage and refuse was disposed properly for 1 of 1 dumpster reviewed for garbage disposal. -The facility failed to ensure the dumpster lids and doors were secured. This failure could place residents at risk of infection from improperly disposed garbage. Findings include: Observation on 06-14-23 at 8:45 am, with the Food Service Manager revealed the facility's dumpster area, which was in the lot behind the dietary department had a commercial -size dumpster and the lid and door were opened. Interview on 06-14-23 at 9:00 am, with the Food Service Manager she stated the dumpster lids always must be closed to keep vermin, pests, and insects out of the dumpster and from entering the facility. She also stated that she is responsible for all requirements be met in the Food Service Department. She will in-service the dietary staff on following Policy and Procedure for Garbage Disposal Record review of the facility policy and procedure revealed waste is disposed in a sanitary manner and in compliance with applicable federal, state, and local regulations. Procedure: All waste is disposed of in leak -proof, non- absorbent containers with tight fitting covers, and all containers are kept clean.

Based on observation, interview and record review, the facility failed to ensure that unnecessary antipsychotic medications were not administered without an adequate rational for use and the facility failed to reevaluate the use of a PRN [CONDITION(S)] drug for 1 of 6 resident's reviewed (Resident #9). - Resident #9 had a PRN order for [MEDICATION(S)] (an anti-anxiety medication) for more than 14 days without physician documentation re-evaluating the medication' to continue its use beyond the 14 days. - The facility failed to attempt a routine gradual dose reduction (GDR) for Resident #9's PRN [MEDICATION(S)], [MEDICATION(S)] and Trazadone. These failures could affect 14 residents receiving psychoactive medications by placing them at risk for adverse side effects due to unnecessary drugs. The findings were: A record review of Resident #9's face sheet dated 5/12/22 revealed a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included recurrent mild major depressive disorder, and anxiety disorder- unspecified. Record review of Resident #9 ' s Comprehensive Minimum Data Set assessment, dated 2/22/22, revealed Resident #9: -had moderate impaired cognitive status; -had trouble staying asleep or going asleep; -was sleeping too much and feeling tired or having little energy nearly every day; -had no hallucinations or delusions; -had no abnormal social behaviors and antianxiety medication once; -used an antidepressant medication 7 out of 7 days; -received no antipsychotic medications in the last seven days; and -gradual dose review and Drug Regimen Review section was not filled out. Record review of Resident #9's care plan dated 11/24/21 reflected in part .[MEDICATION(S)] 50mg daily and Trazadone 50mg at HS for depression: please monitor med side effects . I am on hospice care with following comfort medications for as needed: [MEDICATION(S)] 0.5mg and [MEDICATION(S)] 0.25mg as needed every 4 hours, for anxiety . Monitor side effects . The care plan did not address what behaviors to monitor or what type of medication side effects to monitor. A record review of Resident #9's Medication Profile Orders dated 5/12/22 revealed an order for: -[MEDICATION(S)] 0.25mg tablet given PRN every 4 hours for anxiety disorder, start date 5/13/21. -[MEDICATION(S)] 50mg tablet every morning for major depressive disorder, recurrent, mild, start date 11/15/19. -[MEDICATION(S)] 50mg tablet hour of sleep for [CONDITION(S)], start date 2/11/21. Record review of the Pharmacy Gradual Dose Reduction Tracking Log dated 3/14/22 and 4/18/22 for Resident #9 revealed: -PRN [MEDICATION(S)], last GDR request 7/19/21. Last GDR attempt was blank. -[MEDICATION(S)], last GDR request 11/1/19. Last GDR attempt 11/14/19. -Trazadone, last GDR request 5/2/19. Last GDR attempt 5/8/19. Last dosage increased 2/11/21. A record review of Resident #9's Medication Administration Record for April 2022 and May 2022 revealed she did not receive her PRN [MEDICATION(S)]. Record review of Resident #9 psych consult dated 9/11/21 revealed the case was closed because the resident was stable. An observation of Resident #9 on 5/10/22 at 12:13 p.m. revealed the resident was lying in bed, asleep. Another observation of Resident #9 on 5/10/22 at approximately 1:00 p.m. revealed the resident appeared drowsy while eating her lunch meal in the dining room with staff assistance. An observation of Resident #9 on 5/11/22 at 10:26 p.m. revealed Resident #9 revealed was sitting in her w/c in her room, alert and orientated x 2-3, (person, place, and general time). The resident requested to go to bed because she was tired. An observation of Resident #9 on 5/11/22 at 12:23 p.m. revealed Resident #9 was sitting up in her w/c in the main dining room with her eyes closed and appeared to be asleep. An interview on 5/12/22 at 11:33 a.m. the DON said she and the CNA's monitored medication side effects of anti-psychotropics and documented on a computer program. She explained that if a CNA marked yes, meaning any side effects, they would notify the nurse and the nurse would reassess for those side effects. The DON said the CNA's knew the medication side effects of the anti-psychotropics medications training provided. The surveyor requested from the DON the training provided for [CONDITION(S)] monitor completed by CNA's and not provided prior to exit. The DON said she was responsible for the pharmacy reviews and the gradual dose reductions. Interview on 5/12/22 at 12:26 p.m. with RN A (nurse manager) revealed the nurse staff were to monitor medication side effects on the 24-hour report if concerns were identified. She said if a nurse saw a change, they would also document the side effect into a nurse ' s note. RN A said there was no other place to monitor or document medication side effects except to make a nurse ' s note. In an interview on 5/12/22 at 12:30 p.m. LVN A said she was the floor nurse caring for Resident #9. The LVN A said Resident #9 was so good and did not need her PRN [MEDICATION(S)] for a long time. LVN A said when the resident was admitted to the facility, she was anxious. She said the nurse was to monitor and document medication side effects and behaviors in a nurse ' s note. She said she was not sure what medication side effects behaviors she was to monitor for use of Trazadone or [MEDICATION(S)]. Record review of Resident #9's nurse notes from 2/15/22 to 5/12/22. There was no nurse note related to the resident behavior, anxiety, or [CONDITION(S)]. Record review of the facility provided policy on Psychoactive Medications, dated June 2021, reflected in part .Psychoactive medication therapy shall be used only when it is necessary to achieve specific treatment goals. Once treatment goals have been achieved, residents on psychoactive medications will receive gradual dose reductions and behavioral interventions, as clinically indicated, in an effort to discontinue these medications . 1. All psychoactive medication orders will contain supporting documentation . The minimum documentation required includes a specific diagnosis or condition or a specific target behavior . If PRN antipsychotic medications has not been used within fourteen (14) days, should be discontinued . Sedative/ Hypnotics . The treatment results in maintenance or improvement of the resident's functional status without causing problematic side effects . Use medication daily for no more than 10 consecutive days unless an attempt at gradual dose reduction is unsuccessful

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen, in that: The refrigerator in the dining room had food items that were not properly labeled with use by dates. Can opener blade was greasy and had food debris. These failures could affect all residents who ate food from the facility's kitchen. Findings included: Observation of the facility 's dining room refrigerator and interview on 02/11/20 at 8:30 am with Dietary Manager revealed three opened containers of thickened liquid dairy milk, two thickened juices with no opened date and no used by date. The only date on the containers was 2/20 (February 2020, no day) when it was received by the facility. Food Service Director stated that the staff should have dated, labeled the containers with dates of when they were opened and with a used by date. The Food Service Director further said the date of 2/20 was when the facility had received the product. Observation and interview on 02/11/20 at 8:33 am revealed can opener blade and handle were greasy with food debris. Food Service Director stated the can opener be washed and sanitized after each used. She assigned a staff to wash and sanitize the can opener. Record review of facility's Food and Nutrition Services Policy and Procedure for Food Labeling and Dating read in part. All food and non-food supplies will be clearly labeled, and food items dated. Prepared foods with potentially hazardous ingredients and commercially processed foods with potentially hazardous ingredients must be labeled with a use-by-date. Record review of facility's Food and Nutrition Services Policy and Procedure Food Handling Sanitation dated 5/2012 read in part that cleaning schedules are established to assign specific cleaning tasks to scheduled staff on a daily and weekly basis.

Based on observation, interview, and record review, the facility failed to ensure it is free of medication error rate of less than 5 percent. There were 2 errors out of 32 opportunities which resulted in a 6 percent error rate involving two staff ( LVN #1 and RN #1) and two of seven residents (Resident #25 and 34 ) reviewed for medication errors, in that; LVN #1 did not administer [MEDICATION NAME] 100 mg to Resident #25 as ordered by the doctor. Based on observation, interview and record review, the facility failed to maintain an Infection Prevention and Control Program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for two of two residents (Resident #40, and #90 ) reviewed for infection control, in that; Findings included: Resident #90 Record review of Resident #90's admission face sheet revealed a [AGE] year-old female admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Observation of incontinent/indwelling catheter care on 02/26/20 11:11 AM revealed Resident #90 was lying in bed on her back with indwelling catheter to the bedside drainage with 100 cc of dark urine. Incontinent and indwelling catheter care was performed by CNA #2. CNA #2 using wet wipes , cleaned the groin area and did not clean the indwelling urinary catheter from the insertion site. CNA #2 changed gloves and did not use hand sanitizer or wash her hands. CNA # 2 repositioned resident to her right side, resident had bowel movement cleaned in between buttocks area, did not clean around the buttocks, without changing gloves, open the dresser drawer and picked up A&D ointment and a clean brief and was trying to place it on Resident #90. In an interview with CNA #2 2/26/20at 11:41 am., regarding Peri-Care/Foley Care training. When asked about peri-care / Foley care, She stated that she has been working as a CNA for approximately 9 years and initially received training when she first started working for the facility. When asked about when was the last time she received peri-care re-training, she could not remember the date. In an interview with the DON on 2/26/20 at 12:30 p.m. she said she has not done the competency training for incontinent care and has not had time to monitor the CNAs yet due to other commitments of training the new hires. Record review of Perry and Potter Clinical Nursing Skills and Techniques 6th edition, Chapter 8 page 192 revealed in part: .If hands are not visibly soiled, an alcohol-based hand rub should be used for routinely decontaminating hands in the following situation: 1. Before having direct contact with clients.3. After contact with intact skin.4. After contact with body fluids or excretions, mucous membranes, non-intact skin, and wound dressing.5. When moving from a contaminated body site to a clean body site during care. RN #1 failed to administer [MEDICATION NAME] Inhalation Suspension to Resident #34 according to pharmaceutical recommendation. These failures could affect any resident who receive their medication from facility staff RN#1 and LVN #1. Findings include: Resident #25 Record review of Resident #25 face sheet revealed a [AGE] year-old male admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Record review of Resident #25's admission MDS assessment dated [DATE] revealed the following: Resident #25 had BI[CONDITION] score of 10, indicating moderately impaired cognitive skills. Resident #25 was minimal dependent of staff for all ADL's. Record review of Resident #25 's physician order [REDACTED]. Record review of Resident #25's Medication Administration Record [REDACTED] Observation of medication administration with LVN #1 on 2/11/20 at 9:45 a.m. revealed, LVN #1 did not administer [MEDICATION NAME] with six other medications she administered orally to Resident #25 . Record review of Resident #25's printed electronic MAR indicated [REDACTED]. Resident #34 Review of the Admission Record dated 3/19/19 documented Resident #34 was a [AGE] year old male and [DIAGNOSES REDACTED]. Review of the significant change Minimum Data Set ((MDS) dated [DATE] revealed Resident #34 had a BI[CONDITION] (Brief Interview for Mental Status) of 14 out of 15 indicating moderate cognitive impairment. Record review of Resident #34's physician's orders [REDACTED]. Record review of Resident #34's MAR indicated [REDACTED]. Observation of medication administration for Resident #34 perform by RN # 1 on 02/11/2020 10:17 AM revealed RN #1 picked up [MEDICATION NAME] 0.5mg/2ml suspension 1 [MEDICATION NAME] in the nebulizer without shaking gently. ( [MEDICATION NAME] 0.5mg/2ml suspension had [MEDICATION NAME] 0.5mg/2ml suspension, shake gently, empty 1 [MEDICATION NAME] into nebulizer and inhale every 12 hours. Rinse mouth thoroughly after each use). Further observation on 2/11/202 at 11:09 a.m. revealed Resident #34 completed using [MEDICATION NAME] 0.5mg/2ml suspension inhalation, RN #1 disconnected nebulizer without resident rinsing his mouth. In an interview with RN #1 on 2/11/20 at 4:26 p.m. after showing Resident #34's packet for [MEDICATION NAME] 0.5mg/2ml suspension indicating shake gently and rinse mouth thoroughly after each use. RN # 1 confirmed she did not shake the suspension gently before use , did not rinse mouth thoroughly after each use but thanked surveyor because she was not aware of it. Record review of facility policy on administering medications revised date 04/2010 revealed medications shall be administered in a safe manner and as prescribed. Medications shall be administered in accordance with the orders, including any required time frame. If a dosage is believed to be inappropriate or excessive for resident or medication has been identified as having potential adverse consequences for resident expected of being associated with adverse consequences, person preparing or administering the medication will contact the attending physician or the facility ' s medical director to discuss this concern. The individual administering the medication must check the label 3 times to verify the right medication, the right dosage, the right time and right method throughout administration, before giving the medication. Record review of an online article retrieved from medicine net www.medicinenet.com > [MEDICATION NAME]-suspension_for_nebulizer > article [MEDICATION NAME] suspension for nebulizer revealed If an asthma attack occurs, use your quick-relief inhaler as prescribed. Other . Do not mix [MEDICATION NAME] suspension with other medications in the nebulizer. To prevent dry mouth, hoarseness, and oral yeast infections, gargle and rinse your mouth with water after each use.

