Every finding on record at Dockside Health & Rehab Center

Based on observation and staff interview the facility staff failed to maintain a clean and sanitary food preparation area in accordance with professional standards for food service safety. The findings included; On 5-28-24 at approximately 12:40 PM, the kitchen area of the facility was inspected. The fire suppression hood over the large industrial stove was covered in debris and dust with a fur like appearance, which could not be removed by simply wiping, as the debris was adhered with a sticky greasy substance. The metal food preparation tables in the center of the kitchen immediately parallel to the stove had a shelf under each one running the entire length under the tables. Those shelves were also coated with the sticky substance which could not be wiped off. Adhered to the sticky substance on the shelves was food debris, tiny gnat like insects, and paper particles. There were also multiple clear plastic bins under the tables, and on the shelves, containing clean cooking utensils. The clean items as stated by the Dining Director, and bins, were also noted to have food debris and paper particles in them. The dining Director stated we have someone coming next month to do a deep cleaning here in the kitchen, and they will do the stove hood as well. The inspection observations continued in the walk in freezer, and refrigerator. The walk in refrigerator was noted to have clear plastic strips making a curtain in the refrigerator which had the purpose of being easily pushed aside to access the inner refrigerator while maintaining refrigeration as the door was open for deliveries. The plastic strip curtain was noted to have a black mildew substance 18 inches from the floor upward coating each strip. The substance was easily removed with a paper towel. The Corporate Registered Dietician, and Dining Director were present and stated that they would begin to clean the kitchen immediately. On 5-29-24 the kitchen had been cleaned. No further information was provided.

Based on interview, clinical record review and facility documentation the facility staff failed to ensure that Residents receive adequate supervision and assistance to prevent accidents for 1 Resident (#18) in a survey sample of 24 residents. The findings included: For Resident #18 the facility staff failed to ensure supervision of the resident from the dining room to the hallway on the New Wing causing Resident #18 to trip and fall. On 5/29/24 a review of the clinical record revealed that Resident # 18 was admitted to the facility on [DATE] with diagnoses that included but were not limited to hypo and hypertension, anemia, dementia with behavioral disturbances and history falls and wandering. Resident #18's most recent MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 2/27/24 coded Resident #18 as having a BIMS (Brief Interview of Mental Status) score of 2 out of 15, indicating severe cognitive impairment. A review of the care plan revealed that Resident #18 is care planned for wandering, falls, cognitive decline, resistance to care and redirection, with appropriate interventions in place. On 5/29/24 a review of the progress notes revealed that on 5/14/23, Resident #18 had a fall while ambulating from the dining room after dinner. A review of the fall investigation revealed the following excerpts: Event date: 5/14/24 at 5:17 PM Event details: Fall with minor injury. Location of fall: Hallway What was resident doing prior to fall? Leaving out of dining room walking back to unit. Location of injury: Hands, right knee and shoulder bruised. ROM [Range of Motion]: X 4 without pain or limitations. The fall investigation revealed that first aid was provided, and pain was addressed, the care plan was updated to reflect the fall, the family and physician were notified. On 5/30/24 at approximately 1:00 PM the area from the hallway of the New Wing leading into the dining room was observed and found that the threshold between the hallway and the dining room was not a smooth transition there was a metal strip that created a trip hazard. The Administrator was made aware as well Employees D (maintenance) and H (Regional [NAME] President). Employee D under the direction of Employee H immediately began to remove the threshold strip and make repairs to floor to ensure it would not become a further trip hazard. A review of the incidents and accidents since the New Wing was built revealed this fall to be an isolated incident no falls were noted prior to or since this fall.

Based on staff interview, clinical record review and facility documentation review, the facility failed to ensure that a Medicare Advanced Beneficiary Notice (ABN) was completed and issued to 1 Resident, (Resident #25) in a survey sample of 3 ABN Residents. For Resident #25, the facility failed to ensure receipt for notification of insurance coverage loss was documented on the ABN prior to the loss of coverage. The findings included; On 5-30-24 during the course of the survey, the Administrator was asked for ABN records for three skilled nursing discharged individuals. The documents were received and revealed that one of the three documents had not been signed by the beneficiary nor a responsible party and correctly completed. For Resident's #25, staff have no record of the Resident receiving the Advanced Beneficiary notices and signing them. This indicated that the Resident would be unaware of insurance coverage loss date, and thus have no ability to enact their right to appeal the judgement and continue services until a review was conducted by the Centers for Medicare/Medicaid services (CMS), or their contractors. On 5-30-24 at 5:00 p.m., during the end of day debrief, the Administrator was asked why no signature appeared in the Resident documents denoting when the Resident's insurance would lapse, and she stated We will look into that. On 5-31-24 at 3:00 p.m., during the end of day debrief the Administrator was again made aware of the incomplete ABN documents for Resident #25. She stated it simply wasn't done, and we have nothing further to provide.

Based on observations, staff interviews, facility documentation review, and clinical record review, the facility staff failed to ensure CPR (Cardiopulmonary Resuscitation) was provided for one (1) Resident (Resident # 3) in a survey sample of six (6) residents. For Resident# 3, the facility staff failed to continue CPR after starting it before EMS arrival which placed the resident in an immediate jeopardy situation. Without intervention, the likelihood of immediate jeopardy situations existed for all current full-code residents in the facility. The findings included: Resident # 3 was admitted to the facility on [DATE] with diagnoses that included but were not limited to Dementia, Hypertension, Dysphagia, Gout, and Diabetes. Resident # 3's most recent MDS (minimum data set assessment) was a Quarterly assessment with an ARD (assessment reference date) of [DATE]. It was reviewed and revealed a BIMS score of 5 out of 15 indicating severe cognitive impairment. Resident # 3 also required assistance with ADLs (activities of daily living). Resident # 3 was always incontinent of bowel and bladder. The electronic closed clinical record was reviewed from [DATE] through [DATE]. Resident physician orders were reviewed and revealed a full code status indicating the Resident wished CPR to be performed in the event of cardiac arrest or respiratory failure. Resident # 3's care plan and progress notes were reviewed and revealed that CPR should be performed. Review of the progress notes revealed documentation of a note written on [DATE] at 21:30 (9:30 p.m.) that stated: This nurse (Licensed Practical Nurse-LPN-B) and CNA (Certified Nursing Assistant) went into resident's room @ this time. Resident noted unresponsive. Resident had faint pulse noted by checking carotid pulse and abdomen noted to go up and down one time and then ceased to move, no further pulse noted. No pulse, no respirations noted. Code Status-Full Code. CPR (cardiopulmonary resuscitation) initiated. 911 called. CPR continued until EMT (Emergency Medical Technician) arrived and took over CPR. The subsequent progress notes were as follows: Effective Date: [DATE] 22:09 Type: Nursing Note Note Text: EMT (Emergency Medical Technician) performed CPR for approximately 30 minutes without pulse or respirations noted. EMT called on call Doctor who pronounced Resident deceased @ 2209. Effective Date: [DATE] 22:25 Type: Nursing Note Note Text: On call PCP (Primary Care Provider) notified with new order to release remains to Funeral Home. There was a discharge summary dated [DATE] at 06:52 written by the Director of Nursing (DON) which indicated that the resident was discharged via stretcher to the funeral home. The discharge summary further noted that the resident was a full code and that the nursing staff ran the code until the EMTs came to continue the code and the resident was pronounced at 10:09 pm on [DATE] by the on-call emergency room (ER) doctor. Interviews were conducted with several individuals including LPN-B and EMS Supervisor (Other Staff-N). On [DATE] at 8:15 a.m., an interview was conducted with LPN- (Licensed Practical Nurse)- B who provided CPR. She stated that she went into the room to provide care for Resident #3's roommate and noticed that Resident # 3 was slumped down in the bed. The LPN stated she called a CNA (Certified Nursing Assistant) to help pull Resident # 3 up in the bed. According to LPN-B Resident # 3's breathing was shallow and she noticed when he took his last breath. LPN-B stated she verified the CODE status, called the CODE, got the Crash cart from the 400 hall which was in the closest proximity to service Resident #3, and started CPR (Cardiopulmonary Resuscitation). LPN-B stated EMS (Emergency Medical Services arrived quickly and performed CPR for about 30 minutes. On [DATE] at 2:01 p.m., an interview was conducted with the EMS supervisor (Other Staff-N) who stated the medics informed him that 4 nursing home employees were standing by the bedside of Resident # 3 when the medics arrived. CPR was not in progress when the medics arrived. Other Staff-N stated the nursing home staff said they had stopped CPR compressions because of fluid in the resident's mouth and that the suction machine on the 400-unit cart was not working. According to Other Staff-N, the medics immediately started CPR and treatments, but the resident did not respond. Resident # 3 remained in asystole (no heartbeat). The medics talked with the physician at the hospital and the code was called with a time of death of 22:09 (10:09 p.m.). Other Staff-N promptly forwarded a copy of the EMS run sheet on [DATE]. Documentation from the EMS onsite run sheet was reviewed and indicated the medics were dispatched to the facility for Resident # 3 and that CPR was in progress. Upon arrival at the nursing home, staff told EMTs they had stopped compressions due to fluid in the mouth. The report further indicated that the EMTs suctioned the resident, and CPR resumed with the [NAME] device (automated chest compression machine). Breaths were given via a Bag Valve Mask (BVM) with 15 liters of 02 oxygen. An airway device (I-gel size 3) was inserted into the resident's airway. An intraosseous (IO) line was placed into the left distal tibia and two (2) rounds of epi (epinephrine) were given. The resident was asystole (no heartbeat) and there were no responses to the EMT's treatments. The note further stated a call was made to the hospital and they spoke with the on-call physician and their ended efforts. The time of death was recorded as 2209 (10:09 p.m.). Further review of the run sheet detailed that the call was received at 21:37 (9:37 p.m.) Dispatched at 21:37 (9:37 p.m.,) En Route 21:39 (9:39 p.m.) On Scene 21:51 (9:51 p.m.) At Patient 21:53 (9:53 p.m.) Time of departure 22:15 (10:15 p.m.) Call closed 23:33 (11:33 p.m.) The facility Administrator, [NAME] President of Operations, and Director of Nursing were notified of the Immediate Jeopardy on [DATE] at 2:40 p.m. regarding facility staff not continuing cardiopulmonary resuscitation after starting it. They were also informed that the facility staff members stated the suction machine was not working on the day Resident # 3 expired. As documented on the IJ template presented to the above facility staff: CPR compressions were initiated and then stopped due to fluid in the mouth of the Resident, and an inoperable suctioning machine prior to EMS arrival. EMS documents and interviews support this finding, staff observation and interview revealed that the suction machine on the expired Resident's unit continued to be inoperable and staff were not able to identify that the machine was still inoperable on [DATE]. This occurred for a Resident experiencing cardiac arrest who had a designated full code status. The Resident expired. All current full-code Residents in the facility are at risk. The following observations and interviews were conducted on [DATE]: 12:15 PM- on 400 hall spoke with LPN-L (charge nurse) who identified herself as the Unit Manager for the 400 hall. She was asked where the crash cart was located and stated there were 2 crash carts, 1 on the 400 hall and a second one on the 500 hall. She stated the crash cart for the 400 hall was being housed behind a locked door in the linen room. LPN-L unlocked the linen room door, and the crash cart was against the wall unlocked and uncovered. There was a suction machine on the top of the cart along with the canister and a CPR Ambu bag. When asked how the cart is checked and by whom, she stated the cart is checked on the night shift using a checklist. When asked to see the checklist she stated she would have to go to the nurse's station to get it. When she returned with the book the checklist for [DATE], was checked off up until [DATE]. The surveyor asked what the initials at the bottom indicated. LPN-L stated it indicated that the nurse had checked the cart on the night shift. When asked what the check boxes next to each item indicated, she stated that the check boxes indicated the nurse has checked to see if the supplies are in the cart. The surveyor asked does that mean if the box is checked next to the suction machine, that the suction machine is on the cart, and it is functioning properly or just checking to see if the machine is on the cart. She said the process is that the night nurse gets the book, looks in each drawer, and signs off that the items are in place. The nurse would then check that the suction machine is working as well. LPN-L was then asked to show how to check the function of the suction machine. LPN-L then brought the cart to the hall plugged it in the outlet, turned it on, and said it was working. The surveyor observed the suction machine emitted a barely audible hum. When asked how she knew it was working, she stated it's low, but you can hear the motor. The surveyor asked if she was sure there was suction. She responded, Yes. Two surveyors checked the machine and found there was no suction. LPN-L said she was not aware of how to properly check the machine to see if there was suction. LPN-D stated that she has worked in the facility for almost a year and that she had never actually used the suction machine. 12:27 PM - The two surveyors and LPN-L took the malfunctioning 400 hall suction machine back to the nurse's nurse where another nurse, LPN-C was asked to demonstrate how to check for the function of the suction machine. She plugged it in, covered the valve, looked for the gauge to move and when the gauge stayed stationary, she stated, Obviously, the machine doesn't work. It was verified that the malfunctioning 400 hall suction machine that had not worked during the code event with Resident #3 on [DATE] had not been replaced with a properly functioning suction machine and remained on the 400 hall crash cart placing other residents at risk if there was an emergent need for oral suctioning. It was also revealed that the nursing staff lacked adequate knowledge regarding the operation of the suction machine, also placing residents at risk if there was an emergent need for oral suctioning. 12:33 PM- Once on the 500 unit the crash cart for that unit was in the employee lounge, locked and covered. LPN-L plugged in the suction machine which made a loud noise, and the LPN checked the functioning of the machine as she had seen demonstrated previously by the two surveyors. This machine was working properly. Another nurse, LPN-D was asked, If you were in an emergency and needed to suction someone and found this machine not functioning what would you do? She responded that she would have gotten the suction machine from the other crash cart. 12:45 PM- The DON was asked who was responsible for checking the crash cart. She responded, It is typically a night shift duty. They check the supplies and fill out the checklist. If something gets used and needs to be replaced, they will put a note in my box. If I am not here, I will make sure it gets replaced. When asked do all the nurses know how to check the crash cart. The DON stated, Yes, though it is usually done on nights. The DON was asked if she expected the suction machine to be checked for functioning every night, that the nurses knew how to properly check for the functioning, and the importance of a fully functioning suction machine, the DON responded, Yes. The DON was asked what her expectation was if the suction machine malfunctioned, and she responded, The machine would be pulled off the cart and a new one would be replaced on the cart. The DON stated if the suction machine was broken and urgently needed the staff should use the one on the other crash cart. The facility Administrator and [NAME] President of Operations submitted an immediacy removal plan that was accepted on [DATE] after the rejection of the first plan. The second immediacy plan stated: This will serve as our plan of Immediacy Removal for (name of facility) related to: CPR for resident on [DATE]. Upon discovery of the occurrence, facility implemented the following quality immediacy removal: On [DATE]: Facility initiated training for all licensed nurses on suctioning of residents in person with demonstration of skills required. On [DATE]: Facility audited and inspected 2 code carts and required inventory to ensure compliance with policy. On [DATE]: Facility inspected all four suction machines and ensured functionality; one suction machine removed from the facility. On [DATE]: Facility initiated training with all CPR certified Nurses regarding CPR guidelines per Red Cross guidelines and the need for continuous CPR with no interruptions. On [DATE]: Facility removed inoperable suction machine found on [DATE] from crash cart and replaced with functioning suction machine. ADHOC QAPI was held on [DATE] to discuss plan for immediacy removal. Facility is alleging compliance as of [DATE] The facility had two 12-hour shifts- 7 a.m. -7 p.m. and 7 p.m. - 7 a.m. The surveyors interviewed licensed nursing staff members on [DATE] from 6:26 p.m. to 7:29 p.m. and [DATE] from 8:10 a.m. to 8:19 a.m. to verify the licensed nurses were re-educated about CPR and not stopping CPR once it has begun unless relieved by the EMS or a physician calls the code. Staff members on both shifts were interviewed for a total of 12 licensed personnel. Copies of CPR cards were reviewed for licensed personnel. All Suction machines were verified to be in working order and staff members were able to verify knowledge of how to use the suction machines as well as where other suction machines were stored. The facility Administrator and [NAME] President of Operations were notified that the immediacy had been abated on [DATE] at 8:45 a.m. No further information was provided.

Based on staff interview, facility document review, clinical record review, the facility staff failed to ensure incontinence care was provided timely for one (1) resident (Resident #4) in a survey sample of Six (6) residents. For Resident #4 the facility staff did not provide timely incontinence care. The findings included: Resident #4 was initially admitted to the facility on [DATE] with diagnoses including; Chronic obstructive pulmonary disease (COPD), weakness, morbid obesity, Diabetes type 2, repeated falls, osteoporosis with fracture of left wrist, breast cancer, hypertension, and depression. Resident #4's MDS review included the MDS (Minimum Data Set Assessment) with an ARD (Assessment Reference Date) of 2-5-23 which was a 5 day admission assessment after a readmission from the hospital. The MDS coded Resident #4 as requiring extensive to total assistance from one staff member with bed mobility, dressing, toileting, hygiene, and bathing. The Resident was also coded as 15 of 15 possible points on a brief interview for mental status (BIMS), indicating no cognitive impairment. The Resident was coded as always incontinent of bowel and bladder, and did not use the toilet. During the course of a complaint investigation this Resident's former room mate alleged that this Resident was left soiled for extended periods of time during March 2023, and that this occurred more on night shift because of lack of staff to help. Review of Resident #4's physician orders, Medication and treatment administration records (MAR's/TAR's), Care plan, and progress notes indicated that the Resident suffered from moisture associated dermatitis (MASD) and had been admitted with a pressure ulcer. The Resident was ordered to have moisture barrier cream applied to both buttocks, and the Resident wore incontinence products/briefs. On 1-25-24 the Director of Nursing (DON), and Administrator were interviewed and asked what their expectation for toileting and incontinence care timing was for this Resident. They stated every 2 hours, and as needed, and that the care must be documented after care. Certified Nursing Assistants (CNA's) were interviewed on all three units during survey, and indicated they documented all care in the Point of Care computerized system for each of their residents at the end of every shift. Resident #4's point of care ducumentation which is documented by primary care staff to indicate care that was given every day was reviewed. The facility instituted 12 hour working shifts for staff, and those 2 shifts were 7:00 a.m., to 7:00 p.m., and 7:00 p.m., to 7:00 a.m.,. The records indicated that for the month of March 2023 the Resident was totally dependant on staff for toileting and incontinence care. The record further documented the following; March 2023 7:00 a.m., to 7:00 p.m., (12 hour shift) Resident #4 received toileting and incontinence care every 12 hour day shift with the exception of 3-29-23. March 2023 7:00 p.m., to 7:00a.m., (12 hour shift) Resident #4 did not receive care for 12 hours on 3-1-23, 3-2-23, 3-5-23, 3-11-23, 3-13-23, 3-17-23, and 3-30-23. Staff stated that the facility policy on Perineal Care for Incontinent Residents, was that care would be provided approximately every 2 hours every shift and PRN (as needed), which included removal of wet incontinent briefs, and cleansing. Staff further stated that the expectation is to give incontinence care immediately after every incontinent episode. Resident #4 was not afforded timely incontinence care. The facility Administrator and Director of Nursing (DON) were made aware of the above findings at the end-of-day debrief on 1-25-24 and no additional information was provided to the surveyor by time of exit on 1-31-24.

