Every finding on record at Dardanelle Nursing and Rehabilitation Center,Inc

Number of residents sampled: Number of residents cited: Based on interview, record review and facility document review, the facility failed to ensure the high temperature dishwashing machine reached the required temperature to prevent potential contamination of dishware and the facility failed to ensure that sanitizing solution was present in the three-compartment manual sink, to effectively clean and sanitize dishware and kitchen equipment. This failed practice had the potential to affect 80 residents residing in the facility who ate from dishware provided by the facility kitchen. The findings include: During an interview on 04/01/2026 at 10:55 AM, the Dietary Manager (DM) stated the staff did not have a means of testing the parts per million (PPM) of the sanitizing solution in the three-compartment sink because a staff member had dropped the test strips in water on Monday, 03/30/2025, around 8:30 AM. The DM stated the facility had not had the appropriate test strips to test for the appropriate PPM of sanitizer since 03/30/2025. The DM stated they had borrowed a different type of test strip from a sister facility, but they were bleach test strips and not for the sanitizing solution they used at the facility. The DM stated the bleach test strips do not change color in the chemicals used at the facility and stated they only stayed white. The DM stated it was important to make sure the sanitizer was correct, to know the dishes were being sanitized and cleaned. The DM stated there was no way to know if the sanitizer in the three-compartment sink was correct without the proper test strips. During an interview on 04/01/2026 at 11:05 AM, Dishwasher (DW) #1 stated they had worked at the facility for two months. DW #1 stated they were trained on how to take the temperatures in the dishwasher and on how to use the test strips to test the sanitizer in the three-compartment sink. DW #1 stated they had not checked the PPM in the three-compartment sink on the morning of 04/01/2026 because they did not have the correct test strips. DW #1 stated they had done something they should not have done and had just written down what the PPM was supposed to be because they did not have the test strips. DW #1 stated the PPM should be between 200 – 400 PPM to sanitize the dishes. DW #1 stated the dishwashing machine was a high-temp machine. DW #1 stated it was important to know the dishes were being sanitized and washed at the correct temperature, to know the dishes were clean, because the residents eat on the dishes and if they were not cleaned and sanitized the residents could get sick. DW #1 stated they should have contacted the Maintenance Supervisor (MS) when the temperature was not reaching the required temperature of 180 degrees so the MS could make sure the machine was operating properly. During an interview on 04/01/2026 at 11:45 AM, the DM provided a copy of the temperature logs for the dishwashing machine and the sanitizing logs for the three-compartment sink. The log identified temperatures for Wash/Rinse/Sanitizing. The log recommendation was for the internal sanitizing temperature to be taken prior to breakfast dishes. Review of the Temperature Log for March/April revealed rinsing and sanitizing temperatures recorded for March/April of 2026 did not reach the required temperatures or internal thermometer temperatures on the following 10 days: 03/01/2026 Breakfast: 165/180/16503/02/2026 Breakfast: 155/180/16003/03/2026 Breakfast: 150/180/16503/04/2026 Breakfast: 155/175/170 03/05/2026 Breakfast: 160/180/170 03/06/2026 Breakfast: 155/175/16503/07/2026 Breakfast: 165/180/160 03/08/2026 Breakfast: 150/165/165 03/09/2026 Breakfast: 165/180/175 03/31/2026 Breakfast: No temps taken04/01/2026 Breakfast: 170/175/182 During an interview on 04/01/2026 at 11:45 AM, the DM provided a copy of the PPM sanitizing Logs for the three-compartment sink. The log instructions at the bottom of the log indicated the Sanitizer PPM will be between 200 – 400 PPM for quat sanitizer. The following dates/times did not meet the required level of sanitization: 03/01/2026 AM PPM: 100; Noon PPM: 100; Dinner PPM: 10003/02/2026 Dinner PPM: 10003/03/2026 Noon PPM: 10003/04/2026 AM PPM: 100; Noon PPM: 100; Dinner PPM: 10003/05/2026 AM PPM: 100; Dinner PPM: none logged03/06/2026 Dinner PPM: none logged03/07/2026 AM PPM: 100. 03/08/2026 Noon PPM: 100; Dinner PPM: 100.03/09/2026 AM PPM: 100.03/10/2026 AM PPM: 100.03/11/2026 Noon PPM: 100; Dinner PPM: none logged03/12/2026 Noon PPM 100; Dinner PPM: none logged.03/13/2026 AM PPM: 100.03/14/2026 Dinner PPM: 100.03/15/2026 AM PPM: 100; Noon PPM: 100; Dinner PPM: 100.03/22/2026 Dinner PPM: none logged.03/24/2026 AM PPM: 100; Noon PPM: 100.03/25/2026 AM PPM: 100; Noon PPM: 100; Dinner PPM: 100.03/27/2026 Noon PPM: 100; Dinner PPM: 100.03/28/2026 Noon PPM: 100; Dinner PPM: none logged.03/29/2026 AM PPM: 150; Noon PPM: 100; Dinner PPM: none logged.03/30/026 AM PPM: 150; Noon PPM: 100; Dinner PPM: none logged.03/31/2026 none logged04/01/2026 AM PPM: 150 PPM. During an interview on 04/01/2026 at 11:55 AM, the MS provided a copy of the Dish Machine Specs Sheet which identified the machine as an XL-HT dish machine and indicated the wash minimum temperature should be 150 degrees Fahrenheit and the sanitizing rinse minimum temperature should be 180 degrees Fahrenheit. During an interview on 04/01/2026 at 12:38 PM, the Infection Preventionist (IP) stated if the dishes were not properly cleaned and sanitized it could cause gastrointestinal (GI) issues with the residents. The IP stated they had not had any GI concerns over the past three months. The IP stated it was important for the dishes to be sanitized properly because the residents eat on the dishes from the kitchen. During an interview on 04/02/2026 at 8:56 AM, the facility Physician Assistant – Certified (PA-C), stated it was important for the dishes to be cleaned and sanitized properly for cleanliness sake and due to a risk of cross contamination. The PA-C continued that if one resident had some form of disease it could spread to a different resident or could potentially cause GI issues, such as bacterial or viral infections. During an interview on 04/02/2026 at 1:43 PM, the Administrator stated incorrect test strips and inappropriate temperatures in the dishwasher could affect the residents because the dishes were not properly sanitized and things were not being killed off properly, like bacteria which could affect the GI tract, cause stomach infections and make the residents sick. The Administrator stated they review the dietary department dishwasher, and three-compartment sink logs quarterly. The Administrator stated the dishwasher vendor checked the machine once a month but if a problem was identified the DM would let the MS know, and the MS would contact the vendor. The Administrator stated they had not had any reports of the dishwasher not reaching temperatures or of being without test strips prior to the survey team making them aware of the problem. The Administrator stated the DM was responsible for ensuring the test strips were available for use. During an interview on 04/02/2026 at 1:54 PM, the MS stated it was important to ensure the temperature in the dish machine reached the appropriate temperature for sanitizing to kill bacteria. The MS stated the test strips should be used in the three-compartment sink to ensure the appropriate amount of chemical was being used to keep anybody [who was] eating off the dishes from getting sick. The MS stated the DM should contact the MS if they note a problem and then the MS would contact the vendor, but they had not had any reports of any problems with the dishwasher. The MS stated they do not monitor the temperatures in the dishwasher, just the kitchen hot water heaters. The MS stated that the vendor checks the machine every 30 days or once a month. During an interview on 04/02/2026 at 1:30 PM, the Administrator provided the Safety Data Sheet for the sanitizer solution used in the kitchen which revealed the chemical used was a multi-quat sanitizer solution, not a bleach product.

Number of residents sampled: Number of residents cited: Based on record review and interview, the facility failed to ensure a Comprehensive Care Plan was developed and implemented to address the necessary monitoring and precautions related to the use of antidepressants, anticoagulants and diuretic medications to meet the medical and nursing needs of the resident and minimize the potential for complications for one (Resident #2) of five residents reviewed. The findings include: Review of Resident #2's admission Record revealed the facility admitted Resident #2 on 02/24/2026. Review of an admission Minimum Data Set (MDS) with an Assessment Reference Date of 03/02/2026, revealed Resident #2 had diagnoses which included heart failure, stroke with hemiplegia (paralysis of one side), and unspecified mood (affective) disorder. The MDS also revealed Resident #2 had a Brief Interview for Mental Status score of 14, which indicated the resident was cognitively intact, and received antidepressant, anticoagulant, and diuretic medications. Review of an Order Summary Report dated 03/31/2026, revealed Resident #2 had an order dated 02/24/2026 for an anticoagulant (blood thinner) tablet to be given two times a day related to hemiplegia following stroke affecting the left non-dominant side, and a diuretic to be given two times a day related to heart failure. The Order Summary Report also revealed Resident #2 had an order dated 02/25/2026 for an antidepressant to be given once a day related to unspecified mood (affective) disorder. Review of a Care Plan with an initiation date of 02/25/2026 revealed the Care Plan did not address the use, monitoring or precautions of a diuretic medication, an antidepressant medication or an anticoagulant medication. Review of the Medication Administration Record for 03/01/2026 to 03/31/2026 confirmed Resident #2 had received an antidepressant one time a day, a diuretic twice a day and an anticoagulant twice a day during the month of March. During an interview on 04/01/2026 at 4:28 PM, the Rehabilitation MDS Coordinator indicated she was responsible for completing the comprehensive admission MDS assessment on 03/02/2026 for Resident #2. The Rehabilitation MDS Coordinator was asked when Resident #2's Care Plan was completed, and she stated, it was initiated on 02/24/2026. The Rehabilitation MDS coordinator was asked if the Care Plan was updated after the admission Comprehensive Assessment was completed and she stated, it was not updated by me. The Rehabilitation MDS Coordinator indicated she had not been trained on Care Plans, and she did not know how long she had to complete the Comprehensive Care Plan after the resident's admission Comprehensive Assessment was completed. The Rehabilitation MDS Coordinator was asked if Resident #2 received antidepressant, diuretic, and anticoagulant medications. The Rehabilitation MDS Coordinator reviewed the electronic record and confirmed Resident #2 received an antidepressant, anticoagulant and diuretic medication. The Rehabilitation MDS Coordinator then reviewed the electronic record and confirmed the medications were not addressed on the Care Plan. The Rehabilitation MDS Coordinator was asked if the residents Care Plan should address these medications and she stated, it should so staff knew the resident was on the medications and if the medications were not given correctly there could be interactions with other medications. During an interview on 04/01/2026 at 4:35 PM, the Long-Term Care (LTC) MDS Coordinator indicated the comprehensive Care Plan should be completed within seven days after the completion of the comprehensive admission assessment. When asked how Resident #2 had a Care Plan that addressed some of the residents needs if the Rehabilitation MDS Coordinator did not complete a Care Plan after the comprehensive assessment was completed. The LTC MDS Coordinator stated, Resident #2 had a partial Care Plan because when staff complete the admission/readmission assessment some, but not all care plan items are 'triggered' for creating the initial Care Plan. The LTC MDS Coordinator confirmed that the antidepressant, diuretic and anticoagulant medications that Resident #2 received all carry a black box warning indicating they were all high-risk medications that require precautions and monitoring. During an interview on 04/01/2026 at 4:51 PM, the Director of Nursing (DON) confirmed that Resident #2 received antidepressant, anticoagulant and diuretic medications and that the resident's Care Plan did not address the use of these medications. The DON indicated that these medications should be addressed in the Care Plan so the residents' care could be managed appropriately. During an interview on 04/02/2026 at 10:28 AM, the Administrator stated he would check and let this surveyor know if the facility had a policy on Care Plans. During a second interview on 04/02/2026 at 1:50 PM, the Administrator confirmed that a resident's Comprehensive Care Plan should address high risk medications such as anticoagulants, diuretics, and antidepressants if they were receiving them to ensure everyone was aware of the medications the resident was receiving and what the potential outcomes were. Review of a Care Plan Development Statement provided by the Administrator revealed the facility used the Resident Assessment Instrument (RAI) Manual as the primary guide for developing and implementing individualized Care Plans, ensuring they meet resident needs and regulatory standards. Review of the RAI manual Chapter 4: Care Area Assessment Process and Care Planning revealed the Omnibus Budget Reconciliation Act of 1987 (OBRA 1987) mandates that facilities provide necessary care and services to help each resident attain or maintain the highest practicable well-being. Regulations require facilities to complete an admission comprehensive standardized assessment of each resident within 14 days of admission. The comprehensive care plan, which is an interdisciplinary communication tool must be developed within 7 days of the completion of the comprehensive standardized assessment and must include measurable objectives and timeframes and describe the services that are to be furnished to attain or maintain the residents' highest practical, physical, mental and psychological well-being.