Based on observation, interview and record review, the facility failed to maintain an Infection Prevention and Control Program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for two of two residents (Resident #14, and #39 ) reviewed for infection control, in that; CNA #1 did not perform appropriate hand hygiene during incontinent and catheter care on Resident #14. CNA #2 did not perform appropriate hand hygiene before and during incontinent care to Resident #39 These failures could affect residents who require incontinent and catheter care. Findings included: Resident #14 Record review of Resident #14's Face Sheet revealed he was a [AGE] year-old male who was admitted on [DATE] with [DIAGNOSES REDACTED]. Record review of the MDS dated [DATE] revealed a BI[CONDITION] score of 00 which indicated severe cognitive impairment. Further review of the MDS revealed Resident #14 was frequently incontinent of bowel with indwelling Foley catheter. Record review of the Care Plan for Resident #14 dated 8/6/19 revealed he had bowel incontinence and use an indwelling catheter. Interventions included: be kept clean, dry, and odor free. Resident #14 was to receive two-hour checks and was assisted with pericare as needed. Record review of the physician's orders [REDACTED]. Observation of incontinent/indwelling catheter care on 02/11/20 3:40PM revealed Resident #14 was lying in bed on his back with indwelling catheter to the bedside drainage with 100 cc of yellow urine. Incontinent and indwelling catheter care was performed by CNA #1. CNA # 1 using wet wipes , cleaned the groin area and did not clean the indwelling urinary catheter. CNA #1 did not change gloves. CNA # 1 repositioned resident to his left side, cleaned the buttocks area then placed a clean brief on Resident #14 without changing gloves .CNA #1 used the same glove throughout the procedure. In an interview with CNA # 1 at 4:00 p.m., regarding changing gloves, he said I always change gloves after finishing changing the resident. Resident #39 Record review of the Admission Record for Resident #39 revealed he was [AGE] years old admitted to SNF [DATE]20 with [DIAGNOSES REDACTED]. Record review of Resident #39's MDS assessment dated [DATE] revealed a BI[CONDITION] score of 01, indicative of impaired cognitive skills. The MDS revealed the resident was not able to make himself understood and understood others. Record review of the Care Plan for Resident #39 dated 1/26/20 revealed he had bowel incontinence and use an indwelling catheter. Interventions included: be kept clean, dry, and odor free. Resident #39 was to receive two-hour checks and was assisted with pericare as needed. Record review of the physician's orders [REDACTED]. Observation of incontinent/indwelling catheter care on 02/12/20 4:04PM revealed Resident #39 was lying in bed on his back with indwelling catheter to the bedside drainage with 200 cc of yellow urine. Incontinent care was performed by CNA #2 who was assisted by CNA #4 . CNA #2 using wet wipes cleaned the resident's groin area and cleaned the indwelling urinary catheter. CNA # 2 changed gloves without washing hands or using hand sanitizer then repositioned resident to left side. CNA #2 then cleaned the buttocks and surrounding, changed gloves again without preforming any hand hygiene. CNA #2 then placed a cleaned brief on the resident. In an interview on 2/12/2020 at 4:50 p.m., CNA #2 and CNA #4 were present . CNA #2 confirmed she did not wash hands or using hand sanitizer during incontinent care for Resident #39. CNA # 2 said she forget her hand sanitizer. Record review of CNA # 1 personnel file revealed the skill check off list did include a check-off for incontinent care and infection control. Record review of CNA # 2 personnel file revealed the skill check off list did include a check-off for incontinent care and infection control. In an interview on 2/12/2020 at 4:30 p.m., the ADON said the Development Coordinator was responsible for staff in-services, monitoring and ongoing training along with audits. In an interviewed Development Coordinator immediately following above interview with ADON, the Development Coordinator said the staff receive yearly clinic training where they go to different stations to re-demonstrate how to continue caring for residents. Development Coordinator said the staff will also receive training within their first 90 days of hire, 3 preceptorships and one on one online training as needed. Development Coordinator said the facility did not have any policy regarding gloves changes . Record review of Perry and Potter Clinical Nursing Skills and Techniques 6th edition, Chapter 8 page 192 revealed in part: .If hands are not visibly soiled, an alcohol-based hand rub should be used for routinely decontaminating hands in the following situation: 1. Before having direct contact with clients.3. After contact with intact skin.4. After contact with body fluids or excretions, mucous membranes, non-intact skin, and wound dressing.5. When moving from a contaminated body site to a clean body site during care.

Based on observation, interview and record review, the facility failed to complete a resident assessment using the quarterly review instrument specified by the State and approved by C[CONDITION] not less frequently than once every 3 months for 1 of 12 residents (Resident #1) reviewed for quarterly assessments in that: Resident #1's quarterly assessment was not completed. This failure could affect all residents who may require quarterly MDS assessments Findings include: Record review of the face sheet for Resident #1 revealed an [AGE] year old female admitted on [DATE]. Her [DIAGNOSES REDACTED]. Record review of Resident #1's MDS assessments revealed that an annual MDS was completed on 08/26/19. Further review of her MDS revealed no quarterly MDS was completed in November 2019. Review of her MDS assessments on the computer revealed her quarterly dated 2/4/20 was current and not accepted or signed. Observation and Interview with Resident #1 on 2/12/20 at 9:07am revealed her in the hallway self-propelling herself in the wheelchair. She was well groomed and appeared to be in good mood. She said she was doing well and had no concerns. Interview with ADON on 2/12/20 at 9:15am, she said she was the MDS coordinator before she became the ADON. She said that she was the one doing MDS for Resident #1 before they hired an MDS coordinator. When asked about the missing quarterly for Resident #1 she said she doesn't know what happened to it, i couldn't tell you. She said they did have corporate assisting with MDS at one point but if they did do it, it would be on the computer so if it wasn't there then it probably was not done. She said she does know that quarterly's need to be done every 3 months. Record review of the facility's policy for MDS completion and management dated 08/2019 read in part, .a quarterly MDS is to be completed by the team on each resident who remains in skilled nursing .the MDS coordinator or designee will transmit all MDS assessments in compliance with state and federal guidelines .

Based on observation, interview, and record review, the facility failed to implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment plan of care for 1 of 3 residents (Resident #39) reviewed for comprehensive care plan, in that: Resident #39 's order to have boot to left heel at all times was not implemented as ordered by the physician . The failure could affect any who require physician orders [REDACTED]. Findings included: Resident #39 Record review of the Admission Record for Resident #39 revealed he was [AGE] years old admitted to SNF [DATE]20 with [DIAGNOSES REDACTED]. Record review of Resident #39's MDS assessment dated [DATE] revealed a BI[CONDITION] score of 01, indicative of impaired cognitive skills. The MDS revealed the resident was not able to make herself understood and understood others. Record review of Resident #39's Care Plan dated [DATE], revealed boot on in bed and 2 hours when sitting in wheel chair to allow. The Care Plan revealed Provide treatment per physician order. Record review of physician's orders [REDACTED]. Observation on 02/11/20 at 09:30 AM revealed Resident #39 was sitting on the high back w/chair with CNA #3 at bedside. Resident had socks on. Observation 02/11/2020 around noon ( lunch times) revealed the resident was wheeled to the dining area by CNA #3 with sock on. Further observation 2/11/20 at 4:04 p.m. during incontinent care revealed the resident was lying in bed and did not have boot to left heel boot . Bilateral heels were on pillows. Observation on 2/12/20 at 8:45 a.m. revealed Resident #39 sitting on a high back wheel chair with no boot on the left heel. Observation and interview on 2/12/2020 at 11:42 a.m., CNA #3 was asked to remove Resident #39's sock for observation, CNA #3 took off sock on the heels of Resident #39 revealing an eschar and redness to bilateral heels. Observation and interview on 2/12/20 at 3:00 p.m. revealed Resident #39 was lying in bed asleep. The resident had no boot to left heel and heel was not off loaded while in bed. In an interview with LVN # 2 after observing Resident 2's heel, she said the heels were pressing in the bed, it should be off loaded. LVN # 2 said she was not aware of the left heel boot at times order for Resident #39 . She said she would have to check the order and care plan. LVN # 2 was shown the physician's orders [REDACTED]. LVN # 2 said she would have to order the boot and check Resident # 39's room. Further observation at 4:00 p.m. revealed LVN # 2 found Resident#39's left heel boot on the residents second parked wheel chair near the window. In an interview with the facility NP ( Nurse Practitioner) on 2/12/20 at 4:30 p.m. she said she signed the order for the use of [REDACTED]. In an interview with ADON on 12/12/20 at 5:00 p.m., facilities policy and procedure for implementing physician order [REDACTED].

