Every finding on record at Embassy of Swanton

Based on observation, medical record review, staff interview and policy review, the facility failed to ensure monitoring of Legionella control measures were in place. This had the potential to affect all residents. Additionally, the facility failed to wear proper personal protective equipment while caring for a resident in enhanced barrier precautions. This affected one (#67) of one resident reviewed for infection control measures. The facility census was 64. Findings include:1. Review of the facility Legionella Environmental Assessment Form, dated 02/11/26 revealed interventions to prevent Legionella were specific only to the flushing of the closed Assisted Living unit (ALU) showers and bathrooms. Interview on 06/03/26 at 4:00 P.M. with Director of Maintenance (DOM) #219 confirmed the Legionella Environmental Assessment Form was specific only to the ALU. DOM #219 confirmed he had no Legionella prevention measures listed on the Legionella Environmental Assessment Form that were specific to the nursing home. Review of Environmental Monitoring policy dated 09/2018 revealed Legionella prevention monitoring was to include flushing of hot and cold water in rooms that were vacant for ten or more days. The flushing included the running of hot and cold water for five minutes at a time for five different times to be sure the pipes were clear of standing water. Further review of the Environmental Monitoring policy revealed the Legionella prevention intervention of removing and descaling of shower heads quarterly should be in place.Follow up interview on 06/04/26 at 11:10 A.M. with DOM #219 confirmed there was no documentation of flushing of hot and cold water in empty rooms for five minutes at a time for five different times. Additionally, DOM #219 confirmed he was unable to provide documentation showing shower heads were removed and descaled quarterly. DOM #219 continued to state he was unsure where the Environmental Monitoring policy came from as he had never seen it. Interview on 06/04/26 at 3:25 P.M. with Administrator revealed the policies Environmental Monitoring, Infection Control/Water Systems and Water Safety Plan were developed by the previous administrator and it was assumed the policies were developed and shared with DOM #219. 2. Review of the medical record revealed Resident #67 was admitted to the facility on [DATE]. Diagnoses included chronic obstructive pulmonary disease, acute respiratory failure, traumatic subdural hemorrhage, aphasia, dysphagia, and tracheostomy.Review of the quarterly Minimum Data Set (MDS) for Resident #67 dated 03/31/26 revealed a Brief Interview of Mental Status (BIMS) score of 00, indicating severe cognitive deficit. The resident had no behaviors. Functional abilities included dependence on others for all activities of daily living (ADL) care. Review of physician orders dated 06/14/25 revealed gloves and gown to be worn when dressing bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting as well as during device care or use of central line, urinary catheter, feeding tube, tracheostomy/ventilator.Review of the revised care plan for Resident #67 dated 04/03/26 revealed enhanced barrier precautions were to be in place. Observation on 06/02/26 at 5:30 A.M. revealed Certified Nursing Assistant (CNA) #118 and CNA #180 entered Resident #67's room to provide incontinence care. Gloves were applied; no further personal protective equipment (PPE) was donned. CNA's #118 and #180 continued to cleanse mucous around tracheostomy area, provide incontinence care and reposition Resident #67. Interview on 06/02/26 at 5:35 A.M. with CNA #118 and CNA #180 revealed confirmation neither wore PPE. The Enhanced Barrier Precautions (EBP) signage on the door was reviewed with both CNA #118 and CNA #180, both CNAs stated the EBP sign did not relate to Resident #67, and they were not required to wear PPE when providing care to Resident #67. CNA #180 stated the EBP sign pertained to the roommate of Resident #67, and the roommate was independent in her care. Interview on 06/02/26 at 5:41 A.M. with Licensed Practical Nurse (LPN) #159 revealed Resident #67 was in EBP due to resident having a percutaneous endoscopic gastrostomy (PEG) tube as well as a tracheostomy. LPN #159 confirmed that PPE should be worn when providing care to Resident #67.Review of the policy titled Enhanced Barrier Precautions, dated 07/13/22 revealed EBP refers to the use of gown and gloves during high-contact resident care activities. Further review of the policy revealed high contact areas included dressing, bathing, providing hygiene, and changing briefs.This deficiency represents non-compliance investigated under Complaint Number 2734720.