Based on record review and interview, the facility failed to monitor and supervise a resident with known high-risk elopement assessment and exit seeking behaviors to prevent elopement for 1 (Resident #4) of 6 residents reviewed for elopement. It was determined the facility's non-compliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The Immediate Jeopardy (IJ) was related to State Operations Manual, Appendix PP, 483.25 (Quality of Care) at a scope and severity of J. The Administrator was informed of the IJ on 06/25/2025 at 2:14 pm, and notified it was considered to be Past Non-Compliance (PNC). The findings include: Review of an Internal Investigation dated 03/07/2025 revealed Resident #4, on 03/07/2025 at 5:55 PM, monitored the front door for an opportunity to exit the facility. At 5:55 PM Resident #4 observed a visitor entering the front door of the facility, at that time Resident #4 used their motorized scooter to block the front door from locking and exited the building unsupervised and without staff knowledge. At 6:21 PM off duty Certified Nursing Assistant (CNA) #1 located Resident #4 on a local street (located 1.1 miles from the facility). CNA #1 reported that it was dark outside. (To reach this location, the resident would have traveled on a two-lane highway with no sidewalk on a motorized scooter to a city side street, making it approximately three blocks from a gas station.) CNA #1 discovered Resident #4, and the resident reported they were going to the gas station to get cigarettes. CNA #1 contacted the facility and spoke to the Director of Nursing (DON). She notified the DON of Resident #4's location out of the facility. CNA #1 was able to get Resident #4 into their private vehicle but left the motorized scooter. She then took Resident #4 to get cigarettes. An interview with the resident revealed they did not know the employee, but the employee knew the resident, so they got into the vehicle with CNA #1. A review of an online time and date service revealed that the sun set at 6:10 PM on 03/07/2025. An observation of an electric scooter identical to Resident #4's revealed there were no headlights or reflectors on the scooter. During an interview on 06/23/2025 at 2:18 PM, CNA #1 revealed she was driving in town when she discovered Resident #4 driving their motorized scooter on a street 1.1 miles from the facility. She revealed it was dark, and she notified the facility. CNA #1 reported she had spoken to the DON and the DON revealed that they did not know Resident #4 had left the building. CNA #1 revealed she was only able to convince Resident #4 to get in her car by telling them she would take them to buy some cigarettes. CNA #1 revealed after she bought cigarettes for Resident #4 she drove Resident #4 back to the facility. During an interview on 06/23/2025 at 12:15 PM, CNA #5 revealed Resident #4 previously made several attempts to elope from the facility, but none were successful except for the incident when CNA #1 found them in town. During an interview on 06/23/2025 at 1:55 PM, CNA #4 revealed Resident #4 previously had several attempts to elope from the facility that were not successful. During an interview on 06/23/2025 at 3:20 PM, Licensed Practical Nurse (LPN) #3 revealed she was new at the time, but since she had been employed Resident #4 had tried to get out of the facility numerous times. During an interview on 06/23/2025 at 3:45 PM, the DON revealed the cameras were reviewed, and footage revealed Resident #4 exited the building through the front door of the facility. She reported Resident #4 exited the building behind a visitor coming into the building. The DON reported that the resident had been making daily comments of wanting to go home, but the resident was not aware they did not have a home anymore. The DON revealed staff were not aware of Resident #4 being gone out of the facility, until she got a phone call from CNA #1 stating she found the resident in town. She revealed once Resident #4 returned to the facility, she assessed them and there were no injuries noted. The physician and family were notified. The DON was unsure if the police were notified. The DON revealed Resident #4 was consistently telling her they wanted to go home and would elope again as soon as staff was not looking, because Resident #4 could not smoke when they wanted to. The DON also revealed a family member would take Resident #4 out on pass about twice a month, but as soon as the family member did not come get the resident their behaviors of wanting to go home and exit seeking would start back. A discharge was arranged at that time for the safety of the resident. A family member was notified of immediate discharge. Staff monitored one on one with the resident until the family member came and picked the resident up. The DON reported an in-service was conducted about a green binder at the nurses' stations which identified residents with pictures who were risks for elopement, because it changed frequently. During an interview on 06/23/2025 at 4:00 PM, the Administrator revealed that he received a phone call from the facility at 6:26 PM requesting he come to the facility because Resident #4 had left the facility unsupervised, was found in town by an off-duty staff member and had just been returned to the facility. The Administrator revealed he arrived at the facility after Resident #4 returned to the facility. He revealed the DON assessed Resident #4 and there were no injuries. The Administrator revealed the resident kept telling him they wanted to go home, and they would elope again. The Administrator reviewed the camera footage, and reported it showed Resident #4 sat in front of the doors for approximately 3-4 minutes before a visitor came in, upon which the resident approached the door and used their electric scooter to block the door from locking and exited the building. The resident exited the building at 5:55 PM and returned to the building at 6:21 PM. The Administrator revealed Resident #4 reported they came up with the plan about 15 minutes before they exited the building. The Administrator reported when he asked the resident what would have happened if they had gotten hurt, Resident #4 reported I don't care, let me die and to call their family member to come get them because they wanted to go home. During an interview on 06/24/25 at 4:08 PM, the Assistant Administrator revealed she had returned to the facility with the Administrator at 6:26 PM. She stayed with Resident #4 and took them out to smoke. She reported the resident continued to say they wanted to go home, and the resident kept saying they would do it again as soon as someone turned their head. Resident #4 also reported they could not live there anymore because they didn't get enough cigarettes. The Assistant Administrator revealed Resident #4 had no cognitive impairment and knew what they were doing. She reported Resident #4 kept saying they were going to get cigarettes and would come back to the facility. During an interview on 06/23/2025 at 4:29 PM with CNA #2 she revealed she was assigned to Resident #4. She revealed she had picked up Resident #4's supper tray. She reported she did not see him again until after the resident returned to the facility. She revealed she assisted with packing up the resident's belongings to discharge. On 06/24/2025 at 9:14 AM a request to view camera footage was made to the Administrator but footage was only saved from 05/28/2025. During a phone interview on 06/24/2025 at 4:08 PM, Resident #4 revealed the electric scooter did not have lights on it and did not think it had reflectors on it either. Resident #4 revealed they went out the door when a visitor came in. The resident revealed they were tired of being inside of the facility, so they wanted to go out and had no plans. The resident reported they did not know the staff member who found them, but the staff member knew them, so they got in the car with the staff member. During an interview on 06/25/2025 at 8:25 AM, the Administrator revealed Resident #4 did not have a bracelet which alerted staff when the resident was trying to exit the facility. The Administrator revealed a new alarm system was ordered on 03/31/2025 and an invoice was reviewed. The new system was installed on 04/17/2025. The alarm would sound at the nurses' station when the front door opened. The alarm system could only be deactivated at the front door by the nursing staff. The nursing staff would come to the front door, look out the door, and then deactivate it. He revealed the door alarm they currently had on the front door could not be heard at the nurses' station and especially if a staff member was in a room they would not be able to hear it. He reported that due to many visitors in the evening a sign was placed at the front door asking visitors to enter and exit through the side door. He revealed the front door was locked at 6:00 PM by the charge nurse on duty. A review of a Progress note dated 02/20/2025 at 11:19 AM revealed Resident #4 was discovered attempting to open the front doors to exit the facility but was intercepted by staff. A review of Care Plan with initiation date of 05/19/2023 indicated Resident #4 was high risk to elope/wander related to active exit seeking and diagnosis of psychosis. Interventions included to distract the resident from wandering with activities, food, conversation, television and books. Resident #4 preferred to watch television and smoke. Staff were to identify patterns of wandering behaviors and de-escalate with re-direction or administer an as needed sedative. A review of quarterly Minimum Data Set with an Assessment Reference Date of 12/17/2024 revealed that Resident #4 had a Brief Interview of Mental Status score of 14, which indicates no cognitive impairment. It revealed that Resident #4 felt depressed, hopeless, and feeling down nearly every day during look back period. The MDS also revealed that the Resident felt bad about themselves or that they had let their family down nearly every day during lookback period. A review of Resident #4 ' s Medical Diagnoses revealed diagnoses of psychosis, cerebral infarction, history of suicidal behavior, history of falling, and anxiety disorder. A review of a Release of Responsibility for Leave of Absence sheet revealed that Resident #4 did not sign out prior to leaving the facility on 03/07/2025 at 5:55 PM. A review of a policy titled, Elopement and Wandering, revised 11/22/2016, revealed the facility will identify and respond promptly to elopement and wandering. Interventions will be put in place for resident's specific needs. Residents would be informed of the proper procedure to sign out of facility. Following the elopement and prior to the survey team entering the building, the facility implemented a door monitoring program, installed a secondary alarm system, in-serviced staff on elopement prevention and response, and Resident #4 was discharged from the facility. A review of door monitoring forms was conducted. The front doors were monitored on 2 shifts, 5 days a week for 4 months with no issues noted upon observation. The installation of a secondary alarm system was placed at the front door with a keypad for staff to deactivate, verified to be functional. A staff in-service was performed including a green binder, identifying residents at risk for elopement. Resident #4 was discharged from the facility on 03/07/2025, the day of elopement incident, due to resident wanting to go home and stating they would do it again.

Based on observations, interviews, record review, facility document review, and facility policy review, the facility failed to ensure proper hand hygiene was performed and enhanced barrier precautions were followed for 2 (Residents #7 and #68) of 2 sampled residents reviewed for enhanced barrier precautions (EBP). Findings include: The Administrator provided an article from the Centers for Disease Control (CDC) titled, Consideration for Use of Enhanced Barrier Precautions in Skilled Nursing Facilities dated 06/01/2021, which indicated residents may be placed on EBP when wounds or indwelling medical devices are present. A review of a policy titled Handwashing/Hand Hygiene, dated 11/22/2017, indicated the facility considers hand hygiene the primary way to prevent infections and that all personnel should follow the procedures for handwashing and hand hygiene. A review of the Admission Record, indicated the facility admitted Resident #68 with diagnoses that included dementia, mild without behavioral disturbance, psychotic disturbance, mood disturbance, anxiety, retention of urine, and immunodeficiency due to conditions classified elsewhere. The admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/19/2024, revealed Resident #68 had a Brief Interview for Mental Status (BIMS) score of 3, which indicated the resident had severe cognitive impairment. At the time of the admission MDS, Resident #68 was frequently incontinent of urine. A review of Resident #68's Care Plan, initiated on 08/21/2024, revealed the resident has an indwelling catheter for urinary retention. Interventions included enhanced barrier precautions related to the indwelling catheter. A review of the Order Summary Report for Resident #68 revealed the Resident #68 had an order for enhanced barrier precautions with a start date of 08/16/2024 and 08/20/2024 related to indwelling urinary catheter every shift. During an observation on 08/27/2024 at 8:40 AM, the surveyor knocked on Resident #68's door, response was given resident care. Upon entering the resident's room, the privacy curtain was pulled to prevent resident from being exposed. The Director of Nursing (DON), and Certified Nursing Assistant (CNA) #5 were observed not wearing gloves or a gown while working with Resident #68. The resident was rolled to one side and CNA #5 straightened the linens under the resident, CNA #5 was on the right side of the bed and the DON was on the left side. Once CNA #5 fixed the right side of the bed, the resident was assisted to turn facing the right side, the DON then straightened the left side of the bed. The DON then moved the indwelling catheter bag, adjusted the catheter, and situated the leg band which held the catheter tubing in place. The DON then straightened Resident #68's gown and CNA #5 pulled the covers over the resident. Without sanitizing her hands, the DON then straightened items on the over-the-bed table, then moved the table closer to the resident. Once the task was completed, the DON and CNA #5 walked over to the door and sanitized their hands using the alcohol gel sanitizer dispenser prior to leaving Resident #68's room. During an interview on 08/27/2024 at 8:55 AM, CNA #5 was asked what should you have put on prior to providing catheter care on to Resident #68. CNA #5 responded, A gown and gloves. During an interview on 08/27/2024 at 8:56 AM, the DON was questioned as to what should have been done prior to providing care when dealing with an indwelling urinary catheter. The DON stated that enhanced barrier precautions should have been followed, including gowns and gloves. The DON reported that Resident #68 had recently received the indwelling urinary catheter and as soon as the catheter bag was touched, it was then she realized that enhanced barrier precautions had been forgotten. The DON confirmed that the gown signage would be on the door frame and that supplies should be within reach of those on Enhanced Barrier Precaution. A review of the Admission Record, indicated the facility admitted Resident #7 with diagnoses that included: nontraumatic intracerebral hemorrhage in brain stem and gastrostomy status. The annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/24/2024, revealed Resident #7 had a memory problem per staff interview. Section K0520 Nutritional Approaches was marked as Resident #7 having a feeding tube. Resident #7 is dependent on staff for all activities of daily living. A review of Resident #7's Care Plan, initiated on 09/24/2020 and revised on 05/03/2024, revealed the resident required tube feedings related to dysphagia (difficulty swallowing), vitamin deficiencies, and was obese with body mass index of 36.0-36.9. On 7/29/2021 the resident failed a swallow study. Interventions included: enhanced barrier precautions. A review of the Order Summary Report revealed that Resident #7 had an order for enhanced barrier precautions related to gastrostomy status every shift with a start date of 04/05/2024. During an observation on 08/28/2024 at 1:40 PM, Licensed Practical Nurse (LPN) #1 was preparing to administer medications to Resident #7. LPN #1 sanitized her hands then took a bottle of Phenytoin (a seizure medication) out of the medication cart and shook the bottle to mix, she then used a syringe to draw up three milliliters (ml) of the Phenytoin solution to equal 75 milligrams (mg). LPN #1 then added the solution to a small amount of water and stirred the mixture. LPN #1 sanitized her hands with alcohol gel, LPN #1 put on an isolation gown, a pair of gloves and took a stethoscope and a towel from the top of the medication cart, knocked on Resident #7's door and entered the room. LPN #1 pulled the privacy curtain around the bed, went over to the window and closed the miniblinds with her gloves on. LPN #1 went back to Resident #7, explained what was going to be done, LPN #1 raised the resident's gown and unfastened the abdominal binder to expose the feeding tube. LPN #1 placed the towel below the tube and used a piston syringe filled with 10 ml of air, placed the tip of the syringe into the feeding tube port, placed the stethoscope on Resident #7's abdomen to auscultate/listen for the gurgle from the air being pushed into the feeding tube. Once the gurgle was heard, LPN #1 removed the syringe from the feeding tube, removed the plunger, then placed the syringe back into the feeding tube. LPN #1 flushed with 30 ml of water, once it was delivered, she added the medication mixture, then flushed with 30 ml of water after the medication was delivered. LPN #1 removed the syringe, placed it on a towel, placed the cap back on the feeding tube and placed the abdominal binder back on the resident and pulled the gown down. The syringe was then washed and left to dry. LPN #1 removed her gown and gloves and sanitized her hands before leaving the room. During an interview on 08/28/24 at 3:35 PM, the Director of Nursing (DON) indicated that LPN #1 should have sanitized her hands and put on new gloves after touching the privacy curtain, the mini blinds, and removing the abdominal binder prior to administering the medications through the tube. During an interview on 08/29/24 at 10:12 PM, LPN #1 was asked what should have been done before giving the medications through the feeding tube. LPN #1 indicated that gloves should have been changed and before putting on new gloves, her hands should have been washed or sanitized.