Based on interview, and record review, the facility failed to immediately consult with the physician when the resident experienced a change in condition for 1 of 4 resident (CR #1) reviewed for notification of changes, in that; CR #1's physician was not promptly consulted when CR#1 had difficulty in breathing on the morning -day shift of [DATE] . CR#1's family member requested physician consult on the evening of [DATE] after CR#1 notified family member multiple times. CR #1's physician was not promptly consulted for an update when CR#1 exhibited altered mental status during night shift of [DATE] and during morning shift of [DATE]. CR #1's physician was not promptly consulted CR#1 did not eat breakfast on [DATE] , continued to complain of difficulty with breathing and not feeling well . CR#1 was found unresponsive 2 hours later in his bed, he was then transferred to a local hospital where he died . An immediate jeopardy was identified on [DATE]. While the IJ was lowered on [DATE], the facility remained out of compliance at a scope of isolation and a severity of actual harm that is not immediate jeopardy due to the facility requiring more time to monitor the plan of removal for effectiveness. This failure affected 1 former resident and placed other facility residents at risk of delay in needed care and treatment necessary to prevent decline in health. Findings include: CR #1 Record review of CR #1's Face Sheet dated [DATE] revealed an [AGE] year-old male admitted to the facility [DATE] and discharged on [DATE]. His [DIAGNOSES REDACTED]. Record review of CR #1's Admission MDS dated [DATE] revealed he entered from an acute hospital. His BIMS score was 15 indicating in-tact cognition. He had no signs and symptoms of [MEDICAL CONDITION]. He was coded as feeling tired or having little energy ,[DATE] days out of the 14-day look back period. He required limited assistance of one person for locomotion on the unit via wheelchair and between limited assistance to extensive assistance for ADLs. His active [DIAGNOSES REDACTED]. He rated his worst pain over the last 5 days as a 6 out of 10. He had no signs and symptoms of a possible swallowing disorder and was coded as having a regular diet with thin liquids. He had a stage 2 pressure ulcer present upon admission and 2 unstageable pressure injuries. He was not coded as being on oxygen therapy. Record review of CR #1's Care Plan dated [DATE] revealed My sleep pattern is: I sleep throughout the night. Further review revealed he required two + persons physical assist to ambulate. There was a handwritten note dated [DATE] that said, Refer to speech therapy for swallow evaluation. Another note dated [DATE] said Risk for aspiration due to swallowing difficulties. Another note dated [DATE] revealed Nectar thick liquid per patient request. Further review revealed I need to sit frequently to rest when ambulating daily. I will need assistance from the aide to follow oxygen safety. My nurse will assist with the reduction and/or elimination of factors that will impact my breathing or cardiac status. I will adapt my lifestyle to my level of energy I maintain or achieve a minimal increase in activity tolerance will remain free of preventable discomfort and/or complications. The goal said, I will not have any complications this review period. Under shortness of breath it read n/a. Further review revealed I have a pacemaker (in care approaches document pacemaker check information. There was no care approach for the pacemaker. Record review of CR #1's physician's orders [REDACTED]. - Tylenol 325 mg, two tablets by mouth every 4 hours as needed ordered on [DATE] - magnesium 64 mg tablet, two tablets daily ordered on [DATE] - omega 3 fish oil, three soft gels daily ordered on [DATE] - vitamin b capsule, one capsule ordered on [DATE] - Eliquis 2.5 mg, one tab daily ordered on [DATE] - [MEDICATION NAME] 200 mg, one tablet daily ordered on [DATE] - [MEDICATION NAME] 250 mg, one tablet twice a day ordered on [DATE] - azelastine 137 mcg, one spray per nostril twice a day ordered on [DATE] - [MEDICATION NAME] 50 mcg, one spray per nostril twice a day ordered on [DATE] - [MEDICATION NAME] 50 mcg, one tablet daily ordered on [DATE] - pantoprazole 50 mg, one tablet daily ordered on [DATE] - [MEDICATION NAME] 75 mg, one tablet daily ordered on [DATE] - [MEDICATION NAME] 5 mg, one tablet daily ordered on [DATE] - [MEDICATION NAME] 20 mcg subcutaneous daily was handwritten on the MAR indicated [REDACTED] - [MEDICATION NAME] 10 mL every four hours as needed ordered on [DATE] - [MEDICATION NAME] XXX,[DATE] mg every 6 hours as needed ordered on [DATE] - Oxygen 2 L nasal canula continuously every night ordered on [DATE] Record review of CR #1's Nursing Note dated [DATE] revealed Guest is stable, alert and oriented times 4. able to verbalize his needs, took all scheduled meds with chocolate pudding, on [MEDICATION NAME] BID last dose given, no adverse reactions noted, ate breakfast and lunch in bistro with good appetite. The note was signed by LVN #1. Record review of CR #1's Nursing Note dated [DATE] revealed Guest is alert and oriented times 4. able to verbalize his needs, took all scheduled meds with chocolate pudding, on [MEDICATION NAME] BID last dose given, no adverse reactions noted, ate breakfast and lunch in bistro with good appetite. The note was signed by LVN #1. During an interview on [DATE] at 8:55 am LVN #4 said she was the charge nurse on [DATE] from 4 pm to 12:30 am. She said she could not recall the nurse she received report from, but they told her he didn't look too good. She said she checked on him and he said he wasn't feeling too great but the doctor was coming to visit him. She said Physician A visited and wrote orders for scheduled breathing treatments and [MEDICATION NAME]. She said he got up around dinner time but went back to bed shortly after. She said, I don't think he ate too much that day his appetite wasn't too great. She said some family members had visited with him that night. She said he did not have any trouble sleeping, changes in condition, or anything out of the ordinary. She said she believed he had oxygen, but she did not go into his room during the night. Record review of CR #1's Physician Note dated [DATE] revealed Per staff, patient with anxiety, (family member) and patient asked to be evaluated. Per patient, (family member) here earlier and patient with shortness of breath. When relaxed slowly went away. (Family member) thought having anxiety and thought he would benefit from a benzo. Per patient shortness of breath comes and goes has been the same, taking nebs about once a day and helps. Patient describes getting restless and shortness of breath. Feels anxious at times but not depressed. Biggest issue is not sleeping at night . just cannot get settled and relaxed. The plan revealed unclear episodes, describes [MEDICAL CONDITION] as contributing factor but has been feeling anxious. Appetite has been variable. Would like to avoid benzos may try [MEDICATION NAME] to help address sleep first for the anxiety. Further review revealed nebulizer treatments three times a day for the shortness of breath. The note was signed on [DATE] at 7:23 pm by physician [NAME] Record review of CR #1's physician's orders [REDACTED]. - [MEDICATION NAME] treatment three times a day ordered on [DATE] . ([MEDICATION NAME] is a sterile inhalation solution containing a combination of [MEDICATION NAME] and [MEDICATION NAME]. [MEDICATION NAME] and [MEDICATION NAME] are [MEDICATION NAME][MEDICATION NAME] that relax muscles in airways and increase air flow to the lungs) - Oxygen therapy at 2L/min via nasal canula as needed for oxygen saturation less than 90% by pulse ox and notify MD on [DATE] Record review of CR #1's MAR (MONTH) 2019 revealed the following medications were held on [DATE] because the resident did not feel good: magnesium, omega 3 fish oil, vitamin b capsule, Eliquis, [MEDICATION NAME], and [MEDICATION NAME]. Further review of MAR indicated [REDACTED]. Record review of CR #1's MAR indicated [REDACTED]. Both orders were signed indicating they were administered. The PRN nebulizer treatment ([MEDICATION NAME] XXX,[DATE] mg every 6 hours as needed ordered on [DATE]) was administered for the only time that month. Tylenol was administered at 8 am for the second time that month. PRN [MEDICATION NAME] was administered for the 6th time that month. PRN oxygen was not signed off as administered any time during the month. Record review of CR #1's Vital Signs dated [DATE] revealed the following: Pulse Ox - 98%, Blood Pressure - ,[DATE], Pulse - 78, and temperature 98.1 degrees Fahrenheit. They were entered by CNA #5. Record review of CR #1's Vital Signs dated [DATE] revealed the following: Pulse Ox - 98%, Blood Pressure - ,[DATE], Pulse - 65, and temperature 97.3 degrees Fahrenheit. They were entered by CNA #5. During an interview on [DATE] at 10:43 am CNA #6 said she was assigned to CR #1 from 3 pm - 11 pm on [DATE]. When asked about his condition she said He was the same when I was working with him but his cough was heavy that day. She said, he always eats and usually ate dinner in the dining room. She said she remembered he didn't eat one day but couldn't recall if it was Friday [DATE]. During an interview on [DATE] at 3:18 pm RN #1 said she could not remember the last time she worked with CR #1. She was asked if she recalled writing the nurse's note read out to her and said, if that's what I wrote, then that's what it was. When asked if she recalled any changes in condition during that time she said, If there were any changes I would have definitely documented in the nurse's note. Record review of CR #1's Nursing Note dated [DATE] revealed Guest complained of sore throat and coughing this AM. PRN [MEDICATION NAME] 10 mL was administered twice. The doctor was informed and aware, but no new orders. The note was signed by RN #1. During an interview on [DATE] at 11:10 am LVN #3 said he possibly worked that night on [DATE]. He said he worked as needed from 11 pm - 7:30 am. He said the last time he worked with him he was fine. When asked if he remembered specifics of the last time working with CR #1 he said he remembered he wanted his bed fixed to go to sleep. When asked if he had oxygen on he said, I don't think so because he wasn't in distress. He said to look on the 24-hour report for any updates on CR #1. During an interview on [DATE] at 5:00 pm, CNA #4 said she worked the 11 pm - 7 am shift on [DATE] and was assigned to CR #1. She said when she did rounds at 11 pm he was awake and lying in bed. She said she did not receive report from the previous CNA about any changes in his condition. She said he had not been short of breathing and his coughing had been reduced. She said he did not have any changes that night, but he did ask for his room to be cooler around 2 am. She said she turned the air conditioner down from 74 degrees to 72 degrees. She said around 6:45 am she answered his call light and he asked to be dressed. She said she got him dressed and in his wheelchair by 7 am. During an interview on [DATE] at 11:10 am LVN #3 said he possibly worked that night on [DATE]. He said he worked as needed from 11 pm - 7:30 am. He said the last time he worked with him he was fine. When asked if he remembered specifics of the last time working with CR #1 he said he remembered he wanted his bed fixed to go to sleep. When asked if he had oxygen on he said, I don't think so because he wasn't in distress. He said to look on the 24 hour report for any updates on CR #1. Record review of CR #1's Nursing Note dated [DATE] entered at 3:31 pm revealed Resident found unresponsive at 10:30 am. CPR initiated, 911 called, family notified, (family member) at bedside and resident transported to (hospital) via ambulance at 11:00 am. The note was signed by LVN #1. Record review of CR #1's Emergency Department Provider Note dated [DATE] revealed Patient brought in by EMS from nursing home. Called out for respiratory distress, patient apneic and pulseless. CPR times 4 cycles and 3 epis' given, patient intubated. Patient achieved ROSC prior to arrival. Further review revealed [AGE] year-old male with pmhx of CAD presents to the ED with c/o [MEDICAL CONDITION]. The patient was being brought to the ED post-[MEDICAL CONDITION] when he arrested again while in route to the ED. Patient's initial [MEDICAL CONDITION] was at 10:35am this morning; EMS states that they treated the patient from 10:43am to 11:03am with a return in pulse. Patient is pulseless on arrival to the ED. Patient has a pacemaker in place. Associated symptoms included chest pain and difficulty breathing. During an interview on [DATE] at 11:50 am, CNA #5 said she worked with CR #1 often and he required assistance with dressing and transfers and wheeled himself to the restroom and around the facility. She said she was assigned to CR #1 on [DATE] and [DATE] on the 7 am - 3 pm shift. She said on [DATE] CR #1 was fine. He did tell her I think I didn't sleep well or something but other than that he was normal. She said on the morning of [DATE] she checked his vitals and they were normal. She said that morning CR #1 told her I have a headache, I don't feel very well today. She said she told the nurse who gave him pain medication. She said on that day he was sleepy which was not like him. He did not get up for breakfast and only ate a little of the tray that was delivered to him which was not like before. She said, he always eats well. She said a couple of his family members came by to visit him. She said after the visitation she checked on him and he still was feeling bad. She said she asked him if he needed his oxygen and he said yes. She said he did not ask for his oxygen often but put it on him which made him feel better. She said he was in bed the rest of her shift, but she checked on him frequently. At the end of her shift on her final round she asked how he felt, and he still complained of not feeling well. She said she told the nurse on duty. During a telephone interview on [DATE] at 10:45 am, CR #1's family member said CR#2 was admitted to the facility after he had an incident with his pacemaker. She said before, he was very independent and drove himself around. Following the incident, he was wheelchair bound, incontinent, couldn't walk, and required a catheter. She said he always had a good appetite and gained weight while in the facility. She said she and other family members visited him daily. She said he usually went to therapy after breakfast or would stay up in his wheelchair and was only in bed at night. She said him requesting oxygen was normal previously, but he had been weaned off. She said she was not aware he had scheduled oxygen at night. She said he had been taken off the breathing treatments about a week before he passed and was unaware he was put back on them. She said to her knowledge any treatments were supposed to be on an as needed basis. She said he never refused medications or asked for them later except for his requip for his restless leg syndrome. She said he could only receive so much of the requip in a day so if he was not having symptoms he would ask them to hold the medication until later. She said on [DATE] CR #1 called her ,[DATE] times and said he was having trouble breathing and needed to do something. CR #1 told her Something is wrong, I don't feel good, I'm having trouble breathing, I'm waiting on the nurse. She told him to put his call light on and CR #1 said I have they haven't come. She said she went to the facility because he was calling so much, and hyperventilating. She said she never saw him like that and described him as significantly different. She requested the doctor get involved and left around lunch time. She said she was not present when Physician A saw him, but they felt he was having a panic attack. She was informed that Physician A ordered an antidepressant and they were supposed to be monitoring him very carefully. She and another family member came back that night and he was feeling better but felt he had another panic attack before their arrival. She said around 8 pm he said he was really tired and wanted to rest so they left before he was put into bed. She said on the morning of [DATE] she had not heard from him and got a call before 11 from facility staff informing her he was in the process of being coded. She said he was pronounced dead at the hospital. She said she came to the facility that day along with other family members to gather his belongings. She said she was standing in the hallway when approached by Resident #2 who was a friend of CR #1. He told her CR #1 was not feeling good that morning and wanted to go back to sleep so he pushed CR #1 back to his room. She said she was shocked when CR #1 and Resident #2 developed a friendship because CR #1 had a way with words. She said she told Resident #2 that CR #1 passed away and he sat in the hallway for a while with his head down. During an interview on [DATE] at 11:03 am LVN #1 said she was the charge nurse on [DATE] from 8 am - 4:30 pm. She said she received report during shift change that CR #1 did not sleep well from a PRN nurse who she could not recall. She said he was already up in his wheelchair when she arrived, and he went to breakfast and ate between 50% - 75% of his meal and normally ate between 75% - 100%. Following breakfast Resident #2 informed her CR #1 was not feeling good and he wanted to go bed, so CNA #2 took him to his room. She and CNA #2 got him back in bed around ,[DATE]:30 am via the transfer board. She said CNA #2 took his vitals and she redid them and wrote them in the nursing note. She was informed there were no vitals in the note and said she wrote them on the MAR. She confirmed the vitals were b/p, pulse, o2 saturation ,[DATE] pulse 61. 