Based on observation, review of the medical record review, and staff interview, the facility failed to ensure Minimum Data Set (MDS) assessments were completed accurately. This affected seven (#6, #7, #12, #44, #54, #22 and #46) of 22 records reviewed. The facility census was 64. Findings include: 1. Review of the medical record for Resident #6 revealed an admission date of 05/08/18 with diagnoses of parkinsonism, dementia, and multiple sclerosis. Review of Resident #6's quarterly Minimum Data Set (MDS) assessment, dated 02/15/26, revealed the question Should Brief Interview for Mental Status (BIMS) be conducted? was answered yes. Further review revealed a dash (-) was entered by each question pertaining to the BIMS assessment indicating Resident #6's cognition was not assessed. 2. Review of the medical record for Resident #7 revealed an admission date of 08/03/23 with diagnoses of chronic respiratory failure with hypoxia, dependence on ventilator status, and seizures. Review of the quarterly MDS assessment, dated 01/15/26 revealed Resident #7 had intact cognition. Review of Resident #7's comprehensive annual MDS assessment, dated 04/17/26, revealed the question Should Brief Interview for Mental Status (BIMS) be conducted? was answered with a dash (-). Further review revealed a dash (-) was entered by each question pertaining to the BIMS assessment indicating Resident #7's cognition was not assessed. 3. Review of the medical record for Resident #12 revealed an admission date of 06/26/13 with diagnoses of Alzheimer's disease, neuralgia and parkinsonism. Review of Resident #12's quarterly MDS assessment, dated 02/03/26, revealed the question Should Brief Interview for Mental Status (BIMS) be conducted? was answered yes. Further review revealed a dash (-) was entered by each question pertaining to the BIMS assessment indicating Resident #12's cognition was not assessed. Interview on 06/03/26 at 4:58 P.M. with the Director of Nursing (DON) and Regional Registered Nurse (RRN) #230 revealed the MDS Coordinator worked remotely. 4. Review of Resident #44's medical record revealed an admission date of 11/01/24 with a diagnosis of schizoaffective disorder, congestive heart failure, anemia, dementia, manic episode, and psychosis. Review of Resident #44's annual MDS dated [DATE] revealed section C was failed to be assessed. Interview on 06/04/26 at 9:32 A.M. with the DON confirmed cognition was not assessed in the most recent MDS assessment for Resident #44. 5. Review of the medical record for Resident #54 revealed an admission date of 07/30/25. Diagnoses included anoxic brain injury, dysphagia, hypertension, cerebellar ataxia, and cardiomyopathy. Review of the quarterly MDS assessment dated [DATE] revealed the resident had intact cognition. Review of a significant change MDS assessment dated [DATE] revealed the resident's cognition status was not assessed. Interview on 06/04/26 at 7:59 A.M., RRN #230 verified Resident #54's cognitive assessment was not accurately completed. RRN #230 revealed the Resident Assessment Instrument (RAI) manual guidelines were used to complete resident MDS assessments. Interview on 06/04/26 at approximately 8:30 A.M. with the Administrator confirmed the BIMS assessments were not completed accurately for Resident #6, Resident #7, Resident #12, Resident #44, and Resident #54. 6. Review of the medical record for Resident #22 revealed an admission date of 02/09/26. Diagnoses included end stage renal disease, type two diabetes mellitus, atrial fibrillation, and hypertension. Review of the quarterly MDS assessment dated [DATE] revealed the resident had intact cognition. Further review of the MDS assessment revealed the resident was assessed as not being edentulous (no teeth). Observation on 06/01/26 at 10:42 A.M. of Resident #22 revealed the resident had no teeth. Interview on 06/01/26 at 10:42 A.M., Resident #22 revealed she had no teeth and her old dentures no longer fit. Interview on 06/04/26 at 7:59 A.M., RRN #230 verified the MDS assessment noting the resident was not edentulous was inaccurate as the resident had no teeth. 7. Review of the medical record for Resident #46 revealed an admission date of 02/24/25 with diagnoses of chronic obstructive pulmonary disease, alcoholic cirrhosis of liver, and epilepsy. Review of the annual comprehensive MDS assessment, dated 02/13/26, revealed Resident #46 did not use tobacco. Review of the modified quarterly MDS assessment, dated 03/31/26, revealed Resident #46 had impaired cognition. Review of Resident #46's smoking agreement revealed it was signed by Resident #46 on 02/25/25. Review of the care plan initiated 03/11/25 and revised 11/10/25 revealed Resident #46 had a potential for safety hazard or injury related to smoking. Resident #46 was able to smoke with supervision by staff or family. Review of the undated list of residents who smoke, provided by the facility on 06/01/26, revealed Resident #46 was included on the list. Interview on 06/04/26 at 7:58 A.M. with RRN #230 confirmed Resident #46's comprehensive annual MDS assessment, dated 02/13/26, was completed inaccurately in reference to Resident #46's tobacco use.