Based on staff interview, family interview, facility documentation review and clinical record review, the facility staff failed to notify the responsible party of a change in condition and death of one (1) resident (Resident # 3) in a survey sample of six (6) residents. For Resident # 3, the facility staff failed to notify the family of the Resident's death prior to the Resident's removal to the funeral home. The Resident expired on [DATE] at 10:09 p.m. and the family was not notified until the next day on [DATE] at 5:30 a.m. The findings included: Resident # 3 was admitted to facility on [DATE] with diagnoses that included but were not limited to: Dementia, Hypertension, Dysphagia, Gout and Diabetes. Resident # 3's most recent MDS (minimum data set assessment) with an ARD (assessment reference date) of [DATE] was coded as a Quarterly assessment. It was reviewed and revealed a BIMS score of 5 out of 15 indicating severe cognitive impairment. Resident # 3 also required assistance with ADLs (activities of daily living). The electronic closed clinical record was reviewed on [DATE]-[DATE]. Review of the progress notes revealed documentation of a note written on [DATE] at 21:30 (9:30 p.m.) that stated This Nurse and CNA (Certified Nursing Assistant) went into resident's room @ this time. Resident noted unresponsive. Resident had faint pulse noted by checking carotid pulse and abdomen noted to go up and down one time and then ceased to move, no further pulse noted. No pulse, no respirations noted. Code Status-Full Code. CPR (cardiopulmonary resuscitation) initiated. 911 called. CPR continued until EMT (Emergency Medical Technician) arrived and took over CPR. The subsequent progress notes were: Effective Date: [DATE] 22:09 Type: Nursing Note Note Text: EMT (Emergency Medical Technician) performed CPR for approximately 30 minutes without pulse or respirations noted. EMT called on call Doctor who pronounced Resident deceased @ 2209. Effective Date: [DATE] 22:25 Type: Nursing Note Note Text: On call PCP (Primary Care Provider) notified with new order to release remains to Funeral Home. Effective Date: [DATE] 22:30 Type: Nursing Note Note Text: Police officer @ facility called Resident's RP (Responsible Party), _______ (name redacted), and left voicemail to return call. Funeral Home in record, (name of funeral home redacted), notified. Effective Date: [DATE] 00:00 Type: Nursing Note Note Text : __________ (name redacted) Funeral left facility with resident's remains @ this time. Effective Date: [DATE] 05:30 Type: Nursing Note Note Text: Resident's Son, _______ (name redacted), aware of Resident being deceased and Remains being picked up by Funeral Home on File. There was a discharge summary written by the Director of Nursing (DON) which stated in its entirety: Effective Date: [DATE] 06:52 Type: Discharge Summary Summary of Discharge: Resident discharged To: Funeral Home discharged via: Stretcher Accompanied by Other FUNERAL HOME Resident belongings sent with: STILL IN ROOM AWAITING PICK UP BY FAMILY Dietary Summary: REGULAR MECH SOFT DIET. POOR-FAIR INTAKE. REFUSED SOME MEALS. SUPPLEMENTS WERE IN PLACE. SET UP-SUPERVISION WITH EATING. Activities Summary: 1:1 ACTIVITIES Social Service Summary: FULL CODE RESIDENT, EXPIRED AT 10:09 PM AFTER NURSING STAFF RAN CODE UNTIL EMT CAME TO CONTUNE IT. RESIDENT WAS PROUNOUCED (sic) AT 10:09PM BY ONCALL ER DOCTOR. ALL BELONGINGS ARE STILL IN RESIDENT ROOM AWAITING FAMILY PICK UP. REMAINS WERE RELEASED TO _______ (name redacted) FUENRAL (sic) HOME. Nursing Summary: FULL CODE RESIDENT, NURSING STAFF RAN CODE UNTIL EMT CAME TO CONTUNE IT. RESIDENT WAS PROUNOUCED (sic) AT 10:09 PM BY ON CALL ER (emergency room ) DOCTOR. ALL BELONGINGS ARE STILL IN RESIDENT ROOM AWAITING FAMILY PICK UP. REMAINS WERE RELEASED TO _____name redacted FUENRAL (sic) HOME. Therapy Summary: NO THERAPY. Summary of Length of Stay: discharge date /time: [DATE] 12:00 AM Length of Stay: 1282 Reason for Discharge: EXPIRED Comments: Author: name redacted-(Director of Nursing) - RN [e-SIGNED] The discharge summary had no documentation of the date and time of the family's notification of Resident # 3's death. Interviews were conducted with Emergency Medical Services (EMS), the nurse providing CPR in the facility, the funeral home staff, the resident's grandson and the EMS supervisor. Those interviews are as followed below: The nurse providing CPR in the facility: On [DATE] at 8:04 a.m. an interview was conducted with the nurse (LPN-B) who provided CPR in the facility to Resident #3. She stated she did not notify the family of Resident # 3's death because the officer (Employee-M) stated he was going to call the family. LPN-B stated she witnessed the officer walking down the hall to get a better cell phone signal. LPN-B stated the officer stated he had left a message for the family to call the facility. LPN-B stated she called the family early the next morning when she had not heard from Resident # 3's family. Attempts to reach the deputy police officer (Employee -M) via telephone were unsuccessful. On [DATE] at approximately 3:17 p.m., a voicemail was left for the officer to return the call to the surveyor. There was no return call by the end of the survey nor at the time of the written report findings of the survey. The funeral home staff: An interview was conducted on [DATE] at 2:53 p.m., who stated the funeral home received a call a little after 10 p.m. on [DATE] from the deputy to pick up Resident # 3's body. She stated the funeral home associates picked up Resident # 3's body about an hour and a half later. The Funeral Home director stated Resident # 3's family told her that the nursing home notified them at approximately 6 a.m. on [DATE] that Resident # 3 was deceased and already picked up by the funeral home. The Funeral Home Director stated usually the facility nursing staff would call the funeral home versus a police officer. Resident # 3's grandson was interviewed on [DATE] and stated his family was not notified of Resident # 3's death until the next morning after the funeral home had already picked up the body. The grandson stated that was very upsetting to their family. During the end of day debriefing on [DATE], the facility administrator, Director of Nursing and [NAME] President of Operations were informed of the findings. The [NAME] President of Operations stated the facility staff did not notify the family of the death because the officer notified the family. The [NAME] President of Operations stated anybody who was in the facility could have notified the family of the death. When asked if the sheriff was considered to be facility staff, the [NAME] President of Operations reiterated that anyone who worked with the Resident during the CPR attempt could have notified the family of the death, even the CNA (Certified Nursing Assistant). When asked if the facility staff could understand why the family members were curious about why a sheriff was in attendance and notified the funeral home to pick up the body, the [NAME] President of Operations stated he didn't understand why there would be questions since sheriffs come to all 911 calls. The [NAME] President of Operations and the Administrator stated the facility did not include that information in the admission packet. Copies of the facility's policy regarding notification of change in condition and Post Mortem Care were requested and received. Review of the facility's policy on Resident's Change in Condition Policy, Revision [DATE] revealed the policy that the licensed nurse will recognize and intervene in the event of a change in resident condition. The Physician/Resident Provider and Family/Responsible Party will be notified as soon as the nurse has identified the change of condition and the resident is stable. Under Procedure: 5. The Physician/Resident Provider and Family/Responsible Party will be notified : d. a significant change in the resident's physical,/emotional /mental condition g. a need to transfer the resident to the emergency room and/or admission to the hospital 6. In the event of an emergency situation, 911 will be called immediately and the Physician/Resident Provider and Family/Responsible Party will be notified as soon as practically possible. Review of the policy on Post Mortem Care (reference Elsevier Healthcare Hub. 2022. post mortem care) was reviewed and revealed the following statements: Policy: Post mortem care will be provided to deceased residents in a respectful, private and safe manner. Post mortem care may be provided as soon as a resident has been legally declared dead except in cases where death is a result of an accident, suicide, homicide, potential negligence/abuse or any other suspicious circumstances. In such cases, the Medical Examiner will be informed and the facility will defer post mortem care until further instructions are received. Process: Ensure residents primary care provider (PCP) is informed of death. The PCP will determine if the medical examiner will be notified. Notify resident's representative/family of death if not present. Ask family members if they have requests for the preparation or viewing of the body (such as position of the body, special clothing, culturally sensitive practices, or shaving). Determine if they wish to be present or assist with care of the deceased . Determine if spiritual care is desired and contact clergy as indicated. Once cleared to provide post mortem care. Other excerpts included: Give family members and friends a place to gather. Allowed (sic) them time to ask questions and to [NAME]. If the resident's family requests a viewing, prepare the resident's body and room in a culturally sensitive manner (if possible) and place a clean sheet over the resident's body up to the chin with the arms outside the covers, if desirable. Notify the supervisor that the body is ready. Notify the funeral home. Once funeral home arrives, accompany their personnel to the resident's room and mutually identify the body and assist with removal as needed. The Post mortem policy was listed as a reference from Elsevier Healthcare Hub. 2022. During the end of day debriefing on [DATE], the facility Administrator and [NAME] President of Operations were again informed of the findings that the facility staff did not notify the resident's family of the death and removal of the body to the funeral home until the next morning. No further information was provided.

Based on observation, staff interview, and facility documentation review, the facility staff failed to implement infection control practices as per the CDC (Centers for Disease Control and Prevention) and CMS (Centers for Medicare & Medicaid Services) guidance/requirements to prevent the spread of COVID-19 within the facility by 3 nursing staff members, LPN B, CNA C, and CNA F, out of 3 nursing staff observed providing resident care. The facility nursing staff, LPN B, CNA C, and CNA F, failed to implement proper use of PPE (personal protective equipment) while providing direct resident care for Resident #10. The findings included: On 6/14/22 at approximately 10:30 AM, an Entrance Conference was conducted with the Facility Administrator and the Infection Preventionist (IP) who confirmed the facility was in a COVID-19 Outbreak status and the last positive COVID case in the facility occurred on 6/2/22. The IP also verified that the facility was located in a county with a high (Red) level of COVID transmission. She stated that all staff in the facility were expected to be wearing an N95 level facemask due to the facility Outbreak status as well as the high community COVID transmission levels. The IP confirmed that CDC and CMS requirements were the foundation for the development and implementation of the facility's policies and decisions in the management of COVID-19. A copy of the facility's policies related to general infection prevention and control as well as the facility's policies specific to COVID-19 management were requested and received. On 6/14/22 at approximately 11:00, Surveyor C observed CNA C and CNA F providing incontinence care for Resident #10, during which LPN B also arrived to empty Resident #10's [CONDITION(S)] bag. Surveyor C noted that all 3 staff members were not wearing any eye protection while performing direct resident care for Resident #10 and when queried, the staff members were unaware of the need for eye protection. On 6/14/22 at approximately 2:30, a second interview was conducted with the IP regarding the expectations of personal protective equipment (PPE) usage for source control and she stated, I expect everyone [facility staff] to be wearing an N95 while in the facility, I do not require any eye protection at this time. On 6/15/22, a review of the facility's document entitled, Recommended use of personal protective equipment (PPE) for Health care settings for Coronavirus Disease, update 2/2/2022, read, Facilities in Outbreak Status or Community Transmission Level is Red/High or Orange/Substantial: N95 and Eye Protection for patient care encounters. Per CDC guidance, updated on February 2, 2022, entitled, Interim Infection Prevention and Control Recommendations for Healthcare Personnel [HCP] During the Coronavirus Disease 2019 (COVID-19) Pandemic, page 4, subtitle, Implement Universal Use of Personal Protective Equipment for HCP, read, Additionally, HCP working in facilities located in counties with substantial or high transmission should also use PPE as described below: .*Eye protection (i.e., goggles or a face shield that covers the front and sides of the face) should be worn during all patient care encounters. Accessed online at https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html The Facility Administrator and Director of Nursing were informed of the findings on 6/15/22 at approximately 12:15. No further information was provided.

Based on clinical record review, staff interview, and facility documentation review, the facility staff failed to conduct COVID-19 testing in accordance with the Centers for Disease Control and Prevention (CDC) guidance for 3 Residents, Residents #16, #17, and #19, in a sample of 3 Residents reviewed for resident COVID-19 testing and for contracted agency nursing staff in 2 out of 2 months reviewed for facility staff COVID-19 testing. The findings included: 1. For Residents #16, #17, and #19, facility staff failed to conduct COVID-19 testing for admission/re-admission to the facility and did not document the results of COVID-19 testing in their clinical record. 1a. For Resident #16, the facility staff failed to conduct COVID-19 testing upon her admission to the facility on [DATE] and failed to document the results of a COVID-19 test performed on 5/26/22. On 6/14/22, a clinical record review was conducted and revealed that Resident #16 was admitted to the facility on [DATE], however there was no evidence of any COVID-19 testing until 5/26/22. There was no documented result for the COVID-19 test performed on 5/26/22 in her medical record. 1b. For Resident #17, the facility staff failed to conduct COVID-19 testing upon his readmission to the facility on [DATE] and failed to document the results of a COVID-19 test performed on 6/13/22. On 6/14/22, a clinical record review was conducted and revealed that Resident #17 was readmitted to the facility on [DATE] following his admission to the local hospital on 5/24/22. There was no evidence of any COVID-19 testing until 6/13/22. There was no documented result for the COVID-19 test performed on 6/13/22 in his medical record. 1c. For Resident #19, the facility staff failed to conduct a second COVID-19 test following her admission to the facility on [DATE] and failed to document the result of a COVID-19 test performed on 5/20/22. On 6/14/22, a clinical record review was conducted and revealed facility staff performed a COVID-19 test for Resident #19 on 5/20/22, however failed to document the result of that test in her medical record. There was no evidence of any additional COVID-19 testing for Resident #19 within 5-7 days of her admission. On 6/14/22 at approximately 2:30 PM, an interview was conducted with the facility Infection Preventionist (IP) who confirmed the facility conducts COVID-19 testing for all residents in accordance with CDC (Centers for Disease Control and Prevention) recommendations. The IP was asked about the facility's protocol for testing newly admitted residents for COVID-19 and she stated, we test all new admits within a day of their arrival, after that then only if there is a reason to testing and results are documented in their [medical] record. A copy of the facility's COVID-19 testing policy was requested and received. Review of the facility policy titled, COVID Testing Guidance, updated 6/14/2022, page 2, subheading, Tracking, Reporting and Documentation, read, Documentation of resident test results will be retained in the resident health record and on page 4, subheading, COVID-19 Testing Algorithm, read, Newly admitted residents and residents who have left the facility for >24 hours, regardless of vaccination status, should have a series of two [CONDITION(S)] tests for [CONDITION(S)]-COV-2 infection: approximately 24 hours after admission/readmission and, if negative, again 5-7 days after their admission or return. The CDC document entitled, Interim Infection Prevention and Control Recommendations to Prevent [CONDITION(S)]-CoV-2 Spread in Nursing Homes, updated February 2, 2022, page 4, subheading, Testing, item 3, read, Newly-admitted residents and residents who have left the facility for (greater than) 24 hours, regardless of vaccination status, should have a series of two [CONDITION(S)] tests for [CONDITION(S)]-CoV2 infection; immediately and, if negative, again 5-7 days after their admission. Review of the CMS (Centers for Medicare & Medicaid Services) Memo Ref: QSO-20-38-NH, revision date 3/10/2022, page 11, revealed, the results of tests must be done in accordance with standards for protected health information. For residents, the facility must document [COVID-19] testing results in the medical record. On 6/15/22, the Facility Administrator, Director of Nursing, and IP were made aware of the findings. No further information was provided. 2. For the months of May and June 2022, facility staff failed to conduct COVID-19 testing for 42 contracted agency nursing staff. On 6/14/22 at approximately 10:30 AM, an Entrance Conference was conducted with the Facility Administrator and the Infection Preventionist (IP) who confirmed the facility was in a COVID-19 Outbreak status which began on 5/30/22 and the last positive COVID case occurred on 6/2/22. The IP also verified that COVID-19 testing was currently being performed twice per week for all staff and residents while the facility remained in Outbreak status. The IP confirmed that CDC and CMS requirements were the foundation for the development and implementation of the facility's policies and decisions in the management of COVID-19. A copy of the facility's COVID-19 testing policy was requested and received. The facility COVID-19 staff testing logs and nursing staff work schedules beginning on May 1, 2022 to present were requested and received. On 6/15/22, a review of the facility's staff COVID-19 testing logs and nursing staff work schedules revealed a total of 42 contracted agency nursing staff, to include RNs, LPNs, and CNAs, worked in the month of May 2022 with no documented COVID-19 testing occurrences. From 6/1/22 through 6/14/22, a total of 41 agency nursing staff worked with no documented COVID-19 occurrences. Review of the facility policy titled, COVID Testing Guidance, updated 6/14/2022, page 1, Table 1 titled, Testing Summary, read, Testing Trigger .[COVID-19] Outbreak .Test all staff within 24 hours of first case and then every 3-7 days until no new cases are identified for 14 days. Review of the CDC document entitled, Interim Infection Prevention and Control Recommendations to Prevent [CONDITION(S)]-CoV-2 Spread in Nursing Homes, updated on February 2, 2022, page 8 read, Perform testing for all residents and HCP [Health Care Personnel] .regardless of vaccination status, immediately .and, if negative, again 5-7 days later .if additional cases are identified, testing should continue .every 3-7 days .until there are no new cases for 14 days. On 6/15/22, the Facility Administrator, Director of Nursing, and IP were made aware of the findings. No further information was provided.