Based on observation, and interview, the facility failed to ensure food stored in the freezer was sealed and dated to minimize the potential for food borne illness, failed to ensure dietary staff washed their hands, in the hand washing sink before handling clean equipment or food items, to prevent potential food borne illness for 74 residents who received meals from 1 of 1 kitchen and failed to ensure excessive additives were not used in pureed foods for 3 residents who received a pureed diet. The findings are. 1. On 06/12/23 at 10:19 AM, a bag with 22 cubed steaks was in the freezer not sealed and dated. 2. On 06/15/23 at 9:46 AM, Dietary Employee (DE) #1 put 9 spoons of mixed vegetables in the food processor for the residents who received pureed diets and added chicken broth and 5 spoons of thickener. 3. On 06/15/23 at 10:29 AM, DE #1 put 6 scoops of rice in the food processor for the residents who received pureed diets and added 14 ounces plus 2 teaspoon of broth and 5 scoops of thickener. 4. On 06/15/23 at 11:26 AM, DE #1 added 6 scoops of cantaloupe to the food processor. He then added 2/3 cups of milk, and a total of 8 scoops of thickener to the processor. 5. On 06/15/23 at 10:23 AM, DE #2 pulled her mask down, and wiped her nose and face with a napkin she had in her hand. She then walked over and opened one of the utensil drawers and closed it back up. She opened another utensil drawer and grabbed a grater. She picked up an orange and put it on the counter. She walked over to the sink used for food preparation and washed her hands. 6. On 06/15/23 at 2:20 PM, the Surveyor asked DE #2, Why is it important that you wash your hands after touching your face while you are the kitchen preparing meals? She stated, To keep from spreading germs, contamination. 7. On 06/16/23 at 8:30 AM, the Surveyor asked DE #1, Can you tell me why you put broth in the vegetables and rice yesterday when they both had liquid in them? He stated, I was told to always put broth or another liquid in them. The Surveyor asked, Why is it important to only put liquids and thickener in the foods only when necessary? He stated, To keep the taste.

Based on observation, interview, and record review, the facility failed to ensure an effective pest control program was maintained to rid the facility of pests. The failed practice had the potential to affect all 74 residents who resided in the facility, as documented on the Resident Census and Conditions of Residents provided by the Director of Nursing (DON) on 06/12/23 at 2:25 PM. The findings are: 1. On 06/12/23 at 11:09 AM, on the 100 Hall, the Surveyor observed several flies on the floors, beds, tables, and TVs in each room entered. Staff were observed with fly swatters trying to kill the flies. 2. On 06/12/23 at 11:28 AM, Resident #39 was lying in bed watching television. A fly was observed on both of his eyelids, nose, [NAME], and on his forehead. The Surveyor asked, Are the flies bothering you? He nodded his head up and down. 3. On 06/12/23 at 12:12 PM, during observation of the lunch meal in the Dining Hall, residents and staff were observed waving away flies. 4. On 06/13/23 at 1:37 PM, the Surveyor asked the Laundry Supervisor about the flies, if this was normal for this time of the year. The Laundry Supervisor said, Yes, but they usually come in later in the summer. The Surveyor asked what they usually do for this problem. The Laundry Supervisor said, They go to [Store] and buy sticky poles to hang, and the flies stick to them and die. 5. On 06/14/23 at 3:03 PM, the Surveyor asked Resident #2 if the flies were normal for this time of the year. Resident #2 said, Oh yes, they're bad right now. The Surveyor asked how they handle the flies being so bad. Resident #2 said, Everyone has fly swatters. 6. On 06/15/23 at 9:30 AM, in the Kitchen there was a fly on the cutting board, on the inside of a clean plate, on the edge of 2 clean cooking pans, inside the sink used for food preparation, on the outside of the food processor, and flying around in the kitchen. 7. On 06/15/23 at 9:37 AM, in the Kitchen there were 5 flies on the floor, 8 flies on the counter, 6 flies in the sink, and numerous flies flying around the kitchen. 8. On 06/15/23 at 2:11 PM, the binder for the facilities Pest Control revealed the facility had hired [Pest Control Company] and the last time they were on the property was on 05/24/23. Their employee had put out [Brand] Fly Bait 16 ounces diluted in water and sprayed the exterior perimeter. 9. On 06/15/23 at 3:35 PM, the Surveyor asked the Dietary Manager, How long has the facility had problems with flies in the kitchen? She stated, We had them taken care of, then they started coming back in non-stop. 10. On 06/15/23 at 3:50 PM, the Surveyor asked the DON, What is the facility doing to keep the flies off the residents and out of the Kitchen? She stated, They've had [Pest Control Company] out here several times. We put the fly sticky poles outside, and we ordered the fly lights in the hallway. We have the blowers on the doors, and there should be one on the Kitchen door. The door blowers have been here a couple years. 11. On 06/16/23 at 10:20 AM, the Surveyor asked the Administrator what they have done to fight the fly situation. The Administrator said, We have ordered four more fly lights and they were installed last Friday. We also have a Pest Control contract with [Pest Control Company]. Besides their monthly visits, they're coming every three weeks spraying [Brand] Fly Bait and replacing the glue boards in the fly lights. We have four doors that have blowers on them when opened which stops the flies. Also, we have bought long round poles that hang outside on the patio and behind the kitchen that attract the flies and they stick to it and die. The Surveyor asked, What are you doing in the Kitchen and Dining Room. The Administrator said, A lot of the same thing. We have a fly trap light in the Kitchen and Maintenance is checking and changing the glue board weekly. The Surveyor asked, What are you doing about the Dining Room. The Administrator said I don't think we have those fly trap lights in there. We probably need to order one. 12. On 06/16/23 at 10:34 AM, the Surveyor asked the Maintenance Supervisor what his role was in trying to control the flies. The Maintenance Supervisor said he has hung the glue fly trap poles out on the three patios, behind the kitchen, and in the trees behind the kitchen, changing them out weekly. We have added four more fly trap lights and that has brought the total to nine for this facility. Also, we use a product that is called [Brand] fly bait, looks like blue crystals. We have sprinkled around the outside property and out by the dumpster. The Surveyor asked, Do you think all this has been effective? The Maintenance Supervisor said, Yes. The flies doesn't seem to be as bad as earlier this week. 37634

Based on observation, record review, and interview, the facility failed to ensure the oxygen tubing and water bottle were dated for 2 (Residents #5 and #14) and a humidifier water bottle was not empty for 1 (Resident #14) of 8 (Resident #5, #7, #12, #14, #28, #35 #39 and #44) sampled residents who received oxygen therapy. The findings are. 1. Resident #5 had a diagnosis of Chronic Obstructive Pulmonary Disease (COPD), Unspecified. a. The Physician Orders dated 05/02/23 documented, O2 [oxygen] at 2 L/M [liters per minute] via N.C. [nasal cannula] . change O2 tubing, clean filter and O2 cabinet, date all tubing every Wednesday night on 11-7 [11:00 PM to 7:00 AM] shift . b. A Care Plan with an initiated date of 05/04/23 documented, The resident has oxygen therapy r/t [related to] CHF [Congested Heart Failure], COPD . Change and date O2 tubing and water bottle, clean O2 cabinet and filter weekly . c. On 06/12/23 at 11:14 AM, Resident #5 was sitting in her recliner with her oxygen on at 2 liters by nasal cannula. There was not a date on the water humidifier bottle or the oxygen tubing. d. On 06/12/23 at 11:20 AM, the Surveyor asked Licensed Practical Nurse (LPN) #2, Can you tell me why [Resident #5's] oxygen tubing and humidifier water is not dated? She stated, I'm not sure, they should have put it on there. e. On 06/12/23 at 1:56 PM, Resident #5 was sitting in her recliner with her oxygen on at 2 liters by nasal cannula. There was not a date on the water humidifier bottle or the oxygen tubing. f. On 06/15/23 at 3:50 PM, the Surveyor asked the Director of Nursing (DON), Should the humidifier water bottle be dated? She stated, When they put it on there. 2. Resident #14 had a diagnosis of COPD, UNSPECIFIED. a. A Physician order dated 01/02/20 documented, O2 at 2 L/M via N.C. as needed to maintain O2 Sat [saturation] at or above 90% or shortness of breath. Monitor O2 Sat Q [every] Shift . b. A review of the care plan revised on 6/09/20 documented, The resident has COPD r/t HX. [history] Smoking . Clean O2 cabinet and filter weekly. Change and date water bottle and tubing weekly . OXYGEN SETTINGS: O2 via nasal cannula @ [at] 2L [liters] prn [as needed]. Humidified . c. On 06/12/23 at 10:58 AM, Resident #14 was in her room with oxygen on at 2 liters by nasal cannula. The oxygen water humidifier bottle and the oxygen tubing were not dated. d. On 06/13/23 at 8:20 AM, Resident #14 was in her room with O2 on at 2 liters by nasal cannula, the humidifier bottle was empty. e. On 06/13/23 at 10:22 AM, Resident #14 was in her room with O2 on at 2 liters by nasal cannula, the humidifier bottle was empty. f. On 06/13/23 at 1:01 PM, Resident #14 was not in her room. Her humidifier bottle on the oxygen concentrator was empty. g. On 06/15/23 at 3:50 PM, the Surveyor asked the DON, When should the humidifier water bottle be changed? She stated, Weekly or when it gets dry. The Surveyor asked, Why is it important that the water bottle is changed when the bottle is empty? She stated, So their nasal area doesn't dry out.

Based on observation, interview, and record review, the facility failed to ensure nail care was regularly provided to maintain good hygiene and prevent potential injuries or infections for 1 (Resident #34) of 19 (Residents #1, #5, #6, #7, #10, #11, #12, #13, #14, #28, #31, #34, #39, #44, #49, #66, #72, #85 and #230) sampled residents who required assistance with nail care. This failed practice had the potential to affect 33 residents who required staff assistance for nail care as documented on a list provided by the Administrator on 06/13/23 at 3:45 PM. The findings are: Resident #34 had a diagnosis of Other Specified Peripheral Vascular Diseases. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/15/23 documented the resident required extensive physical assistance of one person with personal hygiene. a. A Physicians Order dated 07/08/21 documented, Dentist, Podiatry, Optometrist and Audiological to see as indicated . b. A Care Plan with an initiated date of 07/01/21 documented, The resident has an ADL [Activities of Daily Living] self-care performance deficit r/t [related to] cognitive impairment, RA [Rheumatoid Arthritis] and Parkinson's . BATHING/SHOWERING: Check nail length and trim and clean on bath day and as necessary. Report any changes to the nurse . c. On 06/12/23 at 1:12 PM, the Surveyor accompanied the Social Worker from [Hospice] into Resident #34's room. Resident #34 was lying in bed with her bare feet exposed. The toenail on her left great toe was approximately 1/4 inch past the tip of the toe, with sharp edges, and the third toenail on her right foot was approximately 1/4 inch in length and appeared to be growing inward toward the skin on toes. The Surveyor asked Resident #34 if her toenails bothered her. Resident #34 answered, Yes, I addressed it with them last week. A Certified Nursing Assistant (CNA) from [Hospice] entered Resident #34's room at 1:15 PM. The Surveyor asked the Hospice CNA who was responsible for nail care for Resident #34. She stated, We can clean and file, but we can't trim them because she's diabetic. The Surveyor asked the Hospice CNA if a Hospice nurse saw Resident #34 and if so, how often. The Hospice CNA said, Yes, twice a week. She has nurses here that see her also. d. On 06/13/23 at 2:20 PM, the Surveyor accompanied CNA #1 into Resident #34's room where Resident #34 was lying in bed awake. The Surveyor asked CNA #1 to describe Resident #34's toenails. CNA #1 answered, Her nails look like they need to be trimmed. They are pretty long and rubbing against her skin. I will tell the nurse. The toenail on the left great toe remained approximately 1/4 inch past the tip of toe with pointed edges on each corner of the toenail, and the third toenail on right toe remained 1/4 inch long past the tip of toe and curving inward toward the skin. e. On 06/14/23 at 9:45 AM, Resident #34 was lying in bed awake. The left great toenail remained long with sharp edges and the third right toenail remained 1/4 inch long past the tip of toe and curving inward toward skin. f. On 06/13/23 at 2:48 PM, the Surveyor asked the Assistant Director of Nursing (ADON) who was responsible for toenail care. The ADON answered, Nurses do it if they are Diabetic, aides do it if not. We have a Podiatrist come in quarterly. The Surveyor asked how often nails should be checked. The ADON answered, Any time they are doing any kind of ADL's. For Diabetics once weekly. The Surveyor asked why nailcare is important and what can happen if it isn't done. The ADON answered, Ingrown nails, infection, and pain. For Diabetics it can cause ulcers. g. On 6/13/23 at 3:35 PM, the Administrator informed the Surveyor that there is no facility Policy and Procedure for nail care.

Based on observation, record review, and interview, the facility failed to ensure resident food preferences were honored and foods listed as dislikes were not served to promote good nutritional intake and promote resident's choices for 1 (Resident #71) of 1 sampled resident. The findings are: Resident #71 had diagnoses of Pleural Effusion and Gastroesophageal Reflux. a. On 06/14/23 at 8:35 AM, the Surveyor accompanied Nursing Assistant (NA) #1 into Resident #71's room. Resident #71's meal tray ticket documented, a regular mechanical soft diet, enhanced foods. The meal ticket noted the resident received wheat toast with a thin layer of peanut butter, scrambled eggs and 2 diced tomatoes, 4 oz [ounces]. The meal ticket noted the resident dislikes oatmeal. Resident #71's served breakfast consisted of wheat toast with a thin layer of peanut butter, scrambled eggs, 2 sliced tomatoes, oatmeal, coffee, a lemon lime soda 8 oz, and water. NA#1 encouraged Resident #71 to try the oatmeal. Resident #71 declined. b. On 06/14/23 at 8:45 AM, Licensed Practical Nurse (LPN) #1 entered Resident #71's room and asked Resident #71 to try the oatmeal. Resident #71 stated, I don't like oatmeal. LPN #1 told the Surveyor, I think she has lost her taste and that may be why she's not eating well. c. On 06/15/23 at 8:25 AM, the Surveyor accompanied Certified Nursing Assistant (CNA) #2 into Resident #71's room. The meal tray ticket documented, a regular mechanical soft diet, enhanced foods. The meal ticket noted the resident received wheat toast with a thin layer of peanut butter, scrambled eggs and 2 diced tomatoes, 4 oz. The meal ticket noted the resident dislikes: Oatmeal, Onions, Pears, Citrus. CNA #2 attempted to feed Resident #71 breakfast. Resident #71 refused to eat any of her food and said, Leave me alone. Breakfast was delivered in a styrofoam container and consisted of 1 slice of bacon, scrambled eggs, gravy and 1 slice of toast. The thin coat of peanut butter and diced tomatoes listed on the meal ticket were not served. d. On 06/15/23 at 9:40 AM, the Surveyor asked the Dietary Manager, Can you tell me why [Resident #71] didn't receive wheat toast, peanut butter, and diced tomatoes on her breakfast tray? She stated, I don't know why. I'll have to ask the cook. e. On 06/15/23 at 9:45 AM, the Surveyor asked the Cook, Dietary Employee #1, Can you tell me why [Resident #71] didn't receive wheat toast, peanut butter, and diced tomatoes on her breakfast tray? He stated, Honestly I forgot about it. I've been out, and just came back to work. I'm trying to get back in the swing of things.

