Every finding on record at Eagle Lake Nursing and Rehab Care Center

Cross Reference F623 and F626 Based on interview and record review, the facility failed to document in the medical record the reasons why they could not meet the needs and readmit one (#1) of two residents reviewed for transfer and discharge rights. Findings included: Review of the Face Sheet revealed Resident #1 was originally admitted to the facility in June of 2023 with diagnoses to include multiple sclerosis (MS), dysphagia, autistic disorder, dysarthria, attention-deficit hyperactivity disorder (ADHD), irritability, bipolar disorder, anxiety, insomnia, and depression. The Face Sheet showed Resident #1 was discharged on [DATE] at 9:25 AM. Review of Resident #1's most recent Quarterly Minimum Data Set (MDS) assessment dated [DATE] showed a Brief Interview of Mental Status (BIMS) score of 10/15, indicating moderate cognitive impairment. Review of Resident #1's care plan for discharge with an original start date of 06/13/2023, and last reviewed/revised on 06/29/2024, revealed the resident's mother has chosen to have resident remain in this facility for long term care and has no plans for him to return to the community or other care setting at this time. Review of Psychiatry Provider Advanced Registered Nurse Practitioner (ARNP) note dated 08/14/2024 showed the following. Per staff, patient has been stable, is cooperative with care, does not have behavioral disturbances, anxiety nor agitation noted. Behavior has been stable; uneventful and medication compliance is good. No side effects are reported or evidenced .Will d/c [discontinue] PRN [as needed] Haldol and start Ativan 0.5 mg [milligram] BID [twice daily] for agitation and anxiety .Continue to monitor how patient tolerates changes and follow up in 1 week. Review of a nursing progress note on 08/17/2024 showed Resident #1 was being disruptive, attempting to exit the building, attempting to hit a staff member. Review of a nursing progress note on 08/19/2024 showed that an Emergency Discharge to the hospital was ordered. Review of a Certificate of Professional Initiating Involuntary Examination dated 08/19/2024 showed there was substantial likelihood that without care or treatment the individual will cause serious bodily harm to self or others. The patient presents with unstable mood, aggressive behaviors, combative with staff members, trying to attack and bite. These behaviors continue to worsen over the past several weeks. Psychopharmacological interventions have been ineffective. We are unable to stabilize the patient within the facility and he poses a danger to himself and others therefore he is requiring a higher level of care at this time. This document was signed by the Psychiatric Provider. Review of a nursing progress note dated 08/29/2024 showed the resident returned to the facility with several medication dosage changes and an additional medication order for a monthly injection was also added with the next dose due on 9/22/24. Review of a Certificate of Professional Initiating Involuntary Examination dated 09/01/2024 showed there was substantial likelihood that without care or treatment the individual will cause serious bodily harm to self. The supporting evidence showed the resident had opened a door of the facility after learning the security code, was making suicidal statements as he claimed his father passed away, was in clear danger to himself, and needed a higher level of care as the facility could not ensure his well-being at that time. This document was signed by the Psychiatric Provider. Review of the hospital's psychiatric initial consult note dated 9/2/24 revealed the patient presented from a long term care facility due to report of expressed suicidal ideation. Patient adamantly denying that he ever expressed suicide to anyone in the facility. He seems to be as well-documented baseline. He was discharged from another inpatient psychiatric unit less than 48 hours before being sent back to our emergency department. Patient has had chronic behavioral issues at the long term care facility and now they are refusing to take him back. Patient will not be held involuntarily. Further inpatient psychiatric hospitalization will not modify his chronic behavioral issues secondary to his developmental delay. An interview with the Social Services Director (SSD) was conducted on 09/18/2024 at 11:15 AM. The SSD stated Resident #1 did not have any discharge planning because he was a long term care resident and his plan was to remain at the facility. The SSD said Resident #1 did not have anywhere to go and his plans were never changed. An interview with the Nursing home Administrator (NHA) and Director of Nursing (DON) was conducted on 09/18/2024 at 12:41 PM. The NHA said, I got a call from the hospital after he had been there a couple days, they felt we should take him back. They felt that he had not been deemed incompetent. I tried to tell them he had said he wanted to die. My thoughts were that he needed a secured unit. They thought we should have put him on 1:1 supervision. I told them we could not take residents who are exit seeking. I told them I could not keep him safe. That was why we did not take him. The NHA stated Resident #1 was a long-term resident and his plan of care was to remain at the facility. She stated after the elopement incident she felt they could not keep him safe. The DON stated he had become aggressive and suicidal. She stated the documentation may not reflect what actually happened that evening. The NHA stated they should have documented better. A follow-up interview with the NHA and DON on 09/18/2024 at 2:45 PM confirmed Resident #1 did not have a discharge plan because they only do so if the resident was discharging home or to an ALF. The NHA said, He was [Emergency Discharge] because he had learnt the code [access code to open external doors], he left the building and waved at the camera, he knew what he was doing. The NHA stated the resident was not seen in person by the doctor who gave the order to send him to the hospital involuntarily. The physician was aware because we called her. I know there is nothing documented. We gave him the discharge notice. The NHA confirmed this was Resident #1's place of residence. He did not have plans to discharge anywhere else. The DON said, He had become aggressive. He wanted to kill himself. The DON stated we sent him to the hospital involuntarily to get him stabilized. The NHA stated there were other residents currently residing in the facility with a BIMS of 10 who could also learn the door code. The NHA stated they should have had the doctor assess Resident #1 in person to confirm he was not safe at this facility. The NHA and DON confirmed the resident's medical record did not clearly document the course of the events relating to Resident #1's transfer and rationale for not allowing the resident to return. Review of Resident #1's Nursing Home Transfer and Discharge Notice revealed the notice was given on 9/1/24 with an effective date of 10/1/24. The location to which the resident was transferred to was the name of the hospital, the hospital address, and the hospital phone number. The reason for the discharge or transfer was your needs cannot be met in this facility. The notice was signed and dated 9/1/24 by the DON as the NHA's designee. The DON documented that the resident's family member was notified by phone on 9/1/24. A phone interview was conducted with Resident #1's family member on 09/18/2024 at 3:28 PM. She stated she was notified by the facility when Resident #1 was taken to the hospital on 09/01/2024. She did not know Resident #1 was not allowed back to the facility until she was called by the hospital and told the facility refused to take Resident #1 back. Telephone interview was conducted with the hospital's Manager of Case Management (MCM) on 10/2/24 at 4:24 PM. The hospital's MCM stated Resident #1 was at the hospital in observation status from 9/1/24 to 9/6/24. She said orders for his discharge back to the nursing home where he had lived since June of 2023 were written by the physician on 9/2/24, but the nursing home refused to accept him back. The hospital MCM reported that it took four additional days to find him placement, and Resident #1 showed no behaviors during this timeframe. The hospital MCM stated it was not good for the patient, the facilty, or the hospital when a resident was not permitted to return, especially when the resident had lived at the facility for well over a year. Review of the undated facility Policy titled Transfer or Discharge, Facility-Initiated, revealed: If discharge is initiated by the facility after an emergency transfer to the hospital, the reason for discharge is based on the resident's status at the time the resident seeks return to the facility (not at the time the resident was transferred to acute care). If the facility determines that the resident cannot return to the facility, the medical record will indicate that the facility made efforts to: a. Determine if the resident still requires the services of the facility and is eligible for Medicare/Medicaid nursing services. b. Ascertain an accurate status of the resident's condition, which can be accomplished via communication between hospital and facility and/or through visits by facility staff to the hospital. c. Find out from the hospital the treatments, medications and services the facility would need to provide to meet the resident's needs upon returning to the facility. If the facility is unable to provide the treatments, medications and services needed the facility may not be able to meet the resident's needs. d. Work with the hospital to ensure the resident's condition and needs are within the facility's scope of care, based on its facility assessment, prior to hospital discharge.

Cross Reference F622 and F623 Based on interview and record review, the facility failed to permit readmission from the hospital for one (#1) of two residents reviewed for transfer and discharge rights. Findings included: Review of the undated facility Policy titled Transfer or Discharge, Facility-Initiated, revealed: When residents are sent emergently to an acute care setting, theses scenarios are considered facility-initiated transfers, NOT discharges, because the resident's return is generally expected. Residents who are sent emergently to an acute care setting such as a hospital, are permitted to return to the facility. If discharge is initiated by the facility after an emergency transfer to the hospital, the reason for discharge is based on the resident's status at the time the resident seeks return to the facility (not at the time the resident was transferred to acute care). If the facility determines that the resident cannot return to the facility, the medical record will indicate that the facility made efforts to: a. Determine if the resident still requires the services of the facility and is eligible for Medicare/Medicaid nursing services. b. Ascertain an accurate status of the resident's condition, which can be accomplished via communication between hospital and facility and/or through visits by facility staff to the hospital. c. Find out from the hospital the treatments, medications and services the facility would need to provide to meet the resident's needs upon returning to the facility. If the facility is unable to provide the treatments, medications and services needed the facility may not be able to meet the resident's needs. d. Work with the hospital to ensure the resident's condition and needs are within the facility's scope of care, based on its facility assessment, prior to hospital discharge. Review of the Face Sheet for Resident #1 revealed an original admitted in June of 2023. The Face Sheet showed Resident #1 was discharged from the facility on 9/9/24 at 9:25 AM. The diagnoses on the Face Sheet included multiple sclerosis (MS), dysphagia, autistic disorder, dysarthria, attention-deficit hyperactivity disorder (ADHD), irritability, bipolar disorder, anxiety, insomnia, and depression. Review of Resident #1's most recent Quarterly Minimum Data Set (MDS) assessment dated [DATE] showed a Brief Interview of Mental Status (BIMS) score of 10/15, indicating moderate cognitive impairment. Review of Resident #1's care plan for discharge with an original start date of 06/13/2023, and last reviewed/revised on 06/29/2024, revealed the resident's mother has chosen to have resident remain in this facility for long term care and has no plans for him to return to the community or other care setting at this time. Review of Psychiatry Provider Advanced Registered Nurse Practitioner (ARNP) note dated 08/14/2024 showed the following. Per staff, patient has been stable, is cooperative with care, does not have behavioral disturbances, anxiety nor agitation noted. Behavior has been stable; uneventful and medication compliance is good. No side effects are reported or evidenced .Will d/c [discontinue] PRN [as needed] Haldol and start Ativan 0.5 mg [milligram] BID [twice daily] for agitation and anxiety .Continue to monitor how patient tolerates changes and follow up in 1 week. Review of a nursing progress note on 08/17/2024 showed Resident #1 was being disruptive, attempting to exit the building, attempting to hit a staff member. Review of a nursing progress note on 08/19/2024 showed that an Emergency Discharge to the hospital was ordered. Review of a Certificate of Professional Initiating Involuntary Examination dated 08/19/2024 showed there was substantial likelihood that without care or treatment the individual will cause serious bodily harm to self or others. The patient presents with unstable mood, aggressive behaviors, combative with staff members, trying to attack and bite. These behaviors continue to worsen over the past several weeks. Psychopharmacological interventions have been ineffective. We are unable to stabilize the patient within the facility and he poses a danger to himself and others therefore he is requiring a higher level of care at this time. This document was signed by the Psychiatric Provider. Review of a nursing progress note dated 08/29/2024 showed the resident returned to the facility with several medication dosage changes and an additional medication order for a monthly injection was also added with the next dose due on 9/22/24. Review of a Certificate of Professional Initiating Involuntary Examination dated 09/01/2024 showed there was substantial likelihood that without care or treatment the individual will cause serious bodily harm to self. The supporting evidence showed the resident had opened a door of the facility after learning the security code, was making suicidal statements as he claimed his father passed away, was in clear danger to himself, and needed a higher level of care as the facility could not ensure his well-being at that time. This document was signed by the Psychiatric Provider. No progress notes, change in condition form, evaluations, or assessments were completed by staff from the facility relating to the 9/1/24 transfer to a higher level of care. Review of Resident #1's Nursing Home Transfer and Discharge Notice revealed the notice was given on 9/1/24 with an effective date of 10/1/24. The location to which the resident was transferred to was the name of the hospital, the hospital address, and the hospital phone number. The reason for the discharge or transfer was your needs cannot be met in this facility. The notice was signed and dated 9/1/24 by the DON as the NHA's designee. The DON documented that the resident's family member was notified by phone on 9/1/24. Review of the hospital's psychiatric initial consult note dated 9/2/24 revealed the patient presented from a long term care facility due to report of expressed suicidal ideation. Patient adamantly denying that he ever expressed suicide to anyone in the facility. He seems to be as well-documented baseline. He was discharged from another inpatient psychiatric unit less than 48 hours before being sent back to our emergency department. Patient has had chronic behavioral issues at the long term care facility and now they are refusing to take him back. Patient will not be held involuntarily. Further inpatient psychiatric hospitalization will not modify his chronic behavioral issues secondary to his developmental delay. A phone interview was conducted with Resident #1's family member on 09/18/2024 at 3:28 PM. She stated she was notified by the facility when Resident #1 was taken to the hospital on 09/01/2024. She did not know Resident #1 was not allowed back to the facility until she was called by the hospital and told the facility refused to take Resident #1 back. Telephone interview was conducted with the hospital's Manager of Case Management (MCM) on 10/2/24 at 4:24 PM. The hospital's MCM stated Resident #1 was at the hospital in observation status from 9/1/24 to 9/6/24. She said orders for his discharge back to the nursing home where he had lived since June of 2023 were written by the physician on 9/2/24, but the nursing home refused to accept him back. The hospital MCM reported that it took four additional days to find him placement, and Resident #1 showed no behaviors during this timeframe. The hospital MCM stated it was not good for the patient, the facilty, or the hospital when a resident was not permitted to return, especially when the resident had lived at the facility for well over a year. An interview with the facility's Social Services Director (SSD) was conducted on 09/18/2024 at 11:15 AM. The SSD stated Resident #1 did not have any discharge planning because he was a long term care resident and his plan was to remain at the facility. The SSD said Resident #1 did not have anywhere to go and his plans were never changed. An interview with the Nursing home Administrator (NHA) and Director of Nursing (DON) was conducted on 09/18/2024 at 12:41 PM. The NHA said, I got a call from the hospital after he had been there a couple days, they felt we should take him back. They felt that he had not been deemed incompetent. I tried to tell them he had said he wanted to die. My thoughts were that he needed a secured unit. They thought we should have put him on 1:1 supervision. I told them we could not take residents who are exit seeking. I told them I could not keep him safe. That was why we did not take him. The NHA stated Resident #1 was a long-term resident and his plan of care was to remain at the facility. She stated after the elopement incident she felt they could not keep him safe. The DON stated he had become aggressive and suicidal. She stated the documentation may not reflect what actually happened that evening. The NHA stated they should have documented better. A follow-up interview with the NHA and DON on 09/18/2024 at 2:45 PM confirmed Resident #1 did not have a discharge plan because they only do so if the resident was discharging home or to an ALF. The NHA said, He was [Emergency Discharge] because he had learnt the code [access code to open external doors], he left the building and waved at the camera, he knew what he was doing. The NHA stated the resident was not seen in person by the doctor who gave the order to send him to the hospital involuntarily. The physician was aware because we called her. I know there is nothing documented. We gave him the discharge notice. The NHA confirmed this was Resident #1's place of residence. He did not have plans to discharge anywhere else. The DON said, He had become aggressive. He wanted to kill himself. The DON stated we sent him to the hospital involuntarily to get him stabilized. The NHA stated there were other residents currently residing in the facility with a BIMS of 10 who could also learn the door code. The NHA stated they should have had the doctor assess Resident #1 in person to confirm he was not safe at this facility. The NHA and DON confirmed the resident's medical record did not clearly document the course of the events relating to Resident #1's transfer and rationale for not allowing the resident to return.

Cross Reference F622 and F626 Based on interview and record review, the facility failed to provide a written transfer and discharge notice to the resident representative, and a copy to the Office of the State Long-Term Care (LTC) Ombudsman for one (#1) of two residents reviewed for transfer and discharge rights. Findings included: Review of the Face Sheet revealed Resident #1 was originally admitted to the facility in June of 2023 with diagnoses to include multiple sclerosis (MS), dysphagia, autistic disorder, dysarthria, attention-deficit hyperactivity disorder (ADHD), irritability, bipolar disorder, anxiety, insomnia, and depression. Review of Resident #1's most recent Quarterly Minimum Data Set (MDS) assessment dated [DATE] showed a Brief Interview of Mental Status (BIMS) score of 10/15, indicating moderate cognitive impairment. Review of Resident #1's care plan for discharge with an original start date of 06/13/2023, and last reviewed/revised on 06/29/2024, revealed the resident's mother has chosen to have resident remain in this facility for long term care and has no plans for him to return to the community or other care setting at this time. Review of a Certificate of Professional Initiating Involuntary Examination dated 09/01/2024 showed there was substantial likelihood that without care or treatment the individual will cause serious bodily harm to self. The supporting evidence showed the resident had opened a door of the facility after learning the security code, was making suicidal statements as he claimed his father passed away, was in clear danger to himself, and needed a higher level of care as the facility could not ensure his well-being at that time. This document was signed by the Psychiatric Provider. Review of Resident #1's Nursing Home Transfer and Discharge Notice revealed the notice was given on 9/1/24 with an effective date of 10/1/24. The location to which the resident was transferred to was the name of the hospital, the hospital address, and the hospital phone number. The reason for the discharge or transfer was your needs cannot be met in this facility. The notice was signed and dated 9/1/24 by the DON as the NHA's designee. The DON documented that the resident's family member was notified by phone on 9/1/24. The area to complete to show that the notice as given to the resident, legal guardian or representative and the local long term care ombudman council was incomplete/blank. A phone interview was conducted with Resident #1's family member on 09/18/2024 at 3:28 PM. She stated she was notified by the facility when Resident #1 was taken to the hospital on 09/01/2024. She did not know Resident #1 was not allowed back to the facility until she was called by the hospital and told the facility refused to take Resident #1 back. The family member did not report receiving a written notice from the facility relating to his discharge from the facility. An interview with the Social Services Director (SSD) was conducted on 09/18/2024 at 11:15 AM. The SSD stated Resident #1 did not have any discharge planning because he was a long term care resident and his plan was to remain at the facility. The SSD said Resident #1 did not have anywhere to go and his plans were never changed. An interview with the Nursing home Administrator (NHA) and Director of Nursing (DON) was conducted on 09/18/2024 at 2:45 PM. The NHA stated they did not have a discharge plan for Resident #1 because they only do so if the resident was discharging home or to an ALF. The NHA said, We gave him the discharge notice. The NHA confirmed this was Resident #1's place of residence. He did not have plans to discharge anywhere else. NHA and DON confirmed the resident's medical record did not clearly document the course of the events relating to Resident #1's transfer/discharge from the facility. Review of the undated facility Policy titled Transfer or Discharge, Facility-Initiated, revealed: Under the following circumstances, the notice is given as soon as it is practicable but before the transfer or discharge: -The health and/or safety of individuals in the facility would be endangered due to the clinical or behavioral status of the resident. -An immediate transfer or discharge is required by the resident's urgent medical needs. Notice of Transfer is provided to the resident and representative as soon as practicable before the transfer and to the LTC ombudsman when practicable.

Based on observations, interviews, and record reviews the facility failed to prevent multiple significant medication errors for 1 resident (#347) out of 4 residents reviewed. Resident #347 was admitted to the facility on [DATE] for intravenous antibiotic administration due to intracranial abscesses and with diagnosis of opioid abuse with withdrawals. She was transferred to the facility with orders to treat the opioid abuse with withdrawals with buprenorphine and naloxone 8-2 mg (Suboxone) sublingually three times a day. The facility failed to provide Resident #347's her Suboxone medication for two and a half days. Resident #347 arrived at the facility with hospital orders to take buprenorphine and naloxone (Suboxone) 8-2mg sublingually film three times a day. The medication was ordered as buprenorphine 2mg sublingually twice day. This failure resulted in Resident #347 being sent back to the hospital two times for opioid withdrawal symptoms and each time the resident returned with orders to administer buprenorphine and naloxone (Suboxone) 8-2mg sublingually three times a day. The facility continued to give Resident #347 buprenorphine 2mg despite the resident telling nurses on all shifts on different days and physicians she was not receiving the correct dose of her Suboxone. It was not until Resident #347's second readmission to the hospital for severe withdrawals did the hospital physician end up calling the facility's pharmacy on 8/26/24 to order the correct medication, Suboxone. The facility also failed to provide Resident #347 her with her antibiotic (vancomycin) per her discharge instruction from the hospital. The vancomycin was ordered on admission under the physician orders with a stop date of 8/26/24. Review of the hospital record revealed the stop date of the vancomycin was to be 9/21/24. This failure resulted in Resident #347 missing two of her vancomycin doses. Resident #347 was readmitted to the hospital for a third time for nausea, seeing halos, shortness of breath, chest pain, feeling hot, and skin was clammy. Findings included: 1. Review of Resident #347's Face Sheet revealed she was admitted to the facility on [DATE] at 2:23 PM with medical diagnoses, not limited to, intracranial abscess and granuloma, endocarditis, pain, opioid abuse with withdrawal, bipolar disorder current episode manic without psychotic features, and psychoactive substance abuse with unspecified psychoactive substance-induced disorder. An observation and interview were conducted on 8/26/24 at 10:46 AM with Resident #347. She was observed to be sitting on her bed eating her breakfast. She was observed to have an intravenous (IV) line in her upper right arm. She said she was receiving intravenous antibiotics for endocarditis. She said she is not getting the right dose of her Suboxone. She said she is only getting two milligrams (mg) three times a day and she is supposed to be getting eight milligrams three times a day. She said the dosing got screwed up when the hospital wrote their paperwork. I have been admitted here since Friday or Saturday and I have been back to the hospital for withdrawals, and the hospital gave me sixteen milligrams of Suboxone to make up for the missed dosing. I told the doctor this morning that I need eight milligrams and she said she was going to have to talk to someone above her because she said she couldn't prescribe the medication, that a substance abuse physician might have to prescribe it. Review of Resident #347's Census Records revealed she was admitted to the facility on [DATE] at 2:23 PM and had been readmitted to the hospital three times from 8/24/24 through 8/28/24. Review of Resident #347's hospital record dated 8/23/24 at 2:57 PM revealed Medication List TAKE these medications CONTINUE buprenorphine-nalOXone 8-2MG [milligram] SL [sublingual] film, Commonly known as: Suboxone, Place 1 Film under the tongue in the morning and 1 Film at noon and 1 Film before bedtime. Last time this was given: August 23, 2024 10:29 AM. There was a handwritten check mark next to the medication with morning, noon, and bedtime underlined. Review of Resident #347's physician orders revealed an order created by Staff C, RN Supervisor with a start date of 8/24/24 and an end date of 8/25/24 for Buprenorphine HCL (hydrochloric acid)-Schedule III tablet, sublingual; 2mg; Amount to Administer: 1 film; sublingual twice a day for psychoactive substance abuse with unspecified psychoactive substance-induced disorder. Review of the internet revealed, Suboxone Film .generic name: buprenorphine-naloxone. This medication contains 2 medicines: buprenorphine and naloxone. It is used to treat opioid use disorder. Buprenorphine belongs to a class of drugs called mixed opioid agonist-antagonists. Buprenorphine helps prevent withdrawal symptoms caused by stopping other opioids. Naloxone is an opioid antagonist that blocks the effect of opioids and can cause severe opioid withdrawal when injected. Withdrawal is less likely when naloxone is taken by mouth, dissolved under the tongue, or dissolved on the inside of the cheek. It is combined with buprenorphine to prevent abuse and misuse (injection) of this medication, according to https://www.webmd.com/drugs/2/drug-64741-1356/suboxone-sublingual/buprenorphine-naloxone-film-sublingual/details, viewed on 8/29/2024. Review of Resident #347's August medication administration record (MAR) revealed she was administered 2mg of buprenorphine twice a day on 8/24/24 at 9:00 p.m. and on 8/25/24 the 9:00 a.m. the dose documentation revealed the medication was charted late for a documented date and time of 8/25/24 at 12:44 p.m. Review of Resident #347's progress notes revealed the following notes: -Progress note dated 8/24/23 at 6:15 PM revealed Resident medications will be here with the early morning pharmacy run. Resident is displayings [sic] withdrawal symptoms awaiting the Buprenorphine 2 mg SL, film. Resident has Ativan 0.5 mg ordered and Staff D, LPN [Licensed Practical Nurse] obtained from the EDK [Emergency Drug Kit] box to administer to resident. Pharmacy called to request the Buprenorphine 2 mg SL, film to be sent STAT. [Staff G, Medical Doctor] notified re [regarding]: the need to order the Buprenorphine 2 mg SL, film electronically. -Progress note dated 8/24/24 at 6:42PM revealed Pharmacy called to check on STAT run for Buprenorphine 2 mg SL, film. Pharmacy informed RN Supervisor that STAT is with four hours. Pharmacy did let me know that the Buprenorphine 2 mg SL, film .will be enroute as soon as possible . -Progress note dated 8/24/24 at 8:47 PM revealed .C/o [complain of] pain scale of 6 @ [at] this time. Alert & oriented x 4. Very anxious, especially concerning meds [medications]. Resident c/o having withdrawals from not having Suboxone since leaving hospital in am [morning]. Visibly shaking. Staff C, RN Supervisor called On [sic] call MD [Medical Doctor] to get orders for all scripts. Called pharmacy, stated they will send Suboxone and Ativan via [Delivery Company] . -Progress note dated 8/25/24 at 9:32 AM revealed Resident became combative during the night due to medication administration not being to her liking regarding pills dosage and amount administered. The resident was sent out to the hospital via 911 around 1045p[sic] due to severe withdrawal symptoms. The resident was returned from the hospital around midnight and rested throughout the night . Review of Resident #347's Hospital record Admission/Registration dated 8/24/24 at 11:04 PM revealed Resident #347 had a Principle Admitting Diagnosis/ Reason for Visit of SUBOXONE WITHDRAWAL. Review of Resident #347's Patient Visit Information dated 8/24/24 revealed You were seen today for: Opiate withdrawal .Medication Dose and Instructions Buprenorphine/Naloxone (Suboxone 8-2mg SL) 8mg-2MG tab. SL 1 tab Sublingual THREE TIMES DAILY #12 TAB [tablet] REF[refill] 0 dated 8/24/24 11:49 pm Status: PRINTED Review of Resident #347's physician order, created by Staff C, RN Supervisor, with a start date of 8/25/24 and an end date of 8/26/24 revealed buprenorphine HCL-Schedule III tablet, sublingual; 2mg; Amount to Administer: 1 film; sublingual three times a day for psychoactive substance abuse with unspecified psychoactive substance-induced disorder. Review of Resident #347's August MAR revealed her order for 2 mg of Buprenorphine HCL three times a day was administered at 3:00 p.m. on 8/25/24. The 8/25/24 at 9:00 p.m. dose, the medication administration note revealed the medication had a charted date of 8/25/24 at 10:39 p.m. with a reason/comment of Late Administration: Charted late The medication was documented as administered on 8/26/24 at 9:00 a.m. and 3:00 p.m. Review of Resident #347's progress notes revealed the following: -A progress note dated 8/25/24 at 6:42 PM revealed .pt [patient] was upset throughout the day because she wants an increase to her Buprenorphine Dosage. Supervising RN went over orders with her to try and help her understand her current dosage. during [sic] the afternoon, resident was calm. around [sic] 2pm prn [as needed] ativan given for anxiety. Tolerated well. Around 5pm pt continued to c/o dosage of Buprenorphine and wanted it increased. She stated she wants to go to the ER to have them fix: her orders to increase medication. VSS [vital signs stable]. MD and supervisor aware. MD gave permission to send pt to ER [emergency room ] if she still wanted to go. pt states she'll wait and see if she wants to go later, she states she is currently ok. no apparent distress noted. will continue to monitor resident. -Progress note dated 8/26/24 at 3:54 AM revealed Resident states she is not receiving [sic] the right dosage for her narcotic so she wants to go to the hospital so she can be given the right dose. This nurse verbalized understanding. Spoke with 911 operator @ 2210 [10:10 PM]. EMT [Emergency Medical Technician] staff arrived at 2215 [10:15 PM]. Updated them on resident. Proper paperwork sent with resident. Resident left facility awake, alert and oriented x3 @ 2230 [10:30 PM] via stretcher; accompanied by EMT staff. -Progress note dated 8/26/24 at 3:47 AM revealed Resident returned from hospital via stretcher; accompanied by EMT staff on 8/26/24 @ 0045 [12:45 AM], awake alert and oriented x3. Review of Resident #347's hospital record dated 8/25/24 at 10:57 a.m. revealed Patient Visit Information You were seen today for: Drug abuse. Review of Resident #347's hospital physicians prescription revealed an issue date of August 24, 2024 for Suboxone 8-2mg SL (8 MG-2 MG TAB. SL) Dispense 12 (twelve) TAB. SIG: 1 TAB SL TID [three time's a day] No refills. handwritten on the paper was Faxed 8/26/24 745am Review of Resident #347's progress note revealed a note dated 8/26/24 at 3:36 PM Resident complaining that Buprenorphine order in hospital was 8 mg TID [three times a day], says it was decreased to 2 mg TID upon admission to this facility without her prior knowledge. She is asking again if [Staff G, MD] will increase med. [Staff C, MD's Nurse Practitioner] in to assess her this am. Made resident aware that she cannot make changes to Buprenorphione [sic] order and would make [Staff G, MD] aware, who already stated he would not increase dose. Called [Staff G, MD]. Left message about resident wanting to increase Buprenorphine. Review of Resident #347's progress note dated 8/26/24 at 4:00 p.m. revealed [Staff G, MD] contacted. He stated [Staff H, MD] will be in tomorrow. He stated he will not make changes to Buprenorphine over the phone. N.o. [new order] Ibuprofen 200 mg PO Q 6 hours as needed for pain. Resident stated no hx [history] of GI bleed. N.o. Benadryl 25 mg PO 30 minutes prior to each dose of IV Vancomycin. Resident made aware. Sent controlled refill sheet for Buprenorphine this am. Made him aware. He stated to have [Pharmacy] call him. Called [Pharmacy] and asked Pharacist [sic] to call [Staff G, MD]. Called back to have med drop shipped for PM dose. Resident very anxious. PRN [as needed] Ativan given @ 08:15 [AM] and 14:10 [2:10 PM]. Gave Buprenorphine SL @ 15:40 [3:40PM]. Stating she will keep requesting to go to hospital if her Buprenorphine is not increased. No s/s [signs/ symptoms] of withdrawals noted. VS [vital signs] stable. Gave IV [intravenous] Vanco [vancomycin] @ 12:00, tolerated well. Review of Resident #347's progress note dated 8/26/24 at 4:49 PM revealed [Hospital] called into [Pharmacy] n.o. Buprenorphine 8/2 mg SL TIS [sic] x 4 days. Will f/u with [Staff H, MD] tomorrow. Review for the August MAR revealed a physician's order with a start date of 8/26/24 and an end date of 8/29/24 for buprenorphine-naloxone - Schedule III tablet, sublingual; 8-2 mg; Amount to Administer: 1 tab; sublingual Three times a day for Opioid abuse with withdrawal. Review of Resident #347's MAR documentation revealed the medication was administered on 8/26/24 at 9:00 PM. On 8/27/24 the documentation revealed she received the medication at 9:00 AM, 3:00 PM, 9:00 PM as ordered, and on 8/28/24 She received the medication at 9:00 AM. An observation and interview were conducted on 08/27/24 at 10:15 AM. Resident #347 was observed to be lying in bed with her hand on her head. She said she is not doing well today. She said she feels hot, has a terrible headache right where her brain abscesses are, and she said she is shaking. She said the nurse just gave her, her suboxone, Xanax, lacosamide, and ibprophen. She said the nurse took her vitals and her temperature was low. She said the suboxone was still dissolving under her tongue, but she said she wanted to go to the hospital. She said she had not told the nurse she wants to go to the hospital. An interview was conducted on 08/27/24 at 10:18 AM with Staff F, Agency, Licensed Practical Nurse (LPN) she said Resident #347 just received her medications and she obtained her vitals, and they were normal. She said the resident is on vancomycin and is expected not to feel well. An interview was conducted on 8/27/24 at 4:45 PM with Resident #347. She said she had not received her Vancomycin and was not sure why. She said she has been back to the hospital twice because the facility was not giving her the correct dose of Suboxone, and she was having withdrawal symptoms. She said the facility is currently using the suboxone prescription from the hospital but that is only for four days. She said she feels better than she did this morning. Review of Resident #347's physician orders revealed a discontinued order with a start date of 8/24/24 and an end date of 8/26/24 for Vancomycin in 0.9% sodium chloride solution 1gram/250ml; amount to administer 750mg intravenous every 8 hours (x7) at 8:00 PM, 4:00 AM, 12:00PM. Review of Resident #347's August MAR revealed Resident #347 only received one dose of vancomycin on 8/27/25 at 5:00 p.m. Review of Resident #347's hospital record dated 8/23/24 revealed Vancomycin 750mg in sodium chloride 0.9% 250ml IVPB [Intravenous piggy back]. Infuse 750mg into a venous catheter every 8 (eight) hours for 7 doses. hand written on the vancomycin order was stop date 9/21 see attached orders. Review of the attached orders revealed Vancomycin 750mg q. [every] 8 hours till 9/21 . Review of Resident #347's progress note dated 8/27/24 at 6:10 PM revealed [Staff H, MD] was in to see resident this morning. Informed that resident is a hospital contract resident that falls under the medical director . notified of Vancomycin medication administration time change, states will be in at 11 am tomorrow to see resident. An interview was conducted with Resident #347 on 08/28/24 at 09:14 AM she was observed to be in her wheelchair, self-propelling in the hallway. She said she was not feeling well and wanted to be sent out to the hospital. She said she couldn't explain what is wrong she just felt off and worse than she did when she was in the hospital. She said she did end up getting her vancomycin last night around 5:00 PM and again around 1:00 AM. but she had not gotten any Vancomycin during the day on 8/27/24. Review of Resident #347's progress note dated 8/28/24 at 10:34 AM Resident complaint of feeling nauseated, seeing halos, sob, and chest pain, vitals obtain BP 149/104, HR 82 regular, 99%RA unlabored, stated feels hot, skin is clammy, refused 9am Vanco infusion and other meds, stated she wanted to go to hospital instead. 911 operator called; EMS arrived within 5 minutes at 10:30 am . DON, MD, Admin [administration] aware, attempted both emergency contact #s on file and both are invalid numbers. Review of Resident #347's progress note dated 8/28/24 at 10:32 PM revealed Resident returned from hospital @ 1925. Ativan 0.5mg PO given @ 1930. Resident awake, alert and oriented x3. Sitting in wheelchair. No complaints voiced or distress noted at this time. Resident continues on IV Vanco. A phone interview was conducted on 08/27/24 at 06:00 PM with Staff G, MD he said he has not seen Resident #347 but he got a call yesterday (8/26/24) saying the resident was not getting the correct pain medication, and they also said oh by the way she says she wants her suboxone increased. I said I'm not going to increase suboxone when I have not seen the resident, but I am happy to reorder the dose the hospital recommended she have. He said he called the pharmacy on 8/26/24 to reorder the medications and the pharmacy said a [Hospital Physician] had sent in a script for suboxone 8-2mg and the pharmacy told him the doctor who sent in the script was the residents pain physician therefore Staff G, MD approved for pharmacy to fill the medication. Staff G, MD said his Physician Assistant (PA-C) saw Resident #347 on Monday (8/26/24) and Staff H, MD was supposed to see her today but he had not seen her because it turns out she under the care of the Medical Director because Resident #347 is under a hospital contract. He said Suboxone is a medication that is made up of 2 medications, buprenorphine and nalOXone. He said if the hospital admitted her with an order to receive buprenorphine-nalOXone 8-2mg three times a day then she should have been getting that dose from the beginning and that is not fair to Resident #347 if she did not receive it. He said if the hospital record said she needed 8-2mg of suboxone three times a day and the facility only ordered buprenorphine 2mg then the resident did not get the correct medication, and it sounds like there might have been a transcription error. He said hopefully the Medical Director comes to see the resident tomorrow (8/28/24), so the resident does not run out of the medication. A phone interview was conducted on 08/27/24 at 06:21 PM with Staff C, RN Supervisor. She said she started at the facility on 8/23/24 as a weekend supervisor. She said she had worked at the facility prior as an agency nurse. She said on 8/24/24 Resident #347 was admitted to the facility. She said she was still training on the day Resident #347 was admitted but she stayed late to learn how to do admissions. She said her and her trainer entered in the orders from hospital into the computer and sent the orders over to the pharmacy to be filled. She said she entered Suboxone 2mg three times a day into the computer She said the pharmacy called her and they needed a prescription for the Suboxone so she called Staff G, MD's, Physician Assistant but she was not on call so she called Staff G, MD and told him the order for Suboxone 2mg three times a day and he called the pharmacy and ordered it. Staff C, RN Supervisor said when the resident first arrived to the facility, Resident #347 said she was having withdrawal symptoms but then she went outside and smoked a cigarette and when she came back in she said she was still having withdrawal symptoms. Her medications had not shown up from the pharmacy so we gave her, her ordered Xanax from the emergency drug kit (EDK). Resident #347 was upset because she said we were not giving her the correct dose of suboxone, and everyone explained to her we were giving her the right dose because the order from the hospital said 8-2mg three times a day which is 2mg of suboxone three times a day. We even showed her the hospital paperwork and explained to her the hospital ordered her to have 2mg. She ended up going out to the hospital because she said we were not giving her the right dose and she returned the same night. Staff C, RN Supervisor said, when I came back the next day, the pharmacy had sent Suboxone 2mg in tablet form even though the ordered said film. Staff C, RN Supervisor said for new admissions the resident arrives, the hospital medications are entered into the computer, the pharmacy gets the orders that are in the computer, and they deliver the medications. For narcotics there has to be a paper prescription, or the doctor has to talk with the pharmacy to get the medication ordered. An interview was conducted on 8/28/24 at 8:36 AM with the Director of Nursing (DON). She said Resident #347 came into the facility over the weekend. She came in while the nurse supervisors were here. Staff C, RN Supervisor was the training nurse supervisor. The DON said Resident #347 is a hospital contract patient we are keeping her here to administer IV Vancomycin . The DON said it came to her attention yesterday morning (8/27/24) there was a transcription error related to her suboxone. She said she was not notified Resident #347 had gone out to the hospital. The DON said Resident #347 was complaining about withdrawal symptoms since she had not received her suboxone on 8/24/24 and the nurses were trying to get the suboxone delivered stat. On 8/24/24 at 6:00 PM she got 0.5mg of Ativan and she went out to the hospital around 10:45 p.m. for severe withdrawal symptoms. She returned from the hospital around midnight and rested through the night. The DON reviewed Resident #347's hospital records dated 8/24/24 and confirmed the hospital recommend the resident received suboxone 8-2mg sublingual three times a day. The DON said the resident should have received 8mg of buprenorphine and 2mg of naloxone three times a day. The DON confirmed Resident #347 should have gotten that order upon admission. The DON said then on 8/25/24 a new order was put in for buprenorphine 2mg three times a day and the resident received 4 doses. Then on 8/25/24 at about 10:30 PM the resident was sent back out to the hospital because resident stated she is not receiving the right dosage for her narcotic so she wants to go to the hospital so she can be given the right dose. Then she goes back to the hospital at 10:30 PM and returns on 8/26/24 at 12:45 AM with a paper script for suboxone 8-2mg three times a day and the script was faxed on 8/26/24 at 7:25 AM and she received her first dose of suboxone 8-2mg on 8/26/24 at 9:00 PM. The DON said she initially thought this was a transcription error until she spoke with Staff C, RN Supervisor and realized it was a miss understanding of what the hospital order was. She said normally with a new admission the nurses would input the orders from the hospital and if there was confusion on an order the nurse would ask the supervisor, and in this case the nurse was the supervisor, so she should have called me, the doctor, or sent the pharmacy the hospital order and had them explain what the order meant. The DON also said Staff C, RN Supervisor put in Resident #347's Vancomycin order and when she did, she put in a stop date that was not the correct stop date. It was put into stop on 8/26/24 and the stop date should have been 9/21/24. So, the DON said she called the doctor had it reordered to start at 5:00 PM on 8/27/24. The DON said yesterday (8/27/25) she had not seen Resident #347 in her room getting her vancomycin, so she asked the nurse when was Resident #347 ordered to get her vancomycin? The nurse told the DON she did not have vancomycin ordered. Then the DON reviewed the chart and noticed the vancomycin was not ordered because the order was put in wrong. A phone interview was conducted on 08/29/24 at 10:18 AM with the facility's Pharmacy and spoke to Staff R, Pharmacist, she said suboxone is prescribed for opioid dependency. Staff R, Pharmacist said Suboxone is a combination of buprenorphine and naloxone that helps to treat withdrawal symptoms and opioid dependence. The Naloxone portion of Suboxone aids to stopping the withdrawals symptoms and the buprenorphine portion of suboxone addresses the cravings of opioids. Suboxone is a stronger drug than just buprenorphine because the two medications that make up Suboxone work together to address the craving of opioids and the withdrawal symptoms of not taking opioids. The pharmacist reviewed Resident #347's pharmacy record and said initially the resident was ordered buprenorphine 2mg sublingual tablet and they delivered a three-day supply on 8/24/24. She said this order was received via telephone with [Staff G, MD] and our pharmacist. Staff R, Pharmacist said 2mg of buprenorphine was not suboxone. Staff R, Pharmacist said on 8/26/24 the pharmacy delivered a four-day supply of Suboxone 8-2mg sublingual. Staff R, Pharmacist said they received the suboxone order via fax from the facility. It looks like the patient went out to the hospital and the hospital physician ordered the suboxone prescription and we filled it off of that prescription. Review of the facility's policy Reconciliation of Medications on Admission, undated, revealed Purpose The Purpose of this procedure is to ensure medication safety by accurately accounting for the resident's medications, routes and dosages upon admission or readmission to the facility. Preparation: 1. Gather the information needed to reconcile the medication list: a. approved medication reconciliation form; b. Discharge summary from referring facility; c. Admission order sheet; d. Most recent medication administration record (MAR), if this is a readmission. General Guidelines 1. Medication reconciliation is the process of comparing pre-discharge medications to post-discharge medications by creating an accurate list of both prescription and over the counter medications that includes the drug name, dosage, frequency, route, and indication for use for the purpose of preventing unintended changes or omissions at transition points in care. 2. Medication reconciliation reduces medication errors and enhances resident safety by ensuring that the medications the resident needs and has been taking continue to be administered without interruption, in the correct dosages and routes, during the admission/transfer process. 3. Medication reconciliation helps to ensure that all medications, routes, and dosages on the list are appropriate for the resident and his/her condition, and do not interact in a negative way with other medications/supplements on the list. 4. Medication reconciliation helps to ensure that medications, routes and dosages have been accurately communicated to the Attending Physician and care team. Steps in the Procedure 1. Using an approved medication reconciliation form or other record, list all medications from the medication history, the discharge summary, the previous MAR (if applicable), and the admitting orders (sources). 2. List the dose, route and frequency for all medications. 3. Review the list carefully to determine if there are discrepancies/conflicts. For example: a. The dosage on the discharge summary does not match the dosage from the resident's previous MAR; b. There is a potential medication interaction between a medication form the admitting orders and a supplement form the resident's medication history; or c. There is a medication listed on the discharge summary for which there is no diagnosis or condition to support the use of the medication. 4. if there is a discrepancy or conflict in medications, dose, route or frequency, determine the most appropriate action to resolve the discrepancy. For example: a. Contact the nurse from the referring facility; b. Contact the physician from the referring facility; c. Discuss with the resident or family; d. Contact the admitting and/or Attending Physician. 5. Notify the Director of Nursing or her Designee of any medication discrepancies. The Director of Nursing or her designee will provide guidance for documentation and resolution. 6. When a resident is transferred to another facility, or within the organization, the reconciled medication list will be sent to the receiving care provider and the communication will be documented.