92%. She said his vitals were normal for after breakfast. She said he began coughing and administered a breathing treatment and 2L of oxygen via nasal canula at his request. When the physician order [REDACTED].#2 who tried to administer his morning medications, but he requested she return in one hour which was normal. She said shortly after while doing rounds she saw him lying in bed pale and called for him, but he was unresponsive. She called for CNA #2 who ran to get two other CNAs. The CNAs put CR #1 on the floor and she took the vitals. She said he was cold and Couldn't find anything when he was on the floor. Thing rang zero which indicated the blood pressure apparatus had a zero reading when it checked. CPR was initiated and within ,[DATE] minutes EMS came and took over CPR and she took over the bag. CR #1's family members were called. He was intubated and put on IV and breathing before he left. She said he did not complain of pain that day. When informed that the MAR indicated [REDACTED]. I gave him Tylenol and it's PRN? I don't remember this. I don't remember him telling me he was in pain. Nothing changed that day. She said nothing from the day was a change in condition. I did my assessment, and everything was okay, so I didn't see a need to call the doctor. She further stated, I don't need to call the doctor that's why I'm here. She said on [DATE] Physician A came to assess CR #1 because he was complaining to his family member about his restless leg syndrome. During a telephone interview on [DATE] at 1:07 pm, LVN #2 said she was CR #1's nurse on [DATE]. She said received report when she arrived at 7 am from the previous nurse that CR #1 was not acting like himself. She said he was talking and saying things that didn't make sense and did not sleep well. She said he stayed in bed all day and did not believe he was dressed. She said he did not eat breakfast because he did not have an appetite. He had a really bad cough that day. She said when passing medications around 8 am or 9 am he was asleep in bed. She said she asked him if he wanted his medications then or if she should return in an hour. She said he requested she return in an hour because he was tired. She said she still administered his requip, blood pressure medication, and heart medication because those were important. She said around 9:15 am she took the breathing treatment of [REDACTED]. She said he did not have on oxygen underneath the breathing treatment. When asked if an assessment was completed following the breathing treatment she said she believed LVN #1 completed it. She said she was checking on CR #1 between other residents and last saw him between 9:30 am and 9:40 am. She said he was responsive but resting. She said the next thing she saw was him being transferred to the floor and CPR being initiated. She said she was not informed by CNA #2 of abnormal vitals from that morning. She said he had not had a change in condition, so the doctor was not notified. During an interview on [DATE] at 3:27 pm CNA #2 said she was assigned to him CR #1 on [DATE]. She said when she arrived for her shift at 7 am, CNA #4 already had him dressed and in his wheelchair. She said she noticed he was drowsy and feeling tired and checked vitals around 7:30 am. She could not recall the vitals but thought his oxygen was very low. CNA#2 said she could not recall the exact number. CNA #2 also said CR#2's oxygen saturation was below 90 because oxygen saturation of 90 was okay. She said she gave the vital signs sheet to LVN #2 but was not sure if LVN #2 followed up. She said after breakfast she saw Resident #2 pushing CR #1 in his wheelchair from breakfast. CNA #2 said Resident #2 told her that CR #1 was not feeling good . CNA #2 said she would take over and pushed CR#1 to his room. She said CR#1 ate less than 25% of his breakfast. She said with the help of LVN #1, they put him back in bed. She said she reported to either LVN #1 or LVN #2 hey it's something going on because he never got back in bed after breakfast. She said she took his vitals and could not recall the numbers but believed his blood pressure was high. CNA #2 said LVN #1 told her she would put oxygen on him. She said after some time, she saw staff getting him out of the bed and called for help. She said he still had the mask on. She was asked what would be considered a change in a resident's condition, but she was unable to provide an example. During an interview on [DATE] at 9:35 am, Resident #2 said he would see CR #1 at dinner sometimes, but they weren't really friends. He said, he was a very sick man. But had no knowledge of his death until the next day. During an interview on [DATE] at 3:27 pm, CNA #2 said she took CR#2's vital signs at 7:30am on [DATE] and after breakfast when CR#2 complained of not feeling well and did not eat breakfast. However, no record of these vital were found or provided as requested. During an interview on [DATE] at 3:45 pm LVN #1, said vital sheets are kept in a binder at the nursing station. The vitals for CR #1 on [DATE] were requested. We walked over to the binder. She flipped through the binder which was separated by the day of the month. There was nothing behind 20th day. She said the vitals from last month were already pulled and she would look for them. During an interview on [DATE] at 4:15 pm with the DON , the handwritten vitals sheet filled out on the 20th for CR #1 was requested from the DON. Several minutes later DON provided a printed out copy of vitals. The handwritten vitals for CR #1 was again requested. She said they don't document on a handwritten form, they document in the computer. When informed there was a binder at the nurse's station with daily vitals documented by the CNAs she said, we can go see. The DON looked at the binders located on the nurse's station and retrieved the one that said VITALS. She flipped through it and said Yeah, this isn't an official document but she would look for the previous months. During an interview on [DATE] at 4:20 pm the DON was again asked for the handwritten vital sheet. She said the vitals were transferred from the sheet into the computer and shredded. Record review of CR #1's Vital Signs dated [DATE] entered at 1:15 pm revealed the same vitals from on the incident report: Respirations - 18, Pulse Ox - 90%, Blood Pressure - ,[DATE], Pulse - 71, and temperature 97 degrees Fahrenheit. The vitals were input by CNA #2. Record review of CR #1's clinical record between 8:00pm on [DATE] and 10:00am on [DATE] revealed no documentation regarding notification to the physician regarding lack of appetite, lethargy, abnormal vitals, or change in respiration. Record review of Provider Investigation Report dated [DATE] revealed Resident was sent to hospital after being found unresponsive in his room on [DATE]. The investigation summary revealed [DATE] resident went to breakfast as usual. When returned to bed, morning medication was provided along with a breathing treatment. During rounds, nurse noted resident to be unresponsive. Nurse assessment noted resident did not have a pulse. CPR was initiated and 911 notified. Family and MD notified. Resident was transported to ER via ambulance and later was pronounced dead at the hospital. Resident history revealed: history of shortness of breath, currently taking breathing treatments, most recent [DIAGNOSES REDACTED]. Emergency doctors reported resident experienced a [MEDICAL CONDITION] related to patient history of CAD. The facility completed an in-service on emergency procedures and followed up with CR #1's family. The attached in-services included abuse prevention/reporting and change in condition charting and notification. During an interview on [DATE] at 9:46 am the Administrator and DON were both present. The Administrator said on [DATE], CR #1 received a breathing treatment; the nurse came back after 20 minutes and found him unresponsive. 911 was called and CPR was initiated. During a telephone interview on [DATE] at 12:04 pm, Clinical Manager said she could not recall CR #1's condition on Friday and did not see him on Saturday. She began gathering details of the incident, interviewing staff, and getting all facts and completed the incident report. On [DATE] at 4:08 pm an interview was attempted with Physician [NAME] He was not in the office. A message was left with the receptionist. On [DATE] at 10:18 am an interview was attempted with Physician [NAME] He was not in the office. A message was left with the receptionist. On [DATE] at 1:00 pm an interview was attempted with Physician [NAME] He was not in the office. A message was left with the receptionist. Record review of CR #1's clinical between 8:00pm on [DATE] and [DATE] record revealed no documentation regarding notification to the physician regarding pain, change in respiration, or not feeling well. During an interview on [DATE] at 1:00 pm the DON said anything unusual was documented on the 24-hour report and stays on there until it was resolved or no longer pertinent. She said they were shredded at the end of the week and was not a form used as part of the medical record. She said nurses transcribe the notes from the 24-hour report into a nurse's note. She said incident reports were usually filled out by the nurse who found the issue, but the Clinical Manager may do it as well. She said sometimes the Clinical Manager would tell the nurse to do the incident report. When the incident was brought up in the morning meeting on Monday [DATE], the staff felt it was an unusual occurrence and felt an incident report should be made. She said if a resident requested oxygen then an assessment should be completed, and the intervention would depend on the outcome of the assessment. She said a change in condition would be anything from baseline in which the family and doctor should be notified. She said she did not see CR #1 on [DATE] and had no changes of condition reported to her. She said she reviewed 24-hour reports and nursing notes every morning from the previous day but did not recall anything abnormal from the [DATE]. She said her expectations for documenting medications was that nurses document when they administer it. She said if the medication was held the nurse signs and circles the initials. She said it was normal for CR #1 to request medications later. She said Physician A, who was the Medical Director, visited the facility every Friday. On [DATE] at 10:10 am an interview was attempted with Physician [NAME] A message was left on his voicemail. The phone call was not returned. Record review of the facility's Physician Notification of Resident's Change in Condition Policy dated (MONTH) 2003 revealed Significant changes in resident medical or psychosocial condition may include but are not limited to abnormal or change in vital signs. changes in appetite. change in respiration (distress, congestion, coughing, O2 saturation levels, etc.). change in psychosocial or cognitive status. change in pain management/level (new or existing). If after the nurse evaluates/assesses a resident and a change in condition is noted the nurse will: Review identified change(s) with resident and document evaluation/assessment in electronic medical record. Contact the medical provider and be prepared to provide summary of changes to include assess, vital signs, medications prescribed and/or if necessary previous labs or x-rays. Conversation and any new orders are documented in residents' electronic medical record. If unable to contact provider or responsible party, document date, time, and name of person attempted to notify. Nurse transcribes any new orders received per professional standards. Nurse documents in resident's electronic medical record orders have been transcribed. Nurse reviews resident's care/service plan and updates as needed to reflect changes as appropriate. The Administrator and DON were notified of Immediate Jeopardy (IJ) on [DATE] due to the above failures. A Plan of removal was requested. The final plan of removal was accepted on [DATE] at 4:30 pm after several revisions were made. The Plan of Removal included the following: (MONTH) 21, 2019- 5:30pm anticipated completion [DATE] at 3pm. DON completed education for ADON/SDC/Clinical Manager on the Erickson policies: Physician Notification post assessment of a change of condition, Change of Condition assessment (examples of change of condition, documentation in EMR, follow up) and documentation guidelines for post identification of a change of condition (see attached designated folder at the nurses' station for details ). Nurses who worked with the resident the night shift [DATE], day shift [DATE] and CNA who worked the day shift of [DATE] were coached/counseled and re-educated on the importance of reporting/assessing/following up/monitoring a resident's change of condition. Nurses were re-educated to complete a full assessment upon receiving a report or observing a potential change in a resident's condition. In addition, nurses were re-educated on notifying the physician promptly, of a resident's assessed change of condition. CNA should notify the nurse promptly assigned