Based on staff interview, facility documentation review, and clinical record review, the facility staff failed to offer COVID vaccination(s) to one Resident (Resident #20), in a sample of 6 Residents reviewed for immunizations and the facility staff failed to obtain and maintain record of the COVID-19 vaccination status for 57 out of 57 contracted nursing agency staff members who worked during the months of May and June. The findings included: 1. For Resident #20, who was not up to date with COVID immunizations, the facility staff failed to provide evidence that he/she was offered, educated and provided/or declined COVID vaccination. On 6/14/22 and 6/15/22, a clinical record review for Resident #20 was conducted. This review revealed the following: Resident #20 had been admitted to the facility on [DATE]. On the immunization tab of the electronic health record (EHR) there was no documentation with regards to the COVID vaccine status of Resident #20. Review of the misc. (miscellaneous) tab a document was noted that indicated COVID vac info. This document indicated Resident #20 had received doses of the Pfizer vaccine on 3/3/21 and 3/24/21. There was no information with regards to a booster dose. There was also a document titled, Admission Notification that indicated the same dates of administration for the COVID vaccine. Review of the Medication Administration Records (MAR) revealed no evidence of a COVID booster dose being provided to Resident #20. The progress notes were read in their entirety and no information was noted of a conversation, offer, education or refusal for a COVID booster. On 6/14/22, during an interview with Surveyor D and Employee C, the Infection Preventionist, the IP confirmed the facility follows all CDC (Centers for Disease Control and Prevention) guidance. On 6/15/22 at 9:45 AM, an interview was conducted with Employee C, the Infection Preventionist (IP). The IP was asked to explain the process when a Resident is admitted , with regards to immunizations. The IP said, We offer immunizations, if they have had it we try to find that information and we offer it to them. If they refuse, we let the doctor know, the doctor will encourage them to take it and sometimes the family will try to encourage them. When asked if any declination or acceptance forms are signed, the IP said, Usually we just put a note in and document in the immunization tab. During the interview with the IP, she accessed the EHR for Resident #20. She observed and confirmed the immunization tab only had a TB ([CONDITION(S)]) skin test and no other data was recorded. She reviewed the misc. tab and nursing notes and confirmed there was no information in the EHR to indicate Resident #20 had been offered a COVID booster, she also confirmed that Resident #20 was eligible for a COVID booster dose. The IP stated, We usually go down and talk to admissions, I will have to look at my papers. She [the IP] was asked to provide her papers if she found them. No further information was provided. Review of the facility policy titled, Infection Prevention and Control Program Policy was conducted. This policy read, .All residents are given the influenza vaccination unless they refuse or have medical contraindications. All residents, meeting criteria, are given the pneumococcal vaccine unless they refuse or medical contraindications. The facility policy titled, Resident Vaccination Policy was reviewed. This policy was noted to read, .COVID vaccination will be offered to all residents and administered per provider orders .The date of historical vaccination(s) will be documented in the health record immunization portal on admission and as information becomes available. Vaccination information may be obtained from the resident/responsible party, past medical records, VIIS documentation, etc. If specific historical vaccination information is not known the resident/representative will provide their best estimate of dates of prior vaccinations and where received. The infection preventionist will track resident immunizations and holds the responsibility for ensuring resident's vaccination history is reviewed with/by their providers and that vaccines are administered timely when ordered .Consents/refusals/medical ineligibility will be documented in the immunization portal in the electronic health record . CDC provides the following guidance to nursing facilities in their document titled Interim Infection Prevention and Control Recommendations to Prevent [CONDITION(S)]-CoV-2 Spread in Nursing Homes. This document read, .New Admissions and Residents who Leave the Facility: Create a Plan for Managing New Admissions and Readmissions In general, all residents who are not up to date with all recommended COVID-19 vaccine doses and are new admissions and readmissions should be placed in quarantine .COVID-19 vaccination should also be offered. Accessed online 6/15/22, at web address: https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html#anchor_ 017 On 6/15/22 at 12:51 PM, an end of day meeting was held with the facility Administrator, Director of Nursing and Infection Preventionist. They were made aware of the above findings. The Administrator reported during this meeting that Resident #20 was cognitively impaired and they had been unable to reach his/her responsible party for consent. The clinical record indicated on the profile tab that Resident #20 was their own responsible party and the family member was noted as an emergency contact. Also, there was documentation in the miscellaneous tab of the chart for Resident #20 which indicated Resident #20 had signed other documents, which included but were not limited to, Resident handbook and an advance beneficiary notice. No further information was provided. 2. The facility staff failed to obtain the COVID-19 vaccination status for 57 contracted nursing agency staff members who provided direct resident care during the months of May and June 2022. On 6/14/22, an interview was conducted with the Facility Administrator and the Infection Preventionist (IP) who stated that the facility had a 100% COVID-19 staff vaccination rate. A staff COVID-19 vaccination list was requested and received. A list of all facility staff members, including contracted agency staff, scheduled to work on 6/14/22 was requested and received. The IP stated that the Human Resources (HR) Director was responsible for obtaining and maintaining the COVID-19 vaccination status for all contracted nursing agency staff. On 6/14/22 at approximately 1:00, Surveyor C conducted an interview with the HR Director to obtain the COVID-19 vaccination status for LPN D and CNA C, both of whom were contracted agency staff working on 6/14/22. The HR Director stated, No one told me how to handle agency [nursing staff], I'm guessing [name redacted, Infection Preventionist] does that [obtain COVID-19 vaccination status]. At approximately 1:15, Surveyor C conducted a group interview with the HR Director and the IP who stated, the agency staff person sends their information to their agency, once they [the agency] complete the [staff] packet, then [name redacted, HR Director] gets the packet which includes abuse and residents rights, HIPPA information, and COVID vaccination--they have to be vaccinated in order to work with us .there is no nursing oversight, we rely on [name redacted, HR Director] with agency staff packets. The HR Director responded, I have never seen anything from agency since I've worked here on March 14th [2022]. The IP stated, I will have to call agency to get their vaccination cards .everyone who works here must be vaccinated. On 6/14/22 at approximately 3:15 PM, the IP stated that she was able to obtain the COVID vaccination status for LPN D and CNA C. The IP submitted a copy of an email sent to her by the Agency liason which revealed that LPN D was fully vaccinated, however CNA C was not vaccinated but had a non-medical exemption that had been submitted to the Agency. The IP confirmed that the COVID vaccination status had not been obtained for any contracted staff that had been employed by the facility except for the recently received status for LPN D and CNA C that was just submitted. The agency nursing staff work schedules beginning on 5/1/22 was requested and received. Review of the agency nursing staff work schedules for 5/1/22-6/14/22 revealed a total of 57 agency nursing staff, 27 RNs/LPNs and 30 CNAs, with unknown COVID-19 vaccination status were permitted by the facility to provide direct care to residents. Review of the facility policy titled, Employee COVID-19 Vaccination Policy, last revision date 4/5/22, read, .All employees are required to receive a FDA authorized and/or approved COVID-19 vaccination . The CDC (Centers for Disease Control and Prevention) document titled, Interim Infection Prevention and Control Recommendations to Prevent [CONDITION(S)]-CoV-2 Spread in Nursing Homes, updated February 2, 2022, page 3, subtitle, Vaccinations, read, Remaining up to date with all recommended COVID-19 vaccine doses is critical to protect both staff and residents against [CONDITION(S)]-CoV-2 infection. The Facility Administrator, Director of Nursing, and IP were updated. No further information was received.

Based on staff interview and facility documentation review, the facility staff failed to implement their COVID policy and procedures and were unaware of the COVID vaccination status of 57 contracted nursing agency staff who worked on all nursing units within the facility during the months of May and June. The facility staff failed to obtain the COVID-19 vaccination status for 57 contracted nursing agency staff members who provided direct resident care during the months of May and June 2022. The findings included: On 6/14/22, an interview was conducted with the Facility Administrator and the Infection Preventionist (IP) who stated that the facility had a 100% COVID-19 staff vaccination rate. A staff COVID-19 vaccination list was requested and received. A list of all facility staff members, including contracted agency staff, scheduled to work on 6/14/22 was requested and received. The IP stated that the Human Resources (HR) Director was responsible for obtaining and maintaining the COVID-19 vaccination status for all contracted nursing agency staff. On 6/14/22 at approximately 1:00, Surveyor C conducted an interview with the HR Director to obtain the COVID-19 vaccination status for LPN D and CNA C, both of whom were contracted agency staff working on 6/14/22. The HR Director stated, No one told me how to handle agency [nursing staff], I'm guessing [name redacted, Infection Preventionist] does that [obtain COVID-19 vaccination status]. At approximately 1:15, Surveyor C conducted a group interview with the HR Director and the IP who stated, the agency staff person sends their information to their agency, once they [the agency] complete the [staff] packet, then [name redacted, HR Director] gets the packet which includes abuse and residents rights, HIPAA information, and COVID vaccination--they have to be vaccinated in order to work with us .there is no nursing oversight, we rely on [name redacted, HR Director] with agency staff packets. The HR Director responded, I have never seen anything from agency since I've worked here on March 14th [2022]. The IP stated, I will have to call agency to get their vaccination cards .everyone who works here must be vaccinated. On 6/14/22 at approximately 3:15 PM, the IP stated that she was able to obtain the COVID vaccination status for LPN D and CNA C. The IP submitted a copy of an email sent to her by the Agency liaison which revealed that LPN D was fully vaccinated, however CNA C was not vaccinated but had a non-medical exemption that had been submitted to the Agency. The IP confirmed that the COVID vaccination status had not been obtained for any contracted staff that had been employed by the facility except for the recently received status for LPN D and CNA C that was just submitted. The agency nursing staff work schedules beginning on 5/1/22 was requested and received. Review of the agency nursing staff work schedules for 5/1/22-6/14/22 revealed a total of 57 agency nursing staff, 27 RNs/LPNs and 30 CNAs, with unknown COVID-19 vaccination status were permitted by the facility to provide direct care to residents. Review of the facility policy titled, Employee COVID-19 Vaccination Policy, last revision date 4/5/22, read, .All employees are required to receive a FDA authorized and/or approved COVID-19 vaccination . The CDC (Centers for Disease Control and Prevention) document titled, Interim Infection Prevention and Control Recommendations to Prevent [CONDITION(S)]-CoV-2 Spread in Nursing Homes, updated February 2, 2022, page 3, subtitle, Vaccinations, read, Remaining up to date with all recommended COVID-19 vaccine doses is critical to protect both staff and residents against [CONDITION(S)]-CoV-2 infection. The Facility Administrator, Director of Nursing, and IP were updated. No further information was received.

Based on staff interview, facility documentation review, and clinical record review, the facility staff failed to implement their immunization policy and ensure each Resident is offered influenza and pneumococcal immunization, for 1 Resident (Resident #20), in a sample of 6 Residents reviewed for immunizations. The findings included: On 6/14/22, during the survey entrance conference the facility, the Administrator identified Employee C as the infection preventionist and stated she was responsible for the vaccination effort within the facility. On 6/14/22 and 6/15/22, clinical record reviews were conducted for the sampled Residents with regards to immunization for flu and pneumonia. This review revealed the following: Resident #20 had been admitted to the facility on [DATE]. On the immunization tab of the electronic health record (EHR) there was no documentation with regards to the pneumonia or flu vaccine status of Resident #20. Review of the misc. (miscellaneous) tab, assessment tab, and progress notes revealed no evidence of vaccine administration or offering of such. Review of the Medication Administration Records (MAR) revealed no evidence of the flu or pneumonia immunization being provided to Resident #20. There was an admission alert scanned in the misc. tab, which indicated COVID vaccination status of Resident #20, but no information was noted with regards to flu or pneumonia immunization status. On 6/15/22 at 9:45 AM, an interview was conducted with Employee C, the Infection Preventionist (IP). The IP was asked to explain the process when a Resident is admitted , with regards to immunizations. The IP said, We offer the flu shot if it is flu season, if they have had it we try to find that information and we offer it to them. If they refuse, we let the doctor know, the doctor will encourage them to take it and sometimes the family will try to encourage them. When asked if any declination or acceptance forms are signed, the IP said, Usually we just put a note in and document in the immunization tab. During the interview with the IP, she accessed the EHR for Resident #20. She observed and confirmed the immunization tab only had a TB ([CONDITION(S)]) skin test and no other data was recorded. She reviewed the misc. tab and nursing notes and confirmed there was no information in the EHR. She stated, We usually go down and talk to admissions, I will have to look at my papers. The IP confirmed that based on the EHR she did not know Resident #20's immunization status with regards to flu or pneumonia immunization and had no evidence of it being offered to the Resident. She was asked to provide her papers if she found them. No further information was provided. Review of the facility policy titled, Infection Prevention and Control Program Policy was conducted. This policy read, .All residents are given the influenza vaccination unless they refuse or have medical contraindications. All residents, meeting criteria, are given the pneumococcal vaccine unless they refuse or medical contraindications. The facility policy titled, Resident Vaccination Policy was reviewed. This policy was noted to read, .The date of historical vaccination(s) will be documented in the health record immunization portal on admission and as information becomes available. Vaccination information may be obtained from the resident/responsible party, past medical records, VIIS documentation, etc. If specific historical vaccination information is not known the resident/representative will provide their best estimate of dates of prior vaccinations and where received. The infection preventionist will track resident immunizations and holds the responsibility for ensuring resident's vaccination history is reviewed with/by their providers and that vaccines are administered timely when ordered .Consents/refusals/medical ineligibility will be documented in the immunization portal in the electronic health record . On 6/15/22 at 12:51 PM, an end of day meeting was held with the facility Administrator, Director of Nursing and Infection Preventionist. They were made aware of the above findings. The Administrator reported during this meeting that Resident #20 was cognitively impaired and they had been unable to reach his/her responsible party for consent. The clinical record indicated on the profile tab that Resident #20 was their own responsible party and the family member was noted as an emergency contact. Also, there was documentation in the miscellaneous tab of the chart for Resident #20 which indicated Resident #20 had signed other documents, which included but were not limited to, Resident handbook and an advance beneficiary notice. No further information was provided.

Based on Resident interview, staff interviews, facility documentation review, clinical record review and during the course of a complaint investigation, the facility staff failed to provide ADL (activities of daily living) assistance to Residents who were dependent on staff to maintain personal hygiene, for two Residents (Resident #10 & #12) in a survey sample of 11 Residents. The findings included: 1. For Resident #10, who was dependent upon facility staff for ADL assistance, the facility failed to provide hair care and nail care, and failed to ensure the Resident's clothing was clean. On 6/14/22 at 10:21 AM, Resident #10 was visited in her room by Surveyor C. Surveyor C observed Resident #10's hair to have three braids, which had a lot of fraying and appeared untended and uncombed. Resident #10 stated, No one does my hair anymore. Resident #10 was observed to have right arm contractures and stated, I can't comb it or do that [referring to braiding] and pointed to her right arm. Resident #10 said she would love it if someone would do her hair. Resident #10 was also observed to have a small crusty substance on the right collar of her shirt, her fingernails were long, with chipped nail polish, and some dirt was noted under the nails. Resident #10 said she would like her nails trimmed and reported to Surveyor C that it has been about 2 weeks since anyone provided any nail care. Review of Resident #10's electronic health record revealed on the ADL sheets that she required extensive assistance to being totally dependent on facility staff. The ADL sheets also noted that Resident #10 frequently refused baths. For the month of May and to date in June, Resident #10 was not noted as having received any baths other than bed baths. On 6/14/22 at 12 PM, an interview was conducted with CNA B. CNA B stated that Resident's hair is washed twice a week. When asked about nail care and the frequency, CNA B stated, I am not sure if we trim nails, I just got here a month ago. On 6/14/22 at 12:26 PM, an interview was conducted with CNA J. CNA J was asked about nail care and she said, CNA's do nail care except for diabetes. [Resident #10's name redacted] refuses for us to cut her nails. CNA J was told Resident #10 was observed to have chipped nail polish, CNA J said, Activities will remove and put on polish a few times a week. When asked who cleans the nails, she said, The CNA's are supposed to be doing that with ADL care. On 6/14/22 at 12:28 PM, an interview was conducted with CNA C. CNA C was told Resident #10's nails are very long, CNA C said, I wiped her up this morning, there was food under her nails when I first went in, I cleaned her with soap and washcloth, they look better than they did. 2. For Resident #12, the facility staff failed to provide ADL assistance to maintain personal hygiene of hair care. On 6/14/22 at approximately 12 Noon, Resident #12 was visited in her room by Surveyor C. Resident #12 was asked about showers and baths. Resident #12 said she doesn't get showers often but gets a bed bath daily. Resident #12 said, My hair needs to be washed, it has been about a month since it's been washed. Resident #12's hair was observed to appear very oily and in need of washing. Review of Resident #12's electronic health record revealed he/she was dependent on facility staff for personal hygiene and bathing. Resident #12 was noted to not have had a shower or tub bath for the month of May, nor to date in June. Resident #12 was noted to only receive bed baths. There was no further information in the clinical record with regards to hair washing. On 6/14/22 at 12 PM, an interview was conducted with CNA B. CNA B stated that Resident's hair is washed twice a week. On 6/14/22 at 2:30 PM, an interview was conducted with the Director of Nursing (DON). She was asked to explain when nail care and hair care is provided. She said, CNA's or nurses provide nail care, cleaning and trimming, they check nails everyday with ADL care and if it is needed they provide it. The DON said they have a shower room where showers are given and they Should be given twice a week. The DON said hair washing is done with showers, but some people prefer to go to the beauty salon. The DON confirmed that the beauty salon is a service Residents have to pay for and she added, Hair washing should be provided when they do showers or a bath in the room. A review was conducted of the facility policy titled, Resident Bath/Showering/Scheduling Policy. This policy read, .Residents will be bathed or showered according to their preferences in order to maintain healthy hygiene and skin condition .(G) If the bath/shower cannot be given or the resident refuses, the nursing assistant will promptly report this to the charge nurse. (H) The charge nurse will speak with the resident who refuses to ascertain why they are refusing and to determine if alternative arrangements that suit the resident can be made. If the resident continues to refuse the charge nurse will inform the DON and document the resident's refusal in the nursing notes and on the 24-hour report. Further attempts and interventions will be documented in the nursing notes and on the 24-hour report . The facility policy titled, Morning Care/AM Care was reviewed. This policy read, Morning care will be offered each day to promote resident comfort, cleanliness, grooming, and general wellbeing .3. Perform hand hygiene . 6. Provide bath/shower as indicated .9. Provide fingernail care .13. Brush/comb hair . On 6/14/22, during an end of day meeting Surveyor C shared her observations of Resident #10 and #12. On 6/15/22, during an end of day meeting the above findings were discussed with the facility Administrator, Director of Nursing and Assistant Director of Nursing/Infection Preventionist. No further information was provided. Complaint related deficiency.