Based on observation, record review, and interview the facility failed to ensure the Quality Assessment and Assurance (QAA) Committee developed and implemented action plans to correct deficient practices identified during an intervening complaint survey conducted on 9/18/24 and the recertification survey originally conducted on 8/26/24 to 8/29/24 as evidenced by: 1) failure to ensure discharge and readmission requirements were met and documentation in the medical record was completed (F622, F623 and F626) for two residents (#1 and #3) of two residents reviewed, 2) a safe, clean and homelike environment for two of two units (F584), 3) failure to ensure the accuracy of the Resident Minimum Data Set (MDS) Assessment for one (#3) of three residents reviewed (F641), 4) failure to develop and implement a comprehensive person-centered care plan for three of seven sampled residents (#53, #54, and #9) related to wound care and enhanced barrier precautions (F656), 5) failure to ensure oxygen was provided according to physician orders for one resident (#50) out of three sampled residents (F695), 6) failure to ensure the medication error rate was less than 5%. Twenty-four medication administration opportunities were observed, and two errors were identified for one resident (#50) out of three residents observed. These errors constituted an 8% medication error rate (F759), and 7) failure to maintain an infection prevention and surveillance program related to reviewing the infection control guidelines policy, hand hygiene, cleaning of medical equipment and ensuring enhanced barrier precautions (EBP) were in place for three residents with wounds (#9, #53, #54) out of 16 residents sampled (F880). Findings included: Review of the facility's policy titled, Quality Assurance and Performance Improvement (QAPI) Program, undated, showed: Implementation 2. The QAPI plan describes the process for identifying and correcting quality deficiencies. Key components of this process included: a. Tracking and measuring performance; establishing goals and thresholds for performance measurement; c. Identifying and prioritizing quality deficiencies; d. Systematically analyzing underlying causes of systemic quality deficiencies; e. Developing and implementing corrective action and performance improvement activities and; Monitoring and evaluating the effectiveness of corrective action/performance improvement activities and revising if needed. During an interview on 10/30/24 at 4:30 p.m. the Nursing Home Administrator (NHA) stated that she could not provide the QAPI (Quality Assurance Performance Improvement) attendance sign-in sheets for August of 2024 and October 2024. The NHA was able to provide the September 2024 QAPI attendance sign-in sheets for review. The NHA stated she would also provide a QAPI meeting agenda to be reviewed as the QAPI meeting agenda never changes. Review of the Quality Assurance Performance Improvement (QAPI) and Risk Management Attendance Sheet, dated 09/16/24, showed the staff who attended included the NHA, Business Office Manager (BOM), Unit Manager/RN (Registered Nurse), Certified Dietary Manager (CDM), Maintenance Director, Residential Services Director, and Staffing Coordinator. Review of the blank Facility QAPI & Risk Management Meeting Agenda showed a blank spreadsheet that directed the QAPI meeting to discuss the following topics: - Census - Staffing - Resident Council - Grievances - Advance Directives - Behavioral Health - Activities - Resident Rights - Ancillary Services - Resident Discharges - Hospital Admissions - Elopements - Abuse/Reporting - Business Office - MDS - Therapies - Catheters - Contractures - Restraints - Falls - Infection Control - Weight Loss - Weight Gain - Antipsychotics - Wounds - Tube Feedings - Special Services - Pain Needs - Pharmacy - Lab - X-Ray. During an interview on 10/30/24 at 6:00 p.m. the NHA confirmed the 09/16/2024 QAPI meeting was the only meeting the facility had regarding the deficient practices identified in previous surveys. The NHA stated the 09/16/24 QAPI meeting, we spent going over the 2567. The NHA stated the Director of Nursing (DON), who also was the facility's Infection Preventionist (IP), and the Medical Director were not present for the 09/16/24 QAPI meeting. The NHA stated the facility had not conducted another QAPI meeting in October yet, but then stated, October is not over yet, we will have a QAPI meeting tomorrow. The NHA stated the facility did not attempt to start correcting the deficient tags after the recertification survey (August 2024) because, we chose to wait to see what the 2567 said and correct from there. 1.Review of the approved plan of correction for the survey ending on 9/18/24 with a completion date of 9/29/24 revealed the following measures would be taken to correct the deficient practice which was identified at F622: The facility Interdisciplinary Team (IDT) has audited the census to determine if there were any other residents in the hospital who would not be returning based upon the facility not being able to safely care for them. The medical record of any resident identified on the audit has been reviewed to ensure that the reasons why the facility could not meet their needs is documented in the medical record by the Interdisciplinary Team. The Administrator/Designee has provided education to the facility IDT on the importance of documenting, in the medical record, the reasons why the facility cannot meet the needs of any resident identified as the facility not being able to safely meet their needs upon discharge to the hospital. The Administrator/Designee will review this documentation and document the review on the Discharge Unable to Safely Return Audit Tool as these decisions occur for the next 90 days. The Discharge Unable to Safely Return Audit Tool will be reviewed in QAPI monthly until substantial compliance is achieved. Review of the approved plan of correction for the survey ending on 9/18/24 with a completion date of 9/29/24 revealed the following measures would be taken to correct the deficient practice which was identified at F623: The Administrator/Designee reviewed the facility census of residents who were in the hospital to determine if there were any residents in the hospital, who would not be returning due to safety reasons, and ensured that the Discharge Notice was sent to the resident representative, if applicable, and the Ombudsman. The Administrator/Designee provided education to the facility Interdisciplinary Care Team regarding the need to send a copy of the Discharge Notice to the resident representative and to the Ombudsman for residents who cannot safely return to the facility following a hospital stay. The Interdisciplinary Team will document on the Discharge Notice Audit Tool the date that a copy of the Discharge Notice, for residents unable to return due to safety reasons, was sent to the resident representative and to the Ombudsman. The Administrator will review the Discharge Audit Tool weekly for 30 days to ensure compliance. The Discharge Notice Audit Tool will be reviewed in QAPI monthly until substantial compliance is achieved. Review of the approved plan of correction for the survey ending on 9/18/24 with a completion date of 9/29/24 revealed the following measures would be taken to correct the deficient practice which was identified at F626: The facility Transfer or Discharge, Facility Initiated, has been reviewed and revised as needed. The facility Administrator educated the facility Interdisciplinary Team on the facility Transfer and Discharge, Facility Initiated policy. The Transfer or Discharge, Facility Initiated, Policy was reviewed in the monthly QAPI meeting. During the revisit survey on 10/30/24, on-going concerns were identified related to transfer and discharge notices. The NHA was asked on 10/30/24 at 9:00 a.m. to provide the Plan of Correction (POC) binder or any other evidence to the State Agency (SA) Survey Team to review the facility's attempts to correct F622, F623, and F626. During an interview on 10/30/24 at 1:09 p.m. the NHA stated she could not provide the SA Survey Team the plan of correction book to be reviewed as she needed more time get the evidence together. The NHA stated everything was just a mess because we just had two hurricanes. The NHA stated she would work on getting the POC binder together in some sort of order and bring the binder to the SA Survey team to review. During an interview on 10/30/24 at 1:39 p.m. the NHA was informed the SA Survey Team could no longer wait for the POC binder and to please provide the SA Survey Team any evidence that was available at the time. Review of the facility's POC binder and additional evidence of corrective actions provided revealed no evidence was present to show substantial compliance for F622, F623, and F626. 2.Review of the facility's plan of correction for the survey ending 8/29/24 with a completion date of 9/29/24 revealed the following measures would be taken to correct the deficient practice which was identified at F584: Repairs were made to Rooms 12, 15, 8, 3A, 6B, 5B, 26A, 26B, 29B, 20B & 28 Repairs were made to the North Hall area. The Administrator/Designees made facility rounds to identify any other physical plant concerns related to homelike environment. The results of these rounds were documented on the Room Audit Checklist and entered into the electronic maintenance system for follow up. The Administrator/Designee provided education to the facility staff regarding Homelike Environment and identifying and/or reporting concerns. To identify needed improvements related to homelike environment, the Administrator/Designees will make Homelike Environment rounds 2 x week until substantial compliance is achieved. The facility will initiate a Physical Plant Improvement Plan, based upon the outcomes of the Homelike Environment Rounds, and the identified improvements will be prioritized and reviewed by the Administrator and Maintenance Director weekly to determine tasks for the week, as well as, tasks completed from prior week. Due to the resident population that we serve in this community, the Administrator/Designee will review the Physical Plant Improvement Plan in QAPI monthly ongoing On 10/30/24 a revisit survey was conducted to ensure compliance with F584. The revisit survey revealed on-going concerns and noncompliance with F584. On 10/30/24 at 5:40 p.m. an interview and review of the Plan of Corrections (POC) binder with the NHA revealed the Maintenance Director (MD) went around and made rounds to identify the issues that needed to be addressed. The NHA stated the MD used a form to document the work that needed to be completed. She said, He [the MD] knows they have more work to do. The NHA stated facility staff were educated on a homelike environment. She stated the department heads complete rounds of the facility. The NHA stated department heads make rounds twice a week. The NHA confirmed the MD, and the part-time maintenance assistant are responsible for repairs. She stated their first Quality Assurance (QA) meeting, post survey that ended on 8/29/24, was on 9/16/24. She stated during the Quality Assurance and Performance Improvement (QAPI) meeting, held on 9/16/24, is where the CMS-2567 form was reviewed. She stated the 2567 form was received on 9/13/24. The NHA stated they discussed the 2567 form during the regular QA meeting they had for that month. The NHA confirmed the Director of Nursing (DON), and the Medical Director were not present during the QA meeting held on 9/16/24. 3.Review of the facility's plan of correction for the survey ending 8/29/24 with a completion date of 9/29/24 revealed the following measures would be taken to correct the deficient practice which was identified at F641: The Interdisciplinary Team reviewed Section H of the most recent MDS and Care Plan for in house residents for accuracy related to the coding for the use of catheters. The outcome of the audit will be documented on the Section H MDS/Care Plan Audit Tool. The Interdisciplinary Team reviewed the Side Rail Observations, Section GG of the most recent MDS and Care Plan for in house residents for accuracy related to the coding of use of side rails. The outcome of the audit will be documented on the Side Rail Accuracy Audit Tool. The Regional MDS Nurse educated facility Interdisciplinary Team on the importance of the accuracy of assessment, coding and care planning of section H regarding the use of catheters. The DON/Designee will audit the completed MDS weekly for 30 days, or until substantial compliance is achieved, for accuracy. The results of the audit will be documented on the Section H MDS/Care Plan Audit Tool. The Regional MDS Nurse educated facility Interdisciplinary Team on the importance of the accuracy of assessment, coding and care planning of section GG regarding the use of side rails. The DON/Designee will audit the completed MDS weekly for 30 days, or until substantial compliance is achieved, for accuracy. The results of the audit will be documented on the Side [NAME] Accuracy Audit Tool. The Administrator/Designee will review the Section H MDS/Care Plan Audit Tool and the Side Rail Accuracy Audit Tool in QAPI monthly until substantial compliance is achieved. On 10/30/24 a revisit survey was conducted to ensure compliance with F641. The revisit survey revealed on-going concerns and noncompliance with F641. 4.Review of the facility's plan of correction for the survey ending 8/29/24 with a completion date of 9/29/24 revealed the following measures would be taken to correct the deficient practice which was identified at F656: The Interdisciplinary Care Team reviewed the Resident Roster to determine a listing of residents who, due to safety or medical reasons, needed to keep their bed in the lowest position. The Resident Services Director/Designee then interviewed these residents to determine their preference for the height of their bed and provided resident safety education. Residents identified as desiring to raise and lower the bed to their preferences, in spite of safety needs, had their care plans updated to reflect their preferences, and the education offered. The results of these interviews and education were documented on the Bed Height Preferences Audit Tool. The Administrator/Designee reviewed the roster of residents who smoke and audited the Smoking Observations and Care Plans to ensure that each resident had a Smoking Observation conducted in the last 60 days and a Smoking Care Plan. Any resident identified as not having a Smoking Observation in the last 60 days, had a Smoking Observation completed and a Care Plan initiated. The results of the audit were documented on the Smoking Observation & Care Plan Audit Tool. Smoking Observations will be completed upon admission for new residents and Smoking Care Plans initiated as appropriate. The Administrator educated the facility Interdisciplinary Care Team on the importance of ensuring that residents, who need their bed in the lowest position, are provided education and that if their preference is still to raise and lower the bed to their own preference that the education and preference is noted on the care plan. The Interdisciplinary Care Team will review the Facility Activity Report 5 x week for 3 weeks, 4 x week for 2 weeks and then 2 x week monthly until substantial compliance is achieved, to identify residents with these preferences and ensure that education is provided and the care plan updated. The results of these reviews will be documented on the Bed Height Preferences Audit Tool. The Administrator educated facility Resident Services Director on the importance of the Smoking Observations and Smoking Care Plans. The MDS Nurse/Designee will review the Smoking Observations and Care Plans monthly for 90 days, until substantial compliance is achieved, to ensure timely and correct completion. The results of this audit will be documented on the Smoking Observation & Care Plan Audit Tool. The Administrator/Designee will review the Bed Height Preferences Audit Tool and the Smoking Observation & Care Plan Audit Tool in QAPI monthly until substantial compliance is achieved. On 10/30/24 a revisit survey was conducted to ensure compliance with F656. The revisit survey revealed on-going concerns and noncompliance with F656. 5.Review of the facility's plan of correction for the survey ending 8/29/24 with a completion date of 9/29/24 revealed the following measures would be taken to correct the deficient practice which was identified at F695: The Director of Nursing (DON)/Designee reviewed the Oxygen orders for residents receiving Oxygen to ensure that orders were correct and appropriate. The results of these audits were documented on the Oxygen Therapy Order Audit Tool. The DON/Designee interviewed & observed other residents receiving Oxygen therapy to identify if there were any other petroleum jelly products in use. The results of these interviews and observations were documented on the Oxygen Therapy Rounding Tool The DON/Designee has provided education to nursing staff regarding the transcribing of Oxygen orders and the use of petroleum jelly products by Oxygen recipients. The DON/Designee will monitor the Facility Activity Report 5 x week for 3 weeks. 3 x week for 2 weeks and weekly for thirty days to ensure that new orders or changes in orders for Oxygen are correct and appropriate. The results of this audit will be documented on the Oxygen Therapy Order Audit Tool. The DON/Designee will round 3 x week for thirty days or until substantial compliance is achieved to monitor for the use of petroleum products by residents using Oxygen. The results of these rounds will be documented on the Oxygen Therapy Rounding Tool. The Administrator/Designee will review Oxygen Therapy Rounding Tool and the Oxygen Therapy Audit Tool in QAPI monthly until substantial compliance is achieved. On 10/30/24 a revisit survey was conducted to ensure compliance with F695. The revisit survey revealed on-going concerns and noncompliance with F695. On 10/30/24 at 5:40 p.m. an interview and review of the Plan of Corrections (POC) binder with the Nursing Home Administrator (NHA) revealed facility wide audits were conducted after 8/29/24. She stated the audits consisted of checking oxygen orders on residents who receive oxygen, to sure they were correct. The NHA stated the facility activity report was used to conduct the audit and is reviewed in the clinical meeting. She stated the Director of Nursing (DON) used the facility activity report to see new orders or changes to orders to follow-up on. The NHA stated the DON continues to use the facility activity report to make sure orders are correct. She stated the nursing staff should be checking orders as well. She stated the previous unit manager (UM) conducted in-services on transcription of orders, understanding reasoning, and ensuring accuracy. The NHA stated the education was provided to the facility's nurses. She stated the previous UM called agency nursing staff and provided education by phone. She stated she is not sure if new staff were educated. The NHA stated based on the education provided she expected nursing staff to look at orders, then look at the oxygen concentrator and see what number it is on. The NHA stated she expected the nursing staff to call the doctor if there was a change. The NHA provided the in-service education sheet regarding the transcription of oxygen orders, dated 9/22/24 - 9/25/24, that included Staff B, Licensed Practical Nurse (LPN) attended. 6.Review of the facility's plan of correction for the survey ending 8/29/24 with a completion date of 9/29/24 revealed the following measures would be taken to correct the deficient practice which was identified at F759: The DON/Designee conducted a medication inventory to identify any other medications that were not available. The results of the inventory were documented on the Medication Cart Inventory Audit Tool. The DON/Designee has provided education to nursing staff regarding the ordering/re-ordering of medications and the obtaining of over-the-counter medications. The DON/Designee has provided education to nursing staff on the measuring and administration of liquid medications. The DON/Designee will perform random observations of administration of liquid medications by nurses 2 x week for thirty days or until substantial compliance is achieved. The results of the audit will be documented on the Liquid Medication Measuring and Administration Audit Tool. The DON/Designee will perform a medication inventory 3 x week for 3 weeks, 2 x week for 2 weeks and 1 x week for thirty days or until substantial compliance is achieved. The results of these inventories will be documented on the Medication Cart Inventory Audit Tool. Any medication identified as not available on the medication cart will be reordered and the physician notified as appropriate. The DON/Designee has provided education to the nursing staff regarding timeliness of medication administration. The DON/Designee will perform a medication administration time management audit 3 x week for 3 weeks, 2 x week for 2 weeks and 1 x week for thirty days or until substantial compliance is achieved. The results of these audits will be documented on the Medication Administration Time Management Audit Tool. The Administrator/Designee will review Medication Cart Inventory Audit Tool, the Liquid Medication Measuring and Administration Audit Tool and the Medication Administration Time Management Audit Tool in QAPI monthly until substantial compliance is achieved. On 10/30/24 a revisit survey was conducted to ensure compliance with F759. The revisit survey revealed on-going concerns and noncompliance with F759. Review of the Inservice Education Sheet dated 09/22/24 to 09/25/24 showed timeliness of medication administration was educated and measuring and administration of liquid medications and ensuring that nurses understand how to order/reorder medications and how to obtain OTC meds. During an interview on 10/30/2024 at 5:38 p.m. the NHA stated the DON made an inventory audit for medications not available. She audited the medication carts make sure medications were available. The NHA stated they have been doing audits 3 x week to make sure medications are available. The educated the ensuing nurses to know how to order and reorder medications and how to obtain over the counter medications on 9/22/24 to 09/26/2024. The NHA stated the timeliness of giving medication was also covered in the education. 7.Review of the facility's plan of correction for the survey ending 8/29/24 with a completion date of 9/29/24 revealed the following measures would be taken to correct the deficient practice which was identified at F880: The DON received her Infection Preventionist Certification The DON and Administrator continued to search for documentation of the Infection Control Prevention and Surveillance Program without success. The DON/Designee monitored meal service and found no other non-compliance with hand washing during meal service. The DON/Designee rounded the facility and found no other non-compliance related to IV Antibiotics and Enhanced Barrier Precautions. The DON/Designee has provided education to nursing staff regarding hand hygiene during meal service. The DON/Designee has provided education to nursing staff regarding enhanced barrier precautions during IV site care and the placement of enhanced barrier precaution supplies. The Don/Designee will monitor meal service 3 x week for 3 weeks, 2 x week for 2 weeks and 1 x week for thirty days to ensure that hand hygiene is completed appropriately. The results of this monitoring will be documented on the Hand Hygiene Observation Tool The Don/Designee will round facility 3 x week for 3 weeks, 2 x week for 2 weeks and 1 x week for thirty days to ensure that supplies for enhanced barrier precautions are maintained outside of the appropriate room doors. The results of these rounds will be documented on the Enhanced Barrier Precaution Rounding Tool The Regional MDS Nurse/Designee will provide education to the facility staff on the Infection Prevention and Surveillance Program. The program/policy will be reviewed and approved upon the education and the review documented on the Policy Review Signature Form. The Policy Review will then be calendared for review on an annual basis. The Administrator/Designee will review the Hand Hygiene Observation Tool and the Enhanced Barrier Precaution Rounding Tool in QAPI monthly until substantial compliance is achieved. The DON/Designee will review the Infection Prevention and Surveillance data with the Administrator in QAPI monthly. On 10/30/24 a revisit survey was conducted to ensure compliance with F880. The revisit survey revealed on-going concerns and noncompliance with F880. During an interview on 10/30/2024 at 1:45 p.m. the DON stated she had been hired as the Unit Manager (UM). When the previous DON resigned five days later, she became the DON. She stated she had been employed at the facility since the end of July 2024. The DON stated she completed the Infection Control Course through the CDC (Centers for Disease Prevention and Control) on 09/06/2024. She stated she has no hands on training for Infection Preventionist. The DON stated she had no other external or internal education. The DON stated she had not been party to the QAPI meetings. She had not attended a QAPI Committee meeting since her hire dare. She had not presented anything regarding Infection Control at the QAPI Committee meetings. The DON stated the policy, and procedures have not been reviewed by the QA Committee. The DON stated her only infection control policy she had was, Implementation of the Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs) (CDC policy). She reached up to a top shelf on a bookcase and brought down a notebook with the facility's Infection Control policies. She stated she used these (policies), and they had not gone to the QA Committee for review. She stated she monitors her staff, and their infection control related practices, to the best of my ability. She stated she was without a UM, and sometimes she was on a cart (medication). The DON stated they did education on hand washing and enhanced barriers. She stated the sign-in sheets for Infection Control education was in the Plan of Correction books, 100% of the staff was educated. The DON stated the last time the staff was educated on hand hygiene and donning and doffing of PPE was after the survey team left in September 2024. She stated she educated the housekeeping and dietary staff at the same time she educated her nursing staff. The DON stated they had a QAPI Committee meeting after the survey, which included only the department heads, the Medical Director was not there. At that meeting they put a plan into place for the Plan of Correction. The DON stated they had not had a surveillance plan since 2022. The DON stated they have not been using [NAME] or any evidence-based surveillance criteria to define infections. She stated they have only been gathering information at this point. They call the physician with the culture results, and he gives the orders for the antibiotics. She stated sometimes the physician puts the resident on antibiotics before the culture has returned. The DON stated, I looked for trends in September after plotting on the floor plan. I did not see a trend. She stated that our UTIs (urinary tract infections) are residents which are more non-mobile and have urinary catheters. She stated she did not see any trends for locations. She stated she did not see trends of room to room. She stated she did not have completed surveillance documentation, some were missing signs and symptoms, the diagnostic tool used and whether the criteria met, nosocomial or not, nor the organism identified. The DON stated she had no documentation for October 2024 at all, no listing was in the book. During an interview on 10/30/2024 at 5:38 p.m. the Nursing Home Administrator (NHA) stated education was provided to the nursing staff regarding infection control prevention and surveillance program, understanding the program and purpose, ability to demonstrate compliance, and report non-compliance, for 100% of the staff. The NHA stated the education was done by the former Unit Manager (UM) and the DON. The NHA stated the UM talked about hand washing, no gloves in hallway, barriers on the doors, blood spills. The NHA stated all the education was done between 09/22/24 and 09/26/24. The NHA stated there was not a policy or information attached to the sign in sheets giving information as what the specific education discussed. The NHA stated they only observed hand hygiene during the meal services due to the citation. The NHA stated they checked the EBP on the following days per the audits: 09/24, 09/25, 0926, 10/1,10/ 2, 10/4, 10/7, 10/14, 10/16, 10/17, 10/21, 10/23, 10/24, 10/28, 10/30. The NHA stated they focused in on meal services and not hand hygiene as a whole due to the specifics of the citation.