Based on observation and interview, the facility failed to ensure food was dated and utilized prior to the expiration date and food in an open carton was placed in a sealed container. The failed practice had the potential to affect 88 residents who received meals from 1 of 1 kitchen as documented by a resident list provided by the Administrator on 3/25/22 at 9:00 AM. The findings are: 1. On 3/21/22 at 11:00 AM, a one-gallon clear, hard plastic container was located on a shelf in the side-by-side refrigerator located in the kitchen. The container was approximately ¼ full of a peanut butter and jelly mixture. The use by date located on the top of the lid was 3/20/22. Also on the shelf was a 1-quart, white plastic container which was ¾ full of chicken salad. The use by date located on the top of the container was 3/19/22. 2. On 3/21/22 at 11:10 AM, inside the walk-in refrigerator, there was a bag of pulled chicken breast located on the second shelf on a wheeled cart. The bag contained approximately 2.5 pounds of chicken and was not dated. 3. On 3/21/22 at 11:13 AM, inside the walk-in refrigerator, a gallon size pitcher which was 1/3 full of ranch dressing was on the top shelf. The dressing had a made date of 2/25/22 and a use by date of 3/10/22. 4. On 3/21/22 at 11:15 AM, inside the walk-in freezer, a bag containing 12 tortillas was on the top shelf. The bag was not dated. 5. On 3/21/22 at 11:25 AM, in the dry storage area, 2 one-gallon containers of prepared mustard were located on the middle shelf. The use by date recorded on the labels were 11/23/21. 6. On 3/22/22 at 11:30 AM, a box of cornstarch was on a shelf, on the wall of the tray line area. The lid of the box was standing open. The box was not placed in a sealed container upon opening. 7. The policies for Dry Food Storage & Cold Storage Areas provided by the Administrator on 3/24/22 at 8:30 AM, documented, .food will be dated upon receipt and stock rotated using first-in, first-out method. Canned foods will be used within 1 year of the date delivered.store cold food until their use-by date, expiration date . 8. On 3/24/22 at 1:30 PM, the Dietary Manager was asked to describe the method in which food is stored. She stated, .we rotate, 1st in and 1st out, .in the refrigerator we put a date on the top and throw it away after three days . Concerning the storage of items after they are opened and only partially used the dietary manager stated, .we put it in another container if possible and if not, we put it in a bag and put a twist tie on it or seal it some way .

Based on observation, record review and interview, the facility failed to ensure a Physician's Order for Knee high Compression hose were followed and documented to prevent or reduce [CONDITION(S)] for 1 (Resident #64) of 1 sampled resident who had orders for Knee high Compression hose. The findings are: Resident #64 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date of 2/21/22 documented the resident scored 8 (8-12 indicates moderately impaired) on the Brief Interview for Mental Status (BIMS), required extensive assistance of 1 person with dressing, toileting, and transfer. a. A Physician's Order dated 12/4/20 documented, .Knee High Compression hose on at 6 [6:00] am and off at hs, [hours of sleep] every morning and at bedtime related to GENERALIZED [CONDITION(S)] . b. The Care plan revised on 12/01/21 documented .altered cardiovascular status related to [CONDITION(S)], [CONDITION(S)], Hypertension, Atherosclerosis, . Knee high compression hose to BLE [bilateral lower extremities] as ordered . c. On 3/21/22 at 11:50 AM, the resident was sitting in a recliner, He stated he was cold. The resident was wearing diabetic socks, non-compression on bilateral feet. There was [CONDITION(S)] in the right lower extremity, noted indention around top of sock area on right lower leg. d. On 03/22/22 at 8:12 AM, the resident was sitting in a chair with the breakfast tray on the bedside table. There was pitting [CONDITION(S)] in both lower extremities around the top of the non-compression socks he was wearing. e. The March 2022 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . A check mark and staff initials on days 3/1/22 through 3/23/22 for the 0600-time frame to indicate the knee compression socks had been applied and a check mark and staff initials appeared on days 3/1/22 through 3/22/22 in the 2000 Hours of Sleep (hs) time frame to indicate the knee compression socks had been removed. f. On 3/24/22 at 8:10 am, Licensed Practical Nurse (LPN) #1 at Station 1 was asked, Who is responsible for applying the knee compression socks to residents? She stated, The Certified Nurse aides are, sometimes they wait till after the resident's shower if it's the residents shower day, they have up till 3:00pm to get them applied on the shower days. But the nurse on that hall is responsible for making sure they are on as ordered. She was asked, Who was responsible for documenting the application and removal of the compression socks on the MAR? The LPN stated, That is the nurse's responsibility, and they chart it when they assure, they are on or removed from the resident. g. On 3/24/22 at 8:15 am, LPN #1 accompanied the surveyor to Resident #64's room. The resident was lying in bed on his left side. LPN looked at the resident's socks he was wearing and stated, No, those are not his knee compression socks, those are just his regular diabetic socks. LPN #1 searched for the knee compression socks and found them in the clothes drawer. h. On 3/24/22 at 8:30 am, the Director of Nursing (DON) was asked, Who is responsible for applying the knee compression socks to residents that the Physician has ordered? The DON stated, Well the CNAs should be doing it and the nurses are to make sure they are done per the orders. She was asked, Who is responsible for charting on the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] ? She stated, Well if they are not being done at that time sounds like we need to fix the MAR, but sometimes they will wait to put them on after the residents shower is done if it is their shower day. She was asked, So if the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] ? She replied, If the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Surveyor explained she had not observed the knee compression hose on the resident all week, but the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . She was asked, What could happen to the resident if the orders are not followed? She stated, Well it could lead to swelling and other skin complications.

Based on record review and interview, the facility failed to ensure the care plan was revised to reflect monitoring for signs and symptoms of aspiration to ensure the safety at mealtimes for 1 (Resident #13) of 1 sampled resident with a Dietary Waiver. The findings are: Resident [R] #13 had diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . a. The Care Plan dated 06/07/19 documented, the resident has a potential for nutritional problem r/t [related to] Dysphagia requiring mechanically altered diet and honey thick liquids. A revision dated 02/15/22 changed to Nectar thick liquids.May have applesauce and pudding. Small bites/sips; swallow 1x [time] after every bite; go slow; upright for all PO [oral] intake; remain upright for 30 minutes; good oral care after meals; intermittent supervision to cue for precautions. Follow instructions of good oral care after meals before use of cup. Resident has a tendency to get thin liquid (soda, coffee) and drink without slow flow cup or thickener . b. A Dietary order dated 2/14/22 documented, Regular diet Mechanical Soft texture, Nectar consistency, Supervision PRN [as needed] (encourage to eat in DR) to cue for precautions; small bites/sips; swallow 1x after every bite; go slow; upright for all PO intakes; remain upright 30 minutes after meals; good oral care. c. The Modified [MEDICATION(S)] Swallow Study by the Speech Language Pathology summary from 2/16/22 through 3/11/22 documented, .Patient continues to have Oropharyngeal Dysphasia and is at risk for aspiration with thin liquids, pt will not drink thickened liquids patient's family signed a no consent form for patient to be on thin liquids patient and family are aware of aspiration risk. Pt. and staff have been trained to use his swallowing precautions during PO intake to decrease aspiration risk. d. The Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . e. A Progress Note dated 3/17/22 documented, Received signed diet waiver with family signature to allow resident to have regular thin liquids at this time, notified dietary, notified floor nurse. f. The Dietary Profile dated 3/23/22 documented, Regular Mechanical Soft diet with Nectar liquids and he has had a stroke affecting his right dominant side. Has been able to feed himself, but 2nd increasing [CONDITION(S)] activity, he has not wanted to do much. Staff will set up his trays, allow him time to feed himself and offer assistance, which he often refuses. g. The resident's tray card for March 2022 documented, Alerts: encourage to eat in dining room, single bites/sips, swallow after every bite, upright 90 degrees and 30 minutes after. Supervision PRN . h. On 3/24/22 at 8:50 AM, the Speech Therapist was asked, Can you tell me about [Resident #13] swallowing? She stated, He absolutely hates thickened liquids he knows the swallowing precautions; he just won't follow them. i. On 3/24/22 at 9:52 AM, Certified Nursing Assistant (CNA) #4 was asked, Where does R#13 usually eat? She stated, Sometimes he gets up usually in his room. She was asked, Are you aware of any swallowing precautions? She stated, He's not aspirating, and he doesn't choke. j. On 03/24/22 at 9:58 AM, Licensed Practical Nurse (LPN) #2 was asked, Where does [R#13] usually eat? She stated, In his room. She was asked, Are you aware of any swallowing precautions? She stated, Nectar thick, up in bed, never seen signs of aspiration. k. On 03/24/22 at 11:13 AM, the MDS Coordinator was asked, When are care plans revised? She stated, Quarterly. She was asked, What if a dysphagia resident is now receiving thin liquids? She stated, Oh, [R #13], I updated his care plan, to identify the waiver his family signed. She was asked, What about the addressing the steps the facility is taking to make sure any aspiration is addressed promptly. She stated, Oh, I see what you mean. She was asked, Does the care plan reflect his current situation? She stated, No it doesn't.

Based on record review and interview, the facility failed to ensure the Minimum Data Set (MDS) were completed accurately for 1 (Resident #19) of 19 (Residents #13, #41, #6, #59, #85, #73, #19, #15, #44, #14, #38, #76, #64, #290, #48, #20, #72, #35, and #62) sampled resident who had physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] Resident #19 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . a. The December 2021 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] = 5 units; 201 - 250 = 7 units; 251 - 300 = 9 units; 301 - 350 = 11 units; 351 - 400 = 13 units; 401 - 450 = 15 units; 451 - 500 = 17 units, subcutaneously before meals and at bedtime related to Type 2 Diabetes Mellitus. Insulin was administered twice daily during the month of December 2021. c. The January 2022 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] = 5 units; 201 - 250 = 7 units; 251 - 300 = 9 units; 301 - 350 = 11 units; 351 - 400 = 13 units; 401 - 450 = 15 units; 451 - 500 = 17 units, subcutaneously before meals and at bedtime related to Type 2 Diabetes Mellitus. Insulin was administered 11 times from 1/1/2022 through 1/3/22. d. On 03/24/22 at 12:16 PM, the MDS Coordinator was asked, Does Resident #19 Quarterly MDS document insulin was administered? She stated, Oh no. She was asked, Did she receive insulin? She stated, Yes, she does. She was asked, Do we have an accurate MDS? She stated, No, I'll fix it.

Based on observation, record review, and interview, the facility failed to ensure a mechanical lift was utilized in accordance with the manufacturer's instructions to minimize the potential for transfer-related injuries for 1 (Resident #19) of 4 (Residents #20, #59, #85, and #19) sampled residents who required the use of a mechanical lift for transfers. The findings are: Resident #19 had diagnoses of Acquired Absence of right leg below the knee, and Systemic Lupus. The Quarterly Minimum Data Set with an Assessment Reference Date of 01/04/22 documented the resident scored 15 (13-15 indicates cognitively intact) on the Brief Interview for Mental Status, was totally dependent on the assistance of two-plus people for transfers. a. The Care Plan revised on 4/19/21 documented, The resident has an ADL self-care performance deficit r/t [related to] bilat BKA [bilateral below the knee [CONDITION(S)]] . requires Mechanical Lift with x [times] 2 staff assistance for transfers (size is M [medium]/L [large], colors are purple/green). b. On 03/23/22 at 10:21 AM, Certified Nursing Assistant CNA #1 and CNA #2 used the mechanical lift to transfer the resident from the bed to an electric wheelchair. The resident was rolled from side to side placing the lift pad under her. The legs of the mechanical lift were wide open as it went under the bed the rear casters were locked on both sides when the resident was lifted from the bed. The legs unlocked and the lift was pushed to the wheelchair with legs wide open, the rear casters were locked as she was lowered to the wheelchair. c. On 03/23/22 at 10:28 PM, CNA #2 was asked, Did you lock the rear casters before you lifted her? She stated, Yes. She was asked, Did you lock the rear casters when she was being lowered into the wheelchair? She stated, Yes. d. On 03/23/22 at 11:00 PM review of the Battery Powered Patient Lift User Manual documented, .Do not lock the rear [NAME] of the patient lift when lifting an individual. Locking the rear casters could cause the patient lift to tip and endanger the patient and assistants. e. On 03/23/22 at 11:08 AM, CNA #1 was asked, When were you last trained on the mechanical lift? She stated, It's been a while. f. On 03/23/22 at 11:12 AM, CNA #2 was asked, When were you last trained on the mechanical lift? She stated, It's been a while. She was asked, Are you aware the user's manual identified the rear casters were not to be locked? She stated, I thought about it, but I chose to lock it. She was asked, Why did you do it? She stated, Sometimes you get all flabbergasted.