Based on staff interview, facility documentation review, clinical record review, and in the course of a complaint investigation, the facility staff failed to ensure Residents were free from significant medication errors for four Residents (Resident #40, #24, #178, and #62) in a survey sample of 41 Residents, which resulted in harm for Resident #40. The findings included: 1. For Resident #40, the facility staff failed to follow physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] #40 having a [CONDITION(S)] and being sent to the hospital, this constituted harm. On 10/12/21 at 2:10 PM, the family member/Resident Representative of Resident #40 met with the survey team. She shared concern that Resident #40 had been hospitalized and during the course of her hospital stay had seizures. Resident #40 was started on [CONDITION(S)] medication, [MEDICATION(S)] while in the hospital. She stated that upon Resident #40's return to the facility the facility staff failed to administer this medication. Resident #40 had another [CONDITION(S)] and had to be sent to the hospital. On 10/13/21 and 10/14/21, a review of the EHR (electronic health record) for Resident #40 was conducted. This review revealed that on 8/7/21, Resident #40 was hospitalized and returned to the facility on [DATE]. Review of the EHR further revealed that hospital records from the hospitalization were in the record. Included in the hospital documents was a neurology consult dated 8/13/21, that read, While undergoing a investigations, yesterday evening, she had brief generalized tonicclonic [CONDITION(S)] with loss of consciousness lasted less than 2 min Patient had mild facial droop. She had a CT scan of brain which was reported unremarkable. She does not have fever or new focal neurological deficit she is back to her baseline. She was started on [MEDICATION(S)] and doing very well. We are unable to do MRI brain due to Permanent pacemaker. A hospital note dated 8/14/21 and 8/15/21, titled General Progress Note, both read On 8/12/21, patient with new onset [CONDITION(S)] activity; CT evaluation negative for etiology. Cannot get MRI due to PPM [permanent pacemaker]. Additional notes in this same document read, She had a brief generalized [CONDITION(S)] on 08/12 in the absence of a [CONDITION(S)] history. There was noticeable left arm weakness subsequently and a stroke alert was called. There was no CT evidence of bleeding or infarction, and CTA did not reveal evidence of a flow limiting lesion. Neuro interventionalist did not feel that further investigation or treatment was warranted at this time. Local neurology consultation was recommended related to the new onset [CONDITION(S)]. She had a 2nd brief [CONDITION(S)] after arrival to the ICU but none since. She has been loaded with [MEDICATION(S)] and will continue that b.i.d. [twice daily] Unable to get MRI due to pacemaker [MEDICATION(S)] 500mg BID, check [MEDICATION(S)] level on 8/16, [CONDITION(S)] precautions. The hospital discharge summary dated 8/16/21, noted diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . This discharge summary went on to note: take these medications: [MEDICAL RECORD OR PHYSICIAN ORDER] 500 mg, Oral, 2 times daily, commonly known as: [MEDICATION(S)]. Hospital course .[CONDITION(S)] She had a brief generalized [CONDITION(S)] on 08/12 in the absence of a [CONDITION(S)] history. There was noticeable left arm weakness subsequently and a stroke alert was called. There was no CT evidence of bleeding or infarction, and CTA did not reveal evidence of a flow limiting lesion. Neuro interventionalist did not feel that further investigation or treatment was warranted at this time. Local neurology consultation was recommended related to the new onset [CONDITION(S)]. She had a 2nd brief [CONDITION(S)] after arrival to the ICU but none since. She has been loaded with [MEDICATION(S)] and will continue that b.i.d. Unable to get MRI due to pacemaker. Review of Resident #40's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . There were multiple notes from the providers (doctor and nurse practitioner) of seeing Resident #40 from 8/16/21-9/6/21, and none of the notes made reference to the [CONDITION(S)] activity she had in the hospital or the orders for [MEDICATION(S)]. On 9/5/21 at 3 PM, there was a nursing note entry that read, Resident's daughter noted to be in the hallway yelling for help. This Nurse, other Nurse and Aide arrived at Resident's room where Resident's daughter stated that Resident had a [CONDITION(S)]. Upon assessment of Resident she was noted to be unresponsive to verbal stimulation and slightly responsive to painful stimuli, with her eyes open; VS [vital signs] 112/58 [blood pressure reading], 69 [pulse], 20 [respirations], O2 88% [oxygen saturation] on 2 LPM [2 liters of oxygen per minute]. Resident was unresponsive for 3 minutes. No further [CONDITION(S)] like activity noted. On call [Nurse Practitioner name redacted] made aware and gave N.O. [new order] Send Resident to ER [emergency room ] for eval [evaluation] and tx [treatment]. Resident and RP [responsible person] made aware. On 9/8/21, there was a progress note written by the nurse practitioner that read, Upon review of previous d/c [discharge] summary, it appears pt [patient] possibly had [CONDITION(S)] like activity at that time and was discharged with recommendation for [MEDICATION(S)], which was somehow overlooked. On 10/13/21, the Director of Nursing provided a document dated 9/6/21, titled Medication Error that read, Upon admission on 8/16/21 [MEDICATION(S)] order not transcribed to EMAR (electronic medication administration record). Also provided was a copy of an IDT (interdisciplinary team) Meeting Progress Note dated 9/10/21, that read, Resident readmitted to facility and [MEDICATION(S)] omitted from active meds. On 10/14/21 at 2:10 PM, a telephone interview was conducted with Employee F, the Nurse Practitioner. Employee F was asked if she would ever not agree to an order from the hospital for a Resident to be on [MEDICATION(S)]. Employee F stated, No, we absolutely would order that. Employee F was asked about the details of Resident #40 not receiving [MEDICATION(S)] as ordered by the hospital following her having 2 seizures while in ICU (intensive care unit) at the hospital. Employee F stated, It could have been prevented, I do carry some fault in that. All of it could have been avoided. On 10/14/21 at approximately 3:50 PM, an interview was conducted with LPN C, who was the admitting nurse when Resident #40 returned to the facility on [DATE]. LPN C stated she had received report from the hospital as well as discharge paperwork. She assessed Resident #40 then called the NP (nurse practitioner) and reviewed the hospital records and orders. LPN C stated she told the NP of the [CONDITION(S)] activity in the hospital and was advised to leave it as is and she [the NP] would review them when she came in the next day. LPN C very emotionally said I would never hurt her, I'm so sorry [referring to Resident #40]. On 10/14/21 at 4:31 PM, the facility Administrator stated their contracted medical provider for physician services has a phone system that tracks phone calls. She then provided an email that indicated the medical provider received a call from the facility staff on 8/16/21 at 1:51 PM. On 10/15/21, the Administrator returned to the conference room and had obtained the recording of the conversation between facility staff and the medical provider regarding Resident #40's readmission to the facility. Surveyors D & F listened to the conversation which was between LPN C and Employee F. During this call Employee F, the nurse practitioner stated, go ahead and start whatever their changes are [the hospital orders], that's fine. I'll look at them tomorrow when I'm in there, we will request their [the hospital] records. Obviously they would have had neurology [evaluation] and I'm curious what they think happened. On 10/15/21 at 11:30 AM, a telephone interview was conducted with Other Staff B, the pharmacist. Other Staff B stated, [MEDICATION(S)] is a central nervous system anticonvulsant, the side effects would be allergy or adverse reaction history or excessive sedation, which can be controlled by dose adjustments. If someone has had a [CONDITION(S)] I don't know why it wouldn't be given unless they were on another medication for this and it would be duplicate therapy. On 10/15/21 at 9:44 AM, an interview was conducted with the Director of Nursing. She was asked what constitutes a medication error, she stated, If a medication is not available, given in error or isn't given. The facility policy titled Medication Related Errors read, 4. Administration Errors: In the event of an administration error, facility staff should follow facility policy relating to the medication administration errors .4.9 Omission Error: Facility fails to administer an ordered dose to the resident, unless refused by the resident or not administered because of recognized contraindication. On 10/15/21, the facility Administrator was notified of Resident #40 not receiving her [CONDITION(S)] medication, which resulted in a [CONDITION(S)] and hospital visit constituting harm. No further information was provided. 2. For Resident #24 the facility staff failed to administer an anticoagulant (blood thinner) for 3 of 4 doses scheduled in a 48 hour time frame, this is a significant medication error. On 10/13/21-10/14/21, a review of Resident #24's EHR (electronic health record) was conducted. Resident #24 was noted to have a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . This order was still active. Review of Resident #24's MAR for October revealed that on 10/4 the 8:30 AM dose was not given and had a code 19 in the block. On 10/5/21, neither of the 2 scheduled doses were administered and both had a code 19 in the block. The last page of the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] =Other / See Nurse Notes. Review of the nursing notes for these 2 days read, [MEDICATION(S)] Tablet 90 MG, Give 1 tablet by mouth two times a day for Blood thinner unavailable, [MEDICATION(S)] Tablet 90 MG, Give 1 tablet by mouth two times a day for Blood thinner not in cart, and [MEDICATION(S)] Tablet 90 MG, Give 1 tablet by mouth two times a day for Blood thinner on order. On 10/13/21, RN D was asked to verify that Resident #24's medication [MEDICATION(S)] was available. At the medication cart RN D was able to verify that [MEDICATION(S)] was currently in stock. She was asked about the notes on 10/4 & 10/5, and why the medication was not given, and she said it says it wasn't available. RN D confirmed that the process is that the staff would order medications several days before running out to ensure the pharmacy had time to deliver a refill. On 10/14/21 at 1:37 PM, an interview was conducted with the DON (Director of Nursing). The DON stated, if meds (medications) are not available staff are to try to get them out of the Omnicell (in-house stock of medications), if they can't they are to call the pharmacy and physician. The DON confirmed the process for reordering medications, which she said, there are several options, you can press the reorder button in the computer or call the pharmacy. When asked when meds are to be ordered, the DON said, when meds get down to a 7 day supply we will go ahead and order them to prevent them from running out. The DON stated the risks of not receiving blood thinners as ordered is, they run the risk of getting a blood clot, which could cause the loss of limb or life. She confirmed this is an important medication to receive. On 10/14/21 at 2:10 PM, a telephone interview was conducted with Employee F, the Nurse Practitioner. Employee F was asked about the medication [MEDICATION(S)] and its use. Employee F stated, it is an anticoagulant usually given when people have heart failure, it is a last ditch effort. When asked the risks if someone doesn't get this as ordered, Employee F stated, it depends on the circumstances, 1 dose is not terrible but missing multiple doses could put them at risk for heart failure or create clots. Employee F was made aware that Resident #24 had missed 3 of 4 scheduled doses in a 48 hour period. Employee F stated she was not aware of this. On 10/15/21 at 11:30 AM, a telephone interview was conducted with Other Staff B, the pharmacist. Other Staff B stated, [MEDICATION(S)] is an antiplatelet medication, the reason someone takes it is to prevent a [CONDITION(S)] (blood clot) or MI ([CONDITION(S)] infarction/heart attack). Missed doses would result in higher risks for these things. Other Staff B stated, the pharmacy makes 2 deliveries to the facility daily and also has a local retail pharmacy that can be used for back-up if medications are not available and are not in the Omnicell [emergency box of medications maintained on-site]. When asked about cut off times, she stated, if a medication is ordered before 11:30 PM, we have it on the delivery that comes that night, same for the day delivery, as long as we get it [the order/refill request] about an hour to 30 minutes before we leave the pharmacy with the delivery, it can be included in that delivery. The facility policy titled Medication Related Errors read, 4. Administration Errors: In the event of an administration error, facility staff should follow facility policy relating to the medication administration errors .4.9 Omission Error: Facility fails to administer an ordered dose to the resident, unless refused by the resident or not administered because of recognized contraindication. On 10/14/21, the facility Administrator and DON were made aware of the findings. No further information was received. 3. For Resident #178 the facility staff failed to administer insulin, antibiotics, pain medications, medications as ordered by physician. A review of the clinical record revealed that Resident #178 was admitted to the facility on [DATE] at 8 PM, after having been hospitalized and had surgery for [MEDICAL RECORD OR PHYSICIAN ORDER] . Among Resident # 178's discharge summary were orders for the following medications: [MEDICAL RECORD OR PHYSICIAN ORDER] Resident #178 had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . -A review of the MAR (Medication Administration Record) revealed that Resident #178 did not receive 5 doses of this medication - A review of the progress notes revealed that nurses documented medication was unavailable. However, a review of the stat box contents revealed this medication was available in the stat box. Resident #178 had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Progress note on 8/14/21 at 11:50 AM read: Pharmacy contacted re: [MEDICATION(S)] HCl solution reconstituted 2 grams as medication not received. Per pharmacy IV department not available at this time message left for a return call. 8/14/21 at 4:11 PM IV department contacted no return call received per pharmacy IV department IV antibiotics order not received order re-faxed to the pharmacy order currently not updated in [name of pharmacy computer program redacted] to pull medication for administration. 8/15/21 at 3:59 PM Pharmacy contacted again this shift as IV abx not received. Per pharmacy medication not sent d/t allergy to [MEDICATION(S)]. Per discharge information, resident was receiving this medication in hospital without side effects. On-call NP made aware with approval to contact pharmacy again and update on approval to send medication. Pharmacy verbally contacted + faxed for notification of approval to continue IV abx per current orders. Resident #178 had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the progress notes revealed the nurses documented medication unavailable awaiting from pharmacy. A review of the Stat Box contents revealed the medication was available in the stat box in a lower dose strength (300 mg) Resident #178 had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] Insulin [MEDICATION(S)] ([MEDICATION(S)]) solution 100 units/ml inject 60 units subcutaneously at bedtime for DM2 (diabetes) Start Date 8/12/21 at 9:00 PM A review of the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . (2 more doses missed). A review of the Nurses notes revealed the nurses were documenting waiting for med from pharmacy. On 10/13/21 at approximately 11:25 AM an interview was conducted with the DON who was stated the Pharmacy makes two runs a day. They come in the middle of the night and in the middle of the day. When asked how long it takes to get orders in the system for a new admission she stated that it takes about 2 hours. When asked what the cutoff time to get the medications on the next run she stated it is at 11:30 PM. She further stated that Resident #178 should have had her medications in the middle of the night run. When asked if there is a backup pharmacy she stated that there was a backup pharmacy. On 10/14/21 during the end of day meeting the Administrator was made aware of the concerns and no further information was provided. 4. For Resident #62, the facility staff failed to administer [MEDICATION(S)] (Insulin [MEDICATION(S)]) on 10/04/2021 and 10/05/2021 as ordered by the physician. Also, Novolog (Insulin [MEDICATION(S)]) was not signed off as administered on 10/06/2021 at 0800 (8:00 A.M.) and 1700 (5:00 P.M.) On 10/25/2021 at approximately 9:45 A.M., Resident #62's clinical record was reviewed. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Inject 5 unit subcutaneously with meals for DMII in addition to sliding scale. The Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] Pertaining to [MEDICATION(S)] (Insulin [MEDICATION(S)]) Inject 65 units subcutaneously at bedtime: The [MEDICATION(S)] was signed off as administered at bedtime with the exception of 10/04/2021 and 10/05/2021. For 10/04/2021 and 10/05/2021, the administration Insulin [MEDICATION(S)] (65 units) at 2100 [9:00 P.M.] was coded as 3 meaning no insulin required (according to the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The BS [blood sugar] value on 10/05/2021 at 2100 was documented as 125. Pertaining to Novolog (Insulin [MEDICATION(S)]) Inject 5 unit subcutaneously with meals for DMII in addition to sliding scale: The Novolog was signed off as administered with the exception of 10/06/2021 at 0800 [8:00 A.M.] which was coded as 19 meaning other/see nurses notes (according to the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] .M.] which was blank. A nurse's note dated 10/06/2021 at 11:23 A.M. documented that the Novolog was on order. There was no nurse's note addressing why Novolog was not signed off as administered on 10/06/2021 at 1700. On 10/25/2021 at 11:50 A.M., an interview with Licensed Practical Nurse D (LPN D) was conducted. When asked about the process if insulin is unavailable for administration, LPN D stated they have an emergency supply of insulin in the refrigerator. LPN D stated they would use the emergency supply and also notify the pharmacy. This surveyor and LPN D then went to observe the ekit contents for insulin which did contain several types of insulin vials and pens including [MEDICATION(S)] and Novolog. On 10/25/2021 at 1:00 P.M., the Director of Nursing (DON) was notified of findings and the DON indicated she would look into it. At 2:20 P.M., the DON stated that it was an agency nurse that documented no insulin required for the [MEDICATION(S)] on 10/04/2021 and 10/05/2021. The DON also stated that I can't speak for her but it looked like she was addressing the sliding scale [where no insulin was required for blood sugar values less than 200] and applied it to the [MEDICATION(S)]. Pertaining to the nurse's note indicating Novolog was on order and not administered, the DON stated that staff are expected to use the extra insulin supply on hand and doesn't know why it wasn't administered. On 10/25/2021 at approximately 3:30 P.M., the administrator was notified of findings. The administrator and DON stated there was no further information or documentation to submit.