Based on observation, record review, and interview the facility failed to ensure the Quality Assessment and Assurance (QAA) Committee developed and implemented action plans to correct deficient practices identified during an intervening complaint survey conducted on 9/18/24 and the recertification survey originally conducted on 8/26/24 to 8/29/24 as evidenced by: 1) failure to ensure discharge and readmission requirements were met and documentation in the medical record was completed (F622, F623 and F626) for two residents (#1 and #3) of two residents reviewed, 2) a safe, clean and homelike environment for two of two units (F584), 3) failure to ensure the accuracy of the Resident Minimum Data Set (MDS) Assessment for one (#3) of three residents reviewed (F641), 4) failure to develop and implement a comprehensive person-centered care plan for three of seven sampled residents (#53, #54, and #9) related to wound care and enhanced barrier precautions (F656), 5) failure to ensure oxygen was provided according to physician orders for one resident (#50) out of three sampled residents (F695), 6) failure to ensure the medication error rate was less than 5%. Twenty-four medication administration opportunities were observed, and two errors were identified for one resident (#50) out of three residents observed. These errors constituted an 8% medication error rate (F759), and 7) failure to maintain an infection prevention and surveillance program related to reviewing the infection control guidelines policy, hand hygiene, cleaning of medical equipment and ensuring enhanced barrier precautions (EBP) were in place for three residents with wounds (#9, #53, #54) out of 16 residents sampled (F880). Findings included: Review of the facility's policy titled, Quality Assurance and Performance Improvement (QAPI) Program, undated, showed: Implementation 2. The QAPI plan describes the process for identifying and correcting quality deficiencies. Key components of this process included: a. Tracking and measuring performance; establishing goals and thresholds for performance measurement; c. Identifying and prioritizing quality deficiencies; d. Systematically analyzing underlying causes of systemic quality deficiencies; e. Developing and implementing corrective action and performance improvement activities and; Monitoring and evaluating the effectiveness of corrective action/performance improvement activities and revising if needed. During an interview on 10/30/24 at 4:30 p.m. the Nursing Home Administrator (NHA) stated that she could not provide the QAPI (Quality Assurance Performance Improvement) attendance sign-in sheets for August of 2024 and October 2024. The NHA was able to provide the September 2024 QAPI attendance sign-in sheets for review. The NHA stated she would also provide a QAPI meeting agenda to be reviewed as the QAPI meeting agenda never changes. Review of the Quality Assurance Performance Improvement (QAPI) and Risk Management Attendance Sheet, dated 09/16/24, showed the staff who attended included the NHA, Business Office Manager (BOM), Unit Manager/RN (Registered Nurse), Certified Dietary Manager (CDM), Maintenance Director, Residential Services Director, and Staffing Coordinator. Review of the blank Facility QAPI & Risk Management Meeting Agenda showed a blank spreadsheet that directed the QAPI meeting to discuss the following topics: - Census - Staffing - Resident Council - Grievances - Advance Directives - Behavioral Health - Activities - Resident Rights - Ancillary Services - Resident Discharges - Hospital Admissions - Elopements - Abuse/Reporting - Business Office - MDS - Therapies - Catheters - Contractures - Restraints - Falls - Infection Control - Weight Loss - Weight Gain - Antipsychotics - Wounds - Tube Feedings - Special Services - Pain Needs - Pharmacy - Lab - X-Ray. During an interview on 10/30/24 at 6:00 p.m. the NHA confirmed the 09/16/2024 QAPI meeting was the only meeting the facility had regarding the deficient practices identified in previous surveys. The NHA stated the 09/16/24 QAPI meeting, we spent going over the 2567. The NHA stated the Director of Nursing (DON), who also was the facility's Infection Preventionist (IP), and the Medical Director were not present for the 09/16/24 QAPI meeting. The NHA stated the facility had not conducted another QAPI meeting in October yet, but then stated, October is not over yet, we will have a QAPI meeting tomorrow. The NHA stated the facility did not attempt to start correcting the deficient tags after the recertification survey (August 2024) because, we chose to wait to see what the 2567 said and correct from there. 1.Review of the approved plan of correction for the survey ending on 9/18/24 with a completion date of 9/29/24 revealed the following measures would be taken to correct the deficient practice which was identified at F622: The facility Interdisciplinary Team (IDT) has audited the census to determine if there were any other residents in the hospital who would not be returning based upon the facility not being able to safely care for them. The medical record of any resident identified on the audit has been reviewed to ensure that the reasons why the facility could not meet their needs is documented in the medical record by the Interdisciplinary Team. The Administrator/Designee has provided education to the facility IDT on the importance of documenting, in the medical record, the reasons why the facility cannot meet the needs of any resident identified as the facility not being able to safely meet their needs upon discharge to the hospital. The Administrator/Designee will review this documentation and document the review on the Discharge Unable to Safely Return Audit Tool as these decisions occur for the next 90 days. The Discharge Unable to Safely Return Audit Tool will be reviewed in QAPI monthly until substantial compliance is achieved. Review of the approved plan of correction for the survey ending on 9/18/24 with a completion date of 9/29/24 revealed the following measures would be taken to correct the deficient practice which was identified at F623: The Administrator/Designee reviewed the facility census of residents who were in the hospital to determine if there were any residents in the hospital, who would not be returning due to safety reasons, and ensured that the Discharge Notice was sent to the resident representative, if applicable, and the Ombudsman. The Administrator/Designee provided education to the facility Interdisciplinary Care Team regarding the need to send a copy of the Discharge Notice to the resident representative and to the Ombudsman for residents who cannot safely return to the facility following a hospital stay. The Interdisciplinary Team will document on the Discharge Notice Audit Tool the date that a copy of the Discharge Notice, for residents unable to return due to safety reasons, was sent to the resident representative and to the Ombudsman. The Administrator will review the Discharge Audit Tool weekly for 30 days to ensure compliance. The Discharge Notice Audit Tool will be reviewed in QAPI monthly until substantial compliance is achieved. Review of the approved plan of correction for the survey ending on 9/18/24 with a completion date of 9/29/24 revealed the following measures would be taken to correct the deficient practice which was identified at F626: The facility Transfer or Discharge, Facility Initiated, has been reviewed and revised as needed. The facility Administrator educated the facility Interdisciplinary Team on the facility Transfer and Discharge, Facility Initiated policy. The Transfer or Discharge, Facility Initiated, Policy was reviewed in the monthly QAPI meeting. During the revisit survey on 10/30/24, on-going concerns were identified related to transfer and discharge notices. The NHA was asked on 10/30/24 at 9:00 a.m. to provide the Plan of Correction (POC) binder or any other evidence to the State Agency (SA) Survey Team to review the facility's attempts to correct F622, F623, and F626. During an interview on 10/30/24 at 1:09 p.m. the NHA stated she could not provide the SA Survey Team the plan of correction book to be reviewed as she needed more time get the evidence together. The NHA stated everything was just a mess because we just had two hurricanes. The NHA stated she would work on getting the POC binder together in some sort of order and bring the binder to the SA Survey team to review. During an interview on 10/30/24 at 1:39 p.m. the NHA was informed the SA Survey Team could no longer wait for the POC binder and to please provide the SA Survey Team any evidence that was available at the time. Review of the facility's POC binder and additional evidence of corrective actions provided revealed no evidence was present to show substantial compliance for F622, F623, and F626. 2.Review of the facility's plan of correction for the survey ending 8/29/24 with a completion date of 9/29/24 revealed the following measures would be taken to correct the deficient practice which was identified at F584: Repairs were made to Rooms 12, 15, 8, 3A, 6B, 5B, 26A, 26B, 29B, 20B & 28 Repairs were made to the North Hall area. The Administrator/Designees made facility rounds to identify any other physical plant concerns related to homelike environment. The results of these rounds were documented on the Room Audit Checklist and entered into the electronic maintenance system for follow up. The Administrator/Designee provided education to the facility staff regarding Homelike Environment and identifying and/or reporting concerns. To identify needed improvements related to homelike environment, the Administrator/Designees will make Homelike Environment rounds 2 x week until substantial compliance is achieved. The facility will initiate a Physical Plant Improvement Plan, based upon the outcomes of the Homelike Environment Rounds, and the identified improvements will be prioritized and reviewed by the Administrator and Maintenance Director weekly to determine tasks for the week, as well as, tasks completed from prior week. Due to the resident population that we serve in this community, the Administrator/Designee will review the Physical Plant Improvement Plan in QAPI monthly ongoing On 10/30/24 a revisit survey was conducted to ensure compliance with F584. The revisit survey revealed on-going concerns and noncompliance with F584. On 10/30/24 at 5:40 p.m. an interview and review of the Plan of Corrections (POC) binder with the NHA revealed the Maintenance Director (MD) went around and made rounds to identify the issues that needed to be addressed. The NHA stated the MD used a form to document the work that needed to be completed. She said, He [the MD] knows they have more work to do. The NHA stated facility staff were educated on a homelike environment. She stated the department heads complete rounds of the facility. The NHA stated department heads make rounds twice a week. The NHA confirmed the MD, and the part-time maintenance assistant are responsible for repairs. She stated their first Quality Assurance (QA) meeting, post survey that ended on 8/29/24, was on 9/16/24. She stated during the Quality Assurance and Performance Improvement (QAPI) meeting, held on 9/16/24, is where the CMS-2567 form was reviewed. She stated the 2567 form was received on 9/13/24. The NHA stated they discussed the 2567 form during the regular QA meeting they had for that month. The NHA confirmed the Director of Nursing (DON), and the Medical Director were not present during the QA meeting held on 9/16/24. 3.Review of the facility's plan of correction for the survey ending 8/29/24 with a completion date of 9/29/24 revealed the following measures would be taken to correct the deficient practice which was identified at F641: The Interdisciplinary Team reviewed Section H of the most recent MDS and Care Plan for in house residents for accuracy related to the coding for the use of catheters. The outcome of the audit will be documented on the Section H MDS/Care Plan Audit Tool. The Interdisciplinary Team reviewed the Side Rail Observations, Section GG of the most recent MDS and Care Plan for in house residents for accuracy related to the coding of use of side rails. The outcome of the audit will be documented on the Side Rail Accuracy Audit Tool. The Regional MDS Nurse educated facility Interdisciplinary Team on the importance of the accuracy of assessment, coding and care planning of section H regarding the use of catheters. The DON/Designee will audit the completed MDS weekly for 30 days, or until substantial compliance is achieved, for accuracy. The results of the audit will be documented on the Section H MDS/Care Plan Audit Tool. The Regional MDS Nurse educated facility Interdisciplinary Team on the importance of the accuracy of assessment, coding and care planning of section GG regarding the use of side rails. The DON/Designee will audit the completed MDS weekly for 30 days, or until substantial compliance is achieved, for accuracy. The results of the audit will be documented on the Side [NAME] Accuracy Audit Tool. The Administrator/Designee will review the Section H MDS/Care Plan Audit Tool and the Side Rail Accuracy Audit Tool in QAPI monthly until substantial compliance is achieved. On 10/30/24 a revisit survey was conducted to ensure compliance with F641. The revisit survey revealed on-going concerns and noncompliance with F641. 4.Review of the facility's plan of correction for the survey ending 8/29/24 with a completion date of 9/29/24 revealed the following measures would be taken to correct the deficient practice which was identified at F656: The Interdisciplinary Care Team reviewed the Resident Roster to determine a listing of residents who, due to safety or medical reasons, needed to keep their bed in the lowest position. The Resident Services Director/Designee then interviewed these residents to determine their preference for the height of their bed and provided resident safety education. Residents identified as desiring to raise and lower the bed to their preferences, in spite of safety needs, had their care plans updated to reflect their preferences, and the education offered. The results of these interviews and education were documented on the Bed Height Preferences Audit Tool. The Administrator/Designee reviewed the roster of residents who smoke and audited the Smoking Observations and Care Plans to ensure that each resident had a Smoking Observation conducted in the last 60 days and a Smoking Care Plan. Any resident identified as not having a Smoking Observation in the last 60 days, had a Smoking Observation completed and a Care Plan initiated. The results of the audit were documented on the Smoking Observation & Care Plan Audit Tool. Smoking Observations will be completed upon admission for new residents and Smoking Care Plans initiated as appropriate. The Administrator educated the facility Interdisciplinary Care Team on the importance of ensuring that residents, who need their bed in the lowest position, are provided education and that if their preference is still to raise and lower the bed to their own preference that the education and preference is noted on the care plan. The Interdisciplinary Care Team will review the Facility Activity Report 5 x week for 3 weeks, 4 x week for 2 weeks and then 2 x week monthly until substantial compliance is achieved, to identify residents with these preferences and ensure that education is provided and the care plan updated. The results of these reviews will be documented on the Bed Height Preferences Audit Tool. The Administrator educated facility Resident Services Director on the importance of the Smoking Observations and Smoking Care Plans. The MDS Nurse/Designee will review the Smoking Observations and Care Plans monthly for 90 days, until substantial compliance is achieved, to ensure timely and correct completion. The results of this audit will be documented on the Smoking Observation & Care Plan Audit Tool. The Administrator/Designee will review the Bed Height Preferences Audit Tool and the Smoking Observation & Care Plan Audit Tool in QAPI monthly until substantial compliance is achieved. On 10/30/24 a revisit survey was conducted to ensure compliance with F656. The revisit survey revealed on-going concerns and noncompliance with F656. 5.Review of the facility's plan of correction for the survey ending 8/29/24 with a completion date of 9/29/24 revealed the following measures would be taken to correct the deficient practice which was identified at F695: The Director of Nursing (DON)/Designee reviewed the Oxygen orders for residents receiving Oxygen to ensure that orders were correct and appropriate. The results of these audits were documented on the Oxygen Therapy Order Audit Tool. The DON/Designee interviewed & observed other residents receiving Oxygen therapy to identify if there were any other petroleum jelly products in use. The results of these interviews and observations were documented on the Oxygen Therapy Rounding Tool The DON/Designee has provided education to nursing staff regarding the transcribing of Oxygen orders and the use of petroleum jelly products by Oxygen recipients. The DON/Designee will monitor the Facility Activity Report 5 x week for 3 weeks. 3 x week for 2 weeks and weekly for thirty days to ensure that new orders or changes in orders for Oxygen are correct and appropriate. The results of this audit will be documented on the Oxygen Therapy Order Audit Tool. The DON/Designee will round 3 x week for thirty days or until substantial compliance is achieved to monitor for the use of petroleum products by residents using Oxygen. The results of these rounds will be documented on the Oxygen Therapy Rounding Tool. The Administrator/Designee will review Oxygen Therapy Rounding Tool and the Oxygen Therapy Audit Tool in QAPI monthly until substantial compliance is achieved. On 10/30/24 a revisit survey was conducted to ensure compliance with F695. The revisit survey revealed on-going concerns and noncompliance with F695. On 10/30/24 at 5:40 p.m. an interview and review of the Plan of Corrections (POC) binder with the Nursing Home Administrator (NHA) revealed facility wide audits were conducted after 8/29/24. She stated the audits consisted of checking oxygen orders on residents who receive oxygen, to sure they were correct. The NHA stated the facility activity report was used to conduct the audit and is reviewed in the clinical meeting. She stated the Director of Nursing (DON) used the facility activity report to see new orders or changes to orders to follow-up on. The NHA stated the DON continues to use the facility activity report to make sure orders are correct. She stated the nursing staff should be checking orders as well. She stated the previous unit manager (UM) conducted in-services on transcription of orders, understanding reasoning, and ensuring accuracy. The NHA stated the education was provided to the facility's nurses. She stated the previous UM called agency nursing staff and provided education by phone. She stated she is not sure if new staff were educated. The NHA stated based on the education provided she expected nursing staff to look at orders, then look at the oxygen concentrator and see what number it is on. The NHA stated she expected the nursing staff to call the doctor if there was a change. The NHA provided the in-service education sheet regarding the transcription of oxygen orders, dated 9/22/24 - 9/25/24, that included Staff B, Licensed Practical Nurse (LPN) attended. 6.Review of the facility's plan of correction for the survey ending 8/29/24 with a completion date of 9/29/24 revealed the following measures would be taken to correct the deficient practice which was identified at F759: The DON/Designee conducted a medication inventory to identify any other medications that were not available. The results of the inventory were documented on the Medication Cart Inventory Audit Tool. The DON/Designee has provided education to nursing staff regarding the ordering/re-ordering of medications and the obtaining of over-the-counter medications. The DON/Designee has provided education to nursing staff on the measuring and administration of liquid medications. The DON/Designee will perform random observations of administration of liquid medications by nurses 2 x week for thirty days or until substantial compliance is achieved. The results of the audit will be documented on the Liquid Medication Measuring and Administration Audit Tool. The DON/Designee will perform a medication inventory 3 x week for 3 weeks, 2 x week for 2 weeks and 1 x week for thirty days or until substantial compliance is achieved. The results of these inventories will be documented on the Medication Cart Inventory Audit Tool. Any medication identified as not available on the medication cart will be reordered and the physician notified as appropriate. The DON/Designee has provided education to the nursing staff regarding timeliness of medication administration. The DON/Designee will perform a medication administration time management audit 3 x week for 3 weeks, 2 x week for 2 weeks and 1 x week for thirty days or until substantial compliance is achieved. The results of these audits will be documented on the Medication Administration Time Management Audit Tool. The Administrator/Designee will review Medication Cart Inventory Audit Tool, the Liquid Medication Measuring and Administration Audit Tool and the Medication Administration Time Management Audit Tool in QAPI monthly until substantial compliance is achieved. On 10/30/24 a revisit survey was conducted to ensure compliance with F759. The revisit survey revealed on-going concerns and noncompliance with F759. Review of the Inservice Education Sheet dated 09/22/24 to 09/25/24 showed timeliness of medication administration was educated and measuring and administration of liquid medications and ensuring that nurses understand how to order/reorder medications and how to obtain OTC meds. During an interview on 10/30/2024 at 5:38 p.m. the NHA stated the DON made an inventory audit for medications not available. She audited the medication carts make sure medications were available. The NHA stated they have been doing audits 3 x week to make sure medications are available. The educated the ensuing nurses to know how to order and reorder medications and how to obtain over the counter medications on 9/22/24 to 09/26/2024. The NHA stated the timeliness of giving medication was also covered in the education. 7.Review of the facility's plan of correction for the survey ending 8/29/24 with a completion date of 9/29/24 revealed the following measures would be taken to correct the deficient practice which was identified at F880: The DON received her Infection Preventionist Certification The DON and Administrator continued to search for documentation of the Infection Control Prevention and Surveillance Program without success. The DON/Designee monitored meal service and found no other non-compliance with hand washing during meal service. The DON/Designee rounded the facility and found no other non-compliance related to IV Antibiotics and Enhanced Barrier Precautions. The DON/Designee has provided education to nursing staff regarding hand hygiene during meal service. The DON/Designee has provided education to nursing staff regarding enhanced barrier precautions during IV site care and the placement of enhanced barrier precaution supplies. The Don/Designee will monitor meal service 3 x week for 3 weeks, 2 x week for 2 weeks and 1 x week for thirty days to ensure that hand hygiene is completed appropriately. The results of this monitoring will be documented on the Hand Hygiene Observation Tool The Don/Designee will round facility 3 x week for 3 weeks, 2 x week for 2 weeks and 1 x week for thirty days to ensure that supplies for enhanced barrier precautions are maintained outside of the appropriate room doors. The results of these rounds will be documented on the Enhanced Barrier Precaution Rounding Tool The Regional MDS Nurse/Designee will provide education to the facility staff on the Infection Prevention and Surveillance Program. The program/policy will be reviewed and approved upon the education and the review documented on the Policy Review Signature Form. The Policy Review will then be calendared for review on an annual basis. The Administrator/Designee will review the Hand Hygiene Observation Tool and the Enhanced Barrier Precaution Rounding Tool in QAPI monthly until substantial compliance is achieved. The DON/Designee will review the Infection Prevention and Surveillance data with the Administrator in QAPI monthly. On 10/30/24 a revisit survey was conducted to ensure compliance with F880. The revisit survey revealed on-going concerns and noncompliance with F880. During an interview on 10/30/2024 at 1:45 p.m. the DON stated she had been hired as the Unit Manager (UM). When the previous DON resigned five days later, she became the DON. She stated she had been employed at the facility since the end of July 2024. The DON stated she completed the Infection Control Course through the CDC (Centers for Disease Prevention and Control) on 09/06/2024. She stated she has no hands on training for Infection Preventionist. The DON stated she had no other external or internal education. The DON stated she had not been party to the QAPI meetings. She had not attended a QAPI Committee meeting since her hire dare. She had not presented anything regarding Infection Control at the QAPI Committee meetings. The DON stated the policy, and procedures have not been reviewed by the QA Committee. The DON stated her only infection control policy she had was, Implementation of the Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs) (CDC policy). She reached up to a top shelf on a bookcase and brought down a notebook with the facility's Infection Control policies. She stated she used these (policies), and they had not gone to the QA Committee for review. She stated she monitors her staff, and their infection control related practices, to the best of my ability. She stated she was without a UM, and sometimes she was on a cart (medication). The DON stated they did education on hand washing and enhanced barriers. She stated the sign-in sheets for Infection Control education was in the Plan of Correction books, 100% of the staff was educated. The DON stated the last time the staff was educated on hand hygiene and donning and doffing of PPE was after the survey team left in September 2024. She stated she educated the housekeeping and dietary staff at the same time she educated her nursing staff. The DON stated they had a QAPI Committee meeting after the survey, which included only the department heads, the Medical Director was not there. At that meeting they put a plan into place for the Plan of Correction. The DON stated they had not had a surveillance plan since 2022. The DON stated they have not been using [NAME] or any evidence-based surveillance criteria to define infections. She stated they have only been gathering information at this point. They call the physician with the culture results, and he gives the orders for the antibiotics. She stated sometimes the physician puts the resident on antibiotics before the culture has returned. The DON stated, I looked for trends in September after plotting on the floor plan. I did not see a trend. She stated that our UTIs (urinary tract infections) are residents which are more non-mobile and have urinary catheters. She stated she did not see any trends for locations. She stated she did not see trends of room to room. She stated she did not have completed surveillance documentation, some were missing signs and symptoms, the diagnostic tool used and whether the criteria met, nosocomial or not, nor the organism identified. The DON stated she had no documentation for October 2024 at all, no listing was in the book. During an interview on 10/30/2024 at 5:38 p.m. the Nursing Home Administrator (NHA) stated education was provided to the nursing staff regarding infection control prevention and surveillance program, understanding the program and purpose, ability to demonstrate compliance, and report non-compliance, for 100% of the staff. The NHA stated the education was done by the former Unit Manager (UM) and the DON. The NHA stated the UM talked about hand washing, no gloves in hallway, barriers on the doors, blood spills. The NHA stated all the education was done between 09/22/24 and 09/26/24. The NHA stated there was not a policy or information attached to the sign in sheets giving information as what the specific education discussed. The NHA stated they only observed hand hygiene during the meal services due to the citation. The NHA stated they checked the EBP on the following days per the audits: 09/24, 09/25, 0926, 10/1,10/ 2, 10/4, 10/7, 10/14, 10/16, 10/17, 10/21, 10/23, 10/24, 10/28, 10/30. The NHA stated they focused in on meal services and not hand hygiene as a whole due to the specifics of the citation.

Based on observation, interview, and record review the facility failed to 1. Maintain an infection prevention and surveillance program for 6 out of 6 months reviewed. 2. The facility also failed to ensure their infection control guidelines policy was reviewed yearly and was revised with current evidence-based practices. 3. The facility also failed to ensure hand hygiene was performed during lunch meal service for one out of three meal observations. 4. The facility also failed to ensure enhanced barrier precautions were in place for two residents with intravenous lines (#347 and #31) out of two residents sampled for intravenous lines. Findings included 1. An interview was conducted on 08/26/24 at 10:41 AM with the Nursing Home Administer (NHA). She said the facility does not have any staff who have completed or started the infection prevention training. She said the current Director of Nursing (DON) started her position the last week of July of 2024 or first week of August 2024 and there has not been any infection surveillance and the NHA was unsure when the last time any infection surveillance had been conducted. An interview was conducted on 08/29/24 at 11:10 AM with the Director of Nursing (DON) she said she started at the facility mid-July as the Unit Manager and became the interim DON two weeks after she started and two weeks ago, she said she would accept the DON position. She said she does not have any formal training in infection control, and she is not certified in infection prevention. She said no one else in the facility is certified. She said she is registered to take the certification, but she is not sure what course to take because there are so many options, so she has not started. She said she had not started gathering infection control documentation until after survey entry and the last infection control documentation she could find was from October of 2022. She said she tried to run antibiotics reports for July but with the electronic medical record system they have it seemed the antibiotic information was incomplete, so she tried to pull the antibiotic information from their pharmacy system and that also seemed incomplete. She said she told the NHA she was not sure what she even needed or what she was even looking for because she had never run an infection prevention program. Review of the facility's Surveillance for Infections policy, revised September 2017, revealed Policy Statement The Infection Preventionist will conduct ongoing surveillance for Healthcare-Associated Infections (HAIs) and other epidemiologically significant infections that have substantial impact on potential resident outcome and that may require transmission-based precautions and other preventative interventions. Policy Interpretation and Implementation 1.The purpose of the surveillance of infections is to identify both individual case and trends of epidemiologically significant organisms and Healthcare-Associated Infections, to guide appropriate interventions, and to prevent future infections. 2.The criteria for such infections are based on the current standard definitions of infections. 3. Infections that will be included in routine surveillance include those with: a. Evidence of transmissibility in a healthcare environment.; b. Available processes and procedures that prevent or reduce the spread of infection; c. Clinically significant morbidity or mortality associated with infection (e.g. pneumonia, UTIs, C. difficile); and d. Pathogens associated with serious outbreaks. (e.g. invasive Streptococcus Group A, acute viral hepatitis, norovirus, scabies, influenza) . Gathering Surveillance Data 1. The Infection Preventionist or designated infection control personnel is responsible for gathering and interpreting surveillance data. The Infection Control Committee and/or QAPI Committee may be involved in interpretation of the data . 2. An interview was conducted with the DON and NHA on 08/29/24 at 11:08 AM they both said they did not know when the last time the infection control policy was updated. The NHA said it may have been reviewed at a regional level but in the facility, it has not been reviewed for over a year. Review of the facility's Infection Control Guidelines for All Nursing Procedures policy, with a revision date of August 2012 revealed Purpose To provide guidelines for general infection control while caring for residents. Preparation 1. Prior to having direct-care responsibilities for residents, staff must have appropriate in-service training on general infection and exposure control issues, including: a. The facility protocols for isolation (standard and transmission-based) precautions; b. The location of all personal protective gear; . .3. Employees must wash their hands for ten (10) to fifteen (15) seconds using antimicrobial or non-antimicrobial soap and water under the following conditions: a. Before and after direct contact with residents . 3. A lunch meal administration was conduncted on the North unit on 8/26/24 from 12:03 PM to 12:27 PM. Staff L, Certified Nursing Assistant (CNA) was observed to provided 8 residents their meal trays in their rooms and did not sanitize her hands in between residents. An interview was conduncted with Staff L, CNA on 8/26/24 at 12:29 PM she said she is supposed to sanitize or wash her hands in between passing meal trays to the residents and she may not have. She said she tries to wash her hands in the resident's room but there's not always soap in there and she said there is hand sanitizer at the front of the facility. 4. Review of Resident #347's Face Sheet revealed she was admitted to the facility on [DATE] with medical diagnoses, not limited to, intracranial abscess and granuloma, endocarditis, pain, bipolar disorder current episode manic without psychotic features, and psychoactive substance abuse with unspecified psychoactive substance-induced disorder. An observation and interview were conducted on 08/26/24 at 10:46 AM with Resident #347. She was observed to be sitting on her bed eating her breakfast. She was observed to have an intravenous (IV) line in her upper right arm. She said she is receiving intravenous antibiotics for endocarditis, and she had a one-on-one staff member in the room, because she is an IV drug user and has an IV. An observation was conducted at the time of the interview and there were no precaution signs on her door and there were no Personal protective equipment (PPE) outside of her room or immediately available. Review of Resident #347's physician orders revealed an order with a start date of 8/27/24 and an end date of 9/21/24 for Vancomycin 750 milligrams (mg); intravenous special instructions: Infused Q8Hhrs [every 8 hours] via PICC [peripherally inserted central catheter] through 9/21/24 for a diagnosis of intracranial abscess and granuloma. An interview was conducted with the DON and NHA on 08/29/24 at 11:08 AM. The DON said the facility does use enhanced barrier precautions for residents who have candida aureus and methicillin resistant staphylococcus aureus (MRSA). The NHA said she will try and find an enhanced barrier policy. The policy was not provided. Review of the Centers for Disease Control and Prevention (CDC) Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs), dated 4/2/2024, revealed For Awareness Updates as of July 12, 2022 3. Multidrug-resistant organism (MDRO) transmission is common in skilled nursing facilities, contributing to substantial resident morbidity and mortality and increased healthcare costs. 4. Enhanced Barrier Precautions (EBP) are an infection control intervention designed to reduce transmission of resistant organisms that employs targeted gown and glove use during high contact resident care activities. 5. EBP may be indicated (when Contact Precautions do not otherwise apply) for residents with any of the following: 1. Wounds or indwelling medical devices, regardless of MDRO colonization status 2. Infection or colonization with an MDRO. 6. Effective implementation of EBP requires staff training on the proper use of personal protective equipment (PPE) and the availability of PPE and hand hygiene supplies at the point of care. 7. Standard Precautions, which are a group of infection prevention practices, continue to apply to the care of all residents, regardless of suspected or confirmed infection or colonization status. https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/PPE.html. 49497 On 08/26/24 at 10:30 a.m. an Intravenous (IV) pole was observed with Resident #31 receiving an active treatment. There was no PPE supplies, other than surgical gloves in or around the resident's room. No enhance barrier precautions signage was displayed on door, door frame or outside of Resident #31's door. Review of electronic medical record (EMR) for Resident #31 showed an admitted [DATE] with diagnoses including generalized anxiety, major depressive disorder, adjustment disorder with mixed anxiety and depressed mood, unspecified atrial fibrillation, spondylosis lumbar region. Review of physician orders revealed Daptomycin intravenous injection; 600mg; amt: 1; intravenous once a day at 9:00 a.m. Flush with normal saline prior and after administering medication, Rocephin injection 2g intravenous. Flush with normal saline prior to administering medication and after administering medication. Once a day at 12:00 p.m. and Provide standard/universal precautions. Review of the MDS dated [DATE] revealed Section C Brief Interview for Mental Status score of 15 indicating no cognitive impairment and Section O showed resident receiving IV antibiotic medication through a central line. Review of Resident #31's progress notes revealed the following: On 08/28/24 at 7:20 p.m. Resident currently on ABT [antibiotics] has had no adverse reactions PICC [peripherally inserted central catheter] line dressing intact and clean and functioning properly. On 08/28/24 at 3:15 a.m. IV ABX [antibiotics] continued. No s/s [signs or symptoms] of infection. Post-op [post-operative] sling in place. Safety precautions in place. On 08/27/24 at 7:47 p.m. Resident PICC line is intact dressing was changed yesterday and is functioning properly. Resident has had no adverse reactions to ABT therapy and is compliant with current plan of care. On 08/26/24 at 3:38 a.m. Right arm IV line dressing clean and intact. No s/s of infiltration, irritation, redness or edema. No complaints noted by the resident. Continue to monitor. An interview was conducted on 08/28/24 at 9:25 a.m. with Resident #31. He stated when the nurse comes to change his Intravenous (IV) dressing and/or start his IV antibiotics she always wears gloves. He stated she has never worn a gown or mask, just gloves. An interview was conducted on 08/29/24 at 11:49 with Staff P. She stated when she completes Resident #31's Intravenous (IV) treatment or IV dressing change her process is to perform hand hygiene, gather her medication and dressing supplies for performing the treatment, complete hand hygiene again, then dons her surgical gloves. She stated she the completes the treatment, removes gloves and disposes of them, then performs hand hygiene again. She stated she was not aware of enhance barrier precautions at facility. She stated she had not received any training or educational in-service regarding enhance barrier precautions. Review of facility infection control policy dated 2012 showed no reference or documentation regarding enhanced barrier precautions.