Based on observation, record review, staff interview and review of the menu spreadsheet, the facility failed to ensure residents received all components of the meal. This affected all residents in the facility except for 14 (#2, #3, #4, #5, #13, #19, #30, #35, #51, #52, #59, #60, #65, and #67) residents identified to receive no food from the kitchen. The facility census was 64. Findings include:1. Review of the medical record for Resident #6 revealed an admission date of 05/08/18 with diagnoses of Parkinsonism, dementia, and multiple sclerosis.Review of the quarterly Minimum Data Set (MDS) assessment, dated 02/15/26, revealed Resident #6's cognition was not assessed. Resident #6 required partial/moderate assistance for eating.Review of the current physician order dated 04/23/26 revealed Resident #6 was on a mechanical soft diet with thin liquids, with crust to be removed from sandwiches, and cups with lids.2. Review of the medical record for Resident #12 revealed an admission date of 06/26/13 with diagnoses of Alzheimer's disease, neuralgia and Parkinsonism. Review of the quarterly MDS assessment, dated 02/03/26, revealed Resident #12's cognition was not assessed. Further review revealed Resident #12 required supervision or touching assistance for eating.Review of the current diet order, dated 12/17/24, revealed Resident #12 received a pureed diet with thin liquids.3. Review of the medical record for Resident #54 revealed an admission date of 07/30/25 with diagnoses of anoxic brain damage, dysphagia, and cerebellar ataxia.Review of the significant change comprehensive MDS assessment, dated 03/03/26, revealed Resident #54's cognition was not assessed, and he was dependent on staff for eating.Review of the physician order dated 03/24/26 revealed Resident #54 received a minced and moist texture diet. Continuous observations on 06/01/26 from 11:59 A.M. through 12:40 P.M. revealed residents being served the noon meal in the dining room.Observation on 06/01/26 at 12:09 P.M. revealed Resident #12 was served two pureed bowls of food. One bowl contained orange colored food, and one bowl contained beige colored food. Concurrent interview with Activities Recreation Director (ARD) #164, who was providing assistance in the dining room, stated she could not determine what the food items were in Resident #12's bowls.Observation on 06/01/26 at approximately 12:15 P.M. of the posted menu in the dining room revealed the noon meal included a salad, penne pasta with meat sauce, garlic bread and marble cake. Observation on 06/01/26 at approximately 12:17 P.M. revealed Resident #6 eating penne pasta. Resident #6 did not receive a salad or garlic bread. Continued observation revealed Resident #54 received only penne pasta and no salad or garlic bread. Follow-up interview on 06/01/26 at 12:47 P.M. with ARD #164 confirmed residents on a mechanical soft diet, such as Resident #12 and Resident #54, who was on a minced and moist diet, only received the penne pasta with meat sauce and did not receive any other items with the meal, such as a salad or vegetable or garlic bread. ARD #164 further confirmed residents on a pureed diet only received two bowls of food.Interview on 06/01/26 at 2:18 P.M. with the Director of Food Services (DFS) #191 confirmed she did not provide a vegetable or bread substitute for residents on a mechanical soft or minced and moist diet. Further, DFS #191 confirmed she did not provide a vegetable substitute for residents on a pureed diet. Concurrent review of the menu spreadsheet revealed residents on a mechanical soft diet should have received shredded tossed salad and a slice of garlic bread, residents on a minced and moist diet should have received minced and moist marinated green beans and pureed garlic toast, and residents on a pureed diet should have received pureed soft marinated green beans and pureed garlic toast. 4. Interview on 06/03/26 at 11:29 A.M. with [NAME] #189, during preparation for the noon meal, revealed the menu called for chicken breast, sweet potatoes, peas and carrots, and a slice of wheat bread. Observations of meal service on 06/03/26 between 11:58 A.M. and 1:02 P.M. revealed no bread was served. Interview on 06/03/26 at 1:08 P.M. with [NAME] #189 confirmed bread could be offered to all residents, regardless of diet order. [NAME] #189 stated the crust would be cut off before it was offered to residents on a mechanical soft diet, and bread would be pureed for residents on a pureed diet. [NAME] #189 confirmed bread was not given to any residents during the noon meal on 06/03/26.