Based on staff interview, clinical record review and facility documentation review and in the course of a complaint investigation, the facility staff failed to ensure Laboratory services were provided to meet the needs of one resident (Resident # 128) in a survey sample of 41 residents resulting in harm. The Findings Included: 1. For Resident # 128, the facility staff failed to obtain a Complete Blood Count, Basic Metabolic Profile as ordered to be drawn on 8/28/2021. The labs were not drawn prior to Resident # 128 being hospitalized on [DATE] for [CONDITION(S)] (low blood pressure), increased confusion and dysphagia (difficulty swallowing). When the labs were checked in the emergency room , there were several values at Critical levels. This is harm. The finding included: Resident # 128 was admitted to the facility on [DATE] Resident # 128's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the Clinical record was conducted on 10/12/2021-10/15/2021. Review of the Nurse Practitioner's Progress Notes revealed documentation of an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Nursing Progress Notes revealed a note written by LPN (Licensed Practical Nurse) B which read: 8/28/2021 12:17 eMAR- Medication Administration Note Text: check CBC, BMP, Mg (Complete Blood Count, Basic Metabolic Profile and Magnesium) one time only for 1 Day Lab to be obtained 7 p-7 a shift by ____ (Name of lab services). Further review of the clinical record revealed no documentation of the nursing staff notifying the Nurse Practitioner or Medical Director that the labs were not drawn on 8/28/2021 as ordered. There was no documentation of the laboratory service drawing blood on Resident # 128 on 8/28/2021 or on any other day during the stay at the facility. Further review of the Nursing Progress Notes and the rest of the clinical record revealed no documentation of the bloodwork being drawn as ordered. Review of the Nurses Notes dated 9/17/2021 revealed documentation of Resident # 128 being transferred to the hospital for altered mental status. Review of the hospital records dated 9/17/2021 revealed Resident # 128 had bloodwork drawn while in the emergency room . Review of the laboratory values revealed several abnormal lab values including many critical values. Among those labs listed as critical lab values were the Hemoglobin and Hematocrit and Magnesium levels. The Hemoglobin was 4.7 (normal value range-12.0-18.0) and the Hematocrit was 15.1 (normal range-37.0 - 47.0). Resident # 128 was admitted to the hospital from the emergency room . On 10/14/2021, during the end of day debriefing at approximately 4:35 PM, copies of all lab results for Resident # 128 were requested. The Administrator stated she had lab results from when Resident # 128 was sent to the hospital and would submit them on 10/15/2021. Review of the laboratory results presented by the Administrator revealed the blood work-a Magnesium level with a Critical Level result = 3.1. The normal range for Magnesium Levels is (1.5-2.4). The Administrator stated that was the only lab value she could find. The Administrator was advised of other Critical Lab values when Resident # 128 was evaluated in the emergency room . Resident # 128 was transferred to the emergency room due to being symptomatic. On 10/15/2021 at 11:05 A.M., an interview was conducted with Licensed Practical Nurse B who stated she reviewed Resident # 128's clinical record and it does not appear that the lab was done. When asked if the laboratory usually would draw labs, LPN B stated the labs were would be drawn on the night shift. LPN B stated the nursing staff was expected to notify the physician if the labs were not drawn. LPN B stated there was no documentation that the doctor was notified of the labs not being drawn as ordered. On 10/15/2021 at 11:35 A.M., an interview was conducted with the Director of Nursing who stated the labs were not drawn. The Director of Nursing stated it looks like the nurse put it on the weekend to be drawn. When informed that the physician scheduled the lab to be drawn specifically on 8/28/2021 which was a Saturday, the Director of Nursing stated she did not realize 8/28/2021 was a Saturday. She stated she had not looked at the calendar prior to talking to the surveyor. The Director of Nursing again stated the labs had not been drawn as ordered by the provider. The Director of Nursing stated the facility has lab services every day because the nurses here can draw labs. But if the lab service is coming, the nurses will get the lab to do it. On 10/15/2021 at 12:04 P.M., the Medical Director returned the call from the surveyor. The Medical Director stated she reviewed the clinical record and that there were no labs drawn on Resident # 128. She stated the expectation was that the lab would have been drawn as ordered on 8/28/2021. The Medical Director stated They got missed for some reason from the lab personnel not coming. They are also short staffed. Sometimes if they do not draw it (labs) on the Saturday, then it should be drawn that Monday and the staff should have informed me. Then she stated at least it would have been drawn on the next possible day. The Medical Director stated she saw a hemoglobin of 8 in the clinical record. When the surveyor informed the Medical Director that the lab value of Hemoglobin result of 8 was prior to admission to the facility, the Medical Director stated she would review the clinical record again. The Medical Director was informed that the clinical record indicated that Resident # 128 was sent to the emergency room by the Nurse Practitioner for [CONDITION(S)], increased confusion, and dysphagia, as the resident's needs can no longer be met in the facility. The Medical Director stated she was unaware that several lab values were critical when Resident # 128 was evaluated in the emergency roiagnom on [DATE]. When this surveyor informed the Medical Director of the critical Hemoglobin value of 4, and Hematocrit of 15, the Medical Director stated those values were very critical. The Medical Director also stated that Resident # 128 was not clinically bleeding, the blood pressure was stable and did not suggest that it was not indicative of a hemoglobin that low. The Medical Director said Oh okay when informed that Resident # 128 was symptomatic and that was why the transfer to the emergency room order was written by the nurse practitioner. The Medical Director was informed that Resident # 128 had an altered mental status and the hospital record revealed vitals signs on 9/17/21 with a Blood pressure-83/52 and heart rate-94. The Medical Director stated it was important to draw labs as ordered. On 10/15/2021 at 12:58 P.M., the Director of Nursing was interviewed after reviewing the medical record. The Director of Nursing stated she found documentation of a Nursing note with a code that indicated the physician and responsible party had been notified about something on 8/28/2021. The Director of Nursing stated she could not determine what information they had been notified of since it was not documented clearly in the note. The Director of Nursing was asked for the name of the On call doctor. The Director of Nursing stated she would submit the name and contact number. The Director of Nursing stated the note should have described what was discussed when the on call doctor and family were notified. Review of the Nurses Note described by the Director of Nursing revealed documentation on 8/28/2021 at 3:02 P.M. that read: Nursing Note-Note Text: On-call MD made aware +emergency contact made aware. According to the documentation by the same nurse (LPN B) who documented about notifying the On Call Physician and Emergency Contact, the labs were not scheduled to be drawn until the 7 p-7 a shift on 8/28/2021. In Summary, the nursing staff failed to draw the blood for labwork as ordered by the provider on 8/28/2021. The resident had a low hemoglobin and Hematocrit upon initial admission to the facility on [DATE] as well as a history that included Gastrointestinal Bleeding. The nurse practitioner ordered labwork to be drawn on 8/28/2021. The labs were never drawn, the resident became symptomatic and had critical lab values when evaluated in theER on [DATE]. Resident # 128 was scheduled to be discharged to home on 9/18/2021 but was admitted to the hospital the day before due the changes in condition. During the end of day debriefing on 10/15/2021, the Facility Administrator, Director of Nursing and Regional Consultant were informed of the findings. No further information was provided. COMPLAINT DEFICIENCY

Based on observation, interview, clinical record review and facility documentation the facility staff failed to provide care that meets professional standards of quality for 1 Resident (#178) in a survey sample of 41 Residents. The findings include: 1a. For Resident #178 the facility staff failed to administer medications as ordered by physician and failed to use saline flush to keep picc line patent. A review of the clinical record revealed that Resident #178 was admitted to the facility on [DATE] at 8 PM, after having been hospitalized and had surgery for [MEDICAL RECORD OR PHYSICIAN ORDER] . Among Resident # 178's discharge summary were orders for the following medications: [MEDICAL RECORD OR PHYSICIAN ORDER] [MEDICATION(S)] 300 mg one capsule every six hours (an antibiotic). -A review of the MAR (Medication Administration Record) revealed that Resident #178 did not receive 5 doses of this medication - A review of the progress notes revealed that nurses documented medication was unavailable. A review of the stat box contents revealed this medication was available in the stat box. [MEDICATION(S)] 600 mg 1 tablet three times a day for neuropathic pain-A review of the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the progress notes revealed the nurses documented medication unavailable awaiting from pharmacy. A review of the Stat Box contents revealed the medication was available in the stat box in a lower dose strength (300 mg) Oxycodone 10 mg tablet immediate release one tablet every six hours as needed for pain. This pain medication was not administered until 8/14/21 this medication also was available in the stat box. On the morning of 10/14/21 an interview was conducted with Employee H (the pharmacist) who stated that the staff could have taken the medications from the stat box as several of the medications were in the stat box. When asked if the Resident had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . She also stated The facility has the ability to reach out to us to get a prescription from our backup pharmacy. Guidance for nursing standards for the administration of medication is provided by Fundamentals of Nursing, 7th Edition, Mosby's/ Potter-Perry, p. 705: Professional standards, such as the American Nurses Association's Nursing Scope and Standards of Nursing Practice of (2004), apply to the activity of medication administration. To prevent medication errors, follow the six rights of medications. Many medication errors can be linked, in some way, to an inconsistency in adhering to the six rights of medication administration. The six rights of medication administration include the following: 1. The right medication 2. The right dose 3. The right client 4. The right route 5. The right time 6. The right documentation. 1b) The facility staff also failed to flush the picc line from admission on 8/12/21 until 8/15/21. The order for the flush read to flush before and after medication administration of IV antibiotics, however the IV antibiotics did not get to the facility until 8/15/21. They did not clarify the order with the MD to get an order for [MEDICAL RECORD OR PHYSICIAN ORDER] https://journals.lww.com/nursing/Citation/2007/ /What_you_need_to_know_about_PICCs,_part_2.14: [NAME] online read: To maintain catheter patency, flush the picc every 12 to 24 hours when it's not in use and before and after any infusions. Infusion Nurses Society standards recommend that the minimum flush volume be at least twice the volume capacity of the catheter and add-on devices. On 10/13/21 during the end of day conference the Administrator was made aware of the concerns and no further information was provided.

Based on interview, clinical record review and facility record review the facility staff failed to provide adequate services to maintain good personal hygiene for 4 Residents (#26, #32, # 65, and #76) in a survey sample of 41 Residents. The findings included: 1. For Resident #26 the facility staff failed to provide routine bathing necessary to maintain proper hygiene. On 10/12/21 at approximately 11:45 AM, Resident #26 was observed in his bed fully dressed asleep. A staff member was sitting in a chair with an over bed table in front of her at the entrance to the room. 10/13/21 at approximately 9:45 AM the Resident was observed sitting in the area in front of the nurse's station with a staff member CNA E sitting beside him. The Resident was dozing in his chair. On 10/13/21 at 3 PM an interview was conducted with CNA E who was asked how often Residents get showered and she stated they showered 2 times a week. When asked what they do if a Resident refuses she stated that they document it on POC (Point of Care computerized charting for CNA's) and they notify the charge nurse. On 10/13/21 during clinical record review it was discovered during the period of time from 9/22/21 until 10/13/21 Resident #26 received 1 shower and 2 bed baths. On 9/22/21 he received a shower and on 10/6/21 and 10/7/21 he received a bed bath. There were no refusals documented on POC for Resident #26. The review showed that Resident #26 has a BIMS (Brief Interview of Mental Status) score of 4 indicating severe cognitive impairment and he is unable to bathe without assistance. The facility provided their policy on ADL care excerpts are as follows: Policy - AM Care Morning care will be offered each day to promote resident comfort, cleanliness, grooming, and general wellbeing. Residents who are capable of performing their own personal care are encouraged to do so but will be provided with setup assistance if needed. Showers and baths are scheduled three times weekly or more or less often according resident preference. Policy: PM Care Nursing staff will offer evening/PM care to residents to promote personal hygiene, comfort, relaxation and safety. Residents who are capable of performing their own care are encouraged to do so, with assistance as needed. PM care may be performed at the bedside or in the bathroom, according to resident preference. On 10/14/21 during the end of day meeting the Administrator was made aware of the concerns and no further information was provided. 2. For Resident # 32 the facility staff failed to provide routine and necessary incontinent care for dependent residents. A record review show that Resident #32 most recent MDS (Minimum Data Set) dated 8/17/21 coded the Resident as unable to stand and bear weight and 4. total dependence on staff for all aspects of ADL care. On 10/12/21 at approximately 11:55 AM Resident #32 was observed sitting in his room in his wheelchair watching TV. An interview was conducted at that time, and Resident #32 stated that night shift does not do rounds and check if he needed to be changed. Resident #32 is unable to walk and is incontinent of bowel and bladder. The Resident stated that they (the Residents) have all complained about it in Resident council. Resident #32 stated that the facility is well aware of the situation and that the Resident has filed a grievance about the staff not answering call bells in a timely manner. Documentation of facility follow up: CNA's were educated on answering the call lights in a timely manner. [Signed by RN Supervisor on 6/29/21] Review of Resident Council minutes revealed that in July, Aug and Sept the Residents complained staff during the night do not check on Residents, or provide care they are sleeping in their cars. On 10/13/21 the Administrator was asked about the concern form from Resident #32 and she stated that they have a lot of agency staff primarily working the evening and night shift (7 pm - 7 am). She stated that they have had complaints about the staff not making rounds and answering call lights, however they have been educated on the importance of answering lights in a timely manner. On 10/14/21 during the end of day meeting the Administrator was made aware of the concerns and no further information was provided. 3. For Resident #65 the facility staff failed to provide routine bathing necessary to maintain proper hygiene. A record review showed that Resident #65 had a BIMS (Brief Interview of Mental Status) score of 5 indicating severe cognitive impairment and was not able to bathe without assistance. On 10/12/21 at approximately 11:20 AM Resident #65 was observed laying in his bed dressed in a hospital gown and brief, asleep. On 10/12/21 at approximately 2:30 PM Resident #65 was observed in his bed wearing a hospital gown watching TV. An attempt to interview the Resident was made but due to his cognitive status he was unable to follow or answer appropriately. On 10/13/21 at 3:00 PM an interview was conducted with CNA E who was asked how often Residents get showered and she stated they showered 2 times a week. When asked what they do if a Resident refuses she stated that they document it on POC (Point of Care computerized charting for CNA's) and they notify the charge nurse. On 10/13/21 during clinical record review it was discovered that Resident #65 had the following bed baths (no showers) during the period of time between 9/17/21 and 10/13/21: 9/17/21 at 3:37 AM 9/18/21 at 3:42 AM 9/28/21 at 12:24 PM 10/1/21 at 3:14 PM 10/11/21 at 2:52 PM 10/12/21 at 12:37 PM There were no refusals of showers documented on POC for Resident #65. On 10/14/21 during the end of day meeting the Administrator was made aware of the concerns and no further information was provided. 4. For Resident #76 the facility staff failed to provide routine bathing and hair washing necessary to maintain proper hygiene. A record review showed that Resident #7 was unable to stand and bear weight and her most recent MDS 9/27/21 coded the Resident as 3. requiring extensive assistance with ADL care. On 10/12/21 at approximately 11:30 AM Resident #76 was observed in her room in her bed with head of bed elevated, watching TV dressed in a hospital gown the Resident had food stains on her gown and hair was uncombed and appeared oily. An interview was conducted with Resident #76 at that time. When asked about showering the Resident stated Honey I have not been out of this bed in 2 whole years. When asked how she bathes she stated the CNA's sponge bathe her and when asked about washing her hair she stated that the CNA's use dry shampoo spray, and they use the spray leave in conditioner. A review of the POC documentation revealed that Resident #76 had 1 Refusal of a bath on 9/20/21. She received the following bed baths (no showers) for the period of 9/13/21 through 10/13/21: 9/22/21 at 6:59 PM 10/6/21 at 6:14 PM 10/7/21 at 3:33 PM On 10/13/21 at 3 PM an interview was conducted with CNA E who was asked how often Residents get showered and she stated they showered 2 times a week. When asked what they do if a Resident refuses she stated that they document it on POC (Point of Care computerized charting for CNA's) and they notify the charge nurse. The facility provided their policy on ADL care excerpts are as follows: Policy - AM Care Morning care will be offered each day to promote resident comfort, cleanliness, grooming, and general wellbeing. Residents who are capable of performing their own personal care are encouraged to do so but will be provided with setup assistance if needed. Showers and baths are scheduled three times weekly or more or less often according resident preference. Policy: PM Care Nursing staff will offer evening/PM care to residents to promote personal hygiene, comfort, relaxation and safety. Residents who are capable of performing their own care are encouraged to do so, with assistance as needed. PM care may be performed at the bedside or in the bathroom, according to resident preference. On 10/14/21 during the end of day meeting the Administrator was made aware of the concerns and no further information was provided.

Based on observations, staff interviews, and facility documentation review, the facility staff failed to store and serve food in accordance with professional standards. Specifically, the gas range top was unclean and contained pasta and rice from previous days according to the menu; there were prepared food items in the walk-in refrigerator which were not dated; and there was milk on the tray line which had a temperature of 54.3 degrees Fahrenheit. The findings included: On 10/12/2021 at approximately 11:15 A.M., this surveyor and the dietary manager made the following observations in the walk-in refrigerator: 1) Three square slices of what appeared to be cake were covered with plastic wrap, unlabeled and undated. The dietary manager stated the cake should be labeled and dated and removed them from the refrigerator. 2) Four cups of pudding (labeled P) were undated. The dietary manager stated the pudding should be dated and removed them from the refrigerator. 3) Ten package of tortilla wraps (approximately 15 tortillas per wrap) had hand written dates of 06/22. There was no year and there was no manufacture's date on the packaging. The dietary manager stated the year and manufacturer's date were unknown and removed the tortilla packages from the refrigerator. On 10/12/2021 at approximately 11:30 A.M., this surveyor and the dietary manager observed several uncooked spaghetti pieces on the gas range top including in the left front burner ring. There were also several white rice kernels observed including some burned kernels stuck to the gas range top. The dietary manager provided a copy of the menu for October 2021. Per the menu, the dietary manager confirmed spaghetti was last served on 10/09/2021 (3 days prior to the observation) and rice the previous day (10/11/2021). When asked about expectations for cleaning the cooktop, the dietary manager stated it should be cleaned daily. On 10/12/2021 at 12:55 P.M., the administrator was notified of findings. On 10/13/2021 at approximately 4:55 P.M., this surveyor observed the dietary manager check the temperature of the milk that was on the tray line to be served. The two milk cartons were on the table and not in the ice bind. The temperatures of the milk in each of the containers were 54.3 degrees Fahrenheit and 53 degrees Fahrenheit. The dietary manager stated the milk was too warm and could not be served at that temperature and removed them. The dietary manager stated she would also educate the staff to keep the milk in the ice bin on the tray line prior to serving. This surveyor and the dietary manager then observed the food temperature log for this tray line. The temperature for milk was not measured. Dietary staff member, Employee M, verified it was her job to record the food temperatures. When asked why the temperatures for the milk were not checked, Employee M stated she did not know milk was on the tray line. On 10/12/2021, the facility staff provided a copy of their policy entitled, Food Temperature Policy. In Section 2 under the sub-header entitled, Cold Foods it was documented, The temperature of potentially hazardous cold foods must be served at a temperature of 41 degrees Fahrenheit or below. On 10/12/2021, the facility staff provided a copy of their policy entitled, Storage of Refrigerated Foods. An excerpt in Section 14 documented, Refrigerated items must have a label showing the name of the food and the date it should be consumed, or discarded. The facility staff also provided a copy of a spreadsheet of food storage expectations. The document indicated that refrigerated pudding was good for 2 days and refrigerated cake was good for 7 days. On 10/14/2021, the administrator was notified of findings and stated they had no further information or documentation to submit.