Based on interview and record review the facility failed to have a qualified infection Preventionist who was qualified by education, training, experience or certification for one of one staff member acting as the infection Preventionist. Findings include: An interview was conducted on 08/26/24 at 10:41 AM with the Nursing Home Administer (NHA). She said the facility does not have any staff who have completed or started the infection prevention training. She said the current Director of Nursing (DON) started her position the last week of July of 2024 or first week of August 2024 and there has not been any infection surveillance and the NHA was unsure when the last time any infection surveillance had been conducted. An interview was conducted on 08/29/24 at 11:10 AM with the Director of Nursing (DON) she said she started at the facility mid-July as the Unit Manager and became the interim DON two weeks after she started and two weeks ago, she said she would accept the DON position. She said she does not have any formal training in infection control, and she is not certified in infection prevention. She said no one else in the facility is certified. She said she is registered to take the certification, but she is not sure what course to take because there are so many options, so she has not started. She said she had not started gathering infection control documentation until after survey entry and the last infection control documentation she could find was from October of 2022. She said she tried to run antibiotics reports for July but with the electronic medical record system they have it seemed the antibiotic information was incomplete, so she tried to pull the antibiotic information from their pharmacy system and that also seemed incomplete. She said she told the NHA she was not sure what she even needed or what she was even looking for because she had never run an infection prevention program. Review of the facility's infection prevention documentation did not reveal a completed infection prevention education, training, experience or certification for the Director of Nursing. Review of the facility's Surveillance for Infections policy, revised September 2017, revealed Policy Statement The Infection Preventionist will conduct ongoing surveillance for Healthcare-Associated Infections (HAIs) and other epidemiologically significant infections that have substantial impact on potential resident outcome and that may require transmission-based precautions and other preventative interventions. Policy Interpretation and Implementation 1.The purpose of the surveillance of infections is to identify both individual case and trends of epidemiologically significant organisms and Healthcare-Associated Infections, to guide appropriate interventions, and to prevent future infections .

Based on observation, record review and interview the facility failed to ensure a clean, sanitary homelike environment for two out of two units in the facility. Findings include: On 08/26/2024 at 11:00 a.m., an observation was made in room [ROOM NUMBER] revealing a hole in the wall next to the window and the wall border trim separated from the wall. The bathroom was dirty with paint chipped off the shower stall floor, rusted grab bars and yellow staining on the walls. room [ROOM NUMBER] were observed with broken, and missing blinds on the sliding doors and broken dressers in the resident's room. room [ROOM NUMBER] was observed with cable cords unattached from the wall, hanging down in the resident's room. On 08/29/2024 at 5:00 p.m., an interview was conducted with the Maintenance Director. He stated he conducts room audits once a month, but he has not done any room audits since he has started in the position. He knows he has to do some painting. Next week he will come up with a scheduled to repair the broken blinds in resident rooms. He stated he knows he has to fix the holes in the walls in resident rooms and fix other things in the facility but he lacks the time. 49497 Initial facility tour on 08/26/24 at 9:57a.m. Observed on North hallway a one by one foot section of stained ceiling with black circular substance and bubble paint/spackle patches. Floor tiles missing at end of hallway. Two end caps missing off hallway handrail exposing sharp handrail edges. (Photographic Evidence Obtained) On 08/26/22024 at 10:05 a.m. Observed in Resident #26 room a cable wire hanging from ceiling next to the resident's bed with exposed end, bathroom door with spackle patches x 2, and ensuite bathroom floor with multicolored paint and missing paint with red speckled substance on shower ro end. (Photographic Evidence Obtained) On 08/26/24 at 2:39 p.m. observed Resident #9 room with broken window sill tile with exposed sharp edges, red/brownish substance extending the base of the bed frame and bedside table, bedside chair with worn exposed patches of missing stain and loose bed enabler rail. (Photographic Evidence Obtained) An interview was conducted on 08/26/24 at 10:15 a.m. with Resident #31. He stated he shares his bathroom with the two guys next door (referencing Resident #9). He stated, take a look at the bathroom floor, it has been that way since I got here, and nothing has been done. He stated staff were aware and he has been told by facility management it would be painted for months and nothing has happened. On 08/29/24 at 2:40 p.m. a tour and interview was conducted with the Maintenance Director (MD) on north hallway. The MD was shown the exposed floor tiles, ceiling patch with black substance, missing handrail end caps, Resident #26's bathroom floor with missing paint, and hanging cable cord with exposed end and bathroom door. Resident #9's broken window sill tiles, discolored bed frame and bedside table, worn bedside chair with missing stain. The MD stated this was not acceptable and was aware all items shown need to be corrected immediately. 50732 On 08/26/2024 at 10:43 a.m. during an interview with Resident #4, a flying insect was observed on the resident's bed along with three other flies in the room. Also observed under the bed an area of broken floor tiles. (Photographic Evidence Obtained) Observations made on 08/26/2024, 08/27/2024, 08/28/2024 and 08/29/2024 of Resident #27's room. There were three missing vertical slats in the vertical blinds covering the sliding glass door in the room. The room faced a courtyard and Resident #27's bed could be seen from the courtyard through the missing vertical slats. On 08/26/2024 at 10:40 a.m. an observation was made of the North Exit Door, just outside of the room for Resident #1 and Resident #4, of trash on the floor, a bed in the hallway, and a dirty mattress leaning against the wall. (Photographic Evidence Obtained) On 08/26/2024 at 11:08 a.m. an observation was made in Resident #24's room of spilled, dried tube feeding on the pole of the tube feeding machine and on the floor around the pole. (Photographic Evidence Obtained) On 08/26/2024 at 11:03 a.m. an observation was made of the bathroom in room [ROOM NUMBER] of the shower floor tiles which showed dirt and mold on the tiles. (Photographic Evidence Obtained) An interview was conducted with the Maintenance Director on 08/29/2024 at 2:37 p.m. The MD said there was no maintenance person in the facility for quite a while before he started in June. He said he does not currently have an assistant and is doing everything by himself. He said he has quite a list of things to do. The MD said he needs to do room audits in every room to see what needs to be repaired. The Maintenance Director said he doesn't have an actual policy for his job and tasks he should be doing. He said he knows he is supposed to do some painting every week and he has the painting supplies in his office, but he has been too busy to complete any painting. He makes handwritten notes of tasks he needs to do and enters it into his work order system. He stated he does not keep the handwritten notes once he enters it into his work order system. A review of the undated facility policy titled, Homelike Environment, showed: Residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible. The Policy Interpretation and Implementation portion of the policy included the following: 2. The facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. The characteristics include: a. clean, sanitary and orderly environment; e. clean bed and bath linens that are in good condition; f. pleasant and neutral scents. A review of the undated policy titled, Environmental Housekeeping Policy for Nursing Home, showed: 1. Purpose: To maintain a clean, sanitary and safe environment for all residents, staff and visitors. To prevent the spread of infections and ensure the overall well-being of residents. 2. Scope: This policy applies to all areas within the nursing home, including resident rooms, common areas, bathrooms, dining areas and staff workspaces. 3. Responsibilities: Housekeeping Staff: Responsible for performing cleaning tasks as per the schedule and guidelines. Nursing and Medical Staff: Assist in maintaining cleanliness and reporting any issues. Management: Ensure the availability of necessary resources and oversee the implementation of the policy. 4. Cleaning Procedures: Daily Cleaning: Resident rooms-dust, vacuum and clean surfaces. Change bed linens and towels Common areas-clean floors, sanitize high-touch surfaces, and ensure restrooms are stocked and clean. Dining areas-clean and sanitize tables and chairs after each meal, and maintain a clean floor area. Weekly Cleaning: Deep clean carpets and upholstery. Wash windows and dust high surfaces. Monthly Cleaning: Clean vents, light fixtures, and other hard to reach areas. Perform detailed cleaning of other areas. 10. Resident Considerations: Ensure that cleaning practices to not disrupt the daily lives of residents. Accommodate residents' specific needs or preferences regarding cleanliness and comfort.

Based on record review and interviews, the facility failed to ensure the Level I Pre-Admission Screening and Resident Review (PASRR) for residents with a mental disorder and individuals with intellectual disability following qualifying mental health diagnoses were accurate for nine residents (#25, #27, #24, #26, #7, #4, #35, #28, #39) out of 20 residents sampled. 1. Review of Resident #4's Admission Record showed Resident #4 was originally admitted on [DATE] with a readmitted [DATE] after returning to the facility from a hospitalization . Resident #4's Admission Record showed he was admitted to the facility with diagnoses to include Psychoactive Substance Dependence and Alcohol Dependence. Review of the Level I Preadmission Screening and Resident Review Process (PASRR) for Resident #4 dated 04/12/2024 revealed an incomplete PASRR with the qualifying diagnosis of Substance Abuse not checked in Section I: PASRR Screen Decision-Making. A 04/17/2024 psychiatric evaluation completed in the facility revealed the resident was diagnosed with major depressive disorder and generalized anxiety disorder. Record review of Resident #4's medical chart revealed an updated PASRR was not completed by the facility to include the new qualifying psychiatric diagnoses. 2. Review of Resident #27's Admission Record showed Resident #27 was admitted to the facility on [DATE] with diagnoses to include Depression. Review of the Level I PASRR for Resident #27 dated 06/06/2024 revealed an incomplete PASRR with the qualifying diagnoses of depression not checked in Section I: PASRR Screen Decision-Making. 3. Review of Resident #39's Admission Record showed Resident #39 was admitted to the facility on [DATE] with diagnoses to include anxiety disorder. Review of the Level I PASRR for Resident #39 dated 09/19/2023 revealed an incomplete PASRR with the qualifying diagnosis for anxiety disorder not checked in Section I: PASRR Screen Decision-Making. 4. Review of Resident #35's Admission Record showed Resident #35 was admitted to the facility on [DATE] with diagnoses to include diffuse traumatic brain injury, depression, nightmare disorder and generalized anxiety disorder. Resident #35 was admitted during the 1135 Waiver Period, which ended on 05/11/2023. Providers must resume compliance with normal rules and regulations as soon as they are able to do so after the end of the waiver period. Review of Resident #35's medical record revealed no PASRR was completed for this resident after the 1135 Waiver Period concluded. An interview was conducted with the Social Services Director (SSD) on 08/29/2024 at 9:03 a.m. The SSD said he is not responsible for completing the PASRRs. He said there is currently no Admissions Director (AD) and the Nursing Home Administrator (NHA) has been responsible for ensuring the completion of the PASRRs. 51062 5. A Review of Resident #25's resident census report revealed Resident #25 was admitted to the facility on [DATE]. A review of Resident #25's Admission Record revealed diagnoses to include but not limited to cognitive communication deficit, other psychoactive substance abuse, delusional disorders, auditory hallucinations, and schizoaffective disorder. A review of the resident #25's Electronic Medical Records revealed no PASRR documentation in the resident's records. A request for Resident #25's PASRR from the Nursing Home Administrator (NHA) revealed the resident did not have a completed PASRR. 39866 6. Review of Resident #7's Face sheet revealed he was admitted to the facility on [DATE] with medical diagnoses of Schizophrenia, auditory hallucinations, major depressive disorder, dementia with psychotic disturbance, generalized anxiety disorder, and sedative, hypnotic or anxiolytic use, unspecified with sedative, hypnotic or anxiolytic-induced anxiety disorder. Review of Resident #7's medical record did not reveal a PASRR was completed. Review of Resident #7's Annual minimal data set (MDS), dated [DATE], section I, Active Diagnoses, revealed Psychiatric/Mood Disorder diagnoses of anxiety disorder, depression, and schizophrenia. Review of Resident #7's admission MDS, dated [DATE], section I, active diagnoses revealed psychiatric/mood disorder diagnoses of anxiety disorder and depression. 46498 7. Review of an Admission Record dated 8/29/2024 showed Resident # 24 was admitted to the facility on [DATE] with diagnosis to include but not limited to bipolar disorder, unspecified, Depression, Unspecified, Suicidal Ideations, Generalized Anxiety. Review of a Minimum Data Set (MDS) dated [DATE] showed Resident # 24 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated cognitively intact. Review of the Preadmission Screening and Resident Review (PASRR) Notice of the Need for Further Evaluation dated 5/27/2024 showed Resident # 24 had a level I PASRR screen completed, with evidence of a serious illness were found. Further review showed Resident # 24 required to have a Level II screen completed but the facility did not obtain the Level II screen. 8. Review of an Admission Record dated 8/29/2024 showed Resident # 28 was admitted to the facility 12/01/2023 with diagnosis to included but not limited to Schizophrenia, unspecified, Unspecified lack of coordination, mood disorder due to known physiological condition, unspecified, anxiety disorder, unspecified, adjustment disorder with depressed mood. Review of a Minimum Data Set (MDS) dated [DATE] showed Resident # 28 had a Brief Interview for Mental Status (BIMS) score of 06, which indicated severely impaired. Review of the Electronic Medical Record (EMR) showed no evidence of a level I PASRR for Resident # 28. 49497 9. Review of electronic medical record (EMR) for Resident #26 showed an admission to facility on 02/13/24 with diagnoses including mood disorder due to known physiological condition, depression, cognitive communication disorder, and unspecified dementia. Review of Resident #26's Minimum Data Set (MDS) dated [DATE] revealed, Section C Brief Interview for Mental Status (BIMS) score of 1 indicating severe cognitive impairment. Review of the care plan for Resident #26 dated 03/08/24 with last revised date of 08/16/24 revealed, a problem of Resident takes antipsychotic medication putting him/her at risk of complications. Dx {diagnosis] of Mood d/o [disorder], with a goal of Resident will not have any adverse side effects from antipsychotic medication through the review date, and a problem of Resident takes antidepressant medication putting him/her at risk of developing complications with a goal of Resident will not experience complications from use through the review date. Review of physician orders for Resident #26 revealed, Aricept tablet 10mg 1 tablet at bedtime, Depakote delayed release 125mg every 12 hours, Lexapro 10mg tablet once a day, Namenda 10mg tablet once a day. Review of the medical record showed no Preadmission Screening and Record Review (PASARR) uploaded. Request made for Resident #26 PASARR on 08/26/24, facility unable to provide by exit on 08/29/24. An interview conducted with the Nursing Home Administrator (NHA) on 08/27/24 at 10:04 a.m. She stated residents that were admitted to facility during time of COVID did not require a PASARR because they had the COVID waiver. She confirmed the COVID waiver ended on 05/11/2023. She stated the facility did not complete any PASARR's for residents that were admitted under the COVID waiver and remained in the facility. She stated, I didn't know we were supposed to. The NHA provided a list of three residents (Residents #25, #7, #36) that were admitted without PASRR's during COVID 1135 waiver that are current residents at facility. She stated she was still looking for Resident #26's PASARR. She confirmed Resident #26 was not admitted during the COVID waiver. An interview was conducted on 08/29/24 at 9:15 a.m. with NHA. She stated the admissions department typically completes PASRRS. She stated we do not currently have an admissions director. She stated she is covering until facility gets position filled. She stated she is ensuring PASRRs are completed prior to admission, until the new admission director is hired and trained. Review of facility undated PASRR Policy provided by NHA revealed the policy statement The Center will a [grammatical error] make sure that all admissions have the appropriate Patient Assessment and Resident Review (PASRR) completed. The NHA provided a copy of the COVID 1135 waiver that revealed: Level one assessments may be performed post-admission. On or before the 30th day of admission, new patients admitted to nursing homes with a mental illness (MI), or intellectual disability (ID) should be referred promptly by the nursing home to state PASARR program for Level two Resident Review. Updated 10/13/2022

Based on observations, record review, and interviews, the facility failed to ensure medications were stored in a secure and safe manner for one resident (Resident #2) of one resident allowed to self-administer medications, and leaving medication unattended on one (North) of two medication carts . Findings included: 1. On 12/26/24 at 9:13 a.m., Resident #2 was observed lying in bed with an over-bed table hovering over the bed and a table next to the bed with a nebulizer machine sitting on it. A nebulizer pipe was connected to the machine. The observation revealed a foil container labeled Anoro Ellipta on top of a pharmacy bag and a vial of clear liquid under the bag sitting on the over-bed table. A vial of clear liquid was observed lying on top of the nebulizer machine. The resident stated the vial on the nebulizer machine was the 6:00 a.m. dose of Albuterol and they were able to self-administer medications, but hadn't woken up to take the 6 a.m. dose, and the vial on the over-bed table was the noon dose (of Albuterol). The resident was wearing a nasal cannula in the nares and the concentrator next to the bed was set at 4 liters per minute. An interview was conducted on 12/26/24 at 9:14 a.m. with Staff B, Licensed Practical Nurse (LPN). The staff member reported being done with med pass, reviewed Resident #2's physician orders, and stated the resident was able to self-administer Albuterol, but not the Anoro Ellipta. The staff member also stated the process for self-administration of medications was to make sure the resident received it, set it up for them, and stay with them during the administration. On 12/26/24 at 9:19 a.m. Resident #2 was observed with Staff B, LPN. The staff member reported leaving the Anoro in the room due to having to run to the bathroom, and she came in at 7 a.m. so the 6 a.m. dose of Albuterol (lying on the nebulizer) was before the staff member had arrived for her shift. Staff B, LPN reported not giving the noon dose of Albuterol (under the Anoro Ellipta) to the resident. On 12/26/24 at 1:22 p.m. an observation was made of two (2) vials containing a clear liquid in a clear plastic cup on Resident #2's over-bed table. Review of Resident #2's Face Sheet showed the resident was admitted on [DATE]. The Face Sheet revealed diagnoses not limited to chronic respiratory failure unspecified whether with hypoxia or hypercapnia, chronic obstructive pulmonary disease (chronic obstructive pulmonary disease) with (acute) exacerbation, and unspecified combined systolic (congestive) and diastolic (congestive) heart failure. Review of Resident #2's Self-Administration of Medication and/or Enteral Feeding evaluation dated 12/18/24 showed the Facility will set up meds for resident. Review of the facility policy titled Policy for Nursing Home Resident Self-Administration of Medications, undated, revealed medications should be stored in a secure location, accessible to the resident, if the resident desires to store the medication at bedside. Review of a letter sent by the Nursing Home Administrator (NHA) and signed by Resident #2, dated November 22, 2024, showed all over the counter and prescription medications required a physicians order and must be kept on the facility medication cart until time for administration. Neither an over the counter or any prescription medication may be kept at bedside. The letter was signed by the NHA and Resident #2. 2. On 12/26/24 at 10:20 a.m., Staff B, LPN was observed during the task of medication administration placing a bottle of glucose testing strips into a bag containing Resident #7's FIASP FlexTouch insulin pen. Resident #8 asked the Staff B, LPN for ice. Staff B, LPN placed the insulin bag on the medication cart and went into a room at the corner of the North Hall, returning shortly, and explaining to the resident there was no ice. During the time the staff member was inside the room retrieving ice for the resident, the bag containing the pen of insulin was out of the staff member's sight and unattended on the medication cart. Review of the undated policy titled Storage of Medications revealed the Policy Statement, the facility stores all drugs and biologicals in a safe, secure, in orderly manner. The policy also revealed the following under Policy Interpretation and Implementation: 1. Drugs and biologicals used in the facility are stored in lot compartments under proper temperature, light, and humidity controls. 2. Drugs and biologicals are stored in the packaging, containers or other dispensing systems in which they are received. Only the issuing pharmacy is authorized to transfer medications between containers. 3. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner.

Based on observation, interview and record review the facility failed to assess with an Interdisciplinary Team approach, obtain physician orders and develop a Comprehensive Person-Centered Care Plan for two of two sampled residents (#50 and #51) related to administering their own medications. Findings included: 1. Resident #51 was admitted on [DATE]. Review of the Resident Face Sheet showed diagnoses including acute bronchitis, shortness of breath, and anxiety disorder. An observation was conducted on 10/30/2024 at 9:08 a.m. with Staff A, Licensed Practical Nurse (LPN) for Resident #51's medication administration. Resident #51 was sitting in his bed. A bottle of Normal Saline Nasal Spray was sitting on the bedside table as well as lotion. A second observation occurred on 10/30/2024 at 1:40 p.m. with the Director of Nursing (DON). The DON asked the resident where the nasal spray came from. He stated his family brought it in for him. She informed him they would need to get an order for the spray and place it in the medication cart. The resident stated he was not using it, and she could take it. During an interview after exiting the room, the DON stated the resident had not been evaluated for performing administration of his own medications. The DON stated the resident had to be evaluated, have the Interdisciplinary Team (IDT) meeting and discuss with the physician. They would also need a physician's order. The DON stated the care plan would also have to be updated. Review of the October 2024 physician's orders did not show an order for nasal spray. Review of the medical record did not reveal an evaluation for self-medicating. Review of the care plans did not show interventions to include self-medicating. 2. Resident #50 was admitted on [DATE]. Review of the Resident Face Sheet showed diagnoses including chronic pain due to trauma-facial pain, glaucoma, chronic obstructive pulmonary disease, and schizoaffective disorder. Review of the October 2024 physician orders showed: Visine tears 15 ml (milliliter) drop both eyes 4 x day, 12, 4 a.m. 8 a.m. 12 p.m., 4 p.m., 8 p.m. given late at 9:56 a.m. Review of the medical record did not reveal an evaluation for self-medicating. Review of the care plans did not show interventions to include self-medicating. An observation was conducted on 10/30/2024 at 9:34 a.m. with Staff B, LPN for Resident #50's medication administration. Resident #50 was lying in bed. Staff B, LPN entered the room with a cup of medications and eye drops in the labeled plastic bag. Staff B applied gloves and handed the resident his eye drops from the plastic bag. She laid the plastic bag on the overbed table (no barrier). The resident was observed administering his own eye drops. Staff B handed him a tissue. Staff B picked up the plastic bag from the table, she placed the eye dops under her left arm and then placed them into the plastic bag and removed her gloves. She then exited the room. During an interview on 10/31/2024 at 2:25 p.m. with the Director of Nursing (DON) she stated none of the current residents had been evaluated for self-medicating. The DON stated that Resident #50 was a new resident. The DON stated that he had not been evaluated to perform self- medication. The DON stated he should not be administering his own eye drops. Review of the facility's policy titled, Administering Medications, not dated, showed medication shall be administered in a safe and timely manner, and as prescribed. 24. Residents may self-administer their own medication only if the Attending Physician, in conjunction with the Interdisciplinary Care Planning Team, has determined that they have the decision-making capacity to do so safely. Review of the facility's policy titled, Self-Administering of Medications, showed the Purpose to outline the guidelines and procedures for residents who are capable of self-administering their medications safely. Scope 1. Eligibility Criteria: residents must be assessed by a qualified health care professional to determine their capability to self- administer medications. Consider factors such as cognitive function, physical ability, and understanding of medication purposes and schedules. 2. Assessment Process: Conduct a comprehensive assessment that includes: Review of medical history and current medications. Evaluation of cognitive and physical abilities. Interviews with the resident and family members, if applicable. 3. Education and Training: Residents who are eligible for self-administration must receive education on: The purpose and dosage of their medications. Proper storage and handling of medications. Recognizing side effects and when to seek help. Staff should provide ongoing support and periodic reevaluations. 4. Medication Management Plan: Develop an individualized medication plan that includes: A list of approved medications for self-administration. A schedule for medication administration. Instructions for missed doses. 5. Storage and Accessibility: Medications should be stored in a secure location, accessible to the patient. Ensure that medications are organized to prevent confusion. 6. Monitoring and Documentation: Staff must regularly monitor residents who self-administer medications for: Adherence to the medication management plan. Any adverse reactions or issues arising from self-administration. Document all observations and any changes in the residence condition.

Based on observation, record review and interviews the facility failed to develop and/or implement an effective care plan for two (#35 and #24) residents out of 20 sampled residents. Findings included: 1. On 08/26/2024, 08/27/2024, 08/28/2024 and 08/29/2024 at various times of the day Resident #35's bed was observed to be in the high position. Review of the Admission Record showed Resident #35 was admitted to the facility on [DATE]. The record revealed diagnoses not limited to diffuse traumatic brain injury, nightmare disorder, depression, generalized anxiety disorder, postconcussional syndrome. Review of the Annual Minimum Data Set (MDS) Quarterly Assessment, dated 07/29/2024, Section C-Cognitive Patterns, showed Resident #35 had a Brief Interview for Mental Status (BIMS) score of 9, showing he has moderate cognitive impairment. Section GG-Functional Abilities and Goals, showed Resident #35 needs Partial/Moderate Assistance to come to a standing position from sitting in a chair, wheelchair, or on the side of the bed. Section GG also showed the Resident needs Partial/Moderate Assistance to transfer to and from a bed to his wheelchair. Review of the Care Plan for Resident #35 revealed the following: The Resident is at risk for falling related to traumatic brain injury (TBI) with impaired cognition with poor decision making, weakness, urinary incontinence, use of psychotropic medication daily. The Resident will remain free from injury. Keep bed in lowest position with the brakes locked. During an interview on 08/29/2024 at 9:54 a.m. with Staff L, Certified Nursing Assistant (CNA), she said Resident #35 always raises the bed on his own and he gets mad if it is lowered. Staff L said is was not aware of the Care Plan stating the bed should always be in the low position. During an interview on 08/29/2024 at 12:26 p.m. with the Director of Nursing (DON), she said she does not know why Resident #35's bed is in the high position. The DON also stated she was not aware of the Care Plan stating the bed should be in the low position or why the bed should be in the low position. 46498 2. On 08/27/2024 at 2:22 p.m., Resident #24 was observed sitting outside smoking a cigarette without supervision. She showed no signs of distress. Resident was dressed and well-groomed with a latex glove on her right hand while smoking. She stated that she wears the latex glove because she has a staph infection all over her body, so she has to wear the glove on her right hand. Review of an Admission Record dated 8/29/2024 showed Resident # 24 was admitted to the facility on [DATE] with diagnosis to include but not limited to bipolar disorder, unspecified, Depression, Unspecified, Suicidal Ideations, Generalized Anxiety. Review of a Minimum Data Set (MDS) dated [DATE] showed Resident # 24 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated cognitively intact. Review of the observation for safe smoking evaluation dated 6/10/24 showed an incomplete smoking evaluation created by Staff U, the Social Services Director. On 08/29/2024 at 5: 30 pm., an interview was conducted with Staff U, the Social Services Director. He stated he completes all the smoking evaluation in the facility on all residents. He was told by the administrator that he did not have to complete the whole smoking evaluation just section 1 and the sensory section on the evaluation. After you interviewed me yesterday, I went back and completed the smoking observation. He stated he only does the smoking observations and not the care plans. On 08/29/24 at 11:05 am., an interview was conducted with Staff B, the Regional Director of Clinical Reimbursement. She stated typically nursing or the social worker would do the resident smoking observation to see if they are a safe smoker. The nursing or the social services director is responsible for creating the smoking care plan after the observation is complete. Social Service or the Minimum Data Set (MDS) nurse would create a smoking care plan on the resident. If there is not one in the system, then a care plan was not created. She reviewed the resident care plan and stated that she did not see a smoking care plan for Resident # 24. She should have had a smoking care plan completed. I don't know why the social worker would do the observations and not create a smoking care plan. I have to come to the facility and do some education with staff regarding care plans. Review of the facility policy, titled, Care Plans and Care Plan Meetings, date revised on 10/4/18 showed, It Is the responsibility of the Interdisciplinary Team to: Conduct an assessment of the resident's strengths and needs. Incorporate the resident's personal and cultural preferences in developing goals of care. Comprehensive Care Plan - A comprehensive care plan must be developed within seven days after the completion of the comprehensive assessment.

Based on observation, record review and interviews the facility failed to ensure Minimum Data Set (MDS) Assessments were completed in a timely manner for two (#20 and #33) residents out of 20 sampled residents. Findings included: 1. On 08/29/2024 it was observed the Quarterly MDS Assessment for Resident #33 was due to be completed on 07/15/2024, however the Quarterly MDS Assessment was not completed and transmitted until 08/20/2024. Review of the Admission Record showed Resident #33 was admitted to the facility on [DATE]. 49497 Review of Resident #20 electronic medical record showed an admission to facility on 04/06/2022. Review of Minimum Data Set (MDS) dated [DATE] showed a status of finalized. Section Z assessment administration part Z0500 Verifying Assessment Completion was signed by Staff A and dated 08/20/2024. An interview was conducted on 08/28/24 at 4:05 p.m. with Staff A. She stated if an MDS assessment status showed finalized it had been completed, but has not been transmitted. She confirmed Residents #20 and Resident #33 quarterly MDS assessments scheduled on 07/15/24 both showed finalized status. She stated she did not know why they had not been transmitted within 14 days of the scheduled assessment date of 07/15/24, it was an oversight. An interview was conducted on 08/28/24 at 4:25 p.m. with Staff B. She stated Resident #20 and #33 assessments were missed. When she discovered the error, she scheduled their assessments and made sure they were completed. She confirmed Resident #20 and #33's assessments were not completed timely. She stated all assessment should be completed within 14 days of being scheduled. She stated the 07/15/24 quarterly MDS assessments for Resident #20 and #33 were completed on 08/20/24 past the 14 day expectation.