Based on record review, staff interview, and policy review, the facility failed to ensure resident funds were reimbursed timely after discharge. This affected two (#77 and #78) of three residents reviewed for fund disbursement. The facility census was 64.Findings include: 1. Review of the medical record revealed Resident #77 was admitted to the facility on [DATE]. Diagnoses included chronic obstructive pulmonary disease, hypertension, type II diabetes mellitus, lymphedema and major depressive disorder. Resident #77 passed away on 02/02/26 while still admitted to the facility. Review of the funds disbursement check for Resident #77 revealed it was dated 03/30/26. The representative of Resident #77 called the facility after receiving the check and stated it was the wrong refund amount. A second check was disbursed on 04/08/26. Interview on 06/04/26 at 3:00 P.M. with Business office Manager (BOM) #177 revealed upon investigation the first disbursement check amount was incorrect because the representative of Resident #77 came in to the office at the beginning of February and paid the month according to the rate per day in cash and there was no record of the payment. 2. Review of the medical record for Resident #78 revealed an admission date of 03/01/17 with diagnoses of hypertension, seizures, and bipolar disorder. Resident #78 discharged to another long term care facility on 12/03/25. Review of the funds disbursement check for Resident #78 revealed it was dated 02/27/26. Interview on 06/04/26 at 2:08 P.M. with Business Office Manager (BOM) #177 revealed the role of BOM was vacant from approximately the end of December 2025 until she began at the end of January 2026. BOM #177 confirmed Resident #78's funds were not paid out within 30 days due to the vacancy and the process of learning the new role. Review of the undated policy Resident Trust Fund Accounting and Records, revealed the personal needs account must be closed within thirty days of death or discharge. This deficiency represents non-compliance investigated under Complaint Numbers 2808521 and 2727019

Based on record review, staff interview, and policy review the facility failed to provide a resident with a 48 hour notice of non-payment of services. This affected one (#76) of three residents reviewed for beneficiary notices. This had the ability to affect all residents. The facility census was 64.Findings include: Review of Former Resident (FR) #75's medical record revealed an admission date of 12/24/25 and a discharge date if 01/01/26. FR #75 was discharged to home. Diagnoses included acute kidney failure, chronic kidney disease, and type II diabetes mellitus. Review of FR #75's Notice of Medicare Non-Coverage dated 12/31/25 revealed the resident's payment for skilled serves would end on 12/31/25. The notice letter of non-coverage was signed on 12/31/25 by the residents' guardian.Interview with the Director of Social Services #104 on 06/04/2026 9:37 A.M. verified FR #75's services ended on the same day the notification was provided. Review of the nursing progress note dated 01/01/26 revealed Resident #75 was discharged to home with his daughter. Review of the undated facility policy titled Advance Beneficiary Notice, revealed to ensure that the resident, or representative, has enough time to make a decision whether or not to receive the services in question and assume financial responsibility, the notice shall be provided at least two days before the end of the Medicare covered Part A stay or when all of Part B therapies are ending. The notices must not be provided while the resident or representative is under duress or in an emergency situation.

Based on observation, medical record review, staff interview and policy review, the facility failed to provide adequate and timely oral care to a dependent resident. This affected one (#67) resident out of one reviewed for oral care. The facility census was 64. Findings include:Review of the medical record revealed Resident #67 was admitted to the facility on [DATE]. Diagnoses included chronic obstructive pulmonary disease, acute respiratory failure, traumatic subdural hemorrhage, aphasia, dysphagia, and tracheostomy.Review of the quarterly Minimum Data Set (MDS) for Resident #67 dated 03/31/26 revealed a Brief Interview of Mental Status (BIMS) score of 00, indicating severe cognitive deficit. No behaviors indicated. Functional abilities included dependence on others for all activities of daily living (ADL) care. Review of revised care plan for Resident #67 dated 04/03/26 revealed staff are to provide oral care every shift and as needed. Review of physician orders entered for Resident #67 on 06/13/25 revealed oral care to be provided every shift and as needed. Observation on 06/02/26 at 5:30 A.M. revealed Certified Nursing Assistant (CNA) #118 and CNA #180 were in with Resident #67 providing incontinence care and repositioning. A white object approximately two inches in length was noted to the right upper lip of Resident #67. CNA #118 felt the object and stated it was skin. CNA #180 voiced to not pull at the object for fear of making Resident #67 bleed. Interview on 06/02/26 at 5:35 A.M. with CNA #118 and CNA #180 revealed because Resident #67 has a tracheostomy, oral care is provided by Respiratory Therapy. Both CNA #118 and CNA #180 verified they did not complete oral care at all during their overnight shift. Interview on 06/02/26 at 5:44 A.M. with Respiratory Therapist (RT) #148 revealed that RT does complete oral care once a shift and as needed. Interview on 06/02/26 at 5:50 A.M. with Registered Nurse (RN) #156 revealed RT provides oral care to residents with a tracheostomy. RN #156 verified she does not provide oral care to residents with a tracheostomy. Interview on 06/02/26 at 6:47 A.M. with the Director of Nursing (DON) revealed RT is assigned to complete oral care once a shift and as needed. CNA's, Licensed Practical Nurses (LPN) and RNs are to complete oral care as needed throughout their shifts. The DON confirmed CNAs, LPNs and RNs are educated on how to provide oral care on residents who have a tracheostomy. Interview on 06/02/26 at 7:45 A.M. with CNA #144 revealed she provides oral care to the outside of the mouth only to residents with a tracheostomy. Interview on 06/02/26 at approximately 1:00 P.M. with Regional Registered Nurse (RRN) #230 revealed CNAs, LPNs and RNs are to complete oral care as needed. RRN #230 continued to state education on oral care to residents with a tracheostomy is provided to all nursing staff upon hire. Review of CNA task documentation with RRN #230 revealed no specific task for completing oral care. Current oral care task states Dependent - helper does all of the effort. Resident does none of the effort to complete the activity or, the assistance of two or more helpers is required for the resident to complete the activity. RRN #230 verified there was no further task documentation noted for oral care. Review of the progress notes for Resident #67 revealed RT completing oral care at least once a shift. No other disciplines documented that oral care was complete. Review of the policy titled Oral Care, dated 2022 revealed it is the practice of the facility to provide oral care to residents in order to prevent and control plaque-associated oral diseases. Review of the undated policy titled Oral Care Procedures for the Dependent Patient, revealed oral care is to be provided every shift, before and after meals as needed. This deficiency represents non-compliance investigated under Complaint Numbers 2734720 and 2727019.