Based on Resident interview, staff interview, facility documentation review, clinical record review and in the course of a complaint investigation, the facility staff failed to respond to Resident Council grievances for 7 of 41 sampled residents. The findings included: On the afternoon of 10/12/21, Surveyor F met with Resident #42, the Resident Council President and obtained permission for the survey team to review Resident Council Minutes. On 10/13/21, Resident Council minutes were reviewed from April 2021-Sept. 2021. The minutes revealed ongoing concerns and complaints regarding: ice not being passed, call bells not working, medications being administered late and not being administered as ordered, staff being rude, and lack of care during the night shift. These concerns persisted over the course of 6 months. On 10/13/21, Surveyor F met with the Resident Council. Seven Residents were in attendance (Resident #13, #15, #32, #42, #53, #67, and #68). The Residents verbalized that the same issues and complaints remain with no resolution. On 10/13/21, the facility staff provided the survey team with grievances that were brought forth from the Resident Council which listed each of these concerns. There was evidence of some staff training, but no evidence that all nursing staff were educated on the concerns to facility resolution of the concerns. On 10/13/21, the facility Administrator was made aware of the concern that Resident Council expresses the same concerns for months with no resolution being indicated. The Administrator stated, I held a special Resident Council with the Residents myself in July, for this very reason. The notes of the council meeting held on 7/28/21, with the facility Administrator revealed that the Residents asked that the Administrator and DON (director of nursing) to attend the next scheduled meeting in August. Review of the meeting minutes from the Resident Council meeting held 8/11/21, revealed that the DON did not attend the meeting as requested by the Resident Council group. On 10/14/21, during an end of day meeting the facility Administrator and DON were made aware of the findings. No additional information was received. Complaint Related Deficiency.

Based on observation, interview, facility documentation and clinical record review the facility staff failed to ensure the Resident was able to self administer medications for 1 Resident (#76) in a survey sample of 41 Residents. The findings included: For Resident #76 facility staff left prescription [MEDICATION(S)] at bedside for two days. On 10/12/21 at approximately 11:30 AM Resident # 76 was observed in bed with head of bed elevated watching TV. On her bedside table were her personal belongings along with a bottle of [MEDICATION(S)] (a prescription cortisone nasal spray). An interview was conducted with Resident # 76 who stated that the nurse from yesterday left it in here so that I could use it when I was ready. When asked if she used it yesterday she stated she was not sure, but when asked if she used it today she stated no not yet. On 10/12/21 at approximately 11:40 AM an interview was conducted with RN C who was asked if Resident #76 can self-administer medications, she stated that the Resident does not have an order to self-administer. When asked if she had been in the room of Resident #76 she stated that she had not given that Resident her medications yet. RN C was asked to step into the room from the hallway so that she could visualize the bedside table. When asked if that medication should be left at the bedside she stated no. RN C was asked what are the risks of leaving a medication at the bedside of someone who has not been screened for self-administration, and she stated there is a risk that they might not take their meds or that they may forget they took them and take more than the prescribed dosage, On the afternoon of 10/12/21 a review of the clinical record was conducted and the Resident did not have orders to self-administer medications, she did not have it care planned nor was an assessment completed. On 10/13/21 at 10:00 AM an interview was conducted with the DON who was asked if Resident #76 was able to self-administer medications and she stated that she was not. When asked what the expectation is for nurses with regards to leaving medications at the bedside, and she stated that medications are not left at the bedside unless the Resident was screened for self-administration and has a doctors order to do so. On 10/14/21 during the end of day meeting the Administrator was made aware of the concerns and no further information was provided.

Based on interview, clinical record review and facility documentation review the facility staff failed to review and revise the care plans for 1 Residents (#26) in a survey sample of 41 Residents. The findings included: For Resident #26 the facility staff failed to review and revise the care plan to include changes in behavior and the need for 1:1 monitoring. On 10/12/21 at approximately 11:45 AM, Resident #26 was observed in his bed fully dressed asleep. A staff member was sitting in a chair with an over bed table in front of her at the entrance to the room. The staff member identified herself as CNA E and was interviewed at that time. CNA E stated that Resident #26 was placed on 1:1 because of behaviors he had exhibited the previous evening. She stated that he has been hitting staff. When asked has he ever hit other Residents she stated that he did and has been placed on 1:1 in the past for that behavior. On 10/12/21 at 12:20 PM an interview was conducted with the RN Supervisor who stated that Resident #26 has a BIMS (Brief Interview of Mental Status) score of 4 indicating severe cognitive impairment and has been having some behavioral issues that are believed to be the progression of his dementia. She stated the facility has the Resident on 1:1 for the safety of other Residents and staff. The RN Supervisor stated the Psychiatric Nurse Practitioner is looking into changing his medications. A review of the clinical record revealed that the facility did reach out to Psychiatric services and they are indeed looking into his medications and any changes that might benefit the Resident. The Resident was discharged from talk therapy as he is unable to effectively participate. On 10/13/21 at approximately 11:00 AM an interview was conducted with the social worker who stated that Resident #26's behaviors have been discussed with the RP and with the doctors, and the facility is keeping him on 1:1 for safety. When asked if this was discussed in the care plan meeting she stated that it was. On 10/13/21 a review of the clinical record revealed that Resident # 26's care plan had not been revised to include 1:1 monitoring for behaviors. On 10/13/21 at 1:00 PM an interview was conducted with the DON. The DON was asked what the purpose of revising the care plan and she stated the care plan is how the nurses know what care the Resident needs. When asked how often should the care plan be updated and she stated that the care plan should be updated quarterly and with any significant changes in condition or treatment. When asked if the 1:1 for behaviors should be listed on the care plan she stated that it should. On 10/14/21 the Administrator was made aware of the issues and no further information was provided.

Based on staff interview, clinical record review, facility documentation review, and in the course of a complaint investigation, the facility staff failed to initiate cardiopulmonary resuscitation for one resident (Resident #2) in a survey sample of 6 residents. This resulted in immediate jeopardy at level four isolated on [DATE]. The immediate jeopardy was removed on [DATE]. This is past non-compliance. The findings included: For Resident #2, the facility staff failed to initiate cardiopulmonary resuscitation or call emergency medical services after he was discovered unresponsive by a certified nursing assistant (CNA). Resident #2 expired at the facility on [DATE]. Resident #2, a [AGE] year old male, was admitted to the facility on [DATE] and expired at the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #2's Minimum Data Set with an Assessment Reference Date of [DATE] was coded as an admission assessment. The Brief Interview for Mental Status was coded as 3 out of possible 15 indicative of severe cognitive impairment. On [DATE], a review of the closed clinical record for a Resident #2 was conducted. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The order did not specify the code status preference. A nurse's notes written by Licensed Practical Nurse (LPN D ) dated [DATE] at 6:02 AM documented, Aide alerted this nurse during morning rounds that patient was not breathing. Upon entering room, no rise and fall of chest noted. No pulse and respiration. Director of Nursing (DON) made aware to declare [NAME] [time of death]. A nurse's note written by Registered Nurse A (RN A) dated [DATE] at 7:16 AM documented, Resident without apical pulse or respiration upon auscultation. Time of death 7:11 AM. Primary nurse aware. A focus on the care plan initiated on [DATE] documented Resident has advanced directives. Resident is full code. Interventions associated with this focus dated [DATE] documented the following: Document resident's advance directives. Involve Physician/NP [nurse practitioner] in advance directive conversations. An excerpt of a physician's progress note dated [DATE] documented, Code Status: Full Code. A facility-reported incident (FRI) investigation dated [DATE] under the header Timeline of Events documented, At approximately 5:45 AM the certified nursing assistant [CNA D] was on her rounds and identified the resident to be not breathing. She immediately summons the LPN [LPN D], who responded and confirmed no vital signs present. LPN proceeded to call the RN [RN A] at approximately 6 AM and request RN support for pronouncement of death. The RN arrived at approximately 7 AM confirmed the absence of vital signs at 7:11 AM and pronounce the resident's death. At approximately 4:45p, the ADON [assistant director of nursing], SW [social worker], and MDS [minimum data set] nurse were meeting when the ADON had a phone conversation with the resident's daughter, who was calling to confirm that the funeral home had obtained the resident's remains. While reviewing the chart, it was identified that a DNR [Do Not Resuscitate] order was not present with subsequent notification of management and the investigation was initiated. Included in the FRI documentation were interviews/written statements from staff. An interview with LPN D dated [DATE] at 1:,d+[DATE]:10 PM by the administrator and Employee E, the MDS coordinator, documented the following handwritten statement: [CNA D] doing rounds. Came out yelled I need you to come down. Not OK. I went to the room. He had expired. I called [RN A] on way down hall and told her he expired. Did not check code status. I honestly didn't think about it, was in hurry. [RN A] gave no directions and ask no questions. Told her she would be in and hung up the phone. States she attempted to call physician name on his phone it rang and cut off. She passed it on to day nurse to try again. Was educated, never had to do here before. An interview with CNA D dated [DATE] by the administrator documented the following excerpt of a statement by CNA D documented, 2:,d+[DATE]ish still breathing started last round at about 5:30 AM got to his room [approximately] 5:45a to 6A. She [CNA D] went in did not think he was breathing. She went in hall and yelled for LPN she came back down. [LPN D] said still warm probably passed between ,d+[DATE]. [LPN D] said she knew he was going. No discussion code status etc. [LPN D] said daughter wanted him sent out two days ago. I usually don't yell but I didn't know his status. An undated hand written statement signed by the administrator and RN A entitled. Interview of [name redacted] RN/DON documented Call at 6 AM [LPN D] she said [Resident #2] gone and no RN in building. Response I'll be there in an hour. Did not ask code status. Knew [Resident #2] not well had clot. Had spoken to Dr. about anticoagulant. If calling you must be DNR. She knew he was declining and no decision to send out. Arrived approximately 7A went to room. [Resident #2] Obviously gone [expired]. Attempted to hear pulse and breathing x 1 min. Documented death at 7:11 AM. Made [LPN D] aware and documented notes. On [DATE] at approximately 11:25 AM, an interview with Employee C, the social worker, was conducted. When asked about the admission process pertaining to code status, Employee C stated she will review advance directives and check physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . When asked about Resident #2's code status, Employee C stated that Resident #2 was a full code and the 'Full Measures' document was in the Code Status Book at the time. A copy of the document was requested and the facility staff provided the document with Resident #2's name and dated [DATE] entitled, Full Measures. Excerpts documented, Full measures means that, if the resident were to need emergency medical treatment, the Facility staff is to provide resuscitative, life-sustaining and/or life-support measures. This resident does not currently have a DNR order in effect and is to receive full measures. On [DATE] at approximately 11:50 AM, an interview with the administrator was conducted. When asked about what the facility did after the incident, the administrator stated that the employment of LPN D and RN A (the previous DON) was terminated for failing to initiate CPR. The administrator also stated they conducted a root-cause analysis, looked at the process about code status, re-educated staff on the code status process and performed mock drills. The administrator also stated that staff were re-educated on the location of the code status book on each unit. On [DATE], the administrator provided a copy of their Quality Assurance Performance Improvement (QAPI) Action Plan and supporting documentation related to this incident. In-service sheets of staff receiving education on entering code status in [electronic health record software name], review process of notifying nurse and location of code status book, review of RN and LPN responsibility during code, CPR review, and checking code status were completed and signed by nursing staff on [DATE] and [DATE]. On [DATE], a 100% audit of current residents to ensure current code status and advanced directive status was completed. Human Resources staff audited all licensed nursing to ensure valid license and current CPR status. On [DATE], the administrator was notified that Immediate Jeopardy [DATE] through [DATE] was being called with past non-compliance. On [DATE] and [DATE], the survey team conducted staff interviews to verify CNA's and LPN's knew how to check for code status, initiate CPR if applicable, and call emergency medical services if applicable. The survey team observed the Code Status Book on each unit which contained documentation of each resident's code status preference. The survey team observed the availability of emergency supplies, equipment, and medications on the nursing units. The survey team reviewed clinical records of current residents in the sample to ensure code status was correctly identified. The survey team observed current CPR cards of nursing staff working at time of survey. The facility staff provided no further information.