Based on interview, and record review, the facility failed to provide treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 of 4 resident (CR#1) reviewed for quality of care. The facility failed to assess and identify CR#1 change in condition of difficulty in breathing on the morning -day shift of [DATE] . CR#1's family member requested physician consult on the evening of [DATE] when CR#1 notified family member. The facility failed to continue assessment of CR#1 and identify change in condition of altered mental status during the night shift and early hours of [DATE]. The facility failed to timely consult CR#1's physician for CR#1's significant change in condition of difficulty with breathing and lethargy which continued on the morning of [DATE] resulting in a delay in intervention/care, hospitalization and death. The facility failed to document CR #1's change in condition in his clinical record and had no record of the resident's vital signs when found unresponsive. An immediate jeopardy was identified on [DATE]. While the IJ was lowered on [DATE], the facility remained out of compliance at a scope of isolation and a severity of actual harm that is not immediate jeopardy due to the facility requiring more time to monitor the plan of removal for effectiveness. These failures affected 1 former resident and placed other facility residents at risk of delay in needed care and treatment necessary to prevent decline in health. Findings include: CR #1 Record review of CR #1's Face Sheet dated [DATE] revealed an [AGE] year-old male admitted to the facility [DATE] and discharged on [DATE]. His [DIAGNOSES REDACTED]. Record review of CR #1's Admission MDS dated [DATE] revealed he entered from an acute hospital. His BIMS score was 15 indicating in-tact cognition. He had no signs and symptoms of [MEDICAL CONDITION]. He was coded as feeling tired or having little energy ,[DATE] days out of the 14-day look back period. He required limited assistance of one person for locomotion on the unit via wheelchair and between limited assistance to extensive assistance for ADLs. His active [DIAGNOSES REDACTED]. He rated his worst pain over the last 5 days as a 6 out of 10. He had no signs and symptoms of a possible swallowing disorder and was coded as having a regular diet with thin liquids. He had a stage 2 pressure ulcer present upon admission and 2 unstageable pressure injuries. He was not coded as being on oxygen therapy. Record review of CR #1's Care Plan dated [DATE] revealed My sleep pattern is: I sleep throughout the night. Further review revealed he required two + persons physical assist to ambulate. There was a handwritten note dated [DATE] that said, Refer to speech therapy for swallow evaluation. Another note dated [DATE] said Risk for aspiration due to swallowing difficulties. Another note dated [DATE] revealed Nectar thick liquid per patient request. Further review revealed I need to sit frequently to rest when ambulating daily. I will need assistance from the aide to follow oxygen safety. My nurse will assist with the reduction and/or elimination of factors that will impact my breathing or cardiac status. I will adapt my lifestyle to my level of energy I maintain or achieve a minimal increase in activity tolerance will remain free of preventable discomfort and/or complications. The goal said, I will not have any complications this review period. Under shortness of breath it read n/a. Further review revealed I have a pacemaker (in care approaches document pacemaker check information. There was no care approach for the pacemaker. Record review of CR #1's physician's orders [REDACTED]. - Tylenol 325 mg, two tablets by mouth every 4 hours as needed ordered on [DATE] - magnesium 64 mg tablet, two tablets daily ordered on [DATE] - omega 3 fish oil, three soft gels daily ordered on [DATE] - vitamin b capsule, one capsule ordered on [DATE] - Eliquis 2.5 mg, one tab daily ordered on [DATE] - [MEDICATION NAME] 200 mg, one tablet daily ordered on [DATE] - [MEDICATION NAME] 250 mg, one tablet twice a day ordered on [DATE] - azelastine 137 mcg, one spray per nostril twice a day ordered on [DATE] - [MEDICATION NAME] 50 mcg, one spray per nostril twice a day ordered on [DATE] - [MEDICATION NAME] 50 mcg, one tablet daily ordered on [DATE] - pantoprazole 50 mg, one tablet daily ordered on [DATE] - [MEDICATION NAME] 75 mg, one tablet daily ordered on [DATE] - [MEDICATION NAME] 5 mg, one tablet daily ordered on [DATE] - [MEDICATION NAME] 20 mcg subcutaneous daily was handwritten on the MAR indicated [REDACTED] - [MEDICATION NAME] 10 mL every four hours as needed ordered on [DATE] - [MEDICATION NAME] XXX,[DATE] mg every 6 hours as needed ordered on [DATE] - Oxygen 2 L nasal canula continuously every night ordered on [DATE] Record review of CR #1's Nursing Note dated [DATE] revealed Guest is stable, alert and oriented times 4. able to verbalize his needs, took all scheduled meds with chocolate pudding, on [MEDICATION NAME] BID last dose given, no adverse reactions noted, ate breakfast and lunch in bistro with good appetite. The note was signed by LVN #1. Record review of CR #1's Nursing Note dated [DATE] revealed Guest is alert and oriented times 4. able to verbalize his needs, took all scheduled meds with chocolate pudding, on [MEDICATION NAME] BID last dose given, no adverse reactions noted, ate breakfast and lunch in bistro with good appetite. The note was signed by LVN #1. During an interview on [DATE] at 8:55 am LVN #4 said she was the charge nurse on [DATE] from 4 pm to 12:30 am. She said she could not recall the nurse she received report from, but they told her he didn't look too good. She said she checked on him and he said he wasn't feeling too great but the doctor was coming to visit him. She said Physician A visited and wrote orders for scheduled breathing treatments and [MEDICATION NAME]. She said he got up around dinner time but went back to bed shortly after. She said, I don't think he ate too much that day his appetite wasn't too great. She said some family members had visited with him that night. She said he did not have any trouble sleeping, changes in condition, or anything out of the ordinary. She said she believed he had oxygen, but she did not go into his room during the night. Record review of CR #1's Physician Note dated [DATE] revealed Per staff, patient with anxiety, (family member) and patient asked to be evaluated. Per patient, (family member) here earlier and patient with shortness of breath. When relaxed slowly went away. (Family member) thought having anxiety and thought he would benefit from a benzo. Per patient shortness of breath comes and goes has been the same, taking nebs about once a day and helps. Patient describes getting restless and shortness of breath. Feels anxious at times but not depressed. Biggest issue is not sleeping at night . just cannot get settled and relaxed. The plan revealed unclear episodes, describes [MEDICAL CONDITION] as contributing factor but has been feeling anxious. Appetite has been variable. Would like to avoid benzos may try [MEDICATION NAME] to help address sleep first for the anxiety. Further review revealed nebulizer treatments three times a day for the shortness of breath. The note was signed on [DATE] at 7:23 pm by physician [NAME] Record review of CR #1's physician's orders [REDACTED]. - [MEDICATION NAME] treatment three times a day ordered on [DATE] . ([MEDICATION NAME] is a sterile inhalation solution containing a combination of [MEDICATION NAME] and [MEDICATION NAME]. [MEDICATION NAME] and [MEDICATION NAME] are [MEDICATION NAME][MEDICATION NAME] that relax muscles in airways and increase air flow to the lungs) - Oxygen therapy at 2L/min via nasal canula as needed for oxygen saturation less than 90% by pulse ox and notify MD on [DATE] Record review of CR #1's MAR (MONTH) 2019 revealed the following medications were held on [DATE] because the resident did not feel good: magnesium, omega 3 fish oil, vitamin b capsule, Eliquis, [MEDICATION NAME], and [MEDICATION NAME]. Further review of MAR indicated [REDACTED]. Record review of CR #1's MAR indicated [REDACTED]. Both orders were signed indicating they were administered. The PRN nebulizer treatment ([MEDICATION NAME] XXX,[DATE] mg every 6 hours as needed ordered on [DATE]) was administered for the only time that month. Tylenol was administered at 8 am for the second time that month. PRN [MEDICATION NAME] was administered for the 6th time that month. PRN oxygen was not signed off as administered any time during the month. Record review of CR #1's Vital Signs dated [DATE] revealed the following: Pulse Ox - 98%, Blood Pressure - ,[DATE], Pulse - 78, and temperature 98.1 degrees Fahrenheit. They were entered by CNA #5. Record review of CR #1's Vital Signs dated [DATE] revealed the following: Pulse Ox - 98%, Blood Pressure - ,[DATE], Pulse - 65, and temperature 97.3 degrees Fahrenheit. They were entered by CNA #5. During an interview on [DATE] at 10:43 am CNA #6 said she was assigned to CR #1 from 3 pm - 11 pm on [DATE]. When asked about his condition she said He was the same when I was working with him but his cough was heavy that day. She said, he always eats and usually ate dinner in the dining room. She said she remembered he didn't eat one day but couldn't recall if it was Friday [DATE]. During an interview on [DATE] at 3:18 pm RN #1 said she could not remember the last time she worked with CR #1. She was asked if she recalled writing the nurse's note read out to her and said, if that's what I wrote, then that's what it was. When asked if she recalled any changes in condition during that time she said, If there were any changes I would have definitely documented in the nurse's note. Record review of CR #1's Nursing Note dated [DATE] revealed Guest complained of sore throat and coughing this AM. PRN [MEDICATION NAME] 10 mL was administered twice. The doctor was informed and aware, but no new orders. The note was signed by RN #1. During an interview on [DATE] at 11:10 am LVN #3 said he possibly worked that night on [DATE]. He said he worked as needed from 11 pm - 7:30 am. He said the last time he worked with him he was fine. When asked if he remembered specifics of the last time working with CR #1 he said he remembered he wanted his bed fixed to go to sleep. When asked if he had oxygen on he said, I don't think so because he wasn't in distress. He said to look on the 24-hour report for any updates on CR #1. During an interview on [DATE] at 5:00 pm, CNA #4 said she worked the 11 pm - 7 am shift on [DATE] and was assigned to CR #1. She said when she did rounds at 11 pm he was awake and lying in bed. She said she did not receive report from the previous CNA about any changes in his condition. She said he had not been short of breathing and his coughing had been reduced. She said he did not have any changes that night, but he did ask for his room to be cooler around 2 am. She said she turned the air conditioner down from 74 degrees to 72 degrees. She said around 6:45 am she answered his call light and he asked to be dressed. She said she got him dressed and in his wheelchair by 7 am. During an interview on [DATE] at 11:10 am LVN #3 said he possibly worked that night on [DATE]. He said he worked as needed from 11 pm - 7:30 am. He said the last time he worked with him he was fine. When asked if he remembered specifics of the last time working with CR #1 he said he remembered he wanted his bed fixed to go to sleep. When asked if he had oxygen on he said, I don't think so because he wasn't in distress. He said to look on the 24 hour report for any updates on CR #1. Record review of CR #1's Nursing Note dated [DATE] entered at 3:31 pm revealed Resident found unresponsive at 10:30 am. CPR initiated, 911 called, family notified, (family member) at bedside and resident transported to (hospital) via ambulance at 11:00 am. The note was signed by LVN #1. Record review of CR #1's Emergency Department Provider Note dated [DATE] revealed Patient brought in by EMS from nursing home. Called out for respiratory distress, patient apneic and pulseless. CPR times 4 cycles and 3 epis' given, patient intubated. Patient achieved ROSC prior to arrival. Further review revealed [AGE] year-old male with pmhx of CAD presents to the ED with c/o [MEDICAL CONDITION]. The patient was being brought to the ED post-[MEDICAL CONDITION] when he arrested again while in route to the ED. Patient's initial [MEDICAL CONDITION] was at 10:35am this morning; EMS states that they treated the patient from 10:43am to 11:03am with a return in pulse. Patient is pulseless on arrival to the ED. Patient has a pacemaker in place. Associated symptoms included chest pain and difficulty breathing. During an interview on [DATE] at 11:50 am, CNA #5 said she worked with CR #1 often and he required assistance with dressing and transfers and wheeled himself to the restroom and around the facility. She said she was assigned to CR #1 on [DATE] and [DATE] on the 7 am - 3 pm shift. She said on [DATE] CR #1 was fine. He did tell her I think I didn't sleep well or something but other than that he was normal. She said on the morning of [DATE] she checked his vitals and they were normal. She said that morning CR #1 told her I have a headache, I don't feel very well today. She said she told the nurse who gave him pain medication. She said on that day he was sleepy which was not like him. He did not get up for breakfast and only ate a little of the tray that was delivered to him which was not like before. She said, he always eats well. She said a couple of his family members came by to visit him. She said after the visitation she checked on him and he still was feeling bad. She said she asked him if he needed his oxygen and he said yes. She said he did not ask for his oxygen often but put it on him which made him feel better. She said he was in bed the rest of her shift, but she checked on him frequently. At the end of her shift on her final round she asked how he felt, and he still complained of not feeling well. She said she told the nurse on duty. During a telephone interview on [DATE] at 10:45 am, CR #1's family member said CR#2 was admitted to the facility after he had an incident with his pacemaker. She said before, he was very independent and drove himself around. Following the incident, he was wheelchair bound, incontinent, couldn't walk, and required a catheter. She said he always had a good appetite and gained weight while in the facility. She said she and other family members visited him daily. She said he usually went to therapy after breakfast or would stay up in his wheelchair and was only in bed at night. She said him requesting oxygen was normal previously, but he had been weaned off. She said she was not aware he had scheduled oxygen at night. She said he had been taken off the breathing treatments about a week before he passed and was unaware he was put back on them. She said to her knowledge any treatments were supposed to be on an as needed basis. She said he never refused medications or asked for them later except for his requip for his restless leg syndrome. She said he could only receive so much of the requip in a day so if he was not having symptoms he would ask them to hold the medication until later. She said on [DATE] CR #1 called her ,[DATE] times and said he was having trouble breathing and needed to do something. CR #1 told her Something is wrong, I don't feel good, I'm having trouble breathing, I'm waiting on the nurse. She told him to put his call light on and CR #1 said I have they haven't come. She said she went to the facility because he was calling so much, and hyperventilating. She said she never saw him like that and described him as significantly different. She requested the doctor get involved and left around lunch time. She said she was not present when Physician A saw him, but they felt he was having a panic attack. She was informed that Physician A ordered an antidepressant and they were supposed to be monitoring him very carefully. She and another family member came back that night and he was feeling better but felt he had another panic attack before their arrival. She said around 8 pm he said he was really tired and wanted to rest so they left before he was put into bed. She said on the morning of [DATE] she had not heard from him and got a call before 11 from facility staff informing her he was in the process of being coded. She said he was pronounced dead at the hospital. She said she came to the facility that day along with other family members to gather his belongings. She said she was standing in the hallway when approached by Resident #2 who was a friend of CR #1. He told her CR #1 was not feeling good that morning and wanted to go back to sleep so he pushed CR #1 back to his room. She said she was shocked when CR #1 and Resident #2 developed a friendship because CR #1 had a way with words. She said she told Resident #2 that CR #1 passed away and he sat in the hallway for a while with his head down. During an interview on [DATE] at 11:03 am LVN #1 said she was the charge nurse on [DATE] from 8 am - 4:30 pm. She said she received report during shift change that CR #1 did not sleep well from a PRN nurse who she could not recall. She said he was already up in his wheelchair when she arrived, and he went to breakfast and ate between 50% - 75% of his meal and normally ate between 75% - 100%. Following breakfast Resident #2 informed her CR #1 was not feeling good and he wanted to go bed, so CNA #2 took him to his room. She and CNA #2 got him back in bed around ,[DATE]:30 am via the transfer board. She said CNA #2 took his vitals and she redid them and wrote them in the nursing note. She was informed there were no vitals in the note and said she wrote them on the MAR. She confirmed the vitals were b/p, pulse, o2 saturation ,[DATE] pulse 61. 