Based on record review and interviews the facility failed to ensure the accuracy of the Resident Assessment Minimum Data Set (MDS) for two residents (#10, #9) of 20 residents reviewed. Findings included: 1. A review of Resident #10's Admission Record revealed she was admitted to the facility on [DATE] with diagnoses to include but not limited to obstructive and reflux uropathy and diabetes mellitus due to underlying condition with diabetic nephropathy. A review of Resident #10's physician's order dated 10/28/2023 revealed foley/supra-pubic: change catheter PRN (as needed) leakage, blockage or dislodgement. A review of Resident #10's nursing progress note dated 10/30/2023 revealed: Alert and oriented resident able to make all needs known to staff. Tolerated all medications administered no adverse effects noted. Resident advised nurse during medication pass that she had broken her catheter. Upon examination nurse found catheter bulb out. Catheter remained out. Nursing notified physician and are awaiting further instructions to either put catheter back in or leave out. A review of the resident #10's MDS assessments revealed: Admission MDS assessment dated [DATE], Section H - Bladder and Bowel A. was marked yes for indwelling catheter (including suprapubic catheter and nephrostomy tube). Quarterly MDS assessment dated [DATE], Section H - Bladder and Bowel A. was marked yes for indwelling catheter (including suprapubic catheter and nephrostomy tube). Quarterly MDS assessment dated [DATE], Section H - Bladder and Bowel A. was marked yes for indwelling catheter (including suprapubic catheter and nephrostomy tube). Quarterly MDS assessment dated [DATE], Section H - Bladder and Bowel A. was marked yes for indwelling catheter (including suprapubic catheter and nephrostomy tube). During an interview on 08/26/2024 at 3:00 PM, Staff E, Licensed Practical Nurse (LPN) stated he did not think Resident #10 had a catheter, but he is new and still in training. During an interview on 08/27/2024 at 10:10 AM, Staff F, LPN stated Resident #10 does not have a catheter. During an interview on 08/27/2024 at 10:15 AM, Staff O, Certified Nursing Assistant (CNA) stated she did not know anything about Resident #10 having a catheter. During an interview on 08/27/24 at 2:50 PM, Resident #10 stated she had a catheter a year ago when she came to the facility. It was removed right after she got to the facility, and she has not had anything since. A review of Resident #10's physician's order dated 08/27/2024 revealed foley/supra-pubic: change catheter PRN (as needed) leakage, blockage or dislodgement discontinued. Discontinue note, catheter not in place as of 10/30/2023. During a phone interview on 08/28/2024 at 2:00 PM, Staff B, Regional Director of Clinical Reimbursement (RDCR) stated she works remote, so she is on the prospective payment system (PPS) calls every day and she is also on the utilization review calls. She stated she uses source documentation to complete the MDS, so she is relying on nursing notes and doctor's orders. She stated the facility does have a part-time MDS person who goes into the facility and is a Registered Nurse (RN). This person does most of the actual physical assessments. Staff B, RDCR stated she reviewed Resident #10's MDS for 11/03/2024, 02/09/2024, 05/05/2024, and 08/07/2024, section H and all indicated the resident had a catheter. Staff B, RDCR stated, I don't have a reasonable explanation to give you. During an interview on 08/28/2024 at 4:03 PM, Staff A, RN/MDS Coordinator (RN/MDSC) stated Staff B, RDCR provides her with a list of residents who need to have an MDS completed. She stated she talks to the residents and completes the assessments. Staff A, RN/MDSC reviewed the MDS assessments for Resident #10, Section H and stated, I don't know what happened with that. 49497 2. On 8/26/2024 at 2:39PM Resident #9's bed was observed to have bilateral enabler rails. Review of electronic medical record (EMR) for Resident #9 showed an admission to facility on 12/04/23 with diagnoses including lymphedema, unspecified convulsions, restless agitation, generalized anxiety, cellulitis of right lower limb, and Ichthyosis vulgaris. Review of the Minimum Data Set (MDS) dated [DATE] revealed, Section C Brief Interview for Mental Status (BIMS) score of 15 indicating no cognitive impairment, Section GG showed resident was independent with bed mobility, transfers, upper and lower body dressing, personal and toileting hygiene and Section P P0100, Physical Restraints showed Part A Bed rails marked not used. Review of Care plan dated 06/14/2024 revealed, a problem of Urinary Incontinence, with an approach Offer assistance with toileting and incontinence care needs frequently, a problem of Resident is not independent with upper and lower body dressing, with an approach Provide assistance with dressing. Provide assistance with putting on socks and shoes on and taking them off when needed. Resident may require extensive assistance at times if he is feeling fatigued or weakness. Review of Resident #9's side rail assessment completed on 06/14/24 revealed it was incomplete. It showed medical reason for side rail box filled in no side rail. Section Risks and Benefits part date the risks/benefits were explained and to who was blank. Sections Signatures part Informed consent and Nurse signature and date were blank. During an interview conducted on 08/28/24 at 9:17 a.m. with Resident #9 he stated he used the enablers all the time to help him roll in the bed and pull himself up in the bed when he slides down. He stated when he sits on the edge of bed for staff to put on my shoes he must hold on the rail to keep my balance. He stated sometimes he can do it by himself, but it takes a long time and needs the enabler for support, so I don't fall. Review of the undated Nursing Home Side Rail Policy revealed Section 5.1 Assessments showed A comprehensive assessment of each resident will be conducted to determine the need for side rails. Review of section P of MDS dated [DATE] Section GG shows Resident #9 is independent with dressing and hygiene.

Based on observation, interview and record review the facility failed to assess with an Interdisciplinary Team approach, obtain physician orders and develop a Comprehensive Person-Centered Care Plan for two of two sampled residents (#50 and #51) related to administering their own medications. Findings included: 1. Resident #51 was admitted on [DATE]. Review of the Resident Face Sheet showed diagnoses including acute bronchitis, shortness of breath, and anxiety disorder. An observation was conducted on 10/30/2024 at 9:08 a.m. with Staff A, Licensed Practical Nurse (LPN) for Resident #51's medication administration. Resident #51 was sitting in his bed. A bottle of Normal Saline Nasal Spray was sitting on the bedside table as well as lotion. A second observation occurred on 10/30/2024 at 1:40 p.m. with the Director of Nursing (DON). The DON asked the resident where the nasal spray came from. He stated his family brought it in for him. She informed him they would need to get an order for the spray and place it in the medication cart. The resident stated he was not using it, and she could take it. During an interview after exiting the room, the DON stated the resident had not been evaluated for performing administration of his own medications. The DON stated the resident had to be evaluated, have the Interdisciplinary Team (IDT) meeting and discuss with the physician. They would also need a physician's order. The DON stated the care plan would also have to be updated. Review of the October 2024 physician's orders did not show an order for nasal spray. Review of the medical record did not reveal an evaluation for self-medicating. Review of the care plans did not show interventions to include self-medicating. 2. Resident #50 was admitted on [DATE]. Review of the Resident Face Sheet showed diagnoses including chronic pain due to trauma-facial pain, glaucoma, chronic obstructive pulmonary disease, and schizoaffective disorder. Review of the October 2024 physician orders showed: Visine tears 15 ml (milliliter) drop both eyes 4 x day, 12, 4 a.m. 8 a.m. 12 p.m., 4 p.m., 8 p.m. given late at 9:56 a.m. Review of the medical record did not reveal an evaluation for self-medicating. Review of the care plans did not show interventions to include self-medicating. An observation was conducted on 10/30/2024 at 9:34 a.m. with Staff B, LPN for Resident #50's medication administration. Resident #50 was lying in bed. Staff B, LPN entered the room with a cup of medications and eye drops in the labeled plastic bag. Staff B applied gloves and handed the resident his eye drops from the plastic bag. She laid the plastic bag on the overbed table (no barrier). The resident was observed administering his own eye drops. Staff B handed him a tissue. Staff B picked up the plastic bag from the table, she placed the eye dops under her left arm and then placed them into the plastic bag and removed her gloves. She then exited the room. During an interview on 10/31/2024 at 2:25 p.m. with the Director of Nursing (DON) she stated none of the current residents had been evaluated for self-medicating. The DON stated that Resident #50 was a new resident. The DON stated that he had not been evaluated to perform self- medication. The DON stated he should not be administering his own eye drops. Review of the facility's policy titled, Administering Medications, not dated, showed medication shall be administered in a safe and timely manner, and as prescribed. 24. Residents may self-administer their own medication only if the Attending Physician, in conjunction with the Interdisciplinary Care Planning Team, has determined that they have the decision-making capacity to do so safely. Review of the facility's policy titled, Self-Administering of Medications, showed the Purpose to outline the guidelines and procedures for residents who are capable of self-administering their medications safely. Scope 1. Eligibility Criteria: residents must be assessed by a qualified health care professional to determine their capability to self- administer medications. Consider factors such as cognitive function, physical ability, and understanding of medication purposes and schedules. 2. Assessment Process: Conduct a comprehensive assessment that includes: Review of medical history and current medications. Evaluation of cognitive and physical abilities. Interviews with the resident and family members, if applicable. 3. Education and Training: Residents who are eligible for self-administration must receive education on: The purpose and dosage of their medications. Proper storage and handling of medications. Recognizing side effects and when to seek help. Staff should provide ongoing support and periodic reevaluations. 4. Medication Management Plan: Develop an individualized medication plan that includes: A list of approved medications for self-administration. A schedule for medication administration. Instructions for missed doses. 5. Storage and Accessibility: Medications should be stored in a secure location, accessible to the patient. Ensure that medications are organized to prevent confusion. 6. Monitoring and Documentation: Staff must regularly monitor residents who self-administer medications for: Adherence to the medication management plan. Any adverse reactions or issues arising from self-administration. Document all observations and any changes in the residence condition.

Based on observations, interviews, and record review the facility failed to ensure one resident (#7) out of one sampled residents received assistance to maintain good grooming and personal hygiene. Findings included: Review of Resident #7's Face Sheet revealed he was admitted to the facility on [DATE] with medical diagnoses of cerebral palsy, lack of coordination, dysphagia, dementia, major depressive disorder, and abnormalities of gait and mobility. An observation and interview were conducted on 08/26/24 at 10:09 AM with Resident #7 he was observed to be lying in bed with his facial hair grown out and his fingernails on both hands grown out past his fingertips with black and brown substance under the majority of his nails on both hands. Resident #7 said he gets a bed bath, and they will shave him but he has not been shaved for about two weeks and he likes to be clean shaven. He looked at his nails on both of his hands and said he wanted his nails trimmed he does not like them long. An observation was conducted on 08/27/24 at 8:48 AM. Resident #7 was observed in bed, eyes closed, with his facial hair grown out and his nails extended past his fingertips with black and brown substances under his nails bilaterally. An observation was conducted on 08/29/24 at 8:55 AM. Resident #7 was observed to be in bed eyes closed, hair disheveled, facial hair was grown out, and nails were extended past his fingertips with brown and black substances under his nails. An interview was conducted on 08/29/24 at 9:00 AM with Staff K, Certified Nursing Assistant (CNA). She said she was taking care of Resident #7 today. She said she thinks he gets a shower on the 3:00 PM-11:00 PM shift because she had not given him a shower and she noticed yesterday his hair needed to be washed, and his nails were long and dirty. She said she doesn't like to clip nails because her eye sight is not good. She confirmed his facial hair was grown out. She said on the assignment board they put who gets a shower for each shift and they document on paper shower sheets and they put them in the shower book. She said they document when a resident is shaved in the computer but they had changed the documentation and it only asks how much assistance the resident needs for shaving and the documentation does not ask if shaving was performed. She exited the room and returned with several wash cloths in her hand and said to Staff D, Licensed Practical Nurse (LPN), there are no towels I only have hand towels, I could ask laundry or I could use a sheet to clean him up. She told Staff D, LPN I don't want to clip his nails because my eye sight is bad. Staff K, CNA then looked at Resident #7's roommate and asked the roommate if Resident #7 had an electric razor and the roommate said he did not know. An interview was conducted on 08/29/24 at 09:05 AM with Staff D, LPN. She observed Resident #7's nails and said his nails needed to be cleaned and trimmed. Review of Resident #7's Care plan with a start date of 7/18/2022 and a revised date of 5/30/24 revealed Problem: Resident has functional limitations and weakness r/t [related to] chronic health conditions and staff must assist to ensure care needs are met. The goal included Will continue to tolerate assistance with care without daily discomfort through the review date. The intervention revealed Approach: .Provide supervision to extensive assistance for care and report changes if any are noted. Review of the Shower Schedule revealed Resident #7 is scheduled to receive showers on the 3:00 PM-11:00 PM shift on Tuesdays and Fridays. Review of the point of care CNA documentation for August revealed Resident #7 was dependent or needed maximum assistance for How did the resident maintain personal hygiene, including combing hair, shaving, applying makeup, washing/drying face and hands (excludes baths, showers, and oral hygiene)? Review of Resident #7's August shower sheets revealed he refused a shower on 8/2/24 and 8/9/24. He received a shower on 8/6/24, 8/23/24, and 8/27/24. There was no documentation Resident #7 received a shower from 8/10/24 through 8/22/24 Review of Resident #7's medical record did not revealed documentation Resident #7's nails were trimmed or he was shaved for the month of August. An interview was conducted on 08/29/24 at 11:15 PM with the Director of Nursing (DON) she said Resident's should be receiving their showers on their scheduled days and if they want a shower in between they are to receive showers whenever they want one. She said residents should be clean, shaved, and nails trimmed and cleaned if they want them. She said staff should be documenting when showers are performed on the shower sheets and those are stored in the shower book and uploaded into the resident's medical record. Review of the facility's Bath, Shower/Tub policy, undated, revealed, Purpose, The purpose of this procedure are to promote cleanliness, provide comfort to the resident and to observe the condition of resident's skin .

Based on observations, interview, and record review 1. The facility failed to provide oxygen according to physician's orders for one resident (#7) out of 2 sampled residents, and 2. the facility failed to ensure flammable products (petroleum jelly) were not used during oxygen use for one resident (#25) out of 2 sampled residents. Findings included: 1. Review of Resident #7's Face Sheet revealed he was admitted to the facility on [DATE] with medical diagnoses of chronic obstructive pulmonary disease, (COPD), cerebral palsy, lack of coordination, dysphagia, oropharyngeal phase, and dementia. An observation and interview were conducted on 8/26/24 at 10:09 AM with Resident #7. He was observed to be lying in bed, with an oxygen concentrator on and set to 3.5 liters per minute (LPM). The nasal cannula was located behind his head and not in his nares. Resident #7 said he was breathing fine and was not sure why he had the oxygen, but he had been on it for a while, and he was not sure how much oxygen he was supposed to be receiving. (Photographic evidence obtained). An observation was conducted on 08/27/24 at 8:48 AM Resident #7 was observed in bed, eyes closed, with his nasal cannula in his nares. The oxygen concentrator was on and set to administer 3.5 LPM. An observation was conducted on 08/29/24 at 8:50 AM Resident #7 was observed to be in bed eyes closed. The nasal cannula was in his nose with the oxygen concentrator on and set to 3.5 LPM. Review of Resident #7's physician orders revealed an order with a start date of 5/19/24 and no end date for O2 [oxygen] via NC [nasal cannula] continuous up to 5 liters to maintain 02% 90 and above every shift. Further physician order review revealed an order with a start date of 3/25/24 and no end date for Oxygen 2 Liters PRN [as needed] special instructions: via nasal cannula sats [oxygen saturation level] below 92% as needed. An interview was conducted with Resident #7's nurse, Staff D, Licensed Practical Nurse (LPN) she reviewed Resident #7's medical record and said he was supposed to be on oxygen, 2 LPM as needed to maintain oxygen saturations above 93%. she entered into Resident #7's room, looked at the oxygen concentrator and said it looks like the resident is on 3LPM of oxygen. She turned the oxygen level down to 2LPM and checked his oxygen saturations and said he is at 93%. Review of Resident #7's treatment Administration record (TAR) revealed the physician's order 02 via NC continuous up to 5 liters to maintain 02% 90 and above every shift was documented every day as administered with documented oxygen saturations of 90% and above for the month of August. Review of the physician order Oxygen 2Liters PRN via nasal cannula sats below 92% revealed no documentation for the month of August. An interview was conducted with the Director of Nursing (DON) on 08/29/24 at 11:48 AM. The DON reviewed Resident #7's physician orders and confirmed he had a 5LPM oxygen order and an as needed 2L oxygen order. She said she did not know why he has two oxygen orders but said if his oxygen was set to 3.5 LPM that does not follow either of the physician's orders. 51062 2. A Review of Resident #25's resident census report revealed Resident #25 was admitted to the facility on [DATE]. A review of Resident #25's Admission Record revealed diagnoses to include but not limited to Chronic respiratory failure with hypercapnia and chronic obstructive pulmonary disease. A Review of Resident #25's physician's order dated 07/03/2024 revealed oxygen at 4 liters per nasal cannula continuous. On 08/26/2024 at 9:49 AM Resident #25 was observed in bed. She was wearing a nasal cannula with an oxygen concentrator on the floor to the left of her bed. The concentrator was set at 4 liters. A container of petroleum jelly was on the bedside table next to the resident. Resident #25 stated she uses it like lotion because it works well. Photographic Evidence Obtained. On 08/27/2024 at 9:28 AM Resident #25 was observed in bed. She was wearing a nasal cannula, and the oxygen concentrator was set at 4 liters. The container of petroleum jelly was on the bedside table. On 08/28/2024 at 9:30 AM Resident #25 was observed in bed. She was wearing a nasal cannula, and the oxygen concentrator was set at 4 liters. The container of petroleum jelly was on the bedside table. During an interview on 08/28/2024 at 3:05 PM, Staff N, Licensed Practical Nurse (LPN) stated if a resident has an oxygen concentrator, they take it with them to activities then plug it in wherever they are. She stated there should be nothing flammable in the area where someone is using oxygen to include lighters and petroleum products. During an interview on 08/29/2024 at 10:49 AM, the Director of Nursing (DON) stated oxygen should be on the correct liters, the tubing should be changed every seven days, and it should be secured appropriately. She stated there should not be anything flammable in the area to include lighters and candles. She was shown the section of the oxygen policy pertaining to removing all potentially flammable items. She stated, I didn't know lotions were flammable. She was asked about petroleum products. She stated, I hadn't thought about that. The DON was informed Resident #25 had a petroleum product in her room. She stated, That's not good. During an interview on 08/29/2024 at 11:05 AM, the NHA stated she did not know how the staff were trained on the oxygen policy, and the nursing staff that takes care of training. A review of the facility's Oxygen Safety form found in the DON's employee file and signed by the DON on 07/09/2024 revealed: Oxygen can be dangerous if not used correctly. Oxygen makes things burn more easily and can even explode. While oxygen is in the room do not use: Oil-based face cream or lotion on the nose and face. Petroleum-based products such as [product name]. A review of the American Lung Associations website (https://action.lung.org/pf/OX3-Using_Oxygen_Safely/files/OX3-Using_Oxygen_Safely_Option2-2020-v2.pdf) revealed: Using oxygen safely: Don't Use Aerosols, Vapor Rubs or Oils, Avoid flammable creams and lotions such as vapor rubs, petroleum jelly or oil-based hand lotion. Use water-based products instead. A review of the facility's policy titled Oxygen Administration, undated, revealed: Purpose: The purpose of this procedure is to provide guidelines for safe oxygen administration. Preparation: 1. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. General Guidelines: 1. Oxygen therapy is administered by way of an oxygen mask, nasal cannula, and/or nasal catheter. b. The nasal cannula is a tube that is placed approximately one-half inch into the resident's nose. It is held in place by an elastic band placed around the resident's head. Steps in the procedure: 4. Remove all potentially flammable items (e.g., lotions, oils, alcohol, smoking articles, etc.) from the immediate area where the oxygen is to be administered.

Based on observations, interviews, and record review, the facility failed to ensure the medication error rate was less than 5.00%. Twenty-five medication administration opportunities were observed, and twelve errors were identified for two residents (#35, #25) out of three residents observed. These errors constituted a 48.00% medication error rate. Findings included: 1) On 08/28/2024 at 9:41 AM a medication administration observation was conducted with Staff M, LPN for Resident #35. Staff M, LPN dispensed the following medications: -Ativan (lorazepam) 1 mg (Milligram) 1 tablet -Famotidine 20 mg 1 tablet -Lactulose 20 gram/30 mL (milliliter) solution 25 mL -Sodium chloride 1 gram 1 tablet -Valproic Acid 250 mg 1 tablet Staff M, LPN stated she did not have the other ordered medications in her cart, and she would have to find them or order them. The missing medications included: -B complex vitamin C-folic acid 400 mcg (Microgram) 1 tablet -Potassium citrate 10 mEq (milliequivalent) extended release 1 tablet Staff M, LPN was observed administering the medications to Resident #35. When Staff M, LPN returned to her cart, she was asked about the Lactulose administration and the fact she had only administered 25 mL instead of the ordered 30 mL. Staff M, LPN responded that she was not aware she had administered the incorrect dosage. A review of Resident #35's physician orders revealed the following: Lactulose solution; 20 gram/30mL; amount 30 mL oral; twice a day 09:00 PM, 09:00 AM; ordered 07/01/2024 - open ended. Famotidine OTC (Over the Counter) tablet 20 mg; amount 1 tablet oral; special instructions: I tablet every 12 hours; twice a day 09:00 AM, 09:00 PM; ordered 04/21/2023 - open ended. B complex-vitamin C-folic acid tablet 400 mg; amount 1 tablet oral; once a day 09:00 AM; ordered 04/22/2023 - open ended. Valporic acid capsule 250 mg; amount 1 tablet oral; twice a day 09:00 AM, 09:00 PM; ordered 12/21/2023 - open ended. Ativan (lorazepam) - schedule IV 1 mg tablet; amount 1 tablet oral; twice a day 09:00 AM, 09:00 PM; ordered 01/24/2024 - open ended. Sodium chloride oral I gram tablet; amount 1 tablet; special instructions: for hyponatremia; once a day 09:00 AM; ordered 02/28/2024 - open ended. Potassium citrate tablet extended release 10 mEq (1,080 mg); amount 1 tablet oral; once a day 09:00 AM; ordered 07/23/2023 - open ended. A review of Resident #35's medication administration history report dated 08/01/2024 - 08/29/2024 revealed Staff M, LPN signed off on the Potassium citrate 10 mEq extended release 1 tablet on 08/28/2024 at 10:22 AM for Late administration: charted late, Comment: late chart administered on time. 2) On 8/28/2024 at 11:01 AM a medication administration observation was conducted with Staff M, LPN for Resident #25. Staff M, LPN dispensed the following medications: -Flecainide 100 mg 1 tablet -Aspirin 81 mg chewable 1 tablet -Ferrous Sulfate 325 mg 1 tablet -Furosemide 20 mg 2 tablets -Magnesium Oxide 400 mg 1 tablet -Metoprolol succinate extended release 50 mg 1 tablet -Multivitamin 1 tablet -Olanzapine 15 mg 1 tablet Staff M, LPN stated she did not have the other ordered medication in her cart, and she would have to find it or order it. The missing medication included: -Ascorbic Acid vitamin C 250 mg 1 tablet Staff M, LPN was observed entering Resident #25's room and taking Resident #25's blood pressure prior to administering the Metoprolol and the other medications. Staff M, LPN stated, I'm running late then exited the room. A review of Resident #25's physician orders revealed the following orders: Aspirin tablet chewable 81 mg; amount 81 mg oral; once a day 09:00 AM; ordered 07/02/2024 - open ended. Ferrous sulfate tablet 325 mg (65 mg iron); amount 1 tablet oral; once a day 09:00 AM; ordered 07/02/2024 -open ended. Flecainide tablet 100 mg; amount 1 tablet oral; twice a day 09:00 AM, 09:00 PM; ordered 07/02/2024 - open ended. Magnesium oxide OTC 1 tablet 400 mg (241.3 mg magnesium); amount 1 tablet oral; once a day 09:00 AM; ordered 07/02/2024. Metoprolol succinate 1 tablet extended release 24-hour 50 mg; amount 1 tablet oral; twice a day 09:00 AM, 09:00 PM; ordered 07/02/2024 - open ended. Multivitamin tablet; amount 1 tablet oral; once a day 09:00 AM; ordered 07/02/2024 - open ended. Olanzapine tablet 15 mg; amount 1 tablet oral; once a day 09:00 AM; ordered 07/02/2024 - open ended. Furosemide tablet 20 mg; amount 2 tablets oral; once a day 09:00 AM; ordered 07/31/2024 - open ended. A review of Resident #25's Medication Administration Record (MAR) revealed: Ascorbic acid (vitamin C) tablet 250 mg; amount to administer 250 mg oral; twice a day 09:00 AM, 09:00 PM; ordered 07/02/2024 discontinued 08/28/2024. During an interview on 08/29/24 at 9:03 AM, Staff D, LPN stated passing medications on the North unit is a very heavy medication pass and if anything goes wrong or she is needed for an emergency there is no way to complete the medication pass in time. During an interview on 08/29/2024 at 10:35 AM, the Director of Nursing (DON) was informed of the medication observations. She stated timeliness was already on her radar as she had noticed how long nurses were spending on the medication carts. She was then asked what her expectations were for medication administration. She stated her expectations are that medications are administered correctly and on time. She stated the nurses are having a hard time with their Electronic Medication Administration Record (EMAR) system and with getting medications completed in a timely manner. She stated the nurses are responsible for ordering resident medications. She requests that if the medications are in a five-day window, the nurses should order the medications. A review of the facility's policy titled, Administering Medications, undated, revealed a policy statement of: Medications shall be administered in a safe and timely manner, and as prescribed. Policy interpretation and implementation: 3. Medications must be administered in accordance with the orders, including any required time frame. 4. Medications must be administered within one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders).

Based on observations, record review, and interviews, the facility failed to ensure medications were stored in a secure and safe manner for one resident (Resident #2) of one resident allowed to self-administer medications, and leaving medication unattended on one (North) of two medication carts . Findings included: 1. On 12/26/24 at 9:13 a.m., Resident #2 was observed lying in bed with an over-bed table hovering over the bed and a table next to the bed with a nebulizer machine sitting on it. A nebulizer pipe was connected to the machine. The observation revealed a foil container labeled Anoro Ellipta on top of a pharmacy bag and a vial of clear liquid under the bag sitting on the over-bed table. A vial of clear liquid was observed lying on top of the nebulizer machine. The resident stated the vial on the nebulizer machine was the 6:00 a.m. dose of Albuterol and they were able to self-administer medications, but hadn't woken up to take the 6 a.m. dose, and the vial on the over-bed table was the noon dose (of Albuterol). The resident was wearing a nasal cannula in the nares and the concentrator next to the bed was set at 4 liters per minute. An interview was conducted on 12/26/24 at 9:14 a.m. with Staff B, Licensed Practical Nurse (LPN). The staff member reported being done with med pass, reviewed Resident #2's physician orders, and stated the resident was able to self-administer Albuterol, but not the Anoro Ellipta. The staff member also stated the process for self-administration of medications was to make sure the resident received it, set it up for them, and stay with them during the administration. On 12/26/24 at 9:19 a.m. Resident #2 was observed with Staff B, LPN. The staff member reported leaving the Anoro in the room due to having to run to the bathroom, and she came in at 7 a.m. so the 6 a.m. dose of Albuterol (lying on the nebulizer) was before the staff member had arrived for her shift. Staff B, LPN reported not giving the noon dose of Albuterol (under the Anoro Ellipta) to the resident. On 12/26/24 at 1:22 p.m. an observation was made of two (2) vials containing a clear liquid in a clear plastic cup on Resident #2's over-bed table. Review of Resident #2's Face Sheet showed the resident was admitted on [DATE]. The Face Sheet revealed diagnoses not limited to chronic respiratory failure unspecified whether with hypoxia or hypercapnia, chronic obstructive pulmonary disease (chronic obstructive pulmonary disease) with (acute) exacerbation, and unspecified combined systolic (congestive) and diastolic (congestive) heart failure. Review of Resident #2's Self-Administration of Medication and/or Enteral Feeding evaluation dated 12/18/24 showed the Facility will set up meds for resident. Review of the facility policy titled Policy for Nursing Home Resident Self-Administration of Medications, undated, revealed medications should be stored in a secure location, accessible to the resident, if the resident desires to store the medication at bedside. Review of a letter sent by the Nursing Home Administrator (NHA) and signed by Resident #2, dated November 22, 2024, showed all over the counter and prescription medications required a physicians order and must be kept on the facility medication cart until time for administration. Neither an over the counter or any prescription medication may be kept at bedside. The letter was signed by the NHA and Resident #2. 2. On 12/26/24 at 10:20 a.m., Staff B, LPN was observed during the task of medication administration placing a bottle of glucose testing strips into a bag containing Resident #7's FIASP FlexTouch insulin pen. Resident #8 asked the Staff B, LPN for ice. Staff B, LPN placed the insulin bag on the medication cart and went into a room at the corner of the North Hall, returning shortly, and explaining to the resident there was no ice. During the time the staff member was inside the room retrieving ice for the resident, the bag containing the pen of insulin was out of the staff member's sight and unattended on the medication cart. Review of the undated policy titled Storage of Medications revealed the Policy Statement, the facility stores all drugs and biologicals in a safe, secure, in orderly manner. The policy also revealed the following under Policy Interpretation and Implementation: 1. Drugs and biologicals used in the facility are stored in lot compartments under proper temperature, light, and humidity controls. 2. Drugs and biologicals are stored in the packaging, containers or other dispensing systems in which they are received. Only the issuing pharmacy is authorized to transfer medications between containers. 3. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner.