Based on observation, staff interview, facility documentation review, clinical record review and in the course of a complaint investigation, the facility staff failed to provide a supervised and safe environment for six residents (Residents #62, 1, 34, 38, 29, and 37) resulting in harm for Resident #62, in a survey sample of 24 residents. 1. For Resident #62, the facility staff failed to provide supervision to prevent a choking hazard, from an improper diet, resulting in death. 2. For Resident #1, the facility staff failed to provide adequate supervision to prevent this Resident from assaulting Resident #34, and failed to provide fall prevention supervision, the correct diet, and feeding services. 3. For Resident # 34, the facility staff failed to provide adequate supervision to prevent an assault/hazard perpetrated by Resident #1. 4. For Resident # 38, the facility staff failed to provide adequate supervision to prevent accidents. 5. Resident #29 was not supervised resulting in resident to resident altercations. 6. Resident #37 was found outside of the facility. He was not wearing his wanderguard. Findings included: 1. Resident #62 was originally admitted to the facility on [DATE], and expired in the facility on [DATE]. [DIAGNOSES REDACTED]. The Resident was a Full Code status, meaning that CPR was requested to be performed as needed. Resident #62's most recent MDS (minimum data set) with an ARD (assessment reference date) of [DATE] was coded as a quarterly Assessment. The Resident was coded as having a BIMS score of 6 indicating moderate to severe cognitive impairment. The Resident was coded as having a poor appetite or overeating ,[DATE] days in the 7 day look back period. Resident #62 was coded as needing limited to extensive assistance of one staff person with activities of daily living, except for locomotion in a wheel chair which only required supervision, and eating, which coded the Resident as independent. Resident #62 was also coded as requiring a mechanically altered diet, always incontinent of bowel and bladder, and requiring a wanderguard elopement bracelet, for supervision, secondary to poor judgement. Review of Resident #62's closed clinical record revealed the most recent Dietary Quarterly Assessment completed by the Registered Dietician (RD), dated [DATE], describing the Current Diet order as Regular, ground texture no hot dogs - choking hazard. This order was never amended or discontinued. Occupational Therapy (OT) notes were reviewed, and revealed an evaluation and planning for therapy dated [DATE]. The document revealed under Functional assessment, self feeding = Did not test (Pt at baseline). on page 3 of the 4 page document. On page 4, the document goes on to say under Self Care, Eating independent, oral hygiene Partial/Moderate assistance. It is unknown how independence in eating was assumed as no actual testing was completed, and oral hygiene required moderate assistance. Speech Therapist (ST) notes were reviewed, and revealed the most recent evaluation and treatment for [REDACTED]. The documents reveal that patient (pt) was observed and noted in chart that patient coughs on some consistencies, including hot dogs. Pt often requires cues to increase accuracy. No choking in this visit, however, patient chart indicated history of choking. Patient frequently requires verbal cues to decrease risk of aspiration, penetration.(choking). A second ST evaluation note revealed, Patient visited while consuming regular ground meat trial. Patient demonstrated increased rate (of eating) and decreased mastication (chewing) while consuming meal. Patient somewhat stimulable to verbal cues (by staff) to reduce rate. Patient requires verbal cues by staff on a regular basis to decrease risk of aspiration/penetration (inhaling food and choking). With cues (from staff) patient is able to reduce rate, and intake amount (smaller bites) as well as demonstrate increased mastication. Patient demonstrated increased difficulty with regular bread at times due to increased rate and bite size. Patient currently on mechanical soft diet, however, has been receiving what is consistent with a regular/ground diet. ST recommend upgrade patient to regular/ground due to patient is able to tolerate at this time. At the time of discharge from ST, all goals were not met and a final discharge document was produced dated [DATE] end of care. The document read; Due to periodic impulsive behavior, it is recommended patient continue to receive cues via staff during unsafe times with provisional supervision. Patient periodically demonstrates impulsivity during PO (eating) that he favors (deserts, sandwiches, or when he is hungry) patient requires cues to practice safe swallowing and reduce rate and masticate and swallow all bolus (mouthful) prior to additional bites. Regular/ground diet, at times patient demonstrates increased rate and decreased mastication when consuming by mouth. Impulsive behaviors at times. Patient demonstrates large bite sizes, increased rate and decreased mastication of bolus. Physician orders [REDACTED]. Certified Nursing Aide (CNA) Resident Care Card care plan instructed staff to always set up and supervise this Resident's meal at lunch and dinner. It is unknown why breakfast was not included. A copy of the current Nursing Care Plan, last revised on [DATE], was reviewed and revealed the following interventions; Impaired safety awareness, the resident is independent with eating, the Resident requires supervision and cueing at times to eat (resolved [DATE]), meals in room or dining room, no hot dogs, serve diet as ordered. The care plan did not specify what the Resident's diet order is, nor did it specify supervision while eating as the doctor's order mandates, and actually rescinds the doctor's supervision order. The facility Care Plan policy was reviewed and revealed the following; Policy: An interdisciplinary plan of care will be established for every resident and updated in accordance with state and federal regulatory requirements and on an as needed basis. A). The facility must develop a comprehensive care plan for each resident that includes measurable objectives and timetables to meet the resident's medical, nursing and mental, and psychosocial needs that are identified in the comprehensive assessments. D). All staff must be familiar with each resident's care plan and all approaches must be implemented. F). The comprehensive care plan is reviewed and updated at least every 90 days by the interdisciplinary team. U). There may be additional problem areas not triggered by the MDS, which will need to be addressed in the care plan. Z). All direct care staff must always know, understand and follow their resident's care plan. If unable to implement any part of the plan, notify your charge nurse or MDS coordinator, so that this can be documented or the care plan changed if necessary. The following nursing note dated [DATE] indicated; Set up help only with eating. Another note dated [DATE] indicated; Set up help only with eating. The same note is documented on [DATE]. On [DATE] a quarterly dietary assessment is documented in the progress notes which stated Current diet order Regular, ground texture - no hot dogs, choking hazard, continues with same diet order. A [DATE] nursing note indicated; Set up help only with eating. A [DATE] nursing note indicated; No set up or physical help from staff with eating. The physician's orders [REDACTED]. On [DATE] at 3:06 p.m. the nursing notes describe the Resident as sitting up in wheel chair in room, denying pain or hurting in the last 5 days On [DATE] at 6:45 p.m. the nursing notes describe the following; 2 nurses were called to Resident #62's room by a CNA who was performing the [MEDICATION NAME] Maneuver unsuccessfully. The Resident was noted to have large amounts of chewed food in the mouth. A nurse then began the [MEDICATION NAME] Maneuver unsuccessfully, and the second nurse then tried to perform the maneuver, and was unsuccessful. The Resident was without respirations or pulse. The Resident was then placed on the floor and the visible food was removed from the Resident's mouth. The nurses were unable to suction the Resident due to large amounts of chewed food in the mouth. Emergency 911 was called, abdominal thrusts were attempted, and CPR (Cardio [MEDICAL CONDITION] Resuscitation) was begun. An Ambu bag with oxygen was used to ventilate the Resident but had no effect as there was no air flow into the Resident's airway. The primary Care Physician was in the building, and arrived in the room and pronounced the Resident deceased at 6:20 p.m. On [DATE] at 11:00 a.m. LPN D was interviewed and asked what she knew about the situation. She stated she was the charge nurse who responded to the Resident that night. She stated when CNA B called her she had been serving meal trays and feeding other residents on the unit, and she ran to the room and found CNA B applying the [MEDICATION NAME] maneuver and she took over for her. She stated a second nurse came and attempted the same maneuver with no success. LPN D stated that there was a third nurse on duty that evening, however, she was busy orienting a new nurse and was not involved. She stated that she and the second nurse laid the Resident on the floor, as he was found sitting in his wheel chair, and continued to sweep the food from his mouth, but it was lodged deeply in his throat and could not be removed. She went on to say they tried to use CPR, and the oxygen and ambu bag to ventilate the Resident, but too much food was in his throat and blocked the airway. She stated the doctor was in the facility doing rounds, and responded to their call, and he pronounced the Resident expired. She was asked who the CNA was, and she responded with a name (CNA B) and was asked to call the CNA so that she could be interviewed as well. On [DATE] at 11:15 a.m. CNA B was contacted via telephone and interviewed. CNA B stated she had delivered the tray from the kitchen to Resident #62's room and set it down and left it looked like a whole sandwich and then I went back to the dining room to feed other residents. She stated she was already busy feeding and orienting a new CNA, and she was not responsible to supervise him. She stated we were already short staffed and with only 3 CNA's that is 20 residents each to care for and we had 2 new CNA's we were training as well. I couldn't stay with him. She further stated I was just doing them a favor, because they refused his dinner tray, and a new one had to be sent down to the unit. Since I was in the dining room already I just took it. She went on to say when she was finished in the dining room around 6:00 she went down to the unit and started collecting trays from the rooms, and found Resident #62 slumped over in his chair, with lots of food in his mouth and one large piece (the size of a quarter) of uneaten chicken patty in front of him. She called for help and started the [MEDICATION NAME] maneuver. The Primary Care Physician's discharge summary documented Resident #62's cause of death as choking. Staffing records were reviewed and revealed That indeed there were 3 CNA's on duty that evening and 2 new CNA orientees, and 1 new LPN orientee. The Dining Services Manager (DSM) was interviewed on [DATE] at 11:30 a.m., and a Menu for [DATE], and a tray card were requested for Resident #62. She stated that she would print it from the computer program. The documents were reviewed and revealed that the Resident was on a Regular/ground diet for all three meals. The documents also reflect that changes were made to the computerized documents on [DATE], one day after the Resident died and was discharged , altering the record. The document changes were made by a Registered Dietician (RD) with computer access known as HL7 interface (employee C). The DSM stated that this particular RD came in sometimes and updated resident records. Those old standing orders from the DSM documented on [DATE], and the new changes made by the RD on [DATE] after the Resident expired are below. DSM [DATE] - Lunch main dining room, dinner main dining room, no hot dogs choking hazard, dislikes raw carrots - but likes cooked carrots. ice tea, allergic: Almonds, shell fish. RD [DATE] - Lunch eats in room, dinner eats in room, no hot dogs choking hazard, No raw carrots or cooked carrots. ice tea, allergic: Almonds, carrot, shell fish. According to facility staff, after discharge, the computer system defaults to eats in room. The DSM was further interviewed and stated she was not present the evening of [DATE], however the cook who served the meal (Employee D) had reported to her the circumstances of the incident. Employee D was not in the building on [DATE]. The DSM stated that the meal for dinner the evening of [DATE] was an omelet, and the nursing staff refused it saying eggs made the Resident have diarrhea, so a chicken patty sandwich was sent as the alternative, and it should have been ground and was not. The facility Administrator and Director of Nursing were made aware of the failure of the facility to protect Resident #62 from accidents and hazards at the end of day debrief on [DATE] at 4:30 p.m They did not offer any comment or documentation in regard to the incident at that time. On [DATE] the DSM was asked if she had any counseling or disciplinary forms for the cook (employee D) and she stated yes. She had 2, one from back in (MONTH) (YEAR) when she didn't use the right serving utensils to do special diets right, and this one for not doing (Mr. name) Resident #62's diet right. She supplied the most recent form which was dated [DATE] at 6:00 p.m. The Dining Services Manager had originally written it on [DATE], and Employee D's signature date was written over and changed. It appeared to be signed on either ,[DATE], ,[DATE], ,[DATE], ,[DATE], or [DATE]. She was asked why the Employee D signature date had been changed, and she stated she did not know, but the form was completed by her on [DATE], and signed by the employee on [DATE]. It is notable to mention, Employee D was observed in the kitchen on [DATE] at 4:30 p.m. preparing the dinner meal, and serving it. On [DATE] at 10:00 a.m., The Facility Administrator stated she had 3 Plans Of Correction (P[NAME]), for the incident, and requested a finding of Past Non-Compliance (PNC). The facility Administrator insisted that the multiple failures involved in the death of Resident #62 had been self identified and corrected prior to this survey with a correction completion date of [DATE], and she supplied them. She went on to say Employee D wrote in her statement that she had chopped the sandwich. The Admin then stated it should have been ground, he had issues, he ate really fast or not at all. Past non-compliance was not the case however, as another resident, Resident #1 had no CP for orders or diet and supervision with diet, and was not being tracked in Quality audits. This non-compliance can be found below in the second example of deficient practice for the 5 Residents contained in this citation. The non-compliance continued during survey. Quality audits to support the Plans of correction were given to surveyors and included a corrective action audit of supervision during meals audit form. The form listed the names of all residents included in the audit, with blank columns for each meal heading, which was for staff to sign if they supervised the resident listed during Breakfast, lunch, and dinner and each day's date. Resident #1 was not named on the document, and so was not being supervised, and was ordered by the physician on [DATE] to have a chopped meat diet add sauce and gravy to meats, which was also recommended by the RD on [DATE]. This order was never discontinued. The Resident was documented in nursing progress notes often, and up until 3 days before survey to require one staff member assistance with eating. This indicated not all residents who had special diets or required supervision and assistance were included in the audit, voiding the validity of the corrective action. The investigation review indicated the following; Resident #62 had a consistent history of choking, aspiration, poor judgement, and eating so quickly he was unsafe to eat without supervision. His diet order was regular ground texture with supervision. Speech therapy documented the Resident would require verbal cues by staff on a regular basis to decrease his risk of aspiration and choking, The ST also indicated the Resident had trouble with regular bread as Resident #62 would eat it more quickly than other foods and take larger bites. Overall the ST stated at discharge from services that the Resident was impulsive, took large bites very quickly, and did not chew his food well. The CNA care card was incomplete. The nursing care plan was incorrect, and incomplete, and did not follow the facility policy. Nursing staff did not provide supervision as was ordered. On [DATE] the Resident was found alone in his room expired from choking, according to the physician, nurses, and CNAs. Staffing was insufficient to care for residents, train new staff, and provide this Resident with supervision while eating, according to all staff accounts. The Dining Services Manager, the Administrator, the Charge nurse, the CNA that delivered the meal, and the cook who prepared the meal all stated that the meal was incorrect for the Resident, and the Resident was left alone in his room to consume it. The cook who was negligent in preparing the special diet meal for Resident #62 on [DATE], had been counseled for this issue previously in (MONTH) (YEAR), and was still preparing meals during survey. The Plan of correction audits did not include others found to be at risk while on survey, and the following documents related to the investigation were found and observed to be altered by facility staff during the survey: On [DATE] at 4:30 p.m., the incident was reviewed again with the Administrator, Corp RN, Regional Vice President, and Director Of Nursing at the end of day meeting. No further information was provided. COMPLAINT DEFICIENCY 2. For Resident #1, the facility staff failed to provide adequate supervision to prevent this Resident from assaulting Resident #34, and failed to provide fall prevention supervision, the correct diet, and feeding services. Resident #1 was initially admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Full Admission Minimum Data Set Assessment (MDS) with an ARD (assessment reference date) of [DATE] coded Resident #1 as having a BIMS (brief interview of mental status) of 2 out of a possible 15, or severely cognitively impaired. Resident #1 was coded as needing extensive assistance with ADL's (activities of daily living) such as bathing and dressing from 1 staff member, and for eating required supervision and set up help. The most recent MDS with an ARD of [DATE] was a significant change full assessment, and coded the resident as requiring extensive assistance from one staff member, and now required extensive assistance from 1 staff member for eating. Nursing progress notes were requested for three months and reviewed. The notes revealed that the Resident experienced 8 repeated falls in a 3 month period. They occurred on [DATE], [DATE], [DATE] twice, [DATE], and was hospitalized on [DATE] with a [MEDICAL CONDITION] from an unwitnessed fall, and was readmitted on [DATE]. The Resident had another fall on [DATE], and her final documented fall prior to survey, was on [DATE]. There was no consistent time for these falls as they occurred approximately at 2:00 a.m., 6:00 a.m., 7:00 p.m., 9:00 p.m., and 10:00 p.m. Day shift appears to be the only time not documented as having falls. This is the time when the Resident is up and more active, with more supervision and staff. Further review of the progress notes revealed the Resident to be documented as physically and verbally abusive toward others upon admission, and was documented as such in the admission MDS. Prior to assaulting her room mate (the room mate was identified as Resident #34 and placed in the survey sample) Resident #1 was documented in the nursing progress notes as combative, aggressive, verbally and physically abusive with staff and Residents. This behavior was documented 8 times in 3 months, and 3 times on [DATE], the day of the assault. After the assault she was moved to another room on [DATE], and continued the abusive behaviors on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE]. Supervision interventions for this Resident were not described. No further documentation indicated Resident aggressive behavior continued after the Resident experienced her last fall on [DATE], except for the [DATE] incident with staff providing care. The Resident was moved on [DATE] back directly across the hall from the room mate she assaulted on [DATE]. No indication why she was moved back in close proximity to her victim could be found. Physician orders [REDACTED]. The RD documented on [DATE] reflects the same. On [DATE] the same RD documents regular diet but does not specify consistency. The physician's orders [REDACTED]. Nursing staff documentation appears confused, and do not appear to know an agreed upon comprehensive plan of care. On [DATE] during initial tour and observation of the lunch meal, Resident #1 was observed in her room with a meal tray in front of her with a whole chicken patty on it. The meat was not chopped. The Resident was just looking at the food, however, not consuming it. The Resident was noted to be edentulous, and would not be able to chew the patty sufficiently to swallow it, causing a choking hazard. The Resident suffered from [MEDICAL CONDITION], oral phase Dysphagia (difficulty eating), [MEDICAL CONDITION], and was confused, putting the Resident at greater risk for aspiration. No staff were in the room to assist the Resident from 11:45 a.m., until tour and observations ended on this hall at 12:45. No 30 minute checks were conducted. The Resident had not been evaluated by Speech therapy ever during her 4 month stay. LPN D was interviewed on [DATE] and asked when 30 minute checks should be performed. She stated when the care plan says to, or when the Resident needs them. She was asked how they could tell if the Resident needed them, she stated that would be decided on an individual basis. She was asked under what circumstances 30 minute checks should be instituted, would be part of the care plan, and she responded absolutely. On [DATE] when exiting the building for lunch break Resident #1 was observed sitting in her wheel chair with the receptionist in the lobby at the front desk. The receptionist was trying to keep the Resident from removing her clothing and exposing herself to visitors who were present there. This continued for approximately 10 minutes while waiting for other surveyors to arrive. The Resident was striking out at the receptionist, and the receptionist kept repeating No, don't do that, you can't take your shirt off here, and the Resident was yelling I don't care who is here, cursing, and hitting the receptionist. The Receptionist did not try to remove the Resident and seemed not to know what to do, stating, I can't do this. We asked if the receptionist was a nurse or CNA, and she stated, no. Review of Resident #1's plan of care was conducted and revealed the interventions below for Falls with 30 min checks, Behaviors, and Diet: Falls - All of the documented falls for the Resident are not documented on the care plan. Interventions include; Dycem to wheel chair seat, assist with transfers, assist with mobility, bed in lowest position, room change closer to nursing station, mat on floor, mats on both sides of bed, body pillow on bed, 30 minute checks on resident (not specified who, when, or how to complete), non-skid footwear, place in supervised area during restlessness. 30 minute checks - were never ordered by a doctor, and were not added to the care plan until [DATE]. These checks were only documented in nursing progress notes as completed, on the following 13 days and times: [DATE] at 12:14 a.m., [DATE] at 12:45 a.m., [DATE] at 6:17 a.m., [DATE] at 6:30 p.m., [DATE] at 11:42 p.m., [DATE] at 11:19 p.m., [DATE] at 2:15 a.m., [DATE] at 12:06 p.m., [DATE] at 9:50 p.m., [DATE] at 4:43 a.m., [DATE] at 2:06 a.m., [DATE] at 1:12 a.m., and on [DATE] at 11:30 p.m. The 30 minute checks have no specific instructions in the clinical record as to why they will be conducted, when it is decided to conduct them, or who will be conducting them. Behaviors - Under Focus The Resident has depression related to admission, dementia, disease process (altered mental status. Interventions included; Administer medications, monitor for side effects and effectiveness, arrange for psyche consult, follow up as indicated, encourage and provide opportunities for exercise, physical activity, encourage movement program, monitor /document/report signs of depression to nurse/doctor, monitor/record/report to doctor as needed risk for harming others. The Resident was documented by staff at different times as being at risk of harming others during her entire stay. Another Focus for behavior included further interventions of room change, provide for positive interaction, attention, stop and talk, discourage from scratching self, encourage expression of feelings appropriately, explain all procedures before starting and allow Resident to adjust to changes, approach and speak in calm manner, intervene as necessary to protect the rights and safety of others, divert attention, remove from situation and take to alternate location as needed, praise improvement in behavior. The following was added to the care plan on [DATE] Referred to (facility area community services board) for psychiatry services on [DATE]. They are unable to add another patient to his caseload at this time. Will refer to telemed psychiatry when available at facility. No projection date is given for telemed psychiatry availability. On [DATE] (2 months later) another revision was made which stated; Left message for (name of group) psychiatry. It is unknown when the actual appointment was made, however, a revision was made to the care plan dated [DATE], and the Resident is now scheduled to see a psychiatrist doctor on [DATE]. The Psyche consult was not attempted to be arranged for 2 months, during which time the Resident was abusive to Residents and staff. On [DATE] weeks after the Resident had assaulted another resident a revision was documented an arranged appointment for [DATE]. The Resident continued to be abusive and aggressive for 3 months before this intervention was implemented. Diet - Interventions for: Encourage to dine in dining room as appropriate, monitor intake, weight, provide diet order, review preferences, and monitor need for increased nutritional intervention. were all applied to the care plan originally on [DATE] on admission. The interventions added after that were; Monitor for signs and symptoms of Aspiration, and Speech Therapy screens as needed, treat as ordered were added to the care plan on [DATE] after survey was in progress under a focus for At risk for Cardiac Respiratory status. This revealed staff recognition at this point of vulnerability of this Resident who was not included in the P[NAME] for issues associated with Resident #62. Resident #1's diet order and assistance needed from staff to eat, was never documented on the care plan, and so staff would not know what to provide. No supervision was specified in the care plan for any of these areas. Who will supervise, when to supervise, and how to supervise this Resident have not been included and are not person centered or measurable indicating staff is unaware of Resident need and how to meet it. No interim comprehensive care plan was developed For Resident #1's surgery for [REDACTED]. Fall mats and 30 minute checks were never ordered by a physician, and 30 minute checks do not appear on the Medication Administration Record [REDACTED]. Fall mats do appear on the (MONTH) and (MONTH) (YEAR) TAR as having been applied. Fall mats were placed on the care plan as an intervention on [DATE], but not documented as implemented until [DATE], a month later. The 30 minute checks were not added to the care plan until [DATE], and were documented as implemented infrequently in nursing progress notes only, from [DATE] for a month before being placed on the care plan on [DATE]. The Director of nursing was asked when 30 minute checks were to be completed, and she stated I will check. She never returned with an answer. In conclusion, the facility failed to maintain adequate supervision of Resident #1, and they further failed to supervise and protect Resident #1 from a fracture caused by frequent falls, and failed to protect Resident #1 from a potential choking hazard. On [DATE], and [DATE] at 4:30 p.m., the facility failure was reviewed with the Administrator, and Director Of Nursing at the end of day meeting. No further information was provided. 3. Resident #34 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Resident #34's most recent Minimum Data Set Assessment was a quarterly assessment with an assessment reference date of [DATE]. She was coded with severe cognitive impairment. She required total assistance with all activities of daily living (ADLs), and bed fast. Resident #34 was first observed on [DATE] during initial tour of the facility at approximately 11:45 a.m. in her room in a low bed. She did not respond to verbal stimulation. Resident #34 exhibited contractures of both hands, in which her fingers were closed inward toward the palm in a loose fist formation. This Resident was the victim of an assault by Resident #1. The incident of assault on this Resident by Resident #1 and the lack of safety provided for this Resident can be found described in this statement of deficiencies (SOD) report, at F-600 abuse. 4. For Resident # 38, the facility staff failed to provide adequate supervision to prevent accidents. Resident # 38 was an [AGE] year old female who was admitted to the facility on [DATE] an