Based on observation, record review and interview, the facility failed to ensure residents' fingernails were cleaned and trimmed to promote good personal hygiene and grooming for 3 (Residents #2, #20, and #9) of 3 sampled residents who were dependent for nail care. The findings are: 1. Resident #2 had a [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/28/2020 documented the resident was severely impaired in cognitive skills for daily decision making per the Staff Assessment for Mental Status (SAMS) and was totally dependent for Activities of Daily Living (ADL). a. The January 2021 Physician orders [REDACTED]. b. The Care plan revised on 4/14/20 documented, The resident has an ADL self-care performance deficit r/t (related to) [MEDICAL CONDITION] DZ (disease) of Basal Ganglia as evidence by poor coordination and lack of use of limbs . NAIL CARE: to be performed by LPN, resident is a diabetic . c. On 01/04/21 at 11:51 AM, the resident was lying in bed. The resident's nails were approximately 1/4-inch-long and had an unknown substance under the nails. d. On 01/07/21 at 02:16 PM, the Director of Nursing (DON) was asked, Should residents' fingernails be kept clean and trimmed? She stated, Yes. e. On 01/07/21 at 02:42 PM, LPN #2 was asked, Should residents' fingernails be kept clean and trimmed? She stated, Absolutely. f. The facility policy for Nails, Care of (Finger and Toe) received from the Administrator on 01/06/21 at 02:34 PM documented, . Procedure 5. Put hands on towel. Trim and clean nails; file smoothly 6. NOTE: FINGERNAILS OF DIABETIC PATIENTS ARE TO BE CUT BY THE NURSE 2. Resident #20 had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/4/20 documented the resident scored 15 (13-15 indicates cognitively intact) on the Brief Interview for Mental Status (BIMS) and required limited assistance with personal hygiene. a. The care plan with a revision date of 8/20/20 documented, .The resident has a potential for an ADL self-care performance deficit r/t Dementia, visual loss, weakness . PERSONAL HYGIENE/ORAL CARE: The resident is able to: perform self with setup, assist prn (as needed) . b. On 01/05/21 at 08:53 AM, Resident #20 was sitting up in bed. The resident's fingernails on both hands extended approximately 1/4 inch past the end of the nail bed. The fingernails were uneven, jagged and there was a brown substance under the nails. A photo was taken. Resident #20 was asked, Do you like your nails to be long? Resident #20 stated, No, would you like them this long? I could scratch myself with them. c. On 01/06/21 at 08:45 AM Resident #20 was sitting up in bed drinking coffee. His fingernails on both hands extend approximately 1/4 inch past the end of the nail bed. The fingernails were uneven, jagged and had a brown substance under them. d. On 01/07/21 at 10:30 AM, LPN #1 was asked, How much assistance with nail care does Resident #20 require? LPN #1 stated, Staff have to do his nail care for him. LPN #1 was asked, does Resident # 20 refuse nail care? LPN #1 stated, No. e. On 01/07/21 at 1:35 PM, the Director of Nursing (DON) was asked, Who is responsible for nail care? The DON stated, the CNAs and the nurses. The DON was asked, When should nail care be performed? The DON stated, It is usually done on the residents shower day. The DON was asked, What could happen if the resident's nails are not kept clean and groomed? The DON stated, They could scratch themselves or others. f. On 01/07/21 at 2:10 PM, Certified Nursing Assistant (CNA) #1 was asked, Who is responsible for nail care? CNA #1 stated, The CNAs on the floor. The Diabetics are done by the nurse. CNA #1 was asked, When should nail care be performed? CNA # 1 stated, Weekly. I always do it after their shower. You should also clean them at any time if they are dirty. CNA #1 was asked, What could happen if a resident's nails are not clean and well groomed? CNA #1 stated, The nail could grow into the skin and cause an infection. 3. Resident #9 had [DIAGNOSES REDACTED]. The annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/8/20 documented the resident was severely impaired in cognitive skills for daily decision making per the Staff Assessment of Mental Status (SAMS) and required extensive assistance with bed mobility, transfers, toileting, and personal hygiene. a. The care plan with a revision date of 10/22/20 documented, The resident has an ADL self-care performance deficit r/t (related to) Dementia . PERSONAL HYGIENE/ORAL CARE: The resident requires extensive assist x (times) 1-2 staff . b. On 01/05/21 at 9:11 AM, Resident #9 was lying in bed. Her fingernails on both hands were long extending approximately 1/4 inch past the end of the nail bed. The nails were uneven, jagged and there was a brown substance under them. A photo was taken. c. On 01/06/21 at 2:00 PM, Resident #9 was sitting in the dining/day room next to the nurses' station. Her fingernails on both hands were long, extending approximately 1/4 inch past the nail bed. The fingernails were uneven, jagged and there was a brown substance under them. A photo was taken. d. On 01/07/21 at 10:30 AM, Licensed Practical Nurse (LPN) #1was asked, Who is responsible for nail care? LPN #1 stated the Certified Nurses Aides (CNAs) or the nurse if the resident is diabetic. LPN #1 was asked, How much assistance with nail care does Resident #9 require with nail care? LPN #1 stated, Staff have to do her nail care for her. LPN #1 was asked, When should nail care be performed? LPN #1 stated, The CNA's should do the residents nails when they get their showers. Diabetic nail care is done once a week. LPN #1 was asked, What could happen if a resident's nails are not kept clean and well groomed? LPN #1 stated, The resident could scratch themselves, get an infection or even a fungus under their nails. LPN #1 accompanied surveyor to look at Resident #9 nails. LPN #1 was asked, What do you see under the resident's nails? LPN #1 stated, It is most likely food, she eats with her fingers at times. LPN #1 was asked, Do Residents #9 nails need to be cleaned and groomed? LPN #1 stated, Yes they need to be cleaned. I will get them cleaned today.

Based on observation, record review and interview the facility failed to ensure oxygen tubing and humidification were dated, and storage bags were present for storage when not in use for 2 (Residents #13 and #31) of 8 (Residents #1, 13, 20, 22, 31, 27 65 and 12) sampled residents. Failed to ensure nebulizer tubing was dated and tubing and mouthpiece were properly stored when not in use for 2 (Residents #31, and 12) of 7 (Residents #31, 69, 5, 1, 22, 27 and 12) sampled residents and failed to ensure oxygen liters were set per physician orders [REDACTED].#1) of 8 (Residents #1, 13, 20, 22, 31, 27 65 and 12) sample resident who used oxygen. These failed practices had the potential to affect 16 residents who used oxygen and 11 residents who use a nebulizer machine, according to a list provided by the Director of Nursing (DON). The findings are: 1. Resident #13 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/26/2020 documented the resident scored 15 (13-15 indicates cognitively intact) on the Brief Interview for Mental Status (BIMS). a. The Care plan revised on 2/7/2020 documented, The resident has oxygen therapy r/t HF . Clean oxygen cabinet and filter weekly. Change and date water bottle and tubing weekly . b. The January 2021 Physician orders [REDACTED]. c. On 01/04/21 at 12:44 PM, the resident had an oxygen concentrator in room that was not on. Humidification bottle not dated, oxygen tubing not dated, and no storage bag present. The resident had oxygen tubing secured on her chair and stated she liked it where it was. 2. Resident #31 had [DIAGNOSES REDACTED]. The Admission Minimum Date Set (MDS) with an Assessment Reference Date (ARD) of 11/19/2020 documented the resident scored 15 (13-15 indicates cognitively intact) on the Brief Interview for Mental Status (MDS) and received oxygen while a resident. a. The Care plan dated 11/10/20 documented, . The resident has [MEDICAL CONDITION]/[MEDICAL CONDITION] Stage 4 with hospice care . Change and date UD (updraft) tubing weekly . Clean O2 cabinet and filter weekly. Change and date water bottle and tubing weekly . b. The Physician orders [REDACTED]. change O2 tubing, clean filter and O2 cabinet, date all tubing every Thursday night on 11-7 (11:00 pm to 7:00 am) shift . Change and date updraft tubing and nebulizer every Thursday night on 11-7 shift c. On 01/04/21 at 12:12 PM, the resident was on 3 liters of oxygen, humidified. Humidification bottle was not dated, tubing was not dated, and there was no storage bag present. Updraft machine present with nebulizer mouthpiece not in a storage bag, no date on tubing. d. On 01/07/21 at 02:16 PM, the Director of Nursing (DON) was asked, Should oxygen tubing, nebulizer tubing, and humidification bottles be dated? She stated, Yes. When asked, Should oxygen tubing and nebulizer tubing have storage bags? She stated, Yes. When asked, Should oxygen tubing and nebulizer tubing be in storage bags when not in use? She stated, Yes. e. On 01/07/21 at 02:42 PM, Licensed Practical Nurse (LPN) #2 was asked, Should oxygen tubing, nebulizer tubing, and humidification bottles be dated? She stated, Yes. When asked, Should oxygen tubing and nebulizer tubing have storage bags? She stated, Absolutely. When asked, Should oxygen tubing and nebulizer tubing be in storage bags when not in use? She stated, Yes. 3. Resident #1 had [DIAGNOSES REDACTED]. The Significant Change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/18/20 documented the resident required extensive assistance with bed mobility, transfers, toileting, and received oxygen therapy. a. The care plan with a revision date of 8/26/20 documented, . The resident has [MEDICAL CONDITION] .Oxygen Settings: O2 via nasal cannula @ 2L prn (as needed) . b. The January 2021 Physician orders [REDACTED].C. (Nasal Canula) to maintain O2 Sat (Saturation) at or above 90% for shortness of breath. Monitor O2 Sat Q (every) Shift . c. On 01/06/21 at 07:47 AM, Resident #1 was lying in bed with her eyes closed. She had oxygen in place per nasal canula with a flow rate set at 2.5 liters per minute. A photo was taken. d. On 01/07/21 at 10:25 AM, Licensed Practical Nurse (LPN) # 1 was asked, Should physician orders [REDACTED].? LPN #1 stated Yes. LPN #1 was asked, Who is responsible for ensuring the resident is receiving the correct oxygen flow rate? LPN #1 stated, The nurses are responsible. LPN #1 was asked, How often should the nurse check to ensure a resident's oxygen is at the correct flow rate? LPN #1 stated, It should be checked every shift. LPN #1 was asked, What flow rate should (Resident #1) oxygen be set at? LPN #1 stated, 2 liters . 4. Resident #12 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/19/20 documented the resident scored 12 (8-12 indicates moderately impaired) on the BIMS. a. The Physician orders [REDACTED]. b. On 1/4/21 at 12:30 PM, The resident was lying in bed. There was a nebulizer setting on the light above the resident's bed and it was not in a storage bag. A photo was taken. The resident was asked, Is that your nebulizer on top of your light? The resident stated, Yes, sometimes they put it up there when I don't have a place to put it on my table. The resident was asked, How many times a day do you use it? The resident stated, 2-3 times a day. c. On 1/7/21 at 8:29 AM, the resident was lying in bed and a nebulizer was sitting on the over bed table and not in a storage bag. A photo was taken. The resident stated, I just finished my treatment. The resident was asked, Did you place it on the table? Resident stated, Yes, I put it there and the nurse will be back shortly to put it in the plastic bag, wherever it is. d. On 1/7/21 at 2:25 PM, LPN #3 was asked, Did you give (Resident #12) the medication for her nebulizer today? LPN #3 stated, Yes, I set it up for her. She held it and performed the treatment and I went across the hall to another room to give medication. I then went back to check on her two times until she completed the treatment. The LPN was asked, When she finished her treatment, did you put the nebulizer in a bag for storage? LPN #3 stated, No, I put it on top of the machine. LPN #3 was shown the picture of the nebulizer on top of the light not in a bag and on the table and not in a bag. She was asked, Is that the proper way to store a nebulizer? LPN #3 laughed at the pictures and stated, No. LPN #3was asked, What can happen when you don't store the nebulizer properly? LPN #3 stated, It can fall to the floor and get germs and get nasty. e. On 1/7/21 at 3:20 PM, the pictures of the nebulizer were shown to the Director of Nursing (DON). The DON was asked, Is that the proper way to store a nebulizer? The DON stated, No, it's not. The DON was asked, Do you have a policy for oxygen storage? The DON stated, No, we don't have one.

Based on observation, record review, and interview, the facility failed to ensure a resident was assessed and physician orders [REDACTED].#31) of 7 (Residents #31, 69, 5, 1, 22, 27 and 12) sampled resident who received inhalation treatments. The findings are: Resident #31 was admitted on [DATE] with [DIAGNOSES REDACTED]. The Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/19/2020 documented a score of 15 (13-15 indicates cognitively intact) on the Brief Interview for Mental Status (MDS). a. The Medication Self Administration Safety Screen dated 11/18/2020 documented, . INSTRUCTIONS Complete this assessment prior to resident initiating self-administration of medication and with any medication order changes, change in function/condition that might affect the resident's ability to safely self-administer medications . A. Medications .Medication #1 1a. Order: ProAir HFA (hydrofluoroalkane) aerosol solution 2 puffs (every) 4 hours 1b. Storage: 1. Bedside with resident . There were no other medications documented on the form. b. The January Order Summary Report documented, .[MEDICATION NAME] Suspension 0.25 mg (milligrams) (per) 2 ml (milliliters) 1 vial inhale orally two times a day . [MEDICATION NAME]-[MEDICATION NAME] Solution 0.5-2.5 (3) mg (per) 3 ml 1 vial inhale orally every 4 hours . [MEDICATION NAME] Nebulization solution 20 mcg (micrograms) (per) 2 ml .2 milliliter inhale orally via nebulizer two times a day . ProAir HFA Aerosol solution 108 (90 Base) mcg (per) ACT (actuation) 2 puff inhale orally every 4 hours .unsupervised self-administration . ProAir HFA was the only medication indicated for unsupervised self-administration. c. On 01/04/21 at 12:12 PM, the resident was observed self-administering ProAir inhaler. [MEDICATION NAME] Solution was also on the bedside table. d. On 01/04/21 at 01:03 PM, the resident self-administered an updraft treatment. There was no nurse present in the room. e. On 01/05/21 at 09:27 AM, in the resident's room there was an inhaler on the bedside table, and [MEDICATION NAME] Solution on the over bed table. There was a clipboard with Medication Administration Record [REDACTED] f. On 01/07/21 at 02:16 PM, the Director of Nursing (DON) was asked, Should a resident have a physician's orders [REDACTED].? She stated, Yes. When asked, If a resident self-administers medication should they be assessed for all self-administered medications? She stated, Yes. When asked, If a resident self-administers medication how should they be stored? She stated, She needs a box. When asked, Should nursing staff be indicating on the Medication Administration Record [REDACTED]? She stated, No. g. The Facility policy for Medication, Self-Administration provided by the DON on 01/06/21 at 01:03 PM documented, . General Guidelines 1.b. Order is obtained from the resident's physician . 2. If self-administration is permitted the following conditions will apply and will be noted on the resident's care plan: a. Storage of medications in the resident's room must be such that it will prevent access by other residents; b. Only the medications permitted for self-administration shall be left at the bedside .