Based on observations, interviews and record reviews, the facility failed to develop and implement a safe and effective discharge planning process for three (#8, #3, and #1) of five residents sampled for discharge. Resident #8, a dialysis dependent resident, was discharged to his condemned mobile home with no arrangements for dialysis or home health services. Resident #3 had severe cognitive impairment and was discharged in a taxi cab to live with a family member who was not present or prepared to care for the resident in the home. Resident #3 had no way to access the home upon his arrival and the taxi cab driver contacted law enforcement for assistance. Resident #1, who was dependent on oxygen, was discharged home without medical equipment to maintain her respiratory status. The facility's system failure placed Resident #8, Resident #3, and Resident #1 at serious risk of injury or death and resulted in the determination of Immediate Jeopardy on 09/23/2023. The findings of Immediate Jeopardy were determined to be removed on 11/02/2023 and the severity and scope was reduced to an E after verification of removal of immediacy of harm. Findings included: 1) Resident #8 was admitted to the facility on [DATE] with diagnoses to include unspecified sequelae of cerebral infarction, chronic pain, abnormalities of gait and mobility, muscle weakness, End Stage Renal Disease (ESRD) requiring dialysis, temporary catheter in upper right chest for dialysis, altered mental status and adult failure to thrive. A review of the MDS (Minimum Data Set) Admission assessment dated [DATE] revealed the resident was able to make himself understood and he was able to understand others. The resident's BIMS (Brief Interview for Mental Status) score was 11, indicating moderately impaired cognition. In Section G: Functional Abilities, the resident was assessed as requiring extensive assistance with one staff for toileting, personal hygiene, and dressing; supervision with one staff for walking in his room or for short distances, with his balance described as unsteady. A review of the resident's care plan, dated 09/26/2023, revealed the following: Problem: Discharge: Resident has D/C (discharge) plan, is uncertain at this time as he lost his home in the community. (start date 09/26/2023) Goal: Resident will receive assistance with discharge planning should preferences change through the review date. (Long term goal target date: 12/26/2023) Approaches included: Ask about returning to the community with each assessment. Re-evaluate preferences regarding discharge planning regularly and PRN (as necessary). (Start date: 09/26/2023) Problem: Nutritional Status: Resident is at nutritional risk r/t (related to ): ESRD, new dialysis, hx (history) CVA (Cerebral Vascular Accident). (Start date: 09/27/2023) Goal: Resident's weight will remain less than +/- 5% weight change within a 30 day time period through next review. (Long term goal target date: 12/27/2023) Approaches included: Monitor lab values per dialysis record Albumin >60 yr: 3.4 - 4.8 g/dl (grams per deciliter); plasma transferrin> 60 yr: 180-380 g/dl; HGB (hemoglobin) - Males: 14-17 g/dl - Females: 12 - 15 g/dl; HCT (hematocrit) - Males 41-53 - Females 36-46; Potassium: 3.5 5.0 mEq/L (milli-Equivalents/Liter); Magnesium: 1.3 - 2.0 mEq/L). Resident will attend dialysis as scheduled T, Th, Sat (Tuesday, Thursday, Saturday). Resident will receive a NAS (no added salt diet), avoid potatoes, tomatoes, bananas, oranges r/t high K (potassium) content. Weigh and monitor results upon admission daily times 3 days, weekly x 4 weeks, then monthly if stable. (Start Date: 09/27/2023). A review of the Transition of Care/Discharge Summary, dated 10/06/2023, revealed Resident #8 would be returning to his home. The document showed the resident was responsible for himself. The Discharge Summary did not include a contact phone number for either the resident or an emergency contact. The summary did not include the ESRD facility address and his schedule to receive dialysis. Under the heading of Care Plan Goals, as a discharge goal, the facility had documented, PT (Physical Therapy), OT (Occupational Therapy) , RN (Registered Nurse) Eval (Evaluation). There was no reference to the referral for a Home Health Agency or who would be conducting the evaluations. The summary did not contain a Post Discharge Plan of Care which would include: arrangements that have been made for follow up care and services; how the IDT (interdisciplinary team) will support the resident or representative in the transition to post-discharge care; what factors may make the resident vulnerable to preventable readmission; and how those factors will be addressed in accordance with the facility's undated policy titled Discharge Summary and Plan. Review of the Social Services Director (SSD) progress note dated 10/05/2023 revealed a referral had been made to a Home Health Agency. A telephone interview was conducted with the Home Health Agency on 10/19/2023 at 11:08 a.m. to ask about services ordered for Resident #8. The Referral Intake Associate at the Home Health Agency reported they did not have Resident #8 in their system to provide home health services following his discharge on 10/06/23. The Referral Intake Associate confirmed they made no visits to Resident #8 after he was discharged from the facility on 10/06/2023 and no PT, OT, or RN services had been rendered. A review of the Therapy Discharge Summary for Physical Therapy services provided from 9/20/2023 - 10/05/2023 for Resident #8 revealed the patient was unable to make significant functional gains due to being dialysis dependent and fatigued post dialysis. The discharge instructions included the resident's need for assistance with all ADLs. A review of Resident #8's progress notes revealed: -Admission note, dated 09/19/2023: The resident was alert, verbalizing appropriately, tearful at times and stated he was unsure of dialysis. -Social Services Director (SSD) note, dated 09/20/2023: The resident appeared alert and oriented x 3, with a plan of discharge to remain in the facility long term care for now. The note included the resident's statement of feeling depressed with the SSD noting she would refer the resident to the psychologist. -An IDT (Interdisciplinary team) note, on 09/26/2023, documented a continued need for a skilled level of care and continued work with therapy. The note indicated the discharge plan was uncertain at this time as he lost his home in the community. -10/02/2023 a note by the SSD indicated the plan for discharge was to go out of state to Indiana. -10/04/2023 the resident was presented with a Notice of Medicare Non-Coverage (NOMNC) showing the LCD (last covered day) of Medicare coverage to the facility was 10/05/23 and the resident chose not to appeal this decision. - SSD note, dated 10/05/2023: The resident would be going home to the address noted on his face sheet from admission and a name and address for the Home Health Agency was listed. -10/06/2023 a nurse's note confirmed the resident had been discharged to home by taxi. - Progress note, dated 10/09/2023 at 1:00 p.m., revealed the Administrator received a call from the Social Worker at the Dialysis center where Resident #8 had been receiving services. The Social Worker asked the Administrator why they discharged the resident to a condemned trailer and apprised the Administrator the resident had missed his last dialysis treatment, on 10/07/2023. The Administrator told the Dialysis Social Worker the facility was not aware the resident's home was condemned and didn't know he had skipped dialysis the day after he was discharged home. The Administrator explained to the Dialysis Social Worker, as documented in her progress note written on 10/09/2023, she had met with the resident with the facility SSD to explain to the resident he was welcome to remain at the facility during the Medicaid pending process. The Administrator documented the resident informing her and the SSD he wanted to return home and showed both of them he had his keys to his home to let himself back in. After the phone call, the Administrator and the facility SSD drove over to the resident's home and saw the home was a trailer that generally was in good repair, but had two windows broken out. The resident was sitting outside of the trailer and told the facility staff his neighbors were working on fixing up the trailer for him. After receiving permission, the SSD looked inside of Resident #8's trailer and documented garbage, filth, a horrible odor, and a piece of orange paper in the doorway. The orange paper was a condemned notice. When the facility staff told Resident #8, he could not remain living in a condemned trailer he became verbally abusive. The facility staff phoned 911 and the police officer who responded told the resident he could not remain in a condemned trailer and if he did, he was trespassing. When the officer offered the resident three choices --going to the hospital, jail, or returning with the facility staff to the facility, he chose to return to the facility. Upon returning to the facility the resident was evaluated by Psychiatric services who determined the resident was a danger to himself and he was involuntarily admitted to the hospital. An interview was conducted with the NHA (Nursing Home Administrator) and the SSD on 10/17/2023 at 5:00 p.m. The NHA reported they were not aware the trailer had been condemned and didn't know why the Home Health Agency hadn't called them to let them know the resident's trailer was condemned. The NHA said the resident told them his home was ok, he showed them his keys indicating he would be able to get into the trailer, and he could discharge to his home. The SSD reported she just hadn't revised the care plan to indicate he had a home in the community. They confirmed they had not investigated the home and the condition of the home. They confirmed they discharged the resident as he requested and had not followed up on the resident's statement that he lost his home in the community as documented in the 09/26/2023 care plan and IDT progress note. A call was placed to the Dialysis Social Worker on 11/02/2023 at 3:10 p.m. She confirmed the dialysis facility had not been notified of the resident's discharge from the nursing home to his mobile home. She stated she would have questioned that discharge as she was aware the mobile home had been condemned. She stated she knew about the trailer from his initial hospitalization paperwork, which led to his transfer into the nursing home. She reported the resident had been receiving dialysis at her facility for a year or two and agreed the address and schedule should have been on his discharge paperwork for him due to his fluctuating cognition. Resident #8 was readmitted to the facility on [DATE] from the hospital. On 11/02/2023 at 9:00 a.m. an interview was conducted with Resident #8. He stated he was found at his mobile home by the lady in charge (NHA), was taken back to the hospital (for an involuntary admission), and then came here (back to the facility). He confirmed he received dialysis services and touched the dressing on his catheter located in his upper right chest, then held up his right arm to expose his new permanent vascular access for dialysis. He wasn't sure if he had gone to dialysis. He said he felt ok and didn't think he needed to go. When asked if he went to dialysis when he was discharged home on 10/06/2023, he stated he hadn't been told the address or the schedule for his dialysis treatments when he was sent home so he had not gone. 2) Resident #3 was admitted to the facility on [DATE] for rehabilitation services after a hospitalization with diagnoses to include senile degeneration of brain, altered mental status, vascular dementia, severe with agitation, schizophrenia, and major depressive disorder. A review of the 08/01/2023 Admission Minimum Data Set (MDS) Assessment, Section C: Cognitive Abilities, showed a Brief Interview for Mental Status (BIMS) score of 00, indicating severe cognitive impairment. The resident's mental status was described as inattentive with disorganized thinking. In Section G: Functional Abilities, the resident was assessed as needing extensive assistance with two staff for bed mobility, transferring, and toileting; extensive assistance with one staff for locomotion around the facility in a wheelchair, dressing, eating, and personal hygiene; and his gait was not steady. A review of the care plan, dated 08/18/2023, revealed the following: Problem: Discharge: Resident has chosen to discharge home with family. Plan to return to community or other care setting at this time. (Start Date: 08/18/2023) Goal: Resident will receive assistance with discharge planning should his preferences change through the review date. (Long Term Goal Target Date: 11/14/2023) Approaches included: Resident preferences regarding his discharge planning regularly and PRN (as necessary). (Start Date: 08/18/2023) A review of progress notes for Resident #3 revealed the following: -Nurses admission note, dated 07/27/2023, revealed the resident required total assistance for his Activities of Daily Living (ADL), but he was able to feed himself after staff set up the meal and provided cueing during the meal. The resident was described as alert and oriented to himself and able to answer simple yes and no questions. -On 07/28/2023 at 1:52 p.m., the SSD documented she attempted to contact the resident's next of kin several times but got no answer, so she left a voice mail. -Nurses notes from 07/28/2023 through to 08/08/2023 continued to document the resident as alert and oriented x 2, able to understand and follow simple commands, without any signs or symptoms of distress. -A note labeled IDT (Interdisciplinary Team) documented on 07/31/2023 staff had tried to contact the family but was unable to make contact and left a message. -On 08/08/2023 at 1:23 p.m., an IDT note documented the resident under skilled level of care, receiving physical and occupation therapy, making minimal progress as his cognition was a barrier to progress. There was to be a new review date by the insurance company on 08/15/2023 and the D/C (discharge) plan was to d/c home with a family member. -On 08/11/2023 the IDT note documented an attempt to make contact with the resident's family member to provide an update on the resident but was unable to make contact with the family and a message was left. -On 08/13/2023 a nurse's note revealed the resident was alert with noted confusion, not able to make his needs known to staff but understood simple commands. -On 08/15/2023 the IDT weekly review described the resident as making slow progress toward therapy goals, he remained a fall risk as he frequently attempted to get up from the wheelchair unassisted and was difficult to redirect due to impaired cognition. He remained at moderate nutritional risk and was followed by the RD (Registered Dietitian). He remained appropriate for skilled level of care. -On 08/21/2023 a nurse documented the resident as alert and oriented x 3, with periods of confusion, but able to make his needs known. He required the assistance of one staff with ADLs, stand by assistance for transfers, and he was incontinent of bowel and bladder. -On 08/22/2023 the IDT documented the resident continued to require a skilled level of care and was receiving therapy. An insurance update had been sent with the outcome pending. His discharge plan remained to discharge home with family. -On 08/29/2023 the facility attempted to contact the family and left a voice mail with an update on the resident. -On 09/05/2023 an IDT note revealed the resident continued at a skilled level of care and was working with therapy. The note showed he was making progress toward his goals. His cognition remained a barrier to his safe discharge. His discharge plan was home with family when all of his goals were met. -On 09/12/2023, at the weekly IDT meeting, the note revealed the resident continued to require a skilled level of care with therapy. His impaired cognition remained a barrier to a higher level of safety. His discharge plan was to go home with family. A new review date for his insurance was 09/15/2023 with the insurance company asking the facility to prepare the resident and family for discharge. -On 09/12/2023 the SSD (Social Services Director) contacted the resident's family to inform them the resident would be discharged after 09/15/2023. She received no answer and left a voice mail. -On 09/14/2023 the SSD documented a note showing it was her third attempt to contact the resident's family about an insurance review and documented her desire to discuss a safe discharge with them. There was no answer, and she left a message, but received no response. -On 09/18/2023 the IDT documented the resident propelling up and down the hallways with attempts to transfer himself without assistance. The note documented the resident was not strong enough to do so and would remain at risk for falls. He continued to work with therapy services to increase his strength. -Later that day, on 09/18/2023, the nurse documented the patient remained severely confused to time and environment. He was not able to make his needs known. He was cooperative with taking medication. He continued to throw himself on the floor numerous times throughout the shift and was seen scooting across the floor several times during the shift. The physician had been made aware of the behaviors and Ativan (as needed) was given but not effective. -On 09/20/2023 the SSD documented the resident's Power of Attorney (POA) had been informed of the resident's NOMNC letter, but he refused to sign the letter. -On 09/20/2023 the SSD documented her visit, with the Maintenance Director to the resident's home to inform the family the resident's last covered day would be 09/22/2023 with a discharge home on 09/23/2023. Her note revealed several unsuccessful attempts at contacting the family by phone, therefore she felt an in-person visit was necessary. She documented the family had refused to sign the NOMNC letter so the resident would be discharged . -On 09/23/2023 at 8:20 a.m., the SSD documented the family had been informed of the resident's discharge and transported home by a cab service. In an interview with the Administrator and the SSD, on 10/17/2023 beginning at 3:30 p.m., the SSD stated due to the family member not responding to phone calls, she went to the home with the facility's Maintenance Director on 09/20/2023 to discuss the NOMNC document and the resident's potential discharge. She reported the family member answered the door and after the SSD explained the NOMNC and applying for Medicaid so Resident #3 could remain at the facility, the family member said no. The family member would not sign the NOMNC and was not interested in applying for Medicaid. The SSD reported during the visit, the family member opened the garage door to the home to show them that work was being done inside the garage to accommodate the resident upon his return. The family member said the work wasn't done yet so he wasn't ready for the resident to return to the home. The SSD reported that because she and the Maintenance Director had spoken with the family member on 09/20/2023 about the resident's plans to return home on 09/23/2023, and the resident would have discharge documents for the family to reference upon his return, she sent the resident home alone in a taxi cab. The SSD reported the family member said they were expecting the resident back and they would provide the care. A telephone interview with Resident #3's family member on 11/07/2023 at 10:30 a.m. revealed he called the facility on 09/22/2023 around 3:00 p.m. and spoke with an unknown staff member to request for the resident to remain in the facility for another week. He said he told the staff member he would come in on Monday, 09/25/2023, to pay privately for the extra time. The family member stated they must not have received his message because they sent Resident #3 out the next day. The family member confirmed he did not sign the NOMNC because he wasn't going to appeal the decision. He was told the resident had to leave the facility or pay privately and that was what he was going to do. The family member confirmed he was not ready for the resident to return on 09/23/2023 because the construction was not completed. A review of the Transition of Care/Discharge Summary report, dated 09/23/2023, revealed the resident was not identified as being responsible for himself. Under the heading of Special Instructions, therapy had documented: Pt (patient) has been receiving skilled PT/OT since admission at this facility. Pt reached max (maximum) potential and is unsafe to ambulate by himself. Pt is WC (wheelchair) bound and is independent with WC mobility within the facility. Pt recommended continued use of WC upon DC (discharge) for safe mobility. The Home Health Agency company was to provide the wheelchair. The summary did not contain a Post Discharge Plan of Care which would include: arrangements that have been made for follow up care and services; how the IDT (interdisciplinary team) will support the resident or representative in the transition to post-discharge care; what factors may make the resident vulnerable to preventable readmission; and how those factors will be addressed in accordance with the facility's undated policy titled Discharge Summary and Plan. A review of the Therapy Discharge Summary for Physical and Occupational Therapy services provided from 7/26/2023 - 9/22/2023 showed: The Physical Therapist documented the resident's inability to make significant functional gain which was limited by poor cognition and the inability to learn new information. The resident was able to transfer and ambulate with minimal assistance. The Discharge recommendations from the Physical Therapist was for 24 hour care. The Occupational Therapist documented the resident's progress was hindered by cognitive deficits. The recommendation stated the family should assist with personal and domestic tasks. A review of a local law enforcement report, dated 09/23/2023, revealed the cab driver who took Resident #3 to his home from the facility notified the police of the resident's inability to enter his home. The police officer notified the facility the resident was sitting outside of his home without the ability to enter the home. The police officer had the resident taken to the local hospital where he was admitted . A review of the hospital records dated 09/23/23 at 1:31 p.m. described the resident as having a history of dementia and presenting to the emergency room due to homelessness. The resident's history was obtained from the paramedics as the resident presented with dementia. The note included the resident's recent stay at the facility where his insurance ran out. The facility, according to the hospital note, had tried to get in touch with the family but were unsuccessful and ultimately put the resident into a cab. The cab took the resident to an address listed on the resident's contact sheet. The note described the cab driver's reluctance to leave the resident at a home that did not appear to be lived in. Attempts by the hospital to contact the family were unsuccessful as well. Resident #3 remained at the hospital for a few days prior to being discharged to another long-term care facility. An interview was conducted with the Nursing Home Administrator (NHA) and the SSD on 10/17/23 at 3:30 p.m. The NHA stated the facility had not received return phone calls from the family about Resident #3's stay or his pending discharge. Neither facility staff could remember whether the family had ever visited the resident at the nursing home. They stated a family member had met with the Business Office staff (which is in a different building from the nursing home) to discuss the NOMNC and possibly apply for Medicare. The NHA stated she was not aware of the family member coming into the facility to visit with the resident after being at the Business Office. The Administrator and the SSD stated looking back, this was not a safe discharge. An interview was conducted with the Director of Rehabilitation (DOR) Services on 11/01/2023 beginning at 12:30 p.m. The DOR confirmed she had worked with Resident #3 for the two months that he had been in the facility. She reported that he had not done well in therapy and actually had regressed in his skills. She said it was due to his decline in mental capacity. She confirmed she attended the Interdisciplinary meetings and had expressed her concern with the discharge plan to live at home with the family. She said she told the team, the resident needed 24 hour care and should not be left alone. She said the IDT talked about how the family was aware of the resident's needs and how they agreed they would provide the care. She reported that the resident was incontinent, needed total care with personal hygiene, could only take a few steps, needed a wheelchair for mobility, would not be able to prepare food for himself, and needed supervision or cueing with meals. An interview was conducted with the Home Health Agency Resident #3 was referred to on 11/01/2023 at 11:50 a.m. The Home Health Agency referral staff reported Resident #3 was marked as no admit in her system. She reported the referral did not include a physician's signature, which they must have to provide the care. She said the referral was faxed back to the facility, and they called the facility but had to leave a voice mail with instructions, to sign the referral and fax it back. She said they never received the signed referral back, so they were not able to provide any home care for Resident #3. 3) Resident #1 was initially admitted to the facility on [DATE] for rehabilitation services after a hospitalization related to dizziness and deconditioning. Diagnoses listed on the face sheet included morbid obesity, diabetes, needs assistance with personal care, high blood pressure, muscle weakness, acute respiratory failure with hypoxia (the body is deprived of adequate oxygen supply), edema (swelling), Obstructive Sleep Apnea (OSA), pain, depression, and anxiety. A review of the Admission MDS Assessment, dated 09/06/2023, Section C - Cognitive Patterns showed a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition. A review of the resident's care plan revealed the following: Problem: Resident has impaired health status related to severe morbid obesity, acute respiratory failure with hypoxia, diabetes, and sleep apnea. (Start Date: 09/19/2023) Goal: To achieve stable health status through next review. (Long Term Goal Target Date: 12/19/2023) Approach: Continuous Positive Airway Pressure mask at night. (Start Date: 10/03/2023) Oxygen at 2 liters via nasal cannula continuous as tolerated. Promote head of bed to be elevated to facilitate stable respiratory status. (Start Date: 09/19/2023) Problem: Resident intends to discharge to home, ensure that discharge needs and goals are met (Start Date: 09/12/2023) Goal: Resident's discharge goals and preferences will be identified and met with staff assistance through the review date. (Long Term Goal Target Date: 12/12/2023) Approach: Define roles and expectations with the resident and caregiver as needed. Ensure that both the caregiver (if there is one) and the resident understand the discharge instructions and identify tasks that they will need additional help with, training for and provide contact information of a person who can serve as a resource and can answer questions that may develop. (Start Date: 09/12/2023) Encourage resident/resident representative participation and selection of provider of home health care if/as ordered. Assist with consultation\ interview if necessary and offer home health care providers contact information. (Start date: 09/12/2023). Provide the post discharge plan of care to include written discharge instructions, i.e. current health status, list of medications, follow up appointments, community resources, etc. (Start Date: 09/12/2023) Review of the physician orders, dated 09/19/2023 to 10/28/2023, revealed: Continuous oxygen at 4 liters (L) by nasal canula (NC). Review of Resident #1's progress notes revealed the following: -On 09/26/2023 at 4:32 p.m., Resident #1 requires continuous oxygen at 2 liters (L) by nasal canula (NC). -On 10/25/2023 at 10:45 a.m., SSD visited resident at bedside. Resident stated her last covered day will be 10/27/2023 that she is planning to discharge home on 10/28/2023 with Durable Medical Equipment (DME) hospital bed bariatric. She has a bariatric wheelchair at home. Resident has her apartment key in her possession. -On 10/26/2023 at 7:35 a.m., Resident is morbidly obese. And constant complaints of shortness of breath when lying flat. Patient is using supplemental oxygen at all times. Physical Therapy recommended bariatric bed for comfort., Ease of breathing. Patient also needs bed rails to assist with repositioning in bed. -On 10/26/2023 facility staff gave Resident #1 instructions to call an ambulance transport company and arrange transportation to the resident's home. Resident #1 was not aware bariatric transport services should be requested. -On 10/27/2023 at 11:14 a.m., Resident #1 requires the head of bed (HOB) elevated 30 degrees, due to difficulty breathing when bed is lowered to provide care. -On 10/28/2023 at 8:25 a.m., Resident #1 will be discharged from the facility and transported on a stretcher by EMS (Emergency Medical Services) at 12 p.m. today. Family and resident have been informed. -On 10/28/2023 at approximately 2:00 p.m., the EMS transport service notified the facility Resident #1 could not be transported home because oxygen and oxygen equipment was not available in the home. -On 10/31/2023 at 1:57 p.m., Resident #1's oxygen (O2) was removed for 5 minutes to evaluate how the resident would tolerate room air saturation (percentage of oxygen in the blood). O2 Sat decreased to 89%. The normal O2 Sat range is 95%-100%. Interview was conducted with the SSD on 10/31/2023 at 3:18 p.m. The SSD said prior to discharge, Resident #1 told the facility staff a hospital bed and mechanical lift were the only items needed for a safe discharge as the Resident stated she had everything else. Interview was conducted with the NHA on 10/31/2023 at 3:29 p.m. The NHA said Resident #1 was her own person, but agreed the facility should have confirmed with the family whether oxygen and oxygen equipment was available at her new residence. A review of Resident #1's Transfer of Care/Discharge Summary, dated 10/28/2023, revealed the name of the medical equipment supplier without a corresponding phone number for the resident to contact the vendor if needed. A review of the Therapy Discharge Summary for Physical Therapy services provided from 8/31/2023 - 9/22/2023 signed by the Physical Therapist on 10/11/2023 showed the resident was unable to make significant functional gain due to medical complications including GI (gastro-intestinal) issues, diarrhea, and obesity. The discharge instructions read: 24 hour care, dependent assist with all ADLs. Discharge recommended location was same skilled nursing facility. A review of the Therapy Discharge Summary for Occupational Therapy services provided from 8/31/2023 - 9/24/2023 and signed by the Occupational Therapist on 09/27/2023 showed the patient's progress in therapy was hindered by medical issues, morbid obesity, decreased strength and endurance. The discharge recommendation was to continue therapy. Interview was conducted on 11/01/2023 at 10:15 a.m. with Resident #1. The resident was observed lying in bed with a nasal cannula delivering oxygen. When asked about the resident's discharge on 10/28/2023, she stated facility staff did not ask her if she had oxygen at home prior to discharge on 10/28/2023. Resident #1 said it wasn't until she was in the