Based on observation, review of the medical record, and interview, the facility failed to ensure compression stockings were administered per physician orders. This affected one (#50) of two residents reviewed for edema. The facility identified 12 residents with physician orders for compression stockings. The facility census was 64. Findings include:Review of the medical record for Resident #50 revealed an admission date of 05/02/25 and a readmission date of 01/05/26. Diagnoses included metabolic encephalopathy, atrial fibrillation, type two diabetes mellitus, hypertension, and chronic kidney disease stage three. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had impaired cognition. The resident required substantial/maximal assistance for lower body dressing, putting on and taking off footwear and socks. Review of the care place dated 08/05/25 revealed the resident had an alteration or potential for alteration in cardiac output related to atrial fibrillation, hypertension, and congestive heart failure. One intervention included applying compression stockings as ordered by the physician. Review of a physician order dated 02/20/26 revealed the resident had an order for compression stockings daily (on in the morning and off at bedtime) for bilateral lower extremity edema. Review of the treatment administration record on 06/01/26 at 2:59 P.M. revealed documentation the resident's compression stockings had been administered. Review of the nurses' notes 05/30/26 through 06/01/26 revealed no documentation the resident had refused the compression stockings. Observation on 06/01/26 at 2:59 P.M. of Resident #50 with Licensed Practical Nurse (LPN) #192 revealed the resident had no compression stockings on. The resident had pitting edema to the bilateral lower extremities. Interview on 06/01/26 at 2:59 P.M., LPN #192 verified the resident had no compression stockings on. LPN #192 verified she had incorrectly documented the compression stocking had been administered. Interview on 06/03/26 at 1:17 P.M., Regional Registered Nurse (RRN) #230 revealed the facility had no policy regarding the application of compression stockings.

Based on review of the medical record, staff interview, resident interview, and policy review, the facility failed to ensure vision services were provided to residents. This affected two (#22, #54) of two residents reviewed for vision services. The facility census was 64.Findings include:1. Review of the medical record for Resident #22 revealed an admission date of 02/09/26. Diagnoses included end stage renal disease, type two diabetes mellitus, atrial fibrillation, and hypertension.Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had intact cognition. Review of the vision care plan dated 02/09/26 revealed the resident was at risk for visual decline and undetected eye diseases related to hypertension, type two diabetes mellitus, aging process, and end stage renal disease. There were no interventions to arrange for vision services. Review of the medical record revealed the resident had no signed admission agreement and no documentation of acceptance or refusal of offered ancillary services upon admission. Further review of the medical record revealed no documentation the resident had received vision services. Review of a physician order dated 02/09/26 revealed orders for ancillary services as needed including an ophthalmology consult and optometrist. Interview on 06/01/26 at 10:46 A.M., Resident #22 revealed she had glasses and needed to see the eye doctor as she was having trouble seeing. Resident #22 revealed she told staff she needed to see the eye doctor shortly after she was admitted to the facility.Interview on 06/02/26 at 9:53 A.M., Social Worker (SW) #104 revealed during the admission process there was a form in the admission packet for residents to elect ancillary services including dental and vision. SW #104 revealed there was no social worker in the facility when Resident #22 was admitted . SW #104 also revealed the resident admitted during a management transition at the facility. SW #104 revealed Resident #22