Based on observation, record review and interview, the facility failed to ensure call lights were placed in reach for resident use to promote prompt response to residents need for assistance for 1 of (Resident #9) 1 case mix resident. The findings are: Resident #9 had [DIAGNOSES REDACTED]. The annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/8/20 documented the resident was severely impaired in cognitive skills for daily decision making per the Staff Assessment of Mental Status (SAMS) and required extensive assistance with bed mobility, transfers, toileting, and eating. a. The Care Plan with a revision date 10/22/20 of documented, The resident is High risk for falls r/t (related to) Dementia . Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance . b. On 01/05/21 at 09:05 AM, Resident #9 was sitting up in bed. The call light was attached to the wall approximately 7 feet from the resident. A photograph was taken. c. On 01/07/21 at 10:35 AM, Licensed Practical Nurse (LPN) #1 was asked, Should a resident's call light be kept within reach? LPN #1 stated, Yes. LPN #1 was asked, Who is responsible for ensuring a resident's call light is kept within reach? LPN #1 stated, The Certified Nurses Aides (CNAs) and the nurses are responsible. Any nursing staff member that is in the room should make sure the call light is within reach. LPN #1 was asked, Why is it important to ensure the residents call light is within the resident's reach? LPN #1 stated, The resident may need something. They might not be able to reach their fluids, or they may try to get up without assistance and fall. d. On 01/07/21 at 1:40 PM the Director of Nursing (DON) was asked, Should a resident's call light be kept within reach? The DON stated, Yes. The DON was asked, Who is responsible for ensuring the residents call light is within reach? The DON stated, Anyone in the Nursing Department. The DON was asked, Why is it important that a resident's call light is kept within reach? The DON stated, It is important so the resident can get assistance with anything they are needing. For example, if they want a drink or something. e. On 01/07/21 at 02:15 PM, Certified Nursing Assistant (CNA) #1 was asked, Should the residents call light be kept within reach? CNA #1 stated, Yes. CNA #1 was asked, Who is responsible for ensuring the residents call light is within reach? CNA #1 stated, The CNAs or any nurse if they go in the room and it is not in reach. CNA #1 was asked, Why is it important that the residents call light is kept within the resident's reach? CNA #1 stated, It is important because that is how they can get help if they need it. It is how they alert us if they need something. If they want something and do not have their call light, they may get up unassisted and they could fall.

Based on observation and interview, the facility failed to ensure effective maintenance services were consistently provided by ensuring the base boards in residents rooms on the 100 and 200 hall were in good repair and not peeling from the walls to maintain a comfortable and orderly environment and enhance the residents' quality of life in 1 of 1 facility. The findings are: 1. On 01/05/21 at 09:14 AM, in room [ROOM NUMBER], approximately 2 foot of base board behind the resident's bed was peeling from the wall. (A photograph was taken). 2. On 01/06/21 at 01:20 PM, in room [ROOM NUMBER], approximately 2 foot of base board was peeling off the wall. Approximately 6 - 8 inches of the peeling baseboard extended beyond the left side of the bed and was in full view of anyone who entered the room. (A photo was taken). 3. On 01/07/21 at 08:28 AM, in room [ROOM NUMBER]-1, approximately 3 feet of base board had fallen off the wall and was lying in the floor at the head of the resident's bed. (A photo was taken) The resident stated, When I got up earlier, I noticed it was down and lying in the floor. 4. On 01/07/21 at 02:20 PM, the Maintenance Employee was asked the accompany the surveyor to room [ROOM NUMBER]-1 and was asked, Should the base board be secured to the wall? Maintenance stated, Yes, It should. He was asked, How often do you check to see if base boards have fallen off the wall? Maintenance stated, We check them monthly. Because of COVID, we have been moving residents like crazy and some of the beds get caught on the base board. We just started this week going around and checking the base boards. He was asked, What can happen when the base board has fallen down? Maintenance stated, Someone can trip and fall. 5. On 01/07/21 at 03:00 PM, the Administrator was asked, Who is responsible for ensuring the residents rooms are in good repair? The Administrator stated, Maintenance is responsible. The Administrator was asked, How often are the residents rooms inspected to ensure that they are in good repair? The Administrator stated, They should be inspected every day, but I know maintenance has a checklist that he should be doing weekly. The Administrator was taken to room [ROOM NUMBER] and shown the baseboard behind the bed. The Administrator stated it looks like the base board is loose. I will get maintenance and get that fixed.

Based on observation, and interviews, the facility failed to ensure medications were labeled and stored in accordance with manufacturer's instructions and accepted standards of pharmacy practice to prevent potential administration of an expired medication to residents from 1 (100 Hall medication cart) of 4 (100, 200, 300 and 400 hall medication carts). The failed practices had the potential to affect 26 residents, according to the census by hall provided by the Administrator on 1/4/21. The findings are: 1. On 01/06/21 at 10:05 AM the 100-hall medication cart was reviewed with Licensed Practical Nurse (LPN) #1 in attendance. a. There was a bottle labeled stock containing Saline Nasal Spray (Sodium Chloride 0.65 %) had an expiration date of 12/20. b. A bottle labeled stock containing [MEDICATION NAME] Coated Aspirin 325 mg (milligram) had an expiration date of 9/20. A photograph of the front and the back of both bottles were taken to verify the expiration dates. c. On 01/06/21 at 10:08 AM, LPN #1 was asked, Are these medications expired? LPN #1 stated, Yes. LPN #1 was asked, Should expired medications be on the medication cart? LPN #1 stated, No. I will take them off right now and replace them. d. On 1/6/21 at 2:05 PM, the Director of Nursing (DON) was asked, Do you have a policy for Medication Storage? The DON stated, We do not have one. The DON was asked, Do you have a policy that addresses expired medications? The DON stated, No. e. On 01/07/21 at 9:20 AM, the DON was asked, Should expired medications be removed from the medication cart? The DON stated, Yes. The DON was asked, Who is responsible for removing expired medications from the medication carts? The DON stated, Anyone who is a nurse should ensure medications are not expired.

Complaint # (AR 190) was substantiated, all or in part, with these findings. Based on observation, record review and interview, the facility failed to ensure necessary care and services were provided to manage pain, by failing to offer and administer pain medication prior to care and / or when the resident cried out, complained of pain or exhibited non-verbal symptoms of pain; failure to ensure a pain management plan of care was coordinated with Hospice services that included interventions for recognizing and managing pain; and failure to assess for pain and revise the pain management interventions as necessary in order to minimize pain to the extent possible for 1 (Resident #11) of 10 (Residents #2, #5, #6, #7, #8, #9, #10, #11, #12 and #13) case mix residents who had physician orders [REDACTED]. These failed practices resulted in a pattern of actual harm to Resident #11, who verbalized complaints of pain or exhibited signs / symptoms of pain on multiple occasions and received no treatment for [REDACTED]. 1. Resident #11 had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/10/16 documented the resident scored 5 (0-7 indicates severe impairment) on a brief interview for mental status; was totally dependent on the assistance of two-plus persons for eating, hygiene, toileting and bathing, had a Stage 2 pressure ulcer and moisture-associated skin damage and had no pain. a. The Plan of Care dated 3/10/16 documented, .Potential for pain or discomfort (related to) [MEDICAL CONDITION]. 1. Will be kept comfortable as possible for next 90 days. 1. Pain meds (medications) as ordered. 2. (Encourage) to tell staff of early onset of pain . 13. Hospice Care (related to) [MEDICAL CONDITION] 1. Will provide caring environment and as pain free as possible for next 90 days. 1. LPN (Licensed Practical Nurse) will monitor care for (resident) and will notify Hospice if any changes . 16. At risk for Mental fluctuations (related to) Dementia. 1. Will be monitored for Mental status changes next 90 days . Nurse to document changes in chart . b. The March 2016 Medication Administration Record [REDACTED]. if unable to verbalize indicate behavior 0-5: Moaning = (equals) 1, Protects Area of Body = 2, (Rubs Area) = 3, Teeth Grinding = 4, Facial Expressions = 5 . Liquid [MEDICATION NAME] 2 (milligrams) / (milliliter) give 0.5 (milliliters) (every) 2 (hours) (as needed) anxiety . The verbal pain scale documented 0 (zero pain) on all 3 shifts on 3/1/16 through 3/23/16, 3/25/16 through 3/28/16, 3/30/16 and 3/31/16. There was no documentation of pain assessments on 3/24/16 or 3/29/16. The MAR indicated [REDACTED]. There was no documentation on why the [MEDICATION NAME] was given. c. The April 2016 Medication Administration Record [REDACTED]. if unable to verbalize indicate behavior 0-5: Moaning = 1, Protects Area of Body = 2, (Rubs Area) = 3, Teeth Grinding = 4, Facial Expressions = 5 . Liquid [MEDICATION NAME] 2 mg/ml give 0.5 ml Q 2 hrs PRN anxiety . The Pain Scale documented, 0 for 4/1/16 to 4/6/16, 4/8/16 to 4/18/16 and 4/20/16 to 4/30/16. There was no non-verbal pain assessment information documented on 4/7/16, 4/19/16 or 4/31/16. The verbal pain scale documented 0 for all shifts throughout the month. The MAR indicated [REDACTED]. The was no documentation on why the [MEDICATION NAME] was given. d. The May 2016 physician's orders [REDACTED].May use Standing-Doctors Orders . APAP ([MEDICATION NAME]) 325 mg (milligrams) 2 PO (by mouth) Q (every) 4 hrs (hours) PRN (as needed) for pain or elevated temp (temperature) . APAP 500 mg - 1 PO Q 4 hrs PRN . ASA (Aspirin) 325 mg - 2 PO Q 4 hrs PRN for pain or temp . ASA 500 mg - 1 PO Q 4 hrs for pain or elevated temp . Aspirin supp (suppository) 600 mg - 1 PR (per rectum) Q 4 hrs PRN for pain or temp . [MEDICATION NAME] 2 mg / 1 ml (milliliter) give 0.5 cc (cubic centimeters) = (equals) 1 mg PO Q 2 hrs PRN anxiety . e. The May 2016 Medication Administration Record [REDACTED]. if unable to verbalize indicate behavior 0-5: Moaning = 1, Protects Area of Body = 2, (Rubs Area) = 3, Teeth Grinding = 4, Facial Expressions = 5 . Liquid [MEDICATION NAME] 2 mg/ml give 0.5 (milliliters) (every) 2 (hours) (as needed) anxiety . The May 2016 MAR indicated [REDACTED]. The behavioral / non-verbal Pain Scale documented, 0 during the 7:00 a.m. to 3:00 p.m. shift and no documentation on the other two shifts (3:00 p.m. to 11:00 p.m. and 11:00 p.m. to 7:00 a.m.). The verbal pain scale documented, 0 for all 3 shifts throughout the month. No [MEDICATION NAME] was documented as administered. f. The Nurses Notes dated 4/19/16 at 8:00 p.m. documented, [MEDICATION NAME] 0.5 ml SL per PRN order r/t (related to) (increased) anxiety. (Call light) in reach . (8:30 p.m.) #18 (French) (Foley catheter) changed, using sterile technique (with) assist (times) 4 staff. (No) immediate return d/t (due to) (resident's) agitation. Urine has been leaking around previous (catheter). (Resident) attempted to scratch and bite CNAs (Certified Nursing Assistants) during cath (catheter) change. Will continue to monitor output. CL (call light) in reach . (8:30 p.m.) LE (late entry) - (Resident) was clenching legs together during FC (Foley catheter) change and yelling, 'You're hurting me.' Explained that it would be easier if she could relax and cooperate. (Resident) cont (continued) to resist. Staff did not sustain injuries . 4/19/16 (10:30 p.m.) 0.5 ml [MEDICATION NAME] to calm her down so I can fix her Foley . (11:30 p.m.) Tried fixing her Foley but, she was still hitting and yelling. (Hospice nurse) phoned and rec'd (received) order to (increase) [MEDICATION NAME] dose. g. Nurse's Notes dated 4/20/16 at 12:00 a.m. documented, [MEDICATION NAME] 1 (milliliter) now ordered . (06:15 a.m.) (Hospice Nurse) from Hospice returned call. Stated she will ask (Hospice Doctor) for order for [MEDICATION NAME] then Hospice will come to (change) Foley . h. Nurse's Notes dated 5/28/16 at 3:00 p.m. documented, (Resident) became very angry, combative (and) cursing at aides when in the shower this afternoon. (Resident) states that she does not want showers anymore, just bed bath . i. Nurse's Notes dated 5/31/16 at 6:10 p.m. documented, Area (right) heel is resolved. (Treatment) (discontinued). Tissue to buttock, (bilateral) inner thighs debrided post tissue eruption sites. (Patient) had been scratching an area (left) inner thigh. (Refused) nail care (with) CNAs on 2 p.m. (rounds) during (treatment) to (bilateral) axilla, thigh, elbow. (Bilateral) axillae remain moist. (Patient) unable to raise arms to allow ventilation. (Treatments) (continued) Fissure to natal cleft resolving. During (treatments) this date (at) previous times (patient) states several (times), You better not hurt me. I questioned (patient) if anyone had ever hurt her here. (Patient) states, No, but I'm making sure it doesn't happen. TLC (tender loving care) and reassurance given. (Patient) then joking and laughing (with) this nurse. j. On 6/2/16 at 9:32 a.m., Certified Nursing Assistants (CNAs) #4 and #5 were attempting to assist Resident #11 with incontinent care, turning and repositioning and catheter care. Both of the resident's lower legs were discolored with a purplish-gray hue. She had bilateral cloth heel protectors on, with no skin breakdown on the heels. There was a dressing on the resident's left anterior inner thigh, with multiple open areas to the left and right gluteal folds, the left and right inner posterior thighs, and on both inner sides of the natal cleft. These open areas ranged in size from approximately a quarter to a half dollar in appearance. The open areas or wounds on the posterior right inner thigh were larger in size than a half dollar and oblong in shape. These open areas were red in the middle with no drainage, odor or depth. The resident also had open wounds under both arms. When the CNAs repositioned the resident, she yelled, What are you doing? You are hurting me! When the CNAs turned the resident to her right side and began to use the cleansing wipes on her skin, she yelled, You are hurting me; that's cold, (expletive) it! The resident grimaced, raised her shoulders up, and clenched her fingers together when the CNAs applied cleansing wipe to her perineum area. The CNAs turned the resident to her left side and she yelled again, Ouch, you are hurting me! Don't! Quit it! The resident was vocal and resistant throughout the provision of care. k. On 6/2/16 at 9:47 a.m., Licensed Practical Nurse (LPN) #5 was asked, Have you ever observed (Resident #11) crying out in pain? LPN stated, No, because she never really complains of pain, except when turning her. l. On 6/2/16 at 9:53 a.m., CNA #5 was asked, Have you ever observed (Resident #11) crying out in pain? CNA #5 stated, Yes, we report it to the nurse, she cries out all the time m. On 6/2/16 at 10:21 a.m., LPN #6 was asked, Have you ever observed (Resident #11) crying out in pain? LPN #6 stated, When they reposition her, she definitely has pain. She cannot raise her arms without hurting. I do not know why I didn't report it; it has been brought to my attention . I am going to call her Hospice Nurse. n. On 6/2/16 at 10:22 a.m., Registered Nurse (RN) #1 was asked, Have you ever observed (Resident #11) crying out in pain? RN #1 stated, I know she is combative during care. o. On 6/2/16 at 10:28 a.m., CNA #4 was asked, Have you ever observed (Resident #11) crying out in pain? CNA #4 stated, She always cries out in pain when we turn her or try to do care. They usually give her what they can; she gets very upset and combative. p. On 6/2/16 at 10:43 a.m., CNA #6 was asked, Have you ever observed (Resident #11) crying out in pain? CNA #6 stated, Every other day - we trade sides - seems like she is in pain . She hollers when we don't touch her at all. It looks like she is in a lot of pain. We always tell the nurse. q. On 6/2/16 at 11:01 a.m., Licensed Practical Nurse (LPN) #6 and Hospice Aides #1 and #2 were assisting with skin care. LPN #6 stated, I spoke to (Hospice Nurse); she is supposed to be going by (Hospice Doctor's) office to pick up a prescription . discussed something for pain. The resident was lying in bed and one of the Hospice Aides was holding up the resident's right arm while LPN #6 applied 4 X 4 gauze soaked with wound cleanser to the axillary wound site. The resident yelled, It's burning. Hospice Aide #2 attempted to reposition the resident's right arm by holding the arm up in a vertical position. The resident yelled, Oh, (expletive), don't! That hurts! Hospice Aides #1 and #2 repositioned the resident in bed and the resident yelled, Please don't! You are going to make me fall, (expletive) it! Don't hurt me! r. On 6/2/16 at 2:48 p.m., the Hospice Registered Nurse (RN) was asked, Did the facility ever request pain medications and were you ever aware of (Resident #11) being in pain? Hospice RN stated, No, every time I have made a nursing visit, she pain. I know our aides and the facility aides have told me that she can be combative. She has anxiety medication in the facility. We thought it was more of an anxiety issue than pain. Her wounds are worse now, and she is having more pain . The RN was asked about the Nurse's Note dated 4/20/16 which documented, (Hospice Nurse) from Hospice returned call. Stated she will ask (Hospice Doctor) for order for [MEDICATION NAME], then Hospice will come to (change) Foley . The RN stated, I talked to the Hospice Doctor and he faxed over orders for pain meds. (Hospice Nurse on call) gave her [MEDICATION NAME], was not aware of the note about [MEDICATION NAME]. They were able to get the catheter in. We did not think that she needed pain medications at that time . before her wounds got to the point they are now. s. On 6/3/16 at 10:54 a.m., Resident #11's son was called via telephone and was asked about the resident's history and pain levels. He stated, .She had a stroke 3 years ago. Her short-term memory is gone. If you ask her if she is hurting, she will tell you no. I know they are treating sores on her bottom . pretty tender. They called me 2 or 3 days ago and told me they were going to administer some pain killers, something topically, so they could address her sores. I can't remember what it was . even if she was hurting real bad, she wouldn't complain .