Based on observations, interviews, and record reviews, the facility failed to advocate and provide medically related social services to ensure three (#8, #3, and #1) of five residents sampled for discharge had the community supports, services, and equipment to ensure a safe discharge to a safe and habitable location. Resident #8, a dialysis dependent resident, was discharged to his condemned mobile home with no arrangements for the continuation of life-saving dialysis treatment, home health services, or community support to ensure food availability and food preparation for special dietary needs. Resident #3, who suffered from severe cognitive impairment, was placed in a taxi cab by himself and sent home to live with family who was not present or prepared to care for the resident. Resident #3 had an invalid order for home health services and no way to access the home upon his arrival. The taxi cab driver contacted law enforcement and Resident #3 was transported to a higher level of care. Resident #1, who was dependent on oxygen, was discharged home without medical equipment to maintain her respiratory status. The facility's system failure to ensure social services advocated and arranged for home health services, dialysis services, medical equipment, and community support services/resources resulted in the need for law enforcement intervention for Resident #8 and #3 and Emergency Medical Services intervention for Resident #1. The facility's failure created situations likely to result in serious injury, harm and/or death to Resident #8, Resident #3, and Resident #1 and resulted in the determination of Immediate Jeopardy on 09/23/2023. The findings of Immediate Jeopardy were determined to be removed on 11/02/2023 and the severity and scope was reduced to an E after verification of removal of immediacy of harm. Findings included: Cross Reference F660 1) A review of the job description for the Resident Services Director (RSD), which was the official job title of the Social Services Director at the facility according to the Nursing Home Administrator on 11/02/2023 at approximately 11:00 a.m. revealed: Summary: Has administrative authority and accountability for the provision of psychosocial needs of the residents and patients. Acts as a resident advocate, provides an ongoing program. Of activities designed to meet. The interest and physical, mental, and psychosocial well-being of each patient. Essential Duties and Responsibilities include: -Completes assessments, MDS (Minimum Data Set) assessments, care plans to collect and assess data relevant to patients' psychosocial needs, risk factors for psychosocial deterioration and responses to interventions. -Records progress notes in the clinical record including subjective findings, objective symptoms, observations of behavior, interventions provided to patient and patient's response to activity interventions. Reviews staff's chart entries for completeness and accuracy. -Delivers ABN (Advance Beneficiary Notice)/NOMNC (Notice of Medicare Non-Coverage) notices and reviews with resident/responsible party for signature. -Participates in care plan meetings and assists residents in participating as well. -Implements social service interventions that achieve treatment goals, address resident needs, link social supports, physical care and physical environment to enhance quality of life. -Coordinates discharge planning. -Facilitates advance directive decision-making process. -Completes required forms and documents in advance with company policy and state and/or federal regulations. Other Requirements: -Monitors and ensures compliance with company policies, procedures, and state and federal law. Review of the undated facility policy titled Transfer or Discharge, Preparing a Resident for revealed: Policy Statement: Residents will be prepared in advance for discharge. Policy Interpretation and Implementation: A post-discharge plan is developed for each resident prior to his or her transfer or discharge. This plan will be reviewed with the resident, and /or his or her family, at least twenty four (24) hours before the resident's discharge or transfer from the facility. Review of the undated facility policy titled Discharge Summary and Plan revealed: Policy Statement: When a resident's discharge is anticipated, a discharge summary and post-discharge plan will be developed to assist the resident to adjust to his/her new living environment. Policy Interpretation and Implementation: -When the facility anticipates a resident's discharge to a private residence, another nursing care facility (i.e., skilled, intermediate care, ICF/IID, etc.) a discharge summary and a post - discharge plan will be developed which will assist the resident to adjust to his or her new living environment. -The discharge summary will include a recapitulation of the resident's stay at this facility and a final summary of the resident's status at the time of the discharge in accordance with established regulations governing release of resident information and as permitted by the resident. The discharge summary shall include a description of the resident's: -Special treatments or procedures (treatments and procedures that are not part of basic services provided); -Medication therapy (all prescription and over the counter medications taken by the resident including dosage, frequency of administration, and recognition of significant side effects that would be most likely to occur in the resident.) -Every resident will be evaluated for his or her discharge needs and will have an individualized post-discharge plan. -The post-discharge plan will be developed by the Care Planning/Interdisciplinary Team with the assistance of the resident and his or her family and will include: - Where the individual plans to reside; - Arrangements that have been made for follow up care and services; - What factors may make the resident vulnerable to preventable readmission; and - How those factors will be addressed. -The discharge plan will be re-evaluated based on changes in the resident's condition or needs prior to discharge. -The resident/representative will be involved in the post-discharge planning process and informed of the final post-discharge plan. -Residents will be asked about their interest in returning to the community. If the resident indicates an interest in returning to the community, he or she will be referred to local agencies and support services that can assist in accommodating the resident's post-discharge preferences. -If it is determined that returning to the community is not feasible, it will be documented why this is the case and who made the determination. 2) Resident #8 was admitted to the facility on [DATE] with diagnoses to include End Stage Renal Disease (ESRD) requiring dialysis, temporary catheter in upper right chest for dialysis, diabetes, altered mental status, adult failure to thrive, unspecified sequelae of cerebral infarction, chronic pain, abnormalities of gait and mobility, and muscle weakness. A review of the MDS (Minimum Data Set) Admission assessment dated [DATE] revealed the resident was able to make himself understood and he was able to understand others. The resident's BIMS (Brief Interview for Mental Status) score was 11, indicating moderately impaired cognition. In Section G: Functional Abilities, the resident was assessed as requiring extensive assistance with one staff for toileting, personal hygiene, and dressing; supervision with one staff for walking in his room or for short distances, with his balance described as unsteady. The resident was occasionally incontinent of urine and frequently incontinent of bowel. A review of the resident's care plan, dated 09/26/2023, revealed the following: Problem: Discharge: Resident's discharge plan is uncertain at this time as he lost his home in the community. (Start date 09/26/2023) Goal: Resident will receive assistance with discharge planning should preferences change through the review date. (Long term goal target date: 12/26/2023) Approaches included: Ask about returning to the community with each assessment; Re-evaluate preferences regarding discharge planning regularly and PRN (as necessary). (Start date: 09/26/2023) Problem: Nutritional Status: Resident is at nutritional risk r/t (related to ): ESRD, new dialysis, hx (history) CVA (Cerebral Vascular Accident). (Start date: 09/27/2023) Goal: Resident's weight will remain less than +/- 5% weight change within a 30 day time period through next review. (Long term goal target date: 12/27/2023) Approaches included: Resident will attend dialysis as scheduled Tuesday, Thursday, Saturday; Resident will receive a no added salt diet, avoid potatoes, tomatoes, bananas, oranges related to high K (potassium) content. Problem: Cognitive Loss/Dementia: Resident has impaired cognitive skills as evidenced by deficits in short and long term memory (Start Date: 10/02/2023) Long Term Goal: Resident will continue to stay safe in his/her environment. (Target Date: 01/02/2024) Approaches included: Provide cue and prompting if resident is unable to complete a task independently; Staff will anticipate and meet resident's needs. (Start Date: 10/02/2023) A review of the Therapy Discharge Summary for Physical Therapy services provided from 9/20/2023 - 10/05/2023 for Resident #8 revealed the patient was unable to make significant functional gains due to being dialysis dependent and fatigued post dialysis. The discharge instructions included the resident's need for assistance with all Activities of Daily Living (ADLs). A review of the Transition of Care/Discharge Summary revealed Resident #8 would be going back to his home address on 10/06/2023. The document showed the resident was responsible for himself with no resident representatives or community support/resources listed. Special instructions on the form recommended for the resident to continue to avoid foods high in potassium and eat 6 small meals a day to aid in controlling blood sugars. A phone number for the Certified Dietary Manager was included to help the resident with food items but no directions were included to indicate how the resident would obtain or prepare food. The form included no information in the area of special treatments and procedures or medical equipment. The form was obsolete of: arrangements for transportation to Dialysis Center, the name, address, and phone number for the Dialysis Center, the scheduled days for Dialysis treatment, any continued arrangements to receive nursing or therapy services to include the name and contact information for a home health agency. Review of the Social Services Director (SSD) progress note dated 10/05/2023 revealed a referral had been made to a Home Health Agency. A telephone interview was conducted with the Home Health Agency on 10/19/2023 at 11:08 a.m. The Referral Intake Associate reported they did not have Resident #8 in their system to provide home health services following his discharge on 10/06/23. The Referral Intake Associate confirmed they made no visits to Resident #8 after he was discharged from the facility on 10/06/2023 and no Physical Therapy, Occupational Therapy, or Registered Nursing services had been rendered. A review of Resident #8's progress notes revealed: -Admission note, dated 09/19/2023: The resident was alert, verbalizing appropriately, tearful at times and stated he was unsure of dialysis. -Social Services Director (SSD) note, dated 09/20/2023: The resident appeared alert and oriented x 3, with a plan of discharge to remain in the facility long term care for now. -An IDT (Interdisciplinary team) note, on 09/26/2023, documented a continued need for a skilled level of care and continued work with therapy. The note indicated the discharge plan was uncertain at this time as he lost his home in the community. -10/02/2023 a note by the SSD indicated the plan for discharge was to go out of state to Indiana. -10/04/2023 the resident was presented with a Notice of Medicare Non-Coverage (NOMNC) showing the LCD (last covered day) of Medicare coverage to the facility was 10/05/23 and the resident chose not to appeal this decision. - SSD note, dated 10/05/2023: The resident would be going home to the address noted on his face sheet from admission and a name and address for the Home Health Agency was listed. -10/06/2023 a nurse's note confirmed the resident had been discharged to home by taxi. - Progress note, dated 10/09/2023 at 1:00 p.m., revealed the Administrator received a call from the Social Worker at the Dialysis center where Resident #8 had been receiving services. The Social Worker asked the Administrator why they discharged the resident to a condemned trailer and also apprised the Administrator the resident had missed his last dialysis treatment, on 10/07/2023. The Administrator told the Dialysis Social Worker the facility was not aware the resident's home was condemned and didn't know he had skipped dialysis the day after he was discharged home. The Administrator explained to the Dialysis Social Worker, as documented in her progress note written on 10/09/2023, she had met with the resident with the facility SSD to explain to the resident he was welcome to remain at the facility during the Medicaid pending process. The Administrator documented the resident informing her and the SSD he wanted to return home and showed both of them he had his keys to his home to let himself back in. After the phone call, the Administrator and the facility SSD drove over to the resident's home and saw the home was a trailer that generally was in good repair, but had two windows broken out. The resident was sitting outside of the trailer and told the facility staff his neighbors were working on fixing up the trailer for him. After receiving permission, the SSD looked inside of Resident #8's trailer and documented garbage, filth, a horrible odor, and a piece of orange paper in the doorway. The orange paper was a condemned notice. When the facility staff told Resident #8, he could not remain living in a condemned trailer he became verbally abusive. The facility staff phoned 911 and the police officer who responded told the resident he could not remain in a condemned trailer and if he did, he was trespassing. When the officer offered the resident three choices --going to the hospital, jail, or returning with the facility staff to the facility, he chose to return to the facility. Upon returning to the facility the resident was evaluated by Psychiatric services who determined the resident was a danger to himself and he was involuntarily admitted to the hospital. An interview was conducted with the NHA (Nursing Home Administrator) and the SSD on 10/17/2023 at 5:00 p.m. The NHA reported they were not aware the trailer had been condemned and didn't know why the Home Health Agency hadn't called them to let them know the resident's trailer was condemned. The NHA said the resident told them his home was ok, he showed them his keys indicating he would be able to get into the trailer, and he could discharge to his home. The SSD reported she just hadn't revised the care plan to indicate he had a home in the community. They confirmed they had not investigated the home and the condition of the home. They confirmed they discharged the resident as he requested and had not followed up on the resident's statement that he lost his home in the community as documented in the 09/26/2023 care plan and IDT progress note. A call was placed to the Dialysis Social Worker on 11/02/2023 at 3:10 p.m. She confirmed the dialysis facility had not been notified of the resident's discharge from the nursing home to his mobile home. She stated she would have questioned that discharge as she was aware the mobile home had been condemned. She stated she knew about the trailer from his initial hospitalization paperwork, which led to his transfer into the nursing home. She reported the resident had been receiving dialysis at her facility for a year or two and agreed the address and schedule should have been on his discharge paperwork for him due to his fluctuating cognition. Resident #8 was readmitted to the facility on [DATE] from the hospital. On 11/02/2023 at 9:00 a.m. an interview was conducted with Resident #8. He stated he was found at his mobile home by the lady in charge (NHA), was taken back to the hospital (for an involuntary admission), and then came here (back to the facility). He confirmed he received dialysis services and touched the dressing on his catheter located in his upper right chest, then held up his right arm to expose his new permanent vascular access for dialysis. When asked if he went to dialysis when he was discharged home on 10/06/2023, he stated he hadn't been told the address or the schedule for his dialysis treatments when he was sent home so he had not gone. 2) Resident #3 was admitted to the facility on [DATE] for rehabilitation services after a hospitalization with diagnoses to include senile degeneration of brain, altered mental status, vascular dementia, severe with agitation, schizophrenia, and major depressive disorder. A review of the 08/01/2023 Admission Minimum Data Set (MDS) Assessment, Section C: Cognitive Abilities, showed a Brief Interview for Mental Status (BIMS) score of 00, indicating severe cognitive impairment. The resident's mental status was described as inattentive with disorganized thinking. In Section G: Functional Abilities, the resident was assessed as needing extensive assistance with two staff for bed mobility, transferring, and toileting; extensive assistance with one staff for locomotion around the facility in a wheelchair, dressing, eating, and personal hygiene; and his gait was not steady. The resident was always incontinent of bowel and bladder. A review of the care plan, dated 08/18/2023, revealed the following: Problem: Discharge: Resident has chosen to discharge home with family. Plan to return to community or other care setting at this time. (Start Date: 08/18/2023) Goal: Resident will receive assistance with discharge planning should his preferences change through the review date. (Long Term Goal Target Date: 11/14/2023) Approaches included: Resident preferences regarding his discharge planning regularly and PRN (as necessary). (Start Date: 08/18/2023) Problem: Cognitive Loss/Dementia: Resident has impaired cognitive skills as evidenced by deficits in short and long term memory with diagnosis of senile degeneration of brain, altered mental status, vascular dementia with severe agitation. (Start Date: 08/09/2023) Goal: Resident will continue to stay safe in environment. (Goal Target Date: 11/09/2023) Approaches: Staff will encourage resident to participate in cognitive stimulating activities and administer medications/monitoring for effectiveness. (Reviewed/Revised: 08/19/2023) Problem: ADL's Functional Status/Rehabilitation Potential: Resident is not independent with upper and lower body dressing. (Start date.: 08/14/2023) Approach: Provide assistance with dressing. Resident needs extensive assistance of 1 to two staff members for bathing, grooming, oral care, bed mobility, and transfers. Up in wheelchair or Geriatric chair per preference for out of bed activities. (Reviewed/Revised: 08/19/2023) Problem: Falls: Resident at risk for falling related to unsteady gait. (Start date: 08/09/2023) Approaches: Wheelchair with anti-tippers for mobility; Give resident verbal reminders not to ambulate/transfer without assistance; Place call light in reach at all times. (Reviewed/Revised: 09/19/2023) Problem: Behavioral symptoms: Resident slides self out of wheelchair onto floor. (Start Date: 09/19/2023) Approach: Assist with repositioning as resident will allow, and encourage resident to stay in well supervised area. (Start Date: 09/19/2023) Problem: Delirium: Resident presents some confusion at times. Requires reorientation, appears forgetful. (Start date: 08/18/2023) Approach: Staff will give simple directions. Allow sufficient time for resident to respond, communicate, and make decisions. (Start date: 08/18/2023) Problem: Communication: has difficulty understanding others related to cognitive loss and dementia. (Start date: 08/18/2023) Approach: Allow time for information to process when speaking to resident. (Start date: 08/18/2023) A review of the Therapy Discharge Summary for Physical and Occupational Therapy services provided from 7/26/2023 - 9/22/2023 showed: The Physical Therapist documented the resident's inability to make significant functional gain which was limited by poor cognition and the inability to learn new information. The resident was able to transfer and ambulate with minimal assistance. The Discharge recommendations from the Physical Therapist was for 24 hour home care with caregiver assistance and support of family and home health services. The Occupational Therapist documented the resident's progress was hindered by cognitive deficits. The recommendation stated the family should assist with personal and domestic tasks and home health services. A review of progress notes for Resident #3 revealed the following: -Nurses admission note, dated 07/27/2023, revealed the resident required total assistance for his Activities of Daily Living (ADL), but he was able to feed himself after staff set up the meal and provided cueing during the meal. The resident was described as alert and oriented to himself and able to answer simple yes and no questions. -On 07/28/2023 at 1:52 p.m., the SSD documented she attempted to contact the resident's next of kin several times but got no answer, so she left a voice mail. -Nurses notes from 07/28/2023 through to 08/08/2023 continued to document the resident as alert and oriented x 2, able to understand and follow simple commands, without any signs or symptoms of distress. -A note labeled IDT (Interdisciplinary Team) documented on 07/31/2023 staff had tried to contact the family but was unable to make contact and left a message. -On 08/08/2023 at 1:23 p.m., an IDT note documented the resident under skilled level of care, receiving physical and occupation therapy, making minimal progress as his cognition was a barrier to progress. There was to be a new review date by the insurance company on 08/15/2023 and the D/C (discharge) plan was to d/c home with a family member. -On 08/11/2023 the IDT note documented an attempt to contact the resident's family member to provide an update on the resident but was unable to contact the family and a message was left. -On 08/13/2023 a nurse's note revealed the resident was alert with noted confusion, not able to make his needs known to staff but understood simple commands. -On 08/15/2023 the IDT weekly review described the resident as making slow progress toward therapy goals, he remained a fall risk as he frequently attempted to get up from the wheelchair unassisted and was difficult to redirect due to impaired cognition. He remained at moderate nutritional risk and was followed by the RD (Registered Dietitian). He remained appropriate for skilled level of care. -On 08/21/2023 a nurse documented the resident as alert and oriented x 3, with periods of confusion, but able to make his needs known. He required the assistance of one staff member with ADLs, stand by assistance for transfers, and he was incontinent of bowel and bladder. -On 08/22/2023 the IDT documented the resident continued to require a skilled level of care and was receiving therapy. An insurance update had been sent with the outcome pending. His discharge plan remained to discharge home with family. -On 08/29/2023 the facility attempted to contact the family and left a voice mail with an update on the resident. -On 09/05/2023 an IDT note revealed the resident continued at a skilled level of care and was working with therapy. The note showed he was making progress toward his goals. His cognition remained a barrier to his safe discharge. His discharge plan was home with family when all of his goals were met. -On 09/12/2023, at the weekly IDT meeting, the note revealed the resident continued to require a skilled level of care with therapy. His impaired cognition remained a barrier to a higher level of safety. His discharge plan was to go home with family. A new review date for his insurance was 09/15/2023 with the insurance company asking the facility to prepare the resident and family for discharge. -On 09/12/2023 the SSD (Social Services Director) contacted the resident's family to inform them the resident would be discharged after 09/15/2023. She received no answer and left a voice mail. -On 09/14/2023 the SSD documented a note showing it was her third attempt to contact the resident's family about an insurance review and documented her desire to discuss a safe discharge with them. There was no answer, and she left a message, but received no response. -On 09/18/2023 the IDT documented the resident propelling up and down the hallways with attempts to transfer himself without assistance. The note documented the resident was not strong enough to do so and would remain at risk for falls. He continued to work with therapy services to increase his strength. -Later that day, on 09/18/2023, the nurse documented the patient remained severely confused to time and environment. He was not able to make his needs known. He was cooperative with taking medication. He continued to throw himself on the floor numerous times throughout the shift and was seen scooting across the floor several times during the shift. The physician had been made aware of the behaviors and Ativan (as needed) was given but not effective. -On 09/20/2023 the SSD documented the resident's Power of Attorney (POA) had been informed of the resident's NOMNC letter, but he refused to sign the letter. -On 09/20/2023 the SSD documented her visit, with the Maintenance Director to the resident's home to inform the family the resident's last covered day would be 09/22/2023 with a discharge home on 09/23/2023. Her note revealed several unsuccessful attempts at contacting the family by phone, therefore she felt an in-person visit was necessary. She documented the family had refused to sign the NOMNC letter so the resident would be discharged . -On 09/23/2023 at 8:20 a.m., the SSD documented the family had been informed of the resident's discharge and transported home by a cab service. A review of the Transition of Care/Discharge Summary report revealed the resident was not identified as being responsible for himself and was being discharged back to his home address on 09/23/2023. Under the heading of Special Instructions, therapy had documented: Pt (patient) has been receiving skilled PT/OT since admission at this facility. Pt reached max (maximum) potential and is unsafe to ambulate by himself. Pt is WC (wheelchair) bound and is independent with WC mobility within the facility. Pt recommended continued use of WC upon DC (discharge) for safe mobility. The Home Health Agency was to provide the wheelchair. A name and phone number for a home health agency was included on the form. The form was signed by the resident who was not responsible for himself and had cognitive deficits documented throughout his stay at the facility. An interview on 11/01/2023 at 11:50 a.m. was conducted with the referral staff for the home health agency listed on Resident #3's discharge paperwork dated 09/23/2023. The referral staff reported Resident #3 was marked as no admit in her system. She reported the referral did not include a physician's signature, which they must have to provide the care. She said the referral was faxed back to the facility, and they called the facility but had to leave a voice mail with instructions, to sign the referral and fax it back. She said they never received the signed referral back, so they were not able to provide any home care for Resident #3. A review of hospital records dated 09/23/23 at 1:31 p.m. described the resident as having a history of dementia and presenting to the emergency room due to homelessness. The resident's history was obtained from the paramedics as the resident presented with dementia. The note included the resident's recent stay at the facility where his insurance ran out. The facility, according to the hospital note, had tried to get in touch with the family but were unsuccessful and ultimately put the resident into a cab. The cab took the resident to an address listed on the resident's contact sheet. The note described the cab driver's reluctance to leave the resident at a home that did not appear to be lived in. Attempts by the hospital to contact the family were unsuccessful as well. Resident #3 remained at the hospital for a few days prior to being discharged to another long-term care facility. A review of a local law enforcement report, dated 09/23/2023, revealed the cab driver who took Resident #3 to his home from the facility notified the police of the resident's inability to enter his home. The police officer notified the facility the resident was sitting outside of his home without the ability to enter the home. The police officer had the resident taken to the local hospital where he was admitted . In an interview with the Administrator and the SSD, on 10/17/2023 beginning at 3:30 p.m., the SSD stated due to the family member not responding to phone calls, she went to the home with the facility's Maintenance Director on 09/20/2023 to discuss the NOMNC document and the resident's potential discharge. She reported the family member answered the door and after the SSD explained the NOMNC and applying for Medicaid so Resident #3 could remain at the facility, the family member said no. The family member would not sign the NOMNC and was not interested in applying for Medicaid. The SSD reported during the visit, the family member opened the garage door to the home to show them that work was being done inside the garage to accommodate the resident upon his return. The family member said the work wasn't done yet so he wasn't ready for the resident to return to the home. The SSD reported that because she and the Maintenance Director had spoken with the family member on 09/20/2023 about the resident's plans to return home on 09/23/2023, and the resident would have discharge documents for the family to reference upon his return, she sent the resident home alone in a taxi cab. The SSD reported the family member said they were expecting the resident back and they would provide the care. A telephone interview with Resident #3's family member on 11/07/2023 at 10:30 a.m. revealed he called the facility on 09/22/2023 around 3:00 p.m. and spoke with an unknown staff member to request for the resident to remain in the facility for another week. He said he told the staff member he would come in on Monday, 09/25/2023, to pay privately for the extra time. The family member stated they must not have received his message because they sent Resident #3 out the next day. The family member confirmed he did not sign the NOMNC because he wasn't going to appeal the decision. He was told the resident had to leave the facility or pay privately and that was what he was going to do. The family member confirmed he was not ready for the resident to return on 09/23/2023 because the construction was not completed. An interview was conducted with the Nursing Home Administrator (NHA) and the SSD on 10/17/23 at 3:30 p.m. The NHA stated the facility had not received return phone calls from the family about Resident #3's stay or his pending discharge. Neither facility staff could remember whether the family had ever visited the resident at the nursing home. The Administrator and the SSD stated looking back, this was not a safe discharge. 3) Resident #1 was initially admitted to the facility on [DATE] for rehabilitation services after a hospitalization related to dizziness and deconditioning. Diagnoses listed on the face sheet included morbid obesity, diabetes, needs assistance with personal care, high b

Based on interviews with the nursing staff, the Nursing Home Administrator, the Director of Nursing, the facility's Speech Language Pathologist, the facility's Registered Dietician, the facility's Medical Director, the resident's family members, and review of the resident's medical record and facility policies, the facility failed to provide goods and services to prevent neglect by failing to ensure that one(Resident #3) of 4 residents, sampled for mechanically altered diets and supervision with meals, was provided with needed supervision and monitoring at meals related to the resident's impulsive behavior toward food and known behavior of grabbing any food that was within his reach that was not a part of his diet restriction, and eating it quickly. The facility nursing staff failed to ensure the safety of Resident #3 on [DATE] at approximately 05:15 PM, when they were unaware that the resident had propelled himself back to his room with his wheelchair and was able to obtain food items that were not consistent with his mechanically altered diet from his roommate, who was cognitively impaired and legally blind. The facility failed to ensure that the resident's assigned aide was aware of the resident's need for supervision at mealtimes related to grabbing food from other resident's trays in the facility dining room and the resident's ability to propel himself in his wheelchair during meals and obtain foods that were not consistent with his mechanically altered diet and consume it impulsively. Resident #3 was discovered by facility staff to be slumped over in his wheelchair in his room, unresponsive, and without respirations. After nursing staff performed finger sweeps of Resident #3's mouth, it was discovered that the resident consumed a half of a baked potato, pieces of meat, and several whole grapes, which were not consistent with Resident #3's mechanically altered pureed diet. The facility nursing staff attempted to perform suctioning of Resident #3's mouth and airway but were not able to dislodge all of the food items and the resident expired. The facility failed to identify that the event was preventable with the intervention of supervision of the resident while food products were available in the resident's proximity, failed to adequately investigate the event, failed to conduct abuse and neglect training in response to the event, and failed to train facility staff regarding inclusion of unsafe behaviors and interventions to those behaviors in the resident's plan of care. This resulted in findings of Immediate Jeopardy on [DATE], which was removed on [DATE] at 04:30 PM. Findings included: A review of Resident #3's Medical Record revealed that Resident #3 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #3's Physician's Orders revealed the following orders: - An order, dated on [DATE], that in case of [CONDITION(S)], the resident was a Do Not Resuscitate (DNR). - An order, dated on [DATE], for Occupational Therapy (OT) to continue treating the resident with self-feeding difficulties 3 times weekly for 30 days with neuromuscular re-education, therapeutic activities, and self-care management. - An order, dated on [DATE], for OT to be provided 3 times a week for 20 days for Activity of Daily Living (ADL) retraining, wheelchair management, therapeutic exercises, and therapeutic activities. - An order, dated on [DATE], for monitoring of target behaviors of extreme fear and combativeness at the end of each shift. Document non-pharmacological interventions attempted, frequency of the behavior, and intensity of the behavior. - An order, dated on [DATE], for monitoring of target behaviors of yelling, cursing, attention seeking behavior, and inappropriate sexual behaviors at the end of each shift. Document non-pharmacological interventions attempted, frequency of the behavior, and intensity of the behavior. Resident #3's Physician's Orders did not reveal a current order for a mechanically altered diet. Resident #3's Physician's Orders also did not reveal monitoring of behaviors related to consuming food that was not part of his mechanically altered diet or impulsive eating. A review of the facility policy titled, Do Not Resuscitate Order, last revised in April of 2017, revealed that the facility would not use cardiopulmonary resuscitation (CPR) and related emergency measures to maintain life functions on a resident when there was a Do No Resuscitate Order in effect. A review of the facility policy titled, Therapeutic Diets, with no effective date, revealed that therapeutic diets were prescribed by the Attending Physician to support the resident's treatment and plan of care and in accordance with his or her goals and preferences. The policy also revealed that a therapeutic diet must be prescribed by the resident's attending physician (or non-physician provider). The attending physician may delegate this task to a registered or licensed dietitian as permitted by law. If a mechanically altered diet was ordered, the provider will specify the texture modification. A review of Resident #3's Care Plan, for the date range of [DATE] to [DATE], revealed a problem, with a start date of [DATE], that Resident #3 was at nutritional risk related to receiving a therapeutic mechanically altered diet and diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Interventions included to provide a Consistent Carbohydrate, puree, with nectar thickened liquids diet and provide a divided plate, built up utensils, and coffee cups with lids for all meals. Resident #3's Care Plan also revealed a problem, with a start date of [DATE], that Resident #3 was at risk for discomfort and adverse effects due to use of [CONDITION(S)] medications related to diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Behaviors included fearfulness, yelling, cursing, combativeness, attention seeking behavior, inappropriate sexual behavior with staff and inappropriate sexual behavior with peers. Interventions included to supervise at all times when with female residents, administer medications as prescribed by the physician, monitor mood and behavior indicators and document per facility protocol, and observe as indicated if the resident's behavioral/mood symptoms present a danger to the resident and/or others and intervene as needed. Resident #3's Care Plan revealed a problem, dated on [DATE], that Resident #3 required staff total care assistance for ADL's due to impaired cognition, incontinence of bowel and bladder, impaired functional mobility, poor self-awareness, and poor safety awareness. Interventions included for staff to provide total care for bathing, personal hygiene, dressing, transfers/mobility, toileting, and eating as indicated and provide wheelchair for mobility. Resident #3's Care Plan also revealed a problem, dated on [DATE], that Resident #3 had a behavioral problem as evidenced by kicking shoes off and asking staff to put them back on for attention, requiring redirection related to verbal abuse and inappropriate sexual behaviors with female staff. Interventions included to assign male staff to the resident, when possible, maintain a calm, slow, and understandable approach with the resident, when the resident begins to become socially inappropriate or disruptive, provide comfort measures for basic needs, offer drink or food to distract, provide quiet time in room when being verbally disruptive and monitor for safety frequently, and use music as a distraction. A review of Resident #3's Quarterly Minimum Data Set (MDS) Assessment, dated on [DATE] revealed, under Section B - Hearing, Speech, and Vision, that Resident #3 had unclear speech - slurred or mumbled words, was usually understood - difficulty communicating some words or finishing thoughts but was able if prompted or given time, and usually understands others - misses some parts or intent of a message but comprehends most conversation. Resident #3's MDS Assessment also revealed, under Section C - Cognitive Patterns, a Brief Interview for Mental Status (BIMS) score of 09, which indicated moderately impaired cognition. Section G - Functional Status of Resident #3's MDS Assessment revealed that the resident required extensive assistance and one-person physical assistance with eating. Section G also revealed that Resident #3 used a wheelchair for a mobility device and required setup help only with locomotion on the unit. Resident #3's MDS Assessment revealed, under Section I - Active Diagnoses, that Resident #3 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #3's MDS Assessment also revealed, under Section K - Swallowing/Nutritional Status, that Resident #3 complained of difficulty or pain with swallowing and had a mechanically altered diet, which required change in texture of food or liquids. A review of Resident #3's Progress Notes revealed a note, dated on [DATE] at 6:45 PM, which documented that around 5:15 PM a Certified Nurse's Aide (CNA) yelled to the writer (Staff F, Licensed Practical Nurse), that a code blue was being initiated. Resident #3 was noted to be a DNR at the time. Staff F, LPN entered the room and Resident #3 appeared purple in color, took a breath, and had a faint pulse. Staff then assisted Resident #3 to the floor and performed a sternal rub as he was not able to stand in order to perform the [MEDICATION(S)] Maneuver. Staff F, LPN performed a finger sweep of Resident #3's mouth and pulled out large chunks of potato, grapes, and meat. Staff F, LPN turned Resident #3 on his side, sat him up, and attempted suctioning with little return. Resident #3 then took his last breath and no pulse was noted. The note also revealed that prior to the incident, Resident #3 was in a small dining area located by the nurse's station after he consumed his dinner meal and began to attempt to consume two other residents' food. Resident #3 was noted to not be easily redirected and became verbally abusive with the staff. Staff then placed Resident #3 by the nurse's station. The progress note revealed that the verbal abuse and attempting to consume other residents' food was frequent behavior of Resident #3 and that it was related to his diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #3 [then consumed his roommate's meal], who was on a regular diet. Resident #3 was noted to be on a puree diet. The progress note then revealed that Resident #3 had a potato with skin on it, grapes, and whole pieces of meat in his mouth. Resident #3's roommate, Resident #15, was blind and was unable to alert staff of Resident #3 taking his food. Resident #3's physician was then notified, and the time of death was 05:25 PM, which was verified by two nurses. A review of Resident #15's Physician's Orders revealed an order, dated [DATE], for a regular diet with thin liquids. A review of Resident #15's Care Plan revealed a problem, dated [DATE], that Resident #15 was legally blind due to severe [CONDITION(S)] and corneal abrasion. Interventions included to provide verbal cue to enhance independence and telling resident where items are placed using the clock method. A review of the facility policy titled Abuse Prevention Program, with no effective date, revealed under the policy statement that residents have the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. The policy also revealed, under the section titled Definitions, that neglect means the failure of the facility, its employees, or outside service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. A review of the facility policy titled Aspiration Disclosure, with no effective date, revealed that residents who are restricted from oral intake require specialized approaches for comfort, care, and safety. The policy described symptoms of aspiration as food, liquid, and saliva that may enter the larynx and subsequently the bronchia. This may be a painful event and may cause choking. The resultant response is loss of breath, rise in blood pressure, and fear and panic. An interview was conducted on [DATE] at 09:24 AM with Staff E, Registered Nurse (RN). Staff E, RN stated that he was familiar with Resident #3 and that he enjoyed talking about the roofing business and cars. Resident #3 was relatively alert and was able to make his needs known. Resident #3 would frequently propel himself in his wheelchair because he could not walk. Staff E, RN also stated that Resident #3 required assistance with his ADLs and stated, I think they fed him. Staff E, RN stated that he has been told by other CNA's that Resident #3 frequently stole food off Resident #15's tray because he was blind, but he never witnessed it himself. Staff E, RN stated that a CNA yelled out for a code blue, where Staff E, RN responded to Resident #3's room along with several other staff members. Staff F, LPN was seen in the room as well as two other CNA's that were trying to get Resident #3 to respond. Staff E, RN stated that Resident #3 appeared purple and was not breathing. Staff F, LPN then told Staff E, RN that she had pulled food out of Resident #3's mouth but saw some grapes further down in his throat. Attempts were made to suction Resident #3, but they were unsuccessful. Staff E, RN stated that Resident #3 never regained consciousness. Staff E, RN also stated that a staff member attempted to call 911, but the call was discontinued once they discovered that he was a DNR. Staff E, RN was not able to state if Resident #3 had behaviors of stealing and consuming other residents' food as part of his care plan. Staff E, RN also stated that in-service training had been conducted recently related to completing 911 calls regardless of whether or not the resident had a DNR code status. The in-service also discussed proper use of the [MEDICATION(S)] Maneuver. A review of the facility policy titled Behavioral Assessment, Intervention, and Monitoring, with no effective date, revealed under the section titled Policy Statement that the facility would provide, and resident would receive behavioral health services as needed to attain or maintain the highest practicable physical, mental, and psychosocial well-being in accordance with the comprehensive assessment and plan of care. The policy also revealed, under the section titled General Guidelines that Behavior is the response of an individual to a wide variety of factors. These factors may include medical, physical, functional, psychosocial, emotional, psychiatric, or environmental causes. Behavior is regulated by the brain and is influenced by past experiences, personality traits, environment, and interactions with other people. Behavior can be a way for an individual in distress to communicate unmet needs, indicate discomfort, or express thoughts that cannot be articulated. The policy revealed under the section titled Assessment that as part of the comprehensive assessment, staff will evaluate, based on input from the resident, family, and caregivers, review of medical record, and general observations the resident's usual patterns of cognition, mood, and behavior; the resident's usual method of communicating things like pain, hunger, thirst, and other physical discomforts; the resident's typical or past responses to stress, fatigue, fear, anxiety, frustration, and other triggers; and the resident's previous patterns of coping with stress, anxiety, and depression. The nursing staff will identify, document, and inform the physician about specific details regarding changes in an individual's mental status, behavior, and cognition, including onset, duration, intensity, and frequency of behavioral symptoms; any recent precipitating or relevant factors or environmental triggers; and appearance and alertness of the resident and related observations. New onset or changes in behavior will be documented regardless of the degree of risk to the resident or others. An interview was conducted on [DATE] at 09:48 AM with Staff G, CNA. Staff G, CNA stated that she cared for Resident #3 frequently and that he required total assistance with eating due to the large amount of food he would attempt to eat at once. Resident #3 was not very good with portion control and would fit as much food as he could on his spoon before taking a bite. Resident #3 was on a puree diet with nectar thickened liquids and would frequently propel himself in his wheelchair around the facility. Staff G, CNA stated that Resident #3 was constantly asking for food and that they once had a going away party for a staff member and a cake was left in the small room next to the dining room. Resident #3 had discovered the cake and attempted to eat a portion of it, but staff was able to redirect him before he consumed any of it. Staff G, CNA stated that she never witnessed Resident #3 take food off another resident's tray, but she would not be surprised if he did. Staff G, CNA also stated that in-service training had been conducted recently related to calling 911 in any emergency and to follow the instructions of Emergency Medical Services (EMS) as well as where to find DNR paperwork. A review of the job description for the Certified Nursing Assistant revealed, under the section titled Summary, that the Resident Care Specialist performs multiple care duties that contribute to the health, wellbeing, and quality of life for the residents of the facility. The job description also revealed, under the section titled Essential Duties and Responsibilities, the following duties and responsibilities of the CNA: - Assisting residents with activities of daily living, such as transferring, turning, and repositioning, giving showers, dressing, grooming, feeding, toileting, and ensuring residents are clean. - Obtaining vital signs and monitoring food and liquid intake. - Delivering meal trays to residents, ensuring food is appropriate to the resident's care plan, delivering alternate food selections when requested, and a providing positive dining experience. - Making daily rounds on assigned residents in accordance with established guidelines. - Consistently and promptly reporting resident changes of condition. - Safely fulfilling all work assignments. - Accepting assignments not part of his/her normal scheduled responsibility as needed. An interview was conducted on [DATE] at 10:04 AM with Staff H, CNA. Staff H, CNA stated that she would normally see Resident #3 during the day in the dining room and that he was assisted with meals by staff. Staff H, CNA also stated that Resident #3 would occasionally feed himself with supervision, but he needed to be supervised because he had a tendency to snatch stuff off people's plate. Staff H, CNA stated that she did not have any in-service training related to the incident. An interview was conducted on [DATE] at 10:12 AM with Staff I, LPN. Staff I, LPN stated that she was very familiar with Resident #3 and saw him on a daily basis. Resident #3 would sometimes have outbursts while being provided care but was usually able to be re-directed by staff. Staff I, LPN stated that Resident #3 was able to propel himself in his wheelchair very well and had a habit of leaving the dining room after meals to roam around the facility. Resident #3 was sometimes able to feed himself with assistance but needed to be supervised because he would try and eat too much too fast. Resident #3 would ask for food often and would sometimes attempt to take the food off of other residents' trays. Staff I, LPN stated that Resident #3 would cough often during meals but that she never witnessed him choking. An interview was conducted on [DATE] at 10:28 AM with Staff J, CNA. Staff J, CNA stated that she was very familiar with Resident #3 and that he required visual supervision and cueing during mealtimes due to eating too fast. Resident #3 tended to shove food and beverages into his mouth during meals if he was not supervised and was constantly seeking out food. Resident #3 was known to frequently grab other residents' food and would shove it down his throat if he felt like he was going to be caught with it. Staff J, CNA stated that she had witnessed Resident #3 take food from other residents' trays before and that he could not be left alone with unattended trays. Resident #3 was on a puree diet with nectar thickened liquids and that he would normally eat his meals in the dining room. Staff J, CNA stated that on [DATE], Resident #3 was being cared for by a newly hired CNA and that the CNA was not familiar with the resident's behaviors of taking food and impulsive eating. Resident #3 was in the facility dining room while staff began to clear out the remaining resident trays from the area. Resident #3 became angry with staff and went into a small side room to watch television. Staff J, CNA stated that she instructed Resident #3's assigned CNA to keep an eye on him due to his behavior of seeking out food. Staff J, CNA stated that herself and the other CNAs on the unit began to clear dinner trays from resident rooms but did not look in Resident #3's room because he was sitting in the small television room. Staff J, CNA stated that Staff K, CNA then pulled her into Resident #3's room, where he was found in his wheelchair with food running from his nose and mouth. Resident #3 was also found to be blue/purple in color and unresponsive. Staff J, CNA then instructed the other CNAs on the floor to call a code blue, call 911, and get the nurse to the room. Staff J, CNA stated that she then performed a mouth sweep of Resident #3 and visualized an entire half of a baked potato, a piece of roast, and a whole bunch of grapes. Staff J, CNA was not able to remove all of the grapes from Resident #3's mouth. Staff J, CNA stated that Resident #3 was noted to have a very faint pulse and was not breathing. Staff F, LPN entered the room and attempted to assist Staff J, CNA in getting Resident #3 out of his wheelchair to perform a [MEDICATION(S)] Maneuver on the resident, but he had to be lowered to the floor. Staff J, CNA stated that Staff E, RN also responded to Resident #3's room and instructed her and Staff F, LPN don't touch him and asked them, how do you know he's not a DNR? Resident #3 was then turned on his side and finger sweep and suctioning were attempted but produced minimal amounts of food products. Resident #3's pulse was no longer able to be palpated, and Resident #3 expired in the room. Staff J, CNA stated that the CNA that called 911 was instructed by Staff E, RN to hang up the 911 call due to Resident #3 being a DNR. Staff J, CNA also stated that education was conducted by the Director of Nursing (DON) related the [MEDICATION(S)] Maneuver and performing it on an unconscious resident as well as residents with DNR code statuses. Staff J, CNA stated that Resident #15 was also in the room during the incident but was not aware of what was happening due to [CONDITION(S)] and cognitive impairment. An interview was attempted on [DATE] 10:31 AM with Staff K, CNA. The DON stated that Staff K, CNA was sent home for good and was not in the facility. A review of the job description for the facility's Nursing Home Administrator revealed, under the section titled Summary, that the NHA was responsible for the overall management of a facility and plans, develops, directs, monitors, and supports all operational, administrative, clinical, human resources, customer service, and fiscal activities for the facility's programs and services. The job description also revealed, under the section titled Essential Duties and Responsibilities, the following duties and responsibilities of the NHA: - Recruits, hires, provides orientation/training, and retains a sufficient number of qualified staff to carry out facility programs and services. - Makes sure facility is a safe, clean, comfortable, and appealing environment for residents, patients, visitors, and staff in accordance with company guidelines. An interview was conducted on [DATE] at 11:07 AM with the facility's Nursing Home Administrator (NHA) and Director of Nursing (DON). The NHA stated that the incident occurred on [DATE] at around 05:45 PM and was reported as an injury of unknown origin. The DON stated that the incident was reported to her by Staff E, RN while the incident was still occurring, but then the phone was passed on to Staff F, LPN. The DON stated that it was reported to her that Resident #3 was eating in the facility dining room and was supervised by the staff during the meal. Resident #3 then went to the room next to the dining room and was watching television. The floor CNAs then started to collect dinner trays from resident rooms when they discovered Resident #3 in his room, up in his wheelchair, and had food coming out of his mouth. The DON stated that a CNA activated a code blue and nursing staff responded to the room right away. Resident #3 was then assisted onto the floor by staff and began to perform the [MEDICATION(S)] Maneuver and finger sweeps. Staff were able to remove some grapes and potato from Resident #3's mouth and attempted to perform suctioning of the resident. The DON stated that during that time, another nurse had verified that Resident #3 had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Staff then notified Resident #3's physician and family of the incident. The DON stated that she started an investigation the following day and had the staff perform a re-enactment of the event. No staff interviews verified that Resident #3 took food items off of his roommate's tray, but they are guessing that the food may have come from the roommate's tray. The DON stated that Resident #15 was blind and that he was not able to provide any information related to the incident. The DON also stated that staff was very aware of Resident #3's behaviors of taking other residents' food and needed to be seated away from other residents at mealtimes. The DON stated that part of her investigation was reviewing Resident #3's record, which included the Care Plan. Resident #3's Care Plan stated that the resident needed to eat in the dining room for meals and needed to be supervised by staff during meals. The DON stated that Resident #3 never had behaviors of taking food from Resident #15 in the past, but that he must have gotten to the food when staff did not realize that Resident #3 propelled himself in his wheelchair and back to his room. In-service training was conducted related to residents with DNR status and whether or not you should perform the [MEDICATION(S)] Maneuver on them. The DON provided the educational materials and staff roster used for the in-service training conducted in response to the event following the interview. A review of the facility's Inservice Education Sheet, dated for [DATE] and [DATE], revealed that the training was conducted by the DON. The section titled Program Title revealed the following topics: - Review of DNR when to honor and when NOT. - Facility policy and procedures (process). - Florida law on Advanced Directives & DNR. The Inservice Education Sheet also revealed, under the section titled Objectives the following objectives for the training: - All will be able to understand and be able to execute the process during emergency. - Employees will be able to assist the licensed professional during emergency. - Employees will be able to respond appropriately in case of emergency. - Employees will be able to locate Crash Cart and respond during emergency situation. A review of the sign in roster for the Inservice Education Sheet revealed that 23 out of 70 facility employees were educated. A follow up interview was conducted on [DATE] at 11:57 AM with the DON. The DON stated that not a high percentage of employees were included in the in-service training and was not able to state how many total employees were educated. The DON stated that her main focus was on the employees that were present during the event on [DATE] and was not able to state why education was not provided to the rest of the staff. The DON shrugged her shoulders and stated, that's all I got and exited the room. A review of the job description for the facility's Director of Nursing revealed, under the section titled Summary, that the DON plans, coordinates, and manages the nursing department and is responsible for the overall direction, coordination, and evaluation of nursing care and services provided to the residents. The DON ensures quality care that is consistent with company and regulatory standards. The job description also revealed, under the section titled Essential Duties and Responsibilities, the following duties and responsibilities of the DON: - Ensures nursing staff is providing quality and appropriate resident/patient care that meet or exceeds company and regulatory standards. - Schedules and performed resident/patient rounds to monitor and evaluate the quality and appropriateness of nursing care. - Maintains administrative authority, responsibility, and accountability for the proper charting and documentation of care and of medications and treatments. - Evaluates current and potential residents and patients to ensure facility can provide appropriate level of care. An interview was conducted on [DATE] at 09:29 AM with Staff M, CNA. Staff M, CNA stated that she cared for Resident #3 very frequently and knew the resident well. Resident #3 was confused and forgetful at times but was able to make his needs known and carry on a conversation. Resident #3 sometimes ate meals in the facility dining room or in his room if he was in bed but required assistance with feeding for all meals. Staff M, CNA stated that if Resident #3 attempted to feed himself, he would eat too fast and he got it all over himself. Resident #3 was on a pureed diet with thickened liquids for all meals. Staff M, CNA stated, you gotta watch him, if a resident were there he would go after the food and that she would sit with him until all the other trays in the dining room were gone before assisting him to leave the dining room. Staff M, CNA stated that if staff was sitting with Resident #3 then he would not grab at food, but if he was left alone then he would grab any food that was in his reach. An interview was conducted on [DATE] at 09:39 AM with Staff N, Speech Language Pathologist (SLP). Staff N, SLP stated that she normally worked with residents at the facility that suffered from cognitive issues and swallowing difficulties. Staff N, SLP also stated that she remembered working with Resident #3 and that she had provided a discharge summary when he was discharged from speech therapy on [DATE] and had not worked with the resident since then. The discharge summary was provided to the DON, the kitchen, the Unit Managers, and the MDS nurses. Staff N, SLP stated that Resident #3 did not necessarily require one to one assistance with meals, but needed cueing and setup help as well as observation. Resident #3 was very impulsive with eating and would keep putting food in his mouth before finishing the previous mouthful of food. Staff N, SLP stated that Resident #3 would be provided nectar thickened coffee and that he would take it like a shot. Staff N, SLP also stated that she had not observed Resident #3 taking food off of other residents' trays, but that he would help himself to Oreo's on the snack carts if it was left unattended. Staff N, SLP stated that she worked with Resident #3 for months but wa[TRUNCATED]