Based on observation, staff interview, facility documentation review, clinical record review and in the course of a complaint investigation, the facility staff failed to provide a therapeutic diet for 2 residents (Residents #62, and #1) resulting in harm for Resident #62, in a survey sample of 24 residents. 1. For Resident #62, the facility staff failed to provide a ground regular diet resulting in death by choking. This is harm. 2. For Resident #1, the facility staff failed to provide the correct diet, and feeding services. Findings included: 1. Resident #62 was originally admitted to the facility on [DATE], and expired in the facility on [DATE]. [DIAGNOSES REDACTED]. The Resident was a Full Code status, meaning that CPR was requested to be performed as needed. Resident #62's most recent MDS (minimum data set) with an ARD (assessment reference date) of [DATE] was coded as a quarterly Assessment. The Resident was coded as having a BIMS score of 6 indicating moderate to severe cognitive impairment. The Resident was coded as having a poor appetite or overeating ,[DATE] days in the 7 day look back period. Resident #62 was coded as needing limited to extensive assistance of one staff person with activities of daily living, except for locomotion in a wheel chair which only required supervision, and eating, which coded the Resident as independent. Resident #62 was also coded as requiring a mechanically altered diet, always incontinent of bowel and bladder, and requiring a wanderguard elopement bracelet, for supervision, secondary to poor judgement. Review of Resident #62's closed clinical record revealed the most recent Dietary Quarterly Assessment completed by the Registered Dietician (RD), dated [DATE], describing the Current Diet order as Regular, ground texture no hot dogs - choking hazard. This order was never amended or discontinued. Occupational Therapy (OT) notes were reviewed, and revealed an evaluation and planning for therapy dated [DATE]. The document revealed under Functional assessment, self feeding = Did not test (Pt at baseline). on page 3 of the 4 page document. On page 4, the document goes on to say under Self Care, Eating independent, oral hygiene Partial/Moderate assistance. It is unknown how independence in eating was assumed as no actual testing was completed, and oral hygiene required moderate assistance. Speech Therapist (ST) notes were reviewed, and revealed the most recent evaluation and treatment for [REDACTED]. The documents reveal that patient (pt) was observed and noted in chart that patient coughs on some consistencies, including hot dogs. Pt often requires cues to increase accuracy. No choking in this visit, however, patient chart indicated history of choking. Patient frequently requires verbal cues to decrease risk of aspiration, penetration.(choking). A second ST evaluation note revealed, Patient visited while consuming regular ground meat trial. Patient demonstrated increased rate (of eating) and decreased mastication (chewing) while consuming meal. Patient somewhat stimulable to verbal cues (by staff) to reduce rate. Patient requires verbal cues by staff on a regular basis to decrease risk of aspiration/penetration (inhaling food and choking). With cues (from staff) patient is able to reduce rate, and intake amount (smaller bites) as well as demonstrate increased mastication. Patient demonstrated increased difficulty with regular bread at times due to increased rate and bite size. Patient currently on mechanical soft diet, however, has been receiving what is consistent with a regular/ground diet. ST recommend upgrade patient to regular/ground due to patient is able to tolerate at this time. At the time of discharge from ST, all goals were not met and a final discharge document was produced dated [DATE] end of care. The document read; Due to periodic impulsive behavior, it is recommended patient continue to receive cues via staff during unsafe times with provisional supervision. Patient periodically demonstrates impulsivity during PO (eating) that he favors (deserts, sandwiches, or when he is hungry) patient requires cues to practice safe swallowing and reduce rate and masticate and swallow all bolus (mouthful) prior to additional bites. Regular/ground diet, at times patient demonstrates increased rate and decreased mastication when consuming by mouth. Impulsive behaviors at times. Patient demonstrates large bite sizes, increased rate and decreased mastication of bolus. Physician orders [REDACTED]. Certified Nursing Aide (CNA) Resident Care Card care plan instructed staff to always set up and supervise this Resident's meal at lunch and dinner. It is unknown why breakfast is not included. A copy of the current Nursing Care Plan, last revised on [DATE], was reviewed and revealed the following interventions; Impaired safety awareness, the resident is independent with eating, the Resident requires supervision and cueing at times to eat (resolved [DATE]), meals in room or dining room, no hot dogs, serve diet as ordered. The care plan does not specify what the Resident's diet order is, nor does it specify supervision while eating as the doctor's order mandates, and actually rescinds the doctor's supervision order. The facility Care Plan policy was reviewed and revealed the following; Policy: An interdisciplinary plan of care will be established for every resident and updated in accordance with state and federal regulatory requirements and on an as needed basis. A). The facility must develop a comprehensive care plan for each resident that includes measurable objectives and timetables to meet the resident's medical, nursing and mental, and psychosocial needs that are identified in the comprehensive assessments. D). All staff must be familiar with each resident's care plan and all approaches must be implemented. F). The comprehensive care plan is reviewed and updated at least every 90 days by the interdisciplinary team. U). There may be additional problem areas not triggered by the MDS, which will need to be addressed in the care plan. Z). All direct care staff must always know, understand and follow their resident's care plan. If unable to implement any part of the plan, notify your charge nurse or MDS coordinator, so that this can be documented or the care plan changed if necessary. The following nursing note dated [DATE] indicated; Set up help only with eating. Another note dated [DATE] indicated; Set up help only with eating. The same note is documented on [DATE]. On [DATE] a quarterly dietary assessment is documented in the progress notes which stated Current diet order Regular, ground texture - no hot dogs, choking hazard, continues with same diet order. A [DATE] nursing note indicated; Set up help only with eating. A [DATE] nursing note indicated; No set up or physical help from staff with eating. The physician's orders [REDACTED]. On [DATE] at 3:06 p.m. the nursing notes describe the Resident as sitting up in wheel chair in room, denying pain or hurting in the last 5 days On [DATE] at 6:45 p.m. the nursing notes describe the following; 2 nurses were called to Resident #62's room by a CNA who was performing the [MEDICATION NAME] Maneuver unsuccessfully. The Resident was noted to have large amounts of chewed food in the mouth. A nurse then began the [MEDICATION NAME] Maneuver unsuccessfully, and the second nurse then tried to perform the maneuver, and was unsuccessful. The Resident was without respirations or pulse. The Resident was then placed on the floor and the visible food was removed from the Resident's mouth. The nurses were unable to suction the Resident due to large amounts of chewed food in the mouth. Emergency 911 was called, abdominal thrusts were attempted, and CPR (Cardio [MEDICAL CONDITION] Resuscitation) was begun. An Ambu bag with oxygen was used to ventilate the Resident but had no effect as there was no air flow into the Resident's airway. The primary Care Physician was in the building, and arrived in the room and pronounced the Resident deceased at 6:20 p.m. On [DATE] at 11:00 a.m. LPN D was interviewed and asked what she knew about the situation. She stated she was the charge nurse who responded to the Resident that night. She stated when CNA B called her she had been serving meal trays and feeding other residents on the unit, and she ran to the room and found CNA B applying the [MEDICATION NAME] maneuver and she took over for her. She stated a second nurse came and attempted the same maneuver with no success. LPN D stated that there was a third nurse on duty that evening, however, she was busy orienting a new nurse and was not involved. She stated that she and the second nurse laid the Resident on the floor, as he was found sitting in his wheel chair, and continued to sweep the food from his mouth, but it was lodged deeply in his throat and could not be removed. She went on to say they tried to use CPR, and the oxygen and ambu bag to ventilate the Resident, but too much food was in his throat and blocked the airway. She stated the doctor was in the facility doing rounds, and responded to their call, and he pronounced the Resident expired. She was asked who the CNA was, and she responded with a name (CNA B) and was asked to call the CNA so that she could be interviewed as well. On [DATE] at 11:15 a.m. CNA B was contacted via telephone and interviewed. CNA B stated she had delivered the tray from the kitchen to Resident #62's room and set it down and left it looked like a whole sandwich and then I went back to the dining room to feed other residents. She stated she was already busy feeding and orienting a new CNA, and she was not responsible to supervise him. She stated we were already short staffed and with only 3 CNA's that is 20 residents each to care for and we had 2 new CNA's we were training as well. I couldn't stay with him. She further stated I was just doing them a favor, because they refused his dinner tray, and a new one had to be sent down to the unit. Since I was in the dining room already I just took it. She went on to say when she was finished in the dining room around 6:00 she went down to the unit and started collecting trays from the rooms, and found Resident #62 slumped over in his chair, with lots of food in his mouth and one large piece (the size of a quarter) of uneaten chicken patty in front of him. She called for help and started the [MEDICATION NAME] maneuver. The Primary Care Physician's discharge summary documented Resident #62's cause of death as choking. Staffing records were reviewed and revealed That indeed there were 3 CNA's on duty that evening and 2 new CNA orientees, and 1 new LPN orientee. The Dining Services Manager (DSM) was interviewed on [DATE] at 11:30 a.m., and a Menu for [DATE], and a tray card were requested for Resident #62. She stated that she would print it from the computer program. The documents were reviewed and revealed that the Resident was on a Regular/ground diet for all three meals. The documents also reflect that changes were made to the computerized documents on [DATE], one day after the Resident died and was discharged , altering the record. The document changes were made by a Registered Dietician (RD) with computer access known as HL7 interface (employee C). The DSM stated that this particular RD came in sometimes and updated resident records. Those old standing orders from the DSM documented on [DATE], and the new changes made by the RD on [DATE] after the Resident expired are below. DSM [DATE] - Lunch main dining room, dinner main dining room, no hot dogs choking hazard, dislikes raw carrots - but likes cooked carrots. ice tea, allergic: Almonds, shell fish. RD [DATE] - Lunch eats in room, dinner eats in room, no hot dogs choking hazard, No raw carrots or cooked carrots. ice tea, allergic: Almonds, carrot, shell fish. According to facility staff, after discharge, the computer system defaults to eats in room. The DSM was further interviewed and stated she was not present the evening of [DATE], however the cook who served the meal (Employee D) had reported to her the circumstances of the incident. Employee D was not in the building on [DATE]. The DSM stated that the meal for dinner the evening of [DATE] was an omelet, and the nursing staff refused it saying eggs made the Resident have diarrhea, so a chicken patty sandwich was sent as the alternative, and it should have been ground and was not. The facility Administrator and Director of nursing were made aware of the failure of the facility to protect Resident #62 from accidents and hazards at the end of day debrief on [DATE] at 4:30 p.m They did not offer any comment or documentation in regard to the incident at that time. On [DATE] the DSM was asked if she had any counseling or disciplinary forms for the cook (employee D) and she stated yes. She had 2, one from back in (MONTH) (YEAR) when she didn't use the right serving utensils to do special diets right, and this one for not doing (Mr. name) Resident #62's diet right. She supplied the most recent form which was dated [DATE] at 6:00 p.m. The Dining Services Manager had originally written it on [DATE], and Employee D's signature date was written over and changed. It appeared to be signed on either ,[DATE], ,[DATE], ,[DATE], ,[DATE], or [DATE]. She was asked why the Employee D signature date had been changed, and she stated she did not know, but the form was completed by her on [DATE], and signed by the employee on [DATE]. It is notable to mention, Employee D was observed in the kitchen on [DATE] at 4:30 p.m. preparing the dinner meal, and serving it. On [DATE] at 10:00 a.m., The Facility Administrator stated she had 3 Plans Of Correction (P[NAME]), for the incident, and requested a finding of Past Non-Compliance (PNC). The facility Administrator insisted that the multiple failures involved in the death of Resident #62 had been self identified and corrected prior to this survey with a correction completion date of [DATE], and she supplied them. She went on to say Employee D wrote in her statement that she had chopped the sandwich. The Admin then stated it should have been ground, he had issues, he ate really fast or not at all. Past non-compliance was not the case however, as another resident, Resident #1 had no CP for orders or diet and supervision with diet, and was not being tracked in Quality audits. On [DATE] at 10:00 a.m., Staff counseling forms for this incident, and Quality Assurance and Process Improvement (QAPI) monthly meeting topics and sign in sheets only were requested from the Administrator. The first document received was from the Human Resources Director (HRD) at approximately 10:15 a.m. The form was the counseling form first seen in the DSM office and was found to have the date altered from [DATE] to [DATE] from the identical document received earlier from the DSM. The HRD was asked if she altered the document, and she stated that she did. She was asked why it was altered, and she said the date was wrong so she fixed it this morning. She was asked if she was involved in the counseling or had any part in completing the document, and she stated no. she was asked why she would alter a document she did not complete and had no knowledge of the events involved in the counseling. She did not answer. Quality audits to support the Plans of correction were given to surveyors and included a corrective action audit of supervision during meals audit form. The form listed the names of all residents included in the audit, with blank columns for each meal heading, which was for staff to sign if they supervised the resident listed during Breakfast, lunch, and dinner and each day's date. Resident #1 was not named on the document, and so was not being supervised, and was ordered by the physician on [DATE] to have a chopped meat diet add sauce and gravy to meats, which was also recommended by the RD on [DATE]. This order was never discontinued. The Resident was documented in nursing progress notes often, and up until 3 days before survey to require one staff member assistance with eating. This indicated not all residents who had special diets or required supervision and assistance were included in the audit, voiding the validity of the corrective action. The investigation review indicated the following; Resident #62 had a consistent history of choking, aspiration, poor judgement, and eating so quickly he was unsafe to eat without supervision. His diet order was regular ground texture with supervision. Speech therapy documented the Resident would require verbal cues by staff on a regular basis to decrease his risk of aspiration and choking, The ST also indicated the Resident had trouble with regular bread as Resident #62 would eat it more quickly than other foods and take larger bites. Overall the ST stated at discharge from services that the Resident was impulsive, took large bites very quickly, and did not chew his food well. The CNA care card was incomplete. The nursing care plan was incorrect, and incomplete, and did not follow the facility policy. Nursing staff did not provide supervision as was ordered. On [DATE] the Resident was found alone in his room expired from choking, according to the physician, nurses, and CNAs. Staffing was insufficient to care for residents, train new staff, and provide this Resident with supervision while eating, according to all staff accounts. The Dining Services Manager, the Administrator, the Charge nurse, the CNA that delivered the meal, and the cook who prepared the meal all stated that the meal was incorrect for the Resident, and the Resident was left alone in his room to consume it. The cook who was negligent in preparing the special diet meal for Resident #62 on [DATE], had been counseled for this issue previously in (MONTH) (YEAR), and was still preparing meals during survey. The Plan of correction audits did not include others found to be at risk while on survey, and the following documents related to the investigation were found and observed to be altered by facility staff during the survey: On [DATE] at 4:30 p.m., the incident was reviewed again with the Administrator, Corp RN, Regional Vice President, and Director Of Nursing at the end of day meeting. No further information was provided. COMPLAINT DEFICIENCY 2. For Resident #1, the facility staff failed to provide the correct diet. Resident #1 chicken was not chopped. The findings included; Resident #1 was initially admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Full Admission Minimum Data Set Assessment (MDS) with an ARD (assessment reference date) of [DATE] coded Resident #1 as having a BIMS (brief interview of mental status) of 2 out of a possible 15, or severely cognitively impaired. Resident #1 was coded as needing extensive assistance with ADL's (activities of daily living) such as bathing and dressing from 1 staff member, and for eating required supervision and set up help. The most recent MDS with an ARD of [DATE] was a significant change full assessment, and coded the resident as requiring extensive assistance from one staff member, and now required extensive assistance from 1 staff member for eating. Physician orders [REDACTED]. The RD documented on [DATE] reflects the same. On [DATE] the same RD documents regular diet but does not specify consistency. The physicians order was never discontinued. Nursing notes denote the Resident requires limited to total feeding, supervision or hands on assistance from 1 staff member to eat, in some notes, and states independent in others. On [DATE] during initial tour and observation of the lunch meal, Resident #1 was observed in her room with a meal tray in front of her with a whole chicken patty on it. The meat was not chopped. The Resident was just looking at the food, however, not consuming it. The Resident was noted to be edentulous, and would not be able to chew the patty sufficiently to swallow it, causing a choking hazard. The Resident suffered from [MEDICAL CONDITION], oral phase Dysphagia (difficulty eating), [MEDICAL CONDITION], and was confused, putting the Resident at greater risk for aspiration. No staff were in the room to assist the Resident from 11:45 a.m., until tour and observations ended on this hall at 12:45 p.m. The Resident had not been evaluated by Speech therapy ever during her entire 4 month stay. Review of Resident #1's plan of care was conducted and revealed the interventions below for Diet: Diet - Interventions for: Encourage to dine in dining room as appropriate, monitor intake, weight, provide diet order, review preferences, and monitor need for increased nutritional intervention. were all applied to the care plan originally on [DATE] on admission. The care plan interventions added after admission were; Monitor for signs and symptoms of Aspiration, and Speech Therapy screens as needed, treat as ordered were added to the care plan on [DATE] after survey was in progress under a focus for At risk for Cardiac Respiratory status. Resident #1's diet order and assistance needed from staff to eat, was never documented on the care plan, and so staff would not know what to provide. On [DATE], and [DATE] at 4:30 p.m., the facility failure was reviewed with the Administrator, and Director Of Nursing at the end of day meeting. No further information was provided.