92%. She said his vitals were normal for after breakfast. She said he began coughing and administered a breathing treatment and 2L of oxygen via nasal canula at his request. When the physician order [REDACTED].#2 who tried to administer his morning medications, but he requested she return in one hour which was normal. She said shortly after while doing rounds she saw him lying in bed pale and called for him, but he was unresponsive. She called for CNA #2 who ran to get two other CNAs. The CNAs put CR #1 on the floor and she took the vitals. She said he was cold and Couldn't find anything when he was on the floor. Thing rang zero which indicated the blood pressure apparatus had a zero reading when it checked. CPR was initiated and within ,[DATE] minutes EMS came and took over CPR and she took over the bag. CR #1's family members were called. He was intubated and put on IV and breathing before he left. She said he did not complain of pain that day. When informed that the MAR indicated [REDACTED]. I gave him Tylenol and it's PRN? I don't remember this. I don't remember him telling me he was in pain. Nothing changed that day. She said nothing from the day was a change in condition. I did my assessment, and everything was okay, so I didn't see a need to call the doctor. She further stated, I don't need to call the doctor that's why I'm here. She said on [DATE] Physician A came to assess CR #1 because he was complaining to his family member about his restless leg syndrome. During a telephone interview on [DATE] at 1:07 pm, LVN #2 said she was CR #1's nurse on [DATE]. She said received report when she arrived at 7 am from the previous nurse that CR #1 was not acting like himself. She said he was talking and saying things that didn't make sense and did not sleep well. She said he stayed in bed all day and did not believe he was dressed. She said he did not eat breakfast because he did not have an appetite. He had a really bad cough that day. She said when passing medications around 8 am or 9 am he was asleep in bed. She said she asked him if he wanted his medications then or if she should return in an hour. She said he requested she return in an hour because he was tired. She said she still administered his requip, blood pressure medication, and heart medication because those were important. She said around 9:15 am she took the breathing treatment of [REDACTED]. She said he did not have on oxygen underneath the breathing treatment. When asked if an assessment was completed following the breathing treatment she said she believed LVN #1 completed it. She said she was checking on CR #1 between other residents and last saw him between 9:30 am and 9:40 am. She said he was responsive but resting. She said the next thing she saw was him being transferred to the floor and CPR being initiated. She said she was not informed by CNA #2 of abnormal vitals from that morning. She said he had not had a change in condition, so the doctor was not notified. During an interview on [DATE] at 3:27 pm CNA #2 said she was assigned to him CR #1 on [DATE]. She said when she arrived for her shift at 7 am, CNA #4 already had him dressed and in his wheelchair. She said she noticed he was drowsy and feeling tired and checked vitals around 7:30 am. She could not recall the vitals but thought his oxygen was very low. CNA#2 said she could not recall the exact number. CNA #2 also said CR#2's oxygen saturation was below 90 because oxygen saturation of 90 was okay. She said she gave the vital signs sheet to LVN #2 but was not sure if LVN #2 followed up. She said after breakfast she saw Resident #2 pushing CR #1 in his wheelchair from breakfast. CNA #2 said Resident #2 told her that CR #1 was not feeling good . CNA #2 said she would take over and pushed CR#1 to his room. She said CR#1 ate less than 25% of his breakfast. She said with the help of LVN #1, they put him back in bed. She said she reported to either LVN #1 or LVN #2 hey it's something going on because he never got back in bed after breakfast. She said she took his vitals and could not recall the numbers but believed his blood pressure was high. CNA #2 said LVN #1 told her she would put oxygen on him. She said after some time, she saw staff getting him out of the bed and called for help. She said he still had the mask on. She was asked what would be considered a change in a resident's condition, but she was unable to provide an example. During an interview on [DATE] at 9:35 am, Resident #2 said he would see CR #1 at dinner sometimes, but they weren't really friends. He said, he was a very sick man. But had no knowledge of his death until the next day. During an interview on [DATE] at 3:27 pm, CNA #2 said she took CR#2's vital signs at 7:30am on [DATE] and after breakfast when CR#2 complained of not feeling well and did not eat breakfast. However, no record of these vital were found or provided as requested. During an interview on [DATE] at 3:45 pm LVN #1, said vital sheets are kept in a binder at the nursing station. The vitals for CR #1 on [DATE] were requested. We walked over to the binder. She flipped through the binder which was separated by the day of the month. There was nothing behind 20th day. She said the vitals from last month were already pulled and she would look for them. During an interview on [DATE] at 4:15 pm with the DON , the handwritten vitals sheet filled out on the 20th for CR #1 was requested from the DON. Several minutes later DON provided a printed out copy of vitals. The handwritten vitals for CR #1 was again requested. She said they don't document on a handwritten form, they document in the computer. When informed there was a binder at the nurse's station with daily vitals documented by the CNAs she said, we can go see. The DON looked at the binders located on the nurse's station and retrieved the one that said VITALS. She flipped through it and said Yeah, this isn't an official document but she would look for the previous months. During an interview on [DATE] at 4:20 pm the DON was again asked for the handwritten vital sheet. She said the vitals were transferred from the sheet into the computer and shredded. Record review of CR #1's Vital Signs dated [DATE] entered at 1:15 pm revealed the same vitals from on the incident report: Respirations - 18, Pulse Ox - 90%, Blood Pressure - ,[DATE], Pulse - 71, and temperature 97 degrees Fahrenheit. The vitals were input by CNA #2. Record review of CR #1's clinical record between 8:00pm on [DATE] and 10:00am on [DATE] revealed no documentation regarding notification to the physician regarding lack of appetite, lethargy, abnormal vitals, or change in respiration. Record review of Provider Investigation Report dated [DATE] revealed Resident was sent to hospital after being found unresponsive in his room on [DATE]. The investigation summary revealed [DATE] resident went to breakfast as usual. When returned to bed, morning medication was provided along with a breathing treatment. During rounds, nurse noted resident to be unresponsive. Nurse assessment noted resident did not have a pulse. CPR was initiated and 911 notified. Family and MD notified. Resident was transported to ER via ambulance and later was pronounced dead at the hospital. Resident history revealed: history of shortness of breath, currently taking breathing treatments, most recent [DIAGNOSES REDACTED]. Emergency doctors reported resident experienced a [MEDICAL CONDITION] related to patient history of CAD. The facility completed an in-service on emergency procedures and followed up with CR #1's family. The attached in-services included abuse prevention/reporting and change in condition charting and notification. During an interview on [DATE] at 9:46 am the Administrator and DON were both present. The Administrator said on [DATE], CR #1 received a breathing treatment; the nurse came back after 20 minutes and found him unresponsive. 911 was called and CPR was initiated. During a telephone interview on [DATE] at 12:04 pm, Clinical Manager said she could not recall CR #1's condition on Friday and did not see him on Saturday. She began gathering details of the incident, interviewing staff, and getting all facts and completed the incident report. On [DATE] at 4:08 pm an interview was attempted with Physician [NAME] He was not in the office. A message was left with the receptionist. On [DATE] at 10:18 am an interview was attempted with Physician [NAME] He was not in the office. A message was left with the receptionist. On [DATE] at 1:00 pm an interview was attempted with Physician [NAME] He was not in the office. A message was left with the receptionist. Record review of CR #1's clinical between 8:00pm on [DATE] and [DATE] record revealed no documentation regarding notification to the physician regarding pain, change in respiration, or not feeling well. During an interview on [DATE] at 1:00 pm the DON said anything unusual was documented on the 24-hour report and stays on there until it was resolved or no longer pertinent. She said they were shredded at the end of the week and was not a form used as part of the medical record. She said nurses transcribe the notes from the 24-hour report into a nurse's note. She said incident reports were usually filled out by the nurse who found the issue, but the Clinical Manager may do it as well. She said sometimes the Clinical Manager would tell the nurse to do the incident report. When the incident was brought up in the morning meeting on Monday [DATE], the staff felt it was an unusual occurrence and felt an incident report should be made. She said if a resident requested oxygen then an assessment should be completed, and the intervention would depend on the outcome of the assessment. She said a change in condition would be anything from baseline in which the family and doctor should be notified. She said she did not see CR #1 on [DATE] and had no changes of condition reported to her. She said she reviewed 24-hour reports and nursing notes every morning from the previous day but did not recall anything abnormal from the [DATE]. She said her expectations for documenting medications was that nurses document when they administer it. She said if the medication was held the nurse signs and circles the initials. She said it was normal for CR #1 to request medications later. She said Physician A, who was the Medical Director, visited the facility every Friday. On [DATE] at 10:10 am an interview was attempted with Physician [NAME] A message was left on his voicemail. The phone call was not returned. Record review of the facility's Physician Notification of Resident's Change in Condition Policy dated (MONTH) 2003 revealed Significant changes in resident medical or psychosocial condition may include but are not limited to abnormal or change in vital signs. changes in appetite. change in respiration (distress, congestion, coughing, O2 saturation levels, etc.). change in psychosocial or cognitive status. change in pain management/level (new or existing). If after the nurse evaluates/assesses a resident and a change in condition is noted the nurse will: Review identified change(s) with resident and document evaluation/assessment in electronic medical record. Contact the medical provider and be prepared to provide summary of changes to include assess, vital signs, medications prescribed and/or if necessary previous labs or x-rays. Conversation and any new orders are documented in residents' electronic medical record. If unable to contact provider or responsible party, document date, time, and name of person attempted to notify. Nurse transcribes any new orders received per professional standards. Nurse documents in resident's electronic medical record orders have been transcribed. Nurse reviews resident's care/service plan and updates as needed to reflect changes as appropriate. The Administrator and DON were notified of Immediate Jeopardy (IJ) on [DATE] due to the above failures. A Plan of removal was requested. The final plan of removal was accepted on [DATE] at 4:30 pm after several revisions were made. The Plan of Removal included the following: (MONTH) 21, 2019- 5:30pm anticipated completion [DATE] at 3pm. DON completed education for ADON/SDC/Clinical Manager on the Erickson policies: Physician Notification post assessment of a change of condition, Change of Condition assessment (examples of change of condition, documentation in EMR, follow up) and documentation guidelines for post identification of a change of condition (see attached designated folder at the nurses' station for details ). Nurses who worked with the resident the night shift [DATE], day shift [DATE] and CNA who worked the day shift of [DATE] were coached/counseled and re-educated on the importance of reporting/assessing/following up/monitoring a resident's change of condition. Nurses were re-educated to complete a full assessment upon receiving a report or observing a potential change in a reside