Based on observation, record review and interview, the facility failed to maintain nutritional parameters for Resident #7. The facility failed to ensure interventions were developed, consistently implemented, and re-evaluated for effectiveness to prevent continued weight loss for 1 of 1 (Resident #7) case mix resident who experienced a severe unplanned weight loss. This failed practice likely resulted in a pattern of actual harm for Resident #7 who had a severe weight loss and had the likelihood of causing more than minimal harm for 6 residents who were at risk for weight loss, as documented on a list provided by the Director of Nursing (DON) dated 2/28/11. The findings are: Resident #7 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of 1/21/11 documented the resident was moderately impaired in cognitive skills for daily decision making per staff assessment for mental status ,required extensive to total assistance with activities of daily living, weight 144 pounds, no swallowing problems, and no significant weight loss. a. The Facility Weight Record documented the following weights for the resident: 1) 09/10 - 153.00 lbs (pounds) 2) 10/10 - 148.00 lbs 3) 11/10 - 152.50 lbs 4) 12/10 - 147.40 lbs 5) 01/11 - 143.50 lbs 6) 02/11 - 134.00 lbs The resident lost 16.2 lbs in 6 months, which was a severe weight loss of 12.4%. The resident also experienced a severe weight loss of 12.1% from December 2010, to February 2011 and a severe weight loss of 6.6% from January 2011 to February 2011. b. The Dietary Progress Notes dated 1/20/11 and signed by the Certified Dietary Manager (CDM) documented, " ...Continued slow (weight) loss ...(down) 15.4 # (pounds)/6 mos (months) (equals) 9.6%. Average documented intake (at) 73%...Takes long time to feed ..." c. The Overall Plan of Care documented: "Date 02/11...Problem ... Has had significant weight loss r/t (related to) meal refusals (and) freq (frequent) ref (refusals) of meds ...Approaches ...1. Weight weekly until stable. 2. Notify MD (physician) significant weight changes... 6. DON (Director of Nursing) will document in chart weight loss... 8. Report refusals to eat to LPN (Licensed Practical Nurse) for documentation. ..10. Risk factors will be assessed by the DON and Interdisciplinary Team" "Date 08/10 ...Problem ...Has had significant weight loss r/t poor appetite 2nd (secondary) Dysphagia treated for [REDACTED]...1. Weight weekly until stable. 2. Notify MD (physician) significant weight changes... 6. DON (Director of Nursing) will document in chart weight loss... 8. Report refusals to eat to LPN (Licensed Practical Nurse) for documentation... 8/10/10 [MEDICATION NAME] as ordered. " d. The Physician's Progress Notes from 11/9/10 through 2/15/11 contained one entry dated 2/15/11 that documented, "appetite poor." Entries dated 11/9/10, 12/7/10, 1/4/11, and 2/2/11 documented, "...Weight stable..." e. The Patient Weight Report signed by the DON and the Physician 2/7/11 documented the resident had experienced a significant weight loss "9.5 pounds in 1 month... A weight loss alert program has begun in our facility as follows: Appetite 72% weekly weight... [MEDICATION NAME] 40 mg Bid (twice daily)... spoonfeed/supervision ...Current diet Blended double portions ...honey thick liquids." The physician's orders [REDACTED]. Supervision w/(with) meals. Double portions..." f. The Dietary Progress Notes dated 2/15/11 and signed by the CDM documented, " ...Average documented intake (at) 9%. Refused 10 meals past week. Usually eats only 10%, sometimes 20% ...wife very adamant about not putting peg tube back in ..." The Dietary Progress Notes dated 2/24/11 and written by the Registered Dietician (RD) documented, "wt (weight) (equal) 134 lbs (greater than) 6.6% wt loss/ 1 mo.(month) Sign. (significant) wt. loss with rehydration with wt. gain Aver.(average) doc. (documentation) (at) 42%. Ate (at) 90% (at) noon. Episodes of vomiting after eating reported. Receives honey thick liq's. (liquids). Tube feeding refused. Totally assisted with meals." g. On 3/1/11 at 1:10 p.m., CNA (Certified Nursing Assistant) #2 stated the resident consumed 10% of his lunch meal. On 3/1/11 at 5:10 p.m., the resident received regular portions instead of double portions: 6 ounces of chicken and dumplings, 4 ounces of green beans, 4 ounces of pears, 12 ounces of fruit punch, 4 ounces of milk, bread and margarine. The resident consumed the 12 ounces of fruit punch and 10% of his meal. h. The snack list was copied on 3/2/11, the resident was not listed on the document for 10 a.m. snack but was listed on the document for thickened ice cream for 2 p.m. snack. The Activity of Daily Living Flow sheet did not document 2 p.m. snacks for the resident. i. On 3/2/11 at 2:20 p.m., the DON was asked where interventions, recommendation and monitoring would be documented and she stated that the documentation would be in the nurses progress notes. The DON was asked what interventions were put in place and she stated, "I'll look at the chart tonight." On 3/3/11 at 8:50 a.m., the DON was asked if she had found any interventions for the resident's weight loss. The DON stated, "I could not find any interventions."

Based on observation, record review and interview, Nursing Administration failed to ensure a system was in place to ensure nutritional parameters were maintained for Resident #7. The facility failed to ensure interventions were developed, consistently implemented, and re-evaluated for effectiveness to prevent continued weight loss for 1 of 1 (Resident #7) case mix resident who experienced a severe unplanned weight loss. This failed practice likely resulted in a pattern of actual harm for Resident #7 who had a severe weight loss and had the likelihood of causing more than minimal harm for 6 residents who were at risk for weight loss, as documented on a list provided by the Director of Nursing (DON) dated 2/28/11. The findings are: 1. The Director of Nursing's Job Description documented, "...Plans, directs, and controls all nursing activities with the guidelines of established policies, procedures, programs, and budgets. Implements nursing policies and procedures... Assures that a written nursing care plan is established for each resident and that the plan is reviewed and modified as necessary..." 2. Resident #7 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of 1/21/11 documented the resident was moderately impaired in cognitive skills for daily decision making per staff assessment for mental status ,required extensive to total assistance with activities of daily living, weight 144 pounds, no swallowing problems, and no significant weight loss. a. The Facility Weight Record documented the following weights for the resident: 1) 09/10 - 153.00 lbs (pounds) 2) 10/10 - 148.00 lbs 3) 11/10 - 152.50 lbs 4) 12/10 - 147.40 lbs 5) 01/11 - 143.50 lbs 6) 02/11 - 134.00 lbs The resident lost 16.2 lbs in 6 months, which was a severe weight loss of 12.4%. The resident also experienced a severe weight loss of 12.1% from December 2010, to February 2011 and a severe weight loss of 6.6% from January 2011 to February 2011. b. The Dietary Progress Notes dated 1/20/11 and signed by the Certified Dietary Manager (CDM) documented, " ...Continued slow (weight) loss ...(down) 15.4 # (pounds)/6 mos (months) (equals) 9.6%. Average documented intake (at) 73%...Takes long time to feed ..." c. The Overall Plan of Care documented: "Date 02/11...Problem ... Has had significant weight loss r/t (related to) meal refusals (and) freq (frequent) ref (refusals) of meds ...Approaches ...1. Weight weekly until stable. 2. Notify MD (physician) significant weight changes... 6. DON (Director of Nursing) will document in chart weight loss... 8. Report refusals to eat to LPN (Licensed Practical Nurse) for documentation. ..10. Risk factors will be assessed by the DON and Interdisciplinary Team" "Date 08/10... Problem... Has had significant weight loss r/t poor appetite 2nd (secondary) Dysphagia treated for [REDACTED]...1. Weight weekly until stable. 2. Notify MD (physician) significant weight changes ...6. DON (Director of Nursing) will document in chart weight loss... 8. Report refusals to eat to LPN (Licensed Practical Nurse) for documentation ...8/10/10 [MEDICATION NAME] as ordered. " d. The Physician's Progress Notes from 11/9/10 through 2/15/11 contained one entry dated 2/15/11 that documented, "appetite poor." Entries dated 11/9/10, 12/7/10, 1/4/11, and 2/2/11 documented, "...Weight stable..." e. The Patient Weight Report signed by the DON and the Physician 2/7/11 documented the resident had experienced a significant weight loss "9.5 pounds in 1 month... A weight loss alert program has begun in our facility as follows: Appetite 72% weekly weight... [MEDICATION NAME] 40 mg Bid (twice daily) ... spoonfeed/supervision ...Current diet Blended double portions ...honey thick liquids." The physician's orders [REDACTED]. Supervision w/(with) meals. Double portions..." f. The Dietary Progress Notes dated 2/15/11 and signed by the CDM documented, "...Average documented intake (at) 9%. Refused 10 meals past week. Usually eats only 10%, sometimes 20... wife very adamant about not putting peg tube back in..." The Dietary Progress Notes dated 2/24/11 and written by the Registered Dietician (RD) documented, "wt (weight) (equal) 134 lbs (greater than) 6.6% wt loss/ 1 mo.(month) Sign. (significant) wt. loss with rehydration with wt. gain Aver.(average) doc. (documentation) (at) 42%. Ate (at) 90% (at) noon. Episodes of vomiting after eating reported. Receives honey thick liq's. (liquids). Tube feeding refused. Totally assisted with meals." g. On 3/1/11 at 1:10 p.m., CNA (Certified Nursing Assistant) #2 stated the resident consumed 10% of his lunch meal. On 3/1/11 at 5:10 p.m., the resident received regular portions instead of double portions: 6 ounces of chicken and dumplings, 4 ounces of green beans, 4 ounces of pears, 12 ounces of fruit punch, 4 ounces of milk, bread and margarine. The resident consumed the 12 ounces of fruit punch and 10% of his meal. h. The snack list was copied on 3/2/11, the resident was not listed on the document for 10 a.m. snack but was listed on the document for thickened ice cream for 2 p.m. snack. The Activity of Daily Living Flow sheet did not document 2 p.m. snacks for the resident. i. On 3/2/11 at 2:20 p.m., the DON was asked where interventions, recommendation and monitoring would be documented and she stated that the documentation would be in the nurses progress notes. The DON was asked what interventions were put in place and she stated, "I'll look at the chart tonight." On 3/3/11 at 8:50 a.m., the DON was asked if she had found any interventions for the resident's weight loss. The DON stated, "I could not find any interventions."