Based on interviews with the nursing staff, the Nursing Home Administrator, the Director of Nursing, the facility's Speech Language Pathologist, Registered Dietician, Medical Director, the resident's family members, and review of the resident's medical record and facility policies, the facility failed to ensure that one (Resident #3) of four residents sampled for therapeutic diets and supervision with meals, was provided with needed supervision and monitoring at meals related to the resident's impulsive and known behavior of grabbing food that was within his reach and not a part of his diet restriction, and eating it quickly. The facility nursing staff failed to provide the level of oversight of whereabouts and supervision necessary to ensure the safety of Resident #3 on [DATE] at approximately 05:45 PM. On that date and time, staff were unaware that Resident #3 propelled his wheelchair to his room and was able to access and consume his blind roommate's (#15) food items that conflicted with Resident #3's therapeutic diet. Facility staff failed to ensure that Resident #3's assigned aide was aware of the resident's need for supervision at mealtimes. Resident #3's assigned aide was not as familiar with all of his behaviors, such as using his wheelchair to self-propel and grab food during meals from the trays of other dining room residents, including foods inconsistent with his diet orders and which he consumed rapidly. The facility's failure to provide consistent supervision of the resident while food products were accessible in the resident's proximity and room, contrary to his therapeutic diet, presented a direct threat to his health and safety, resulting in findings of Immediate Jeopardy on [DATE], which was removed on [DATE] at 04:30 PM. Findings included: A review of Resident #3's Progress Notes revealed a note, dated on [DATE] at 6:45 PM, which documented that around 5:15 PM a Certified Nurse's Aide (CNA) yelled to the writer (Staff F, Licensed Practical Nurse), that a code blue was being initiated. Staff F, LPN entered the room and Resident #3 appeared purple in color, took a breathe, and had a faint pulse. Staff then assisted Resident #3 to the floor and performed a sternal rub as he was not able to stand in order to perform the [MEDICATION(S)] Maneuver. Staff F, LPN performed a finger sweep of Resident #3's mouth and pulled out large chunks of potato, grapes, and meat. Staff F, LPN turned Resident #3 on his side, sat him up, and attempted suctioning with little return. Resident #3 then took his last breath and no pulse was noted. The note also revealed that prior to the incident, Resident #3 was in a small dining area, located by the nurse's station after he consumed his dinner meal, and began to attempt to consume the food of two other residents. Resident #3 was noted to not be easily redirected and became verbally abusive with the staff. Staff then placed Resident #3 by the nurse's station. The progress note revealed that the verbal abuse and attempting to consume other residents' food was frequent behavior of Resident #3 and that it was related to his diagnosis of [CONDITION(S)]. Resident #3 then self-propelled to his room while staff was cleaning up after dinner and a CNA had eyes on the resident a few minutes prior to the event. Resident #3 then consumed his roommate's meal, who was on a regular diet. Resident #3 was noted to be on a puree diet. The progress note then revealed that Resident #3 had potato with skin on it, grapes, and whole pieces of meat in his mouth. Resident #3's roommate, Resident #15, was blind and was unable to alert staff of Resident #3 taking his food. Resident #3's physician was then notified, and the time of death was 05:25 PM, which was verified by two nurses. According to the Mayo Clinic, choking occurs when a foreign object lodges in the throat or windpipe, blocking the flow of air. In adults, a piece of food often is the culprit. Because choking cuts off oxygen to the brain, give first aid as quickly as possible. The universal sign for choking is hands clutched to the throat. If the person does not give the signal, look for these indications: - Inability to talk - Difficulty breathing or noisy breathing - Squeaky sounds when trying to breathe - Cough, which may either be weak or forceful - Skin, lips, and nails turning blue or dusky - Skin that is flushed, then turns pale or bluish in color - Loss of consciousness https://www.mayoclinic.org/first-aid/first-aid-choking/basics/art- 637#:~:text=To%20perform%20abdominal%20thrusts%20([MEDICATION(S)]%20maneuver)%20on%20yourself%2C%20place,do%20in%20a%20choking%20emergency. A review of Resident #3's Medical Record revealed that Resident #3 was admitted to the facility on [DATE] with diagnoses of [CONDITION(S)] and [CONDITION(S)] following cerebral infarction affecting left dominant side, feeding difficulties, dysphagia following unspecified [CONDITION(S)] disease, dysphagia, oropharyngeal phase, unspecified dementia with behavioral disturbance, cognitive communication deficit, other specified intracranial injury without loss of consciousness, subsequent encounter, mood disorder due to known physiological condition with mixed features, personal history of [CONDITION(S)], paranoid [CONDITION(S)], and major depressive disorder, recurrent, severe with psychotic symptoms. A review of Resident #3's Physician's Orders revealed the following orders: - An order, dated on [DATE], that in case of [CONDITION(S)], the resident is a Do Not Resuscitate (DNR). - An order, dated on [DATE], for Occupational Therapy (OT) to continue treating the resident with self-feeding difficulties 3 times weekly for 30 days with neuromuscular re-education, therapeutic activities, and self-care management. - An order, dated on [DATE], for OT to be provided 3 times a week for 20 days for Activity of Daily Living (ADL) retraining, wheelchair management, therapeutic exercises, and therapeutic activities. - An order, dated on [DATE], for monitoring of target behaviors of extreme fear and combativeness at the end of each shift. Document non-pharmacological interventions attempted, frequency of the behavior, and intensity of the behavior. - An order, dated on [DATE], for monitoring of target behaviors of yelling, cursing, attention seeking behavior, and inappropriate sexual behaviors at the end of each shift. Document non-pharmacological interventions attempted, frequency of the behavior, and intensity of the behavior. Resident #3's Physician's Orders did not reveal a current order for a mechanically altered diet. Resident #3's Physician's Orders also did not reveal monitoring of behaviors related to consuming food that was not part of his mechanically altered diet or impulsive eating. A review of the facility policy titled Do Not Resuscitate Order, last revised in April of 2017, revealed that the facility would not use cardiopulmonary resuscitation (CPR) and related emergency measures to maintain life functions on a resident when there is a Do No Resuscitate Order in effect. A review of the facility policy titled Therapeutic Diets, with no effective date, revealed that therapeutic diets were prescribed by the Attending Physician to support the resident's treatment and plan of care and in accordance with his or her goals and preferences. The policy also revealed that a therapeutic diet must be prescribed by the resident's attending physician (or non-physician provider). The attending physician may delegate this task to a registered or licensed dietitian as permitted by law. If a mechanically altered diet is ordered, the provider will specify the texture modification. A review of Resident #3's Care Plan, for the date range of [DATE] to [DATE], revealed a problem, with a start date of [DATE], that Resident #3 was at nutritional risk related to receiving a therapeutic mechanically altered diet and diagnoses of dysphagia, Diabetes Mellitus 2, and history of [CONDITION(S)]. Interventions included to provide a Consistent Carbohydrate, puree, with nectar thickened liquids diet and provide a divided plate, built up utensils, and coffee cups with lids for all meals. Resident #3's Care Plan also revealed a problem, with a start date of [DATE], that Resident #3 was at risk for discomfort and adverse effects due to use of [CONDITION(S)] medications related to diagnoses of [CONDITION(S)] and depression. Behaviors included fearfulness, yelling, cursing, combativeness, attention seeking behavior, inappropriate sexual behavior with staff and inappropriate sexual behavior with peers. Interventions included to supervise at all times when with female residents, administer medications as prescribed by the physician, monitor mood and behavior indicators, and documented per facility protocol, and observe as indicated if the resident's behavioral/mood symptoms present a danger to the resident and/or others and intervene as needed. Resident #3's Care Plan revealed a problem, dated on [DATE], that Resident #3 required staff total care assistance for ADL's due to impaired cognition, incontinence of bowel and bladder, impaired functional mobility, poor self-awareness, and poor safety awareness. Interventions included for staff to provide total care for bathing, personal hygiene, dressing, transfers/mobility, toileting, and eating as indicated and provide wheelchair for mobility. Resident #3's Care Plan also revealed a problem, dated on [DATE], that Resident #3 had a behavioral problem as evidenced by kicking shoes off and asking staff to put them back on for attention, requiring redirection related to verbal abuse and inappropriate sexual behaviors with female staff. Interventions included to assign male staff to the resident, when possible, maintain a calm, slow, and understandable approach with the resident, when the resident begins to become socially inappropriate or disruptive, provide comfort measures for basic needs, offer drink or food to distract, provide quiet time in room when being verbally disruptive and monitor for safety frequently, and use music as a distraction. A level 1 dysphagia diet, or puree diet, consists of foods that are pureed, homogenous and cohesive. Foods should be pudding-like. Foods that require bolus formation, controlled manipulation and chewing are not allowed. Some items recommended for a puree diet include pureed meats, pureed eggs, soufflés that are smooth, hummus or other pureed legume spreads, mashed or pureed potatoes with gravy, butter, margarine or sour cream and pureed fruits or well mashed fresh bananas. Food items that should be avoided while on a puree diet include whole fruits (fresh, frozen, canned, or dried), whole or ground meats, fish or poultry, non-pureed lentil, or legumes, fried, scrambled, or soft and hard-cooked eggs, cheeses, cottage cheese, peanut butter, unless pureed into a food, all other potatoes, rice and noodles, plain mashed potatoes, cooked grains, and non-pureed bread dressing / stuffing. https://www.dysphagia-diet.com/Images/Level%201%20Dysphagia%20Pureed%20Diet.pdf. A review of Resident #3's Quarterly Minimum Data Set (MDS) Assessment, dated on [DATE] revealed, under Section B - Hearing, Speech, and Vision, that Resident #3 had unclear speech - slurred or mumbled words, was usually understood - difficulty communicating some words or finishing thoughts but is able if prompted or given time, and usually understands others - misses some parts or intent of a message but comprehends most conversation. Resident #3's MDS Assessment also revealed, under Section C - Cognitive Patterns, a Brief Interview for Mental Status (BIMS) score of 09, which indicated moderately impaired cognition. Section G - Functional Status of Resident #3's MDS Assessment revealed that the resident required extensive assistance and one-person physical assistance with eating. Section G also revealed that Resident #3 used a wheelchair for a mobility device and required setup help only with locomotion on the unit. Resident #3's MDS Assessment revealed, under Section I - Active Diagnoses, that Resident #3 had diagnoses of [CONDITION(S)] and history of [CONDITION(S)]. Resident #3's MDS Assessment also revealed, under Section K - Swallowing/Nutritional Status, that Resident #3 complained of difficulty or pain with swallowing and had a mechanically altered diet, which required change in texture of food or liquids. A review of Resident #15's Physician's Orders revealed an order, dated [DATE], for a regular diet with thin liquids. A review of Resident #15's Care Plan revealed a problem, dated [DATE], that Resident #15 was legally blind due to severe [CONDITION(S)] and corneal abrasion. Interventions included to provide verbal cue to enhance independence and telling resident where items are placed using the clock method. An interview was conducted on [DATE] at 09:24 AM with Staff E, Registered Nurse (RN). Staff E, RN stated that he was familiar with Resident #3. Resident #3 was relatively alert and was able to make his needs known. Resident #3 would frequently propel himself in his wheelchair because he could not walk. Staff E, RN also stated that Resident #3 required assistance with his ADLs and stated, I think they fed him. Staff E, RN stated that he has been told by other CNA's that Resident #3 frequently stole food off of Resident #15's tray because he was blind, but he never witnessed it himself. Staff E, RN stated that a CNA yelled out for a code blue, where Staff E, RN responded to Resident #3's room along with several other staff members. Staff F, LPN was seen in the room as well as two other CNA's that were trying to get Resident #3 to respond. Staff E, RN stated that Resident #3 appeared purple and was not breathing. Staff F, LPN then told Staff E, RN that she had pulled food out of Resident #3's mouth but saw some grapes further down in his throat. Attempts were made to suction Resident #3, but they were unsuccessful. Staff E, RN stated that Resident #3 never regained consciousness. Staff E, RN also stated that a staff member attempted to call 911, but the call was discontinued once they discovered that he was a DNR. Staff E, RN was not able to state if Resident #3 had behaviors of stealing and consuming other resident's food as part of his care plan. Staff E, RN also stated that in-service training had been conducted recently related to completing 911 calls regardless of whether or not the resident had a DNR code status. The in-service also discussed proper use of the [MEDICATION(S)] Maneuver. An interview was conducted on [DATE] at 09:48 AM with Staff G, CNA. Staff G, CNA stated that she cared for Resident #3 frequently and that he required total assistance with eating due to the large amount of food that he would attempt to eat at once. Resident #3 was not very good with portion control and would fit as much food as he could on his spoon before taking a bite. Resident #3 was on a puree diet with nectar thickened liquids and would frequently propel himself in his wheelchair around the facility. Staff G, CNA stated that Resident #3 was constantly asking for food and that they once had a going away party for a staff member and a cake was left in the small room next to the dining room. Resident #3 had discovered the cake and attempted to eat a portion of it, but staff was able to redirect him before he consumed any of it. Staff G, CNA stated that she never witnessed Resident #3 take food off another resident's tray, but she would not be surprised if he did. Staff G, CNA also stated that in-service training had been conducted recently related to calling 911 in any emergency and to follow the instructions of Emergency Medical Services (EMS) as well as where to find DNR paperwork. A review of the facility policy titled Behavioral Assessment, Intervention, and Monitoring, with no effective date, revealed under the section titled Policy Statement that the facility would provide, and resident would receive behavioral health services as needed to attain or maintain the highest practicable physical, mental, and psychosocial well-being in accordance with the comprehensive assessment and plan of care. The policy also revealed, under the section titled General Guidelines that Behavior is the response of an individual to a wide variety of factors. These factors may include medical, physical, functional, psychosocial, emotional, psychiatric, or environmental causes. Behavior is regulated by the brain and is influenced by past experiences, personality traits, environment, and interactions with other people. Behavior can be a way for an individual in distress to communicate unmet needs, indicate discomfort, or express thoughts that cannot be articulated. The policy revealed under the section titled Assessment that as part of the comprehensive assessment, staff will evaluate, based on input from the resident, family, and caregivers, review of medical record, and general observations the resident's usual patterns of cognition, mood, and behavior; the resident's usual method of communicating things like pain, hunger, thirst, and other physical discomforts; the resident's typical or past responses to stress, fatigue, fear, anxiety, frustration, and other triggers; and the residents previous patterns of coping with stress, anxiety, and depression. The nursing staff will identify, document, and inform the physician about specific details regarding changes in an individual's mental status, behavior, and cognition, including onset, duration, intensity, and frequency of behavioral symptoms; any recent precipitating or relevant factors or environmental triggers; and appearance and alertness of the resident and related observations. New onset or changes in behavior will be documented regardless of the degree of risk to the resident or others. An interview was conducted on [DATE] at 10:04 AM with Staff H, CNA. Staff H, CNA stated that she would normally see Resident #3 during the day in the dining room and that he was assisted with meals by staff. Staff H, CNA also stated that Resident #3 would occasionally feed himself with supervision, but he needed to be supervised because he tended to snatch stuff off people's plate. Staff H, CNA stated that she did not have any in-service training related to the incident. An interview was conducted on [DATE] at 10:12 AM with Staff I, LPN. Staff I, LPN stated that she was very familiar with Resident #3 and saw him daily. Resident #3 would sometimes have outbursts while being provided care but was usually able to be re-directed by staff. Staff I, LPN stated that Resident #3 was able to propel himself in his wheelchair very well and had a habit of leaving the dining room after meals to roam around the facility. Resident #3 was sometimes able to feed himself with assistance but needed to be supervised because he would try and eat too much too fast. Resident #3 would ask for food often and would sometimes attempt to take the food off other resident's trays. Staff I, LPN stated that Resident #3 would cough often during meals but that she never witnessed him choking. An interview was conducted on [DATE] at 10:28 AM with Staff J, CNA. Staff J, CNA stated that she was very familiar with Resident #3 and that he required visual supervision and cueing during mealtimes due to eating too fast. Resident #3 had a tendency to shove food and beverages into his mouth during meals if he was not supervised and was constantly seeking out food. Resident #3 was known to frequently grab other resident's food and would shove it down his throat if he felt like he was going to be caught with it. Staff J, CNA stated that she had witnessed Resident #3 take food from other resident's trays before and that he could not be left alone with unattended trays. Resident #3 was on a puree diet with nectar thickened liquids and that he would normally eat his meals in the dining room. Staff J, CNA stated that on [DATE], Resident #3 was being cared for by a newly hired CNA (Staff L, CNA) and that the CNA was not familiar with the resident's behaviors of taking food and impulsive eating. Resident #3 was in the facility dining room while staff began to clear out the remaining resident trays from the area. Resident #3 became angry with staff and went into a small side room to watch television. Staff J, CNA stated that she instructed Resident #3's assigned Staff L, CNA to keep an eye on him due to his behavior of seeking out food. Staff J, CNA stated that herself and the other CNAs on the unit began to clear dinner trays from resident rooms but did not look in Resident #3's room because he was sitting in the small television room. Staff J, CNA stated that Staff K, CNA then pulled her into Resident #3's room, where he was found in his wheelchair with food running from his nose and mouth. Resident #3 was also found to be blue/purple in color and unresponsive. Staff J, CNA then instructed the other CNAs on the floor to call a code blue, call 911, and get the nurse to the room. Staff J, CNA stated that she then performed a mouth sweep of Resident #3 and visualized an entire half of a baked potato, a piece of roast, and a whole bunch of grapes. Staff J, CNA was not able to remove all of the grapes from Resident #3's mouth. Staff J, CNA stated that Resident #3 was noted to have a very faint pulse and was not breathing. Staff F, LPN entered the room and attempted to assist Staff J, CNA in getting Resident #3 out of his wheelchair to perform a [MEDICATION(S)] Maneuver on the resident, but he had to be lowered to the floor. Staff J, CNA stated that Staff E, RN also responded to Resident #3's room and instructed her and Staff F, LPN don't touch him and asked them how do you know he's not a DNR?. Resident #3 was then turned on his side and finger sweeps and suctioning were attempted, but produced minimal amounts of food products. Resident #3's pulse was no longer able to be palpated and Resident #3 expired in the room. Staff J, CNA stated that the CNA that called 911 was instructed by Staff E, RN to hang up the 911 call due to Resident #3 being a DNR. Staff J, CNA also stated that education was conducted by the Director of Nursing (DON) related the [MEDICATION(S)] Maneuver and performing it on an unconscious resident as well as residents with DNR code statuses. Staff J, CNA stated that Resident #15 was also in the room during the incident but was not aware of what was happening due to [CONDITION(S)] and cognitive impairment. A review of the job description for the Certified Nursing Assistant revealed, under the section titled Summary, that the Resident Care Specialist performs multiple care duties that contribute to the health, wellbeing, and quality of life for the residents of the facility. The job description also revealed, under the section titled Essential Duties and Responsibilities, the following duties and responsibilities of the CNA: - Assisting residents with activities of daily living, such as transferring, turning, and repositioning, giving showers, dressing, grooming, feeding, toileting, and ensuring residents are clean. - Obtaining vital signs and monitoring food and liquid intake. - Delivering meal trays to residents, ensuring food is appropriate to the resident's care plan, delivering alternate food selections when requested, and a providing positive dining experience. - Making daily rounds on assigned residents in accordance with established guidelines. - Consistently and promptly reporting resident changes of condition. - Safely fulfilling all work assignments. - Accepting assignments not part of his/her normal scheduled responsibility as needed. An interview was attempted on [DATE] 10:31 AM with Staff K, CNA. The DON stated that Staff K, CNA was sent home for good and was not in the facility. An interview was conducted on [DATE] at 11:07 AM with the facility's Nursing Home Administrator (NHA) and DON. The NHA stated that the incident occurred on [DATE] at around 05:45 PM and was reported as an injury of unknown origin. The DON stated that the incident was reported to her by Staff E, RN while the incident was still occurring, but then the phone was passed on to Staff F, LPN. The DON stated that it was reported to her that Resident #3 was eating in the facility dining room and was supervised by the staff during the meal. Resident #3 then went to the room next to the dining room and was watching television. The floor CNAs then started to collect dinner trays from resident rooms when they discovered Resident #3 in his room, up in his wheelchair, and had food coming out of his mouth. The DON stated that a CNA activated a code blue and nursing staff responded to the room right away. Resident #3 was then assisted onto the floor by staff and began to perform the [MEDICATION(S)] Maneuver and finger sweeps. Staff were able to remove some grapes and potato from Resident #3's mouth and attempted to perform suctioning of the resident. The DON stated that during that time, another nurse had verified that Resident #3 had an order for DNR. The DON stated that Resident #3 took 3 small breathes and eventually stopped breathing. Staff then notified Resident #3's physician and family of the incident. The DON stated that she started an investigation the following day and had the staff perform a re-enactment of the event. No staff interviews verified that Resident #3 took food items off his roommate's tray, but they are guessing that the food may have come from the roommate's tray. The DON stated that Resident #15 was blind and that he was not able to provide any information related to the incident. The DON also stated that staff was very aware of Resident #3's behaviors of taking other resident's food and needed to be seated away from other residents at mealtimes. The DON stated that part of her investigation was reviewing Resident #3's record, which included the Care Plan. Resident #3's Care Plan stated that the resident needed to eat in the dining room for meals and needed to be supervised by staff during meals. The DON stated that Resident #3 never had behaviors of taking food from Resident #15 in the past, but that he must have gotten to the food when staff did not realize that Resident #3 propelled himself in his wheelchair and back to his room. In-service training was conducted related to resident's with DNR status and whether or not you should perform the [MEDICATION(S)] Maneuver on them. The DON provided the educational materials and staff roster used for the in-service training conducted in response to the event following the interview. A review of the job description for the facility's Nursing Home Administrator revealed, under the section titled Summary, that the NHA was responsible for the overall management of a facility and plans, develops, directs, monitors, and supports all operational, administrative, clinical, human resources, customer service, and fiscal activities for the facility's programs and services. The job description also revealed, under the section titled Essential Duties and Responsibilities, the following duties and responsibilities of the NHA: - Ensures the quality and appropriateness of resident/patient care meets or exceeds company and regulatory standards. - Recruits, hires, provides orientation/training, and retains a sufficient number of qualified staff to carry out facility programs and services. - Makes sure facility is a safe, clean, comfortable, and appealing environment for residents, patients, visitors, and staff in accordance with company guidelines. A review of the facility's Inservice Education Sheet, dated for [DATE] and [DATE], revealed that the training was conducted by the DON. The section titled Program Title revealed the following topics: - Review of DNR when to honor and when NOT. - Facility policy and procedures (process). - Florida law on Advanced Directives & DNR. The Inservice Education Sheet also revealed, under the section titled Objectives the following objectives for the training: - All will be able to understand and be able to execute the process during emergency. - Employees will be able to assist the licensed professional during emergency. - Employees will be able to respond appropriately in case of emergency. - Employees will be able to locate Crash Cart and respond during emergency situation. A review of the sign in roster for the Inservice Education Sheet revealed that 23 out of 70 facility employees were educated. A follow up interview was conducted on [DATE] at 11:57 AM with the DON. The DON stated that not a high percentage of employees were included in the Inservice training and was not able to state how many total employees were educated. The DON stated that her main focus was on the employees that were present during the event on [DATE] and was not able to state why education was not provided to the rest of the staff. The DON shrugged her shoulders and stated, that's all I got, before exiting the room. A review of the job description for the facility's Director of Nursing revealed, under the section titled Summary, that the DON plans, coordinates, and manages the nursing department and is responsible for the overall direction, coordination, and evaluation of nursing care and services provided to the residents. The DON ensures quality care that is consistent with company and regulatory standards. The job description also revealed, under the section titled Essential Duties and Responsibilities, the following duties and responsibilities of the DON: - Ensures nursing staff is providing quality and appropriate resident/patient care that meet or exceeds company and regulatory standards. - Schedules and performed resident/patient rounds to monitor and evaluate the quality and appropriateness of nursing care. - Maintains administrative authority, responsibility, and accountability for the proper charting and documentation of care and of medications and treatments. - Evaluates current and potential residents and patients to ensure facility can provide appropriate level of care. An interview was conducted on [DATE] at 09:29 AM with Staff M, CNA. Staff M, CNA stated that she cared for Resident #3 very frequently and knew the resident well. Resident #3 was confused and forgetful at times but was able to make his needs known and carry on a conversation. Resident #3 sometimes ate meals in the facility dining room or in his room if he was in bed but required assistance with feeding for all meals. Staff M, CNA stated that if Resident #3 attempted to feed himself he would eat too fast and he got it all over himself. Resident #3 was on a pureed diet with thickened liquids for all meals. Staff M, CNA stated you gotta watch him, if a resident is there he would go after the food and that she would sit with him until all the other trays in the dining room were gone before assisting him to leave the dining room. Staff M, CNA stated that if staff was sitting with Resident #3 then he would not grab at food, but if he was left alone then he would grab any food that was in his reach. An interview was conducted on [DATE] at 09:39 AM with Staff N, Speech Language Pathologist (SLP). Staff N, SLP stated that she normally worked with residents at the facility that suffered from cognitive issues and swallowing difficulties. Staff N, SLP also stated that she remembered working with Resident #3 and that she had provided a discharge summary when he was discharged from speech therapy on [DATE] and had not worked with the resident since then. The discharge summary was provided to the DON, the kitchen, the Unit Managers, and the MDS nurses. Staff N, SLP stated that Resident #3 did not necessarily require one to one assistance with meals, but needed cueing and setup help as well as observation. Resident #3 was very impulsive with eating and would keep putting food in his mouth before finishing the previous mouthful of food. Staff N, SLP stated that Resident #3 would be provided nectar thickened coffee and that he would take it like a shot. Staff N, SLP also stated that she had not observed Resident #3 taking food off other resident's tray, but that he would help himself to Oreo's on the snack carts if it was left unattended. Staff N, SLP stated that she worked with R[TRUNCATED]