Based on record review, observation and interview the facility failed to have staff trained on signs and symptoms of aspiration and the thickening of liquids so staff could adequately supervise, assist, and prevent hazards for 3 of 4 resident's (Resident #5 #18, and #38) who were reviewed for having increased risks in aspirating. Resident #5, who had a history of [REDACTED]. Resident # 5 and #18 had honey thickened liquids ordered by the physician which were being prepared by CNAs who had not been trained on how to prepare thickened liquids. Resident #18, who had an admitting [DIAGNOSES REDACTED]. Resident #38, who was to have nectar thickened liquids, was having thin liquids thickened by untrained family members. CNAs were not trained in procedures of thickening liquids to different consistencies, and signs and symptoms of aspiration. An immediate jeopardy (IJ) was identified on 7/8/14 at 6:59 P.M. The IJ was removed on 7/11/2014 at 10:15 A.M. however the facility remained out of compliance at a scope of isolated and a severity level of Actual Harm that is not Immediate Jeopardy because all staff had not been trained on policies and procedures concerning thickening liquids. This failure affected 3 residents with 2 of the residents having hospitalization s and treatment for [REDACTED]. Findings include: Interview on 07/07/2014 at 12:00 noon the Dietitian stated residents requiring thickened liquids have containers of thickener in the resident ' s room. She stated the staff members (CNAs and Nurses) mixed the thickener into the liquids. She stated in the facility there were two dining rooms and (nursing) staff mixed the thickener kept in the dining rooms, into the liquids of the resident ' s drinks that had orders for thickened liquids. Resident #5 Record review of Resident #5 ' s face sheet revealed he was a [AGE] year old male admitted to the facility on [DATE] and readmitted on [DATE]. His [DIAGNOSES REDACTED]. Record review of Resident #5's quarterly MDS dated [DATE] revealed a BIMS score of 13, which meant the resident, was cognitively intact. He was on a mechanically altered diet (e.g. mech. soft diet, thickened liquids). Record review of Resident #5's speech therapist notes dated 5/6/2014 revealed the resident had a history of [REDACTED]. Record review of Resident #5's physician's orders [REDACTED]. soft/nectar thick liquids. Record review of Resident #5 ' s care plan dated 6/16/2014 revealed the following: Swallowing, Nutritional Status: Nectar thickened liquids - Care Plan Approach (es): Blank There were no specific care plans or approaches to address history of aspirating when swallowing. Record review of the facility diet roster listed Resident #5's diet as mech. soft, chopped, with nectar thick liquids. Record review of Resident #5's meal tickets on 7/8/2014 at 5:30 P.M. and on 7/9/2014 at 9:00 A.M. did not specify Resident #5's diet (mech. soft, chopped with nectar thick liquids). Interview on 7/8/2014 at 5:10 P.M. Resident #5 stated he was on thickened liquids but he did not like them very much. He stated some of his liquids came on his tray in a per-mixed sealed package that he just opened and drank. He stated some liquids did not come pre-mixed and he would add some of the thickener that was in his room to the liquid. He stated he was not taught how much of the thickener to add so he would just add some but usually just drank the liquids without adding the thickener. He stated the CNAs sometimes mixed the thickener in his liquids for him. He stated if a regular glass of liquids came on his tray he would often just drink it without the thickener in it. He stated he had done that a few times in the past and he ended up having aspiration pneumonia. Observation and Interview on 7/8/2014 at 5:30 P.M. revealed Resident #5 in the dining room. He had a mech. soft diet and a ? glass of thickened ice tea. Resident #5 stated the tea was a special mix of ? ice tea and ? lemonade that the kitchen made for him. He stated the glass in front of him was his 2nd glass and the drink never came out thickened from the kitchen. He stated he drank the first glass before the CNA could put the thickener in it. He stated when he asked for the 2nd glass the CNA got it for him and she added the thickener. He stated he did not like the way the thickener tasted but he knew it was better for him. He said if he drank the liquids without the thickener he would aspirate and end up with pneumonia again. Interview on 7/8/2014 at 5:35 P.M. CNA #44 confirmed Resident #5 ' s ice tea would always come out on his tray without the thickener in it. She stated he did drink the first glass without any thickener in it. When he asked for a second glass CNA #44 stated she got it from the kitchen and added thickener to it. She stated she read the back of the canister to know how much thickener to add to the ice tea to make it nectar thick. She stated she had not had any training to make the various consistencies of thickened liquids. She said she had not had any training for signs and symptoms of aspiration. When asked how she knew Resident #5 was on nectar thick liquids because it was not listed on his meal ticket on his tray, she said she just knew because she knew the resident. She was not sure how a new CNA or someone that had never worked with the resident before would know he was on thickened liquids. Resident #18 Record review of Resident # 18 ' s face sheet revealed a [AGE] year old female admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Record review of Resident# 18 ' s physician's orders [REDACTED]. Ordered dated 6/30/14 revealed status Aspiration Pneumonia/Shortness of breath. Speech therapy clarification, swallowing precaution in place, small bites /sips, upright position for 30 minutes after meals/bites/sips. Order dated 7/1/14 speech therapy- diet change to Honey thickened liquids, with regular diet consistency. Record review of Resident # 18 ' s care plan dated 6/30/14 revealed the resident required supervision for meals and required honey thickened liquids due to dysphagia. Further review of the care plan revealed approaches outlined included: will make own food choices on regular diet and " nectar " thick liquids. Record review of Resident # 18 ' s speech language and pathology evaluation and plan of care dated 7/1/14 revealed prior level of function- " guest (resident) stated that she had sudden onset of difficulty swallowing and her difficulty was with intake of liquids primarily. She stated that her swallowing difficulty has been going on for at least the past 6 months. Further review of the same speech therapy notes revealed the speech therapist also recommended treatment for [REDACTED]. Record review of Resident # 18 ' s radiology report dated 7/7/14 revealed there were infiltrates noted in the lungs diffusely. Record review of Resident # 18 ' s physician order [REDACTED]. Interview on 7/8/2014 at 6:30 P.M. RN #10 stated Resident #18 received thickened liquids but ate all of her meals in her room. She stated the resident was not supervised by staff during her meals. Observation on 7/9/2014 at 9:00 A.M., after resident returned from evaluation in hospital, revealed the resident eating breakfast in her room unsupervised. No liquids were observed on the tray. Interview on 7/10/2014 at 1:30 P.M. Resident #18 stated she always ate all meals in her room. When asked if staff was in her room during meals she stated no. She stated her liquids come thickened on her tray and she did not like them. She stated she had only been at the facility a few days and she did not have any of the thickening powder in her room. Resident #38 Record Review of Resident #38 ' s face sheet revealed an [AGE] year old female admitted to the facility on [DATE]. Admitting [DIAGNOSES REDACTED]. Record Review of Resident #38 ' s Modified Barium Swallow Study dated 12/19/2013 revealed the resident was to be supervised with one on one feeding and staff were to allow the resident extra time when receiving foods by mouth. Further review revealed the patient was at high risk for aspiration pneumonia and choking episodes. She was approved for nectar liquids, thin or thick puree and mechanical soft foods. Record Review of Resident #38 ' s physician ' s telephone orders dated 6/9/2014 revealed the dietary consultant requested an evaluation to assess opinion of [DEVICE] removal. It read the dietary consult requested this due to the resident being on nectar thickened liquids and a mechanical soft diet. Interview on 7/7/2014 at 11:00 A.M. the responsible party of Resident #38 revealed the resident was receiving thickening liquids with all of her meals and was progressing after he decided to provide 24 hour care for her while she resided in the facility. He stated the facility staffs were not trained how to thicken liquids or assisting residents who required thickened liquids and were at risk of aspirating. The family member stated he kept the thickener, which was provided by the facility, for the resident's liquids in the room. He stated he, his sibling or his paid sitter thickened all of Resident #38's liquids and ensured the resident received an adequate amount of liquids daily. He stated he was never trained on how to thicken the liquids by the facility. Observation on 7/9/2014 at 10:00 A.M. revealed Resident #38 in her room sitting up in bed eating breakfast with the assistance of a family member. Further observation revealed two cans of thickening liquid powder. One container had a scoop inside of it and the other can was not opened. Interview on 7/10/2014 at 11:00 A.M. the responsible party said he was not happy the facility decided to take the resident's thickened liquids from the room. He stated he was happy they had decided to do all thickened liquids in the kitchen but he wanted the thickening powder also in the resident's room so when he brought in personal beverages he knew Resident #38 would enjoy, he would be able to thicken the beverage. He stated he told the facility he did not mind being trained and he would sign documents confirming he was trained in order to get the thickening powder returned to the room. Interview on 7/8/14 at 3:40 P.M., CNA#44 said she had worked at the facility for about a year and was not given any training on how to thicken liquids. Interview on 7/8/2014 at 3:35 P.M. CNA #51 stated she had not had any formal training for mixing thickened liquids or on signs and symptoms of aspiration. She stated she had asked a speech therapist for instruction on mixing the different types of thickening consistencies ordered and the Speech Therapist explained to her how to mix the thickener for the different types of thickened liquids. Interview on 7/8/2014 at 3:45 P.M. LVN #16 stated the thickened liquids came out on the meal trays for the residents. She stated she had not had in-services on mixing thickened liquids. She was able to explain the signs and symptoms of aspiration. Interview on 7/8/2014 at 6:20 P.M. CNA #21 revealed she was not trained on thickening liquids upon hire nor had she had training since hire. Interview on 7/10/14 at 9:30 A.M. CNA # 21 stated she usually worked in the memory care area but she was put to work on this unit today because it was short of help. She stated she was never trained on chocking or aspiration signs and symptoms. Record review of the Facility in-services for the past 6 months revealed the facility did not have any training for staff in regards to thickening liquids or signs and symptoms of aspiration or complications of residents at risk for aspiration. Record Review of facility policy titled Thickened Liquids dated 4/2014 revealed "... The thickener is used to promote ease of swallowing, to prevent choking and aspiration and to aid in maintaining nutrition... Thickened liquids will be provided when ordered... Pre-Thicken liquids will be used when available... The thickened liquid is used at each meal by the designated continuing care staff, following the guidelines on the label of the thickening additive to dispense... Education regarding this policy and procedure will be completed with each new hire orientation. Further training will occur during the employee ' s department-specific orientation. Ongoing training and education will be provided on an as needed basis, as determined by the employee ' s direct supervisor/manager... " A plan to remove the immediate jeopardy (IJ) was submitted and accepted on 7/09/2014. The plan included: The Speech and Language Pathologist, Dietitian and Registered Nurses in servicing licensed nurses, certified nursing assistants and dietary service associates on signs and symptoms of aspiration, thickening liquids protocol and how to monitor residents for signs and symptoms of aspiration. Further review revealed all thickening liquid solutions were removed from all residents rooms on 7/8/2014 and only dietary staff were allowed to thicken any liquids and if they were not available, trained nurses and certified nursing assistants would thicken the liquids based on the resident ' s diet. A sign was posted in every resident ' s room that required thickening liquids to please see a nurse before offering resident a beverage. The plan of removal stated the facility would in service all family members and monitoring would be done by the Director of Nursing/or designee. The DON or designee did room audits and would continue to do audits to ensure no thickening liquids were in the room and this will continue three times a day for the next three weeks, daily for three weeks and weekly for two months. Any and all issues from that point will be reported to their QA committee. Record review of the In-service form dated 7/8/14 and 7/11/14 revealed approximately 50% of the staff representing all three shifts had been in-serviced on thickening liquids and signs and symptoms of aspiration. Monitoring of resident's rooms on 7/10/2014 and 7/11/2014 revealed signs in resident's who required thickened liquids rooms to direct visitors to contact the nurse prior to offering resident's beverages Interviews conducted on 7/10/2014 and 7/11/14 with 12 nursing staffs representing all three shifts revealed staff were competent in the protocol for thickening liquids and signs and symptoms of aspiration. Record Review of the revised facility policy titled Thickened Liquids dated 7/2014 revealed " ...Thickened liquids will be provided when ordered... Pre-thickened liquids will be used unless otherwise instructed by the speech therapist, provider and/or resident preference/choice... Pre-thickened products will be used unless otherwise specified... " Record Review of facility policy titled Aspiration Precautions dated 7/2014 revealed " To minimize residents ' risk of aspiration, residents on aspiration precautions will still need to receive appropriate hydration. Protocols should be followed... Ongoing monitoring for supervision to be in accordance with the plan of care. May include: Encourage resident or guest to eat in supervised dining room setting or in their room with staff monitoring as specified. Observe resident for symptoms of aspiration, including coughing, choking, excessive oral resident/pocketing, prolonged chewing and/or leakage from mouth with solids, liquids or saliva, wet gurgling vocal quality of breathing, alterations in pulmonary status and/or reported feeling of food caught in throat... Education regarding this policy and procedure will be completed with each new hire orientation. Further training will occur during the employee ' s department-specific orientation. Ongoing training and education will be provided on an as needed basis, as determined by the employee ' s direct supervisor/manager. The IJ was lifted on 7/11/14 at 10:15 A.M. and the Administrator was notified after verification of the plan implementation had occurred. However while the IJ was removed on 7/11/2014 the facility remained out of compliance at a scope of isolated and a severity level of Actual Harm that is not Immediate Jeopardy because all staff had not been trained on the policies and procedures concerning thickening liquids and signs and symptoms of aspiration. Dietitian reported 6 residents required thickened liquids.