Complaint # was substantiated (all or in part) with these findings. Based on record review and interview, the facility failed to ensure a complete assessment was performed after a significant change of condition; to ensure the physician was immediately consulted regarding a significant change in condition; and to ensure licensed staff remained at the bedside of an unresponsive resident to implement necessary emergency interventions until a resident was transported to the emergency room for 1 (Resident #2) of 4 (Residents #2, #3, #4 and #5) case mix residents experienced a significant change of condition. The failed practice resulted in Immediate Jeopardy, which caused or could have caused serious harm, injury or death to Resident #2 and had the potential to cause more than minimal harm for 98 residents, who resided in the facility and had the potential for a change in condition, as documented on a list provided by the Director of Nursing on 12/7/10 at 2:35 p.m. The facility was informed of the Immediate Jeopardy condition on 12/8/10 at 12:47 p.m. The findings are: 1. Resident #2 had [DIAGNOSES REDACTED]. The Minimum (MDS) data set [DATE] documented the resident had moderately impaired cognitive skills for daily decision-making and had full loss of range of motion of one hand. a. The Plan of Care with a review date of 6/8/10 documented a problem of "at risk for cardiac irreg (irregularities) 2nd (secondary) [MEDICAL CONDITION](Hypertension) and CAD ([MEDICAL CONDITION])" with interventions "cardiac meds as ordered, antihypertensives as ordered, check BP (blood pressure) q (every) 4 hours and monitor for s/sx (signs and symptoms) of cardiac distress." b. A Physician order [REDACTED]." c. The August 2010 Physician order [REDACTED]./10 ... [MEDICATION NAME] 10 mg 1 PO (by mouth) QD (every day) [MEDICAL CONDITION]/18/08 ... [MEDICATION NAME] 25 mg (milligrams) BID (twice daily) 12/18/08 . " d. The Plan of Care with a review date of 6/8/10 documented a problem of "at risk for cardiac irreg (irregularities) 2nd (secondary) [MEDICAL CONDITION](Hypertension) and CAD ([MEDICAL CONDITION])" with interventions that included "cardiac meds as ordered, antihypertensives as ordered, check BP (blood pressure) q (every) 4 hours and monitor for s/sx (signs and symptoms) of cardiac distress." e. The August 2010 blood pressure documentation for 8/22/10 at 12:00 a.m. was 175/89, at 4:00 a.m. was 168/74, at 8:00 a.m. was 140/70, at 12:00 p.m. was 100/63, at 4:00 p.m. was 129/63 and at 8:00 a.m. was 140/60. f. Nurses Notes dated 8/23/10 at 2:00 a.m., signed by Licensed Practical Nurse (LPN) #1, documented, "Called to room. Resident c/o (complained) not being able to breathe. Color pink. Is sweating. c/o choking on water. V/S (vital signs) (blood pressure) 186/86 - (pulse) 93 - (respirations) 24 - (temperature) 98.4 94% O2 (oxygen) sat (saturation). Will monitor." There was no description of the quality of respirations or of the pulse in the notes and no assessment of the resident's swallowing ability. There was no documented attempt to consult the physician. g. Nurse Notes dated 8/23/10 at 2:42 a.m., signed by LPN #1, documented, " Resident not talking to staff. Has vomited x (times) 3. (Physician #1) on call for (Physician #2) beeped to inform of resident's condition. (LPN #1) received order from (Physician) to transfer to (Hospital) for eval (evaluation)." 1) On 12/8/10 at 8:30 a.m., CNA #1 (Certified Nursing Assistant) stated, "I have been here since March of 2010. (Resident #2) got sick in July. I don't know the specifics. The night of 8/23/10, I was working the 400 hall. I started at 11:00 p.m. I saw (Resident #2) when I passed water pitchers a little bit after 11:00 p.m. A little bit after midnight, I saw her again. She was alert and talking. Between 1:00 a.m. and 1:30 a.m., she turned her light on and (CNA #2) and I went to the room. She was coughing and red in the face. She said she got choked on her water. (CNA #2) rolled her head up (the head of the bed) and I went to get (Licensed Practical Nurse (LPN) #). I told (LPN #1) that (Resident #2) said she could not breathe. (LPN #1) went with me to (Resident #2's) room. (Resident #2) told (LPN #1) that she was having trouble breathing. (LPN #1) rolled the head of the bed up more. Me and (CNA #2) left with (LPN #1) still with (Resident #2). Approximately 5-10 minutes later, I answered (Resident #2's) light. (LPN #1) was still in there. (LPN #1) said that (Resident #2) had vomited and told me to clean her up and get a set of vitals. I left and told (CNA #2). We got our stuff and went to the room. (LPN #1) then left. I took the vitals and reported to (LPN #1). Then (CNA #2) and I cleaned (Resident #2) up. While we were cleaning her up she vomited two more times. We rolled her head back up. She did not appear to still be having trouble breathing. We left. About a little after 2:00 a.m., me and (CNA #2) went in her room to check her for incontinence. She would not respond. She wouldn't open her eyes. I left and went and got (LPN #1). (LPN #1) came back with me to the room. (LPN #1) did a sternal rub and (Resident #2) did not respond. I got a cold rag and (LPN #1) wiped her face. I don't remember any assessment made by (LPN #1). (LPN #1) left the room. (CNA #2) left the room. I stayed with (Resident #2) because I felt she shouldn't be by herself. No one told me to stay. I left the room after maybe 5 minutes. I went to the desk and sat down. (LPN #1) was on the phone. It wasn't much later that (LPN #1) said she was sending (Resident #2) out and to get (Resident #2) ready. (CNA #2) and I went to (Resident #2's) room. We moved the chair and table. (Resident #2) was clean and dry. (Resident #2) did not have oxygen on. The ambulance came. They picked up (Resident #2)." 2) On 12/8/10 at 9:00 a.m., CNA #2 stated, "I have worked here three years. I took care of (Resident #2). In July she had problems with her blood pressure and then we did her blood pressure around between 11:00 p.m. and midnight and then around 4:00 a.m. On 8/23/10 we did not do her vital signs between 11:00 p.m. and 12:00 p.m. because the nurse (LPN #1) did not ask us to. Between 12:00 midnight and 12:30 a.m. (8/23/10), (CNA #1) and I went into (Resident #2's) room. There was nothing out of the ordinary. (Resident #2) turned the light on between 1:15 a.m. and 1:40 a.m. (CNA #1) and I answered the light. (Resident #2) said she was choking and could not breathe right. Her face was a little flushed. (Resident #2) was coughing. I rolled her head up and (CNA #1) went to tell (LPN #1). (LPN #1) and (CNA #1) came back. (Resident #2) was coughing and said she had choked on her water and could not breathe right. (LPN #1) held her hand and (CNA #1) and me left the room. 5-10 minutes later, (CNA #1) came to me and said (LPN #1) said (Resident #2) had thrown up and we needed to clean her up. We got linen and the vital machine and went to the room. We took (Resident #2's) vitals and gave them to (LPN #1) at the desk. We cleaned (Resident #2) up. She threw up two more times and she had a bowel movement. We finished cleaning her up and we left. I went and told (LPN #1) that (Resident #2) had thrown up two more times. (LPN #1) said 'o.k.' I did not see (LPN #1) leave the desk. Around 2:30 a.m., we went to check on (Resident #2). She was unresponsive. (CNA #1) went to get (LPN #1). (LPN #1) and (CNA #1) came in the room. (LPN #1) rubbed her chest. (LPN #1) raised her eye lids. The light was on in the room. (LPN #1) did not tell us to do anything. (LPN #1) left the room. I left. (LPN #1) later told me to get (Resident #2) ready. (CNA #1) and me moved the furniture for access. The ambulance came and took (Resident #2). We were not asked to take vital signs after (Resident #2) became unresponsive." 3) On 12/8/10 at 10:17 a.m., LPN #1 stated, "I have worked here a little over a year. I worked 11-7 (11 p.m. to 7 a.m.) on the 300 and 400 halls. I have taken care of (Resident #2) ever since I started. We were having to take her vital signs ever shift. We did not have orders to take her vital signs. That was a precautionary measure on my own since she was on [MEDICATION NAME]. On 8/23/10 there were no orders to take her vital signs on 11:00 p.m.-7:00 a.m. On 8/23/10 somewhere between 1:00 a.m. and 2:00 a.m., I was called by (CNA #1) to (Resident #2's) room because (Resident #2) was complaining that she was choking. I immediately went to check on (Resident #2). (Resident #2) was coughing. She said she got choked on water. She was red in the face. She was not sweating. I did not listen to her lungs. I did not do an assessment. I told the CNAs to get a set of vital signs. They did. They were within normal limits. Her oxygen saturation was 94. Before the vital signs, she vomited a moderate amount of bile colored emesis. Then the CNAs took the vital signs that I told you about before. I left the room before they took the vital signs. Five to ten minutes later the CNAs came and got me. This time, she was not responding at all. I left and went and called the doctor. I did not do an assessment. I did not tell the CNAs to do vital signs at that time. I did not instruct either CNA to stay with the resident. I called the doctor on call and I told him I thought she might have aspirated and could I send her to the ER (emergency room ) for an evaluation. He said 'send her'. I called the daughter and told her we were sending (Resident #2) to the ER. I don't remember what I told her. I told her after she said could it wait till morning if she didn't want her sent we would not send her. She said go ahead and send her. I called the EMTs (Emergency Medical Technicians). It was not an emergency transfer. She did not appear in any distress whatever. I called the hospital and gave them report. The EMTs came and transported her. In my opinion looking at her, that was assessing. It was not an emergency transport because she was still breathing." h. A Physician order [REDACTED]. " i. A Nurse's Notes dated 8/23/10 at 2:45 p.m. documented, "Daughter notified of transfer." j. A Nurse's Notes dated 8/23/10 at 2:50 a.m. documented, " ...EMS (Emergency Medical System) notified of need to transport to ER (emergency room ) for eval." k. On 8/23/10 at 2:57 a.m., the EMS (Emergency Medical Services) Report dated 8/23/10 at 2:57 a.m. documented, "possible aspiration ...upon arrival found pt (patient) unresponsive with hypertension." The Paramedic Assessment documented, "Nursing home called p (post) pt (patient) c/o (complaining) n/v (nausea and vomiting). Staff advised pt was alert. Pt had emesis and then was found to be unresponsive. Pt supine in bed with head up 45 degrees. Pt unresponsive. Skin warm/dry/pink. Lungs clear and equal. Abdomen soft. Pupils equal and responsive. Pt placed on cot and loaded into unit. Glucometer 150. Sat 94%. Cardiac Monitor sinus with PAC (Premature [MEDICAL CONDITION] Contractions)/PVC (Premature Ventricular Contractions). Pt place on O2 (oxygen) SAT (saturation) 98% post O2." l. Nurse's Notes dated 8/23/10 at 3:00 a.m. documented, "Hosp (hospital) called, report given to RN (Registered Nurse) in ER." m. Nurse's Notes dated 8:23 a.m. at 3:05 a.m. documented, " ...EMS here to transport." n. The Hospital Emergency Nursing Record dated 8/23/10 at 3:20 a.m. documented, "Vitals: BP (blood pressure) 151/109, p (pulse) 109, RR (respiration Rate) 20 and SaO2 (oxygen saturation) 68.7 ...Initial Assessment: General Appearance ...decreased LOC (level of consciousness), Respirator: Severe distress, CVS (Cardiovascular System): [MEDICAL CONDITION] Neuro (Neurological): Pupils unequal pinpoint, unresponsive to all stimuli. Gasping respirations." o. An Arterial Blood Gas Report dated 8/23/10 at 3:20 a.m. documented, "pH 7.21 (reference range 7.3-7.45), pCO2 (partial pressure of carbon [MEDICATION NAME]) 82 mmHg (millimeter of mercury) (reference range 35 mmHG to 45 mmHg) and pO2 (partial pressure of oxygen) 332 mmHG (reference range 75 mmHG to 100 mmHG)." p. The Emergency Physician Record dated 8/23/10 at 5:30 a.m. documented, "arrived in resp (respiratory) distress (secondary) [MEDICAL CONDITION](Cardiovascular Accident); became apneic; family wished no heroic measures; pronounced dead at 0530 (5:30 a.m.) 8/ 23/10." On 12/8/10 at 10:05 a.m., (emergency room Physician on duty the night of 8/23/10) stated, "I saw (Resident #2) at 3:25 a.m. (on 8/23/10). When she came in she was unresponsive with snoring respirations. She had a 68% oxygen saturation. Arterial Blood Gases were done at 3:20 a.m. She was in Respiratory Acidosis severe. We could not take her for a CT scan. It looked like another hemorraghic stroke. She was comatose. I do not know how long she had Respiratory Acidosis." 2. The Immediate Jeopardy was removed and the scope/severity reduced to "G" on 12/8/10 at 4:27 p.m. when the facility implemented the following Plan of Removal: "Plan of Removal for IJ, Initiated at 12:46 p.m. on 12/8/10: 1). At 2:00 p.m. on 12/8/10 the nurse consultant inserviced the Administrator and DON (Director of Nursing) on the policy and procedure for abuse and neglect. 2). Beginning 12/8/10 the DON/Designee will begin face to face inservices with all LPN (Licensed Practical Nurse) and RN (Registered Nurse) staff on duty and to continue shift to shift prior to the nurse providing patient care until all LPN/RN staff are inserviced on: a. Identification of changes in condition. b. Assessment of resident status with full assessment of system in regards to symptoms. c. The policy and procedure, and process of notification of emergency transport services with full report of assessment and urgent need for transfer. d. Policy and procedure of notification of the physician with change of condition. e. Policy and procedure on abuse and neglect that includes immediate action for reported or suspected neglect. f. All professional employees on vacation, leave of absence, PRN (as needed) staff, or any new hires will be inserviced on all of the above information prior to providing patient care. 3). All I & A ' s (Incident and Accidents reports), as well as voiced or written grievances will be reviewed by the Administrator and DON/Designee to assure adherence to the policy and procedure for abuse and neglect. 4). DON/Designee will monitor all 24 Hour Nurses Reports and Physician order [REDACTED]. All interventions to I & A's or written or voiced grievances will be reported by the DON or Administrator on the date of occurrence to the Nurse Consultant for review to assure adherence to the Abuse and Neglect Policy and Procedure."