Based on observation, interview, and record review, the facility's Administration failed to manage the facility by not appointing a RN to supervise, train and oversee nursing services and by not monitoring the dietary needs of 3 of 4 residents (Residents #38, #18 and #5 ) who had identified high risks for aspiration and required thickened liquids to maintain their highest practicable physical well being. The Administrator did not appoint a facility Registered Nurse who worked forty hours per week to assume responsibility to supervise nursing services and resident care. The Administrator did not oversee the training of staff to assess, supervise, provide care and services to residents who had been identified as high risks for aspirations. The Dietitian did not have a system in place to provide thickened liquids to residents per the physician's orders [REDACTED]. An immediate jeopardy (IJ) was identified on 7/8/14 at 6:59 P.M. The IJ was removed on 7/11/2014 at 10:15 A.M. however the facility remained out of compliance at a scope of isolated and a severity level of Actual Harm that is not Immediate Jeopardy because all staff had not been trained on policies and procedures concerning thickening liquids. This failure affected 3 residents with 2 of the residents having hospitalization s and treatment for [REDACTED]. Findings include: Interview on 7/7/2014 at 8:30 A.M. the Administrator during Entrance stated the interim Director of Nursing was not present and only worked on Saturdays. He then said currently RN #21 was in charge of the nursing staff. Interview on 07/07/2014 at 12:00 noon the Dietitian stated residents requiring thickened liquids have containers of thickener in the resident ' s room. She stated the staff members (CNAs and Nurses) mixed the thickener into the liquids. She stated in the facility there were two dining rooms and (nursing) staff mixed the thickener kept in the dining rooms, into the liquids of the resident ' s drinks that had orders for thickened liquids. Resident #5 Record review of Resident #5 ' s face sheet revealed he was a [AGE] year old male admitted to the facility on [DATE] and readmitted on [DATE]. His [DIAGNOSES REDACTED]. Record review of Resident #5's physician's orders [REDACTED]. soft/nectar thick liquids. Interview on 7/8/2014 at 5:10 P.M. Resident #5 stated he was on thickened liquids but he did not like them very much. He stated some of his liquids came on his tray in a per-mixed sealed package that he just opened and drank. He stated some liquids did not come premixed and he would add some of the thickener that was in his room to the liquid. He stated he was not taught how much of the thickener to add so he would just add some but usually just drank the liquids without adding the thickener. He stated the CNAs sometimes mixed the thickener in his liquids for him. He stated if a regular glass of liquids came on his tray he would often just drink it without the thickener in it. He stated he had done that a few times in the past and he ended up having aspiration pneumonia. Resident #18 Record review of Resident # 18 ' s face sheet revealed a [AGE] year old female admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Record review of Resident# 18 ' s physician's orders [REDACTED]. Ordered dated 6/30/14 revealed status Aspiration Pneumonia/Shortness of breath. Speech therapy clarification, swallowing precaution in place, small bites /sips, upright position for 30 minutes after meals/bites/sips. Order dated 7/1/14 speech therapy- diet change to Honey thickened liquids, with regular diet consistency. Record review of Resident # 18 ' s care plan dated 6/30/14 revealed the resident required supervision for meals and required honey thickened liquids due to dysphagia. Further review of the care plan revealed approaches outlined included: will make own food choices on regular diet and " nectar " thick liquids. Record review of Resident # 18 ' s speech language and pathology evaluation and plan of care dated 7/1/14 revealed prior level of function- " guest (resident) stated that she had sudden onset of difficulty swallowing and her difficulty was with intake of liquids primarily. She stated that her swallowing difficulty has been going on for at least the past 6 months. Further review of the same speech therapy notes revealed the speech therapist also recommended treatment for [REDACTED]. Record review of Resident # 18 ' s radiology report dated 7/7/14 revealed there were infiltrates noted in the lungs diffusely. Record review of Resident # 18 ' s physician order [REDACTED]. Interview on 7/8/2014 at 6:30 P.M. RN #10 stated Resident #18 received thickened liquids but ate all of her meals in her room. She stated the resident was not supervised by staff during her meals. Observation on 7/9/2014 at 9:00 A.M., after resident returned from evaluation in hospital, revealed the resident eating breakfast in her room unsupervised. No liquids were observed on the tray. Interview on 7/10/2014 at 1:30 P.M. Resident #18 stated she always ate all meals in her room. When asked if staff was in her room during meals she stated no. She stated her liquids come thickened on her tray and she did not like them. She stated she had only been at the facility a few days and she did not have any of the thickening powder in her room. Resident #38 Record Review of Resident #38 ' s face sheet revealed a [AGE] year old female admitted to the facility on [DATE]. admitting [DIAGNOSES REDACTED]. Interview on 7/7/2014 at 11:00 A.M. with the responsible party of Resident #38 revealed the resident was receiving thickened liquids with all of her meals and was progressing after he decided to provide private sitters for 24 hour care for her while she resided in the facility. He stated the facility staff were not trained in thickening liquids or assisting residents who required thickened liquids. He stated he kept the thickener, provided to him by the facility, in the resident's room. He stated he, his sibling or the paid sitter thickened all of Resident #38' s liquids and ensured she received an adequate amount of liquids daily. He stated he was never trained on how to thicken the liquids by the facility staff. He stated he had some challenges with therapy and had temporarily placed therapy services on hold until the resident started progressing again. Record Review of Resident #38 ' s Modified [MEDICATION NAME] Swallow Study dated 12/19/2013 revealed the resident was to be supervised one to one during feedings to allow extra time when receiving foods by mouth. Further review revealed the resident was at high risk for an aspiration pneumonia and choking episodes. Resident #38 had been approved for nectar liquids, thin or thick pureed and mechanical soft foods. Record Review of Facility in-services revealed the facility did not have any training for staff in regards to thickening liquids or signs of aspiration. Interview on 7/8/14 at 3:40 P.M., CNA#44 said she had worked at the facility for about a year and was not given any training on how to thicken liquids. Interview on 7/8/2014 at 3:35 P.M. CNA #51 stated she had not had any formal training for mixing thickened liquids or on signs and symptoms of aspiration. She stated she had asked a speech therapist for instruction on mixing the different types of thickening consistencies ordered and the Speech Therapist explained to her how to mix the thickener for the different types of thickened liquids. Interview on 7/8/2014 at 3:45 P.M. LVN #16 stated the thickened liquids came out on the meal trays for the residents. She stated she had not had in-services on mixing thickened liquids. She was able to explain the signs and symptoms of aspiration. Interview on 7/8/2014 at 6:20 P.M. CNA #21 revealed she was not trained on thickening liquids upon hire nor had she had an training since hire. Interview on 7/10/14 at 9:30 A.M. CNA # 21 stated she usually worked in the memory care area but she was put to work on this unit today because it was short of help. She stated she was never trained on chocking or aspiration signs and symptoms. Record review of the Facility in-services for the past 6 months revealed the facility did not have any training for staff in regards to thickening liquids or signs and symptoms of aspiration or complications of residents at risk for aspiration. Interview on 7/9/2014 at 10:00 A.M. the Administrator said he was not aware there was problem involving residents who had thickened liquids ordered by their physicians. He stated staff members were in-serviced briefly about thickening liquids during their orientation. He stated there had not been a training involving thickened liquids or aspiration precautions in a year. He stated since the Immediate Jeopardy had been identified, the facility had removed all thickening liquid powder from resident's rooms and now all thickened liquids had to be prepared by the dietary staff who were in- serviced first. He said from this point forward all nursing staff members will have in- services on thickening liquids and signs of aspiration before they were allowed to work. He stated he had an interim Director of Nursing who only worked on Saturdays and was not able to be at the facility during the standard survey. He stated since the interim Director of Nursing was not present RN #21 was the acting Director of Nursing. He stated he would monitor staff members to ensure all training were being completed. Interview on 7/9/2014 at 10:15 A.M. RN #21 said she was not in charge of the nursing staff. She stated she was the MDS Coordinator #1. She stated she was not sure how the process with thickened liquids being mixed in the resident's rooms came about. She stated nursing staff members were briefly trained on thickened liquids during their orientation but stated she was unable to provide documentation of what specifically they were trained. She stated there had been no additional training concerning thickened liquids or signs and symptoms of aspiration that she was aware of. Record Review of facility policy titled Thickened Liquids dated 4/2014 revealed "... The thickener is used to promote ease of swallowing, to prevent choking and aspiration and to aid in maintaining nutrition... Thickened liquids will be provided when ordered... Pre-Thicken liquids will be used when available... The thickened liquid is used at each meal by the designated continuing care staff, following the guidelines on the label of the thickening additive to dispense... Education regarding this policy and procedure will be completed with each new hire orientation. Further training will occur during the employee ' s department-specific orientation. Ongoing training and education will be provided on an as needed basis, as determined by the employee ' s direct supervisor/manager... " A plan to remove the immediate jeopardy (IJ) was submitted and accepted on 7/09/2014. The plan included: The Speech and Language Pathologist, Dietitian and Registered Nurses in servicing licensed nurses, certified nursing assistants and dietary service associates on signs and symptoms of aspiration, thickening liquids protocol and how to monitor residents for signs and symptoms of aspiration. Further review revealed all thickening liquid solutions were removed from all residents rooms on 7/8/2014 and only dietary staff were allowed to thicken any liquids and if they were not available, trained nurses and certified nursing assistants would thicken the liquids based on the resident ' s diet. A sign was posted in every resident ' s room that required thickening liquids to please see a nurse before offering resident a beverage. The plan of removal stated the facility would in service all family members and monitoring would be done by the Director of Nursing/or designee. The DON or designee did room audits and would continue to do audits to ensure no thickening liquids were in the room and this will continue three times a day for the next three weeks, daily for three weeks and weekly for two months. Any and all issues from that point will be reported to their QA committee. Record review of the In-service form dated 7/8/14 and 7/11/14 revealed approximately 50% of the staff representing all three shifts had been in-serviced on thickening liquids and signs and symptoms of aspiration. Interviews conducted on 7/10/2014 and 7/11/14 with 12 nursing staff representing all three shifts revealed staff were competent in the protocol for thickening liquids and signs and symptoms of aspiration. Monitoring of resident's rooms on 7/10/2014 and 7/11/2014 revealed signs in resident's who required thickened liquids rooms to direct visitors to contact the nurse prior to offering resident's beverages Record Review of the revised facility policy titled Thickened Liquids dated 7/2014 revealed " ...Thickened liquids will be provided when ordered... Pre-thickened liquids will be used unless otherwise instructed by the speech therapist, provider and/or resident preference/choice... Pre-thickened products will be used unless otherwise specified... " Record Review of facility policy titled Aspiration Precautions dated 7/2014 revealed " To minimize residents ' risk of aspiration, residents on aspiration precautions will still need to receive appropriate hydration. Protocols should be followed... Ongoing monitoring for supervision to be in accordance with the plan of care. May include: Encourage resident or guest to eat in supervised dining room setting or in their room with staff monitoring as specified. Observe resident for symptoms of aspiration, including coughing, choking, excessive oral resident/pocketing, prolonged chewing and/or leakage from mouth with solids, liquids or saliva, wet gurgling vocal quality of breathing, alterations in [MEDICAL CONDITION] status and/or reported feeling of food caught in throat... Education regarding this policy and procedure will be completed with each new hire orientation. Further training will occur during the employee ' s department-specific orientation. Ongoing training and education will be provided on an as needed basis, as determined by the employee ' s direct supervisor/manager. The IJ was lifted on 7/11/14 at 10:15 A.M. and the Administrator was notified after verification of the plan implementation had occurred. However while the IJ was removed on 7/11/2014 the facility remained out of compliance at a scope of " wide spread" and a severity level of " Actual Harm that is not Immediate Jeopardy " because all staff had not been trained on the policies and procedures concerning thickening liquids and signs and symptoms of aspiration. Facility 672 reported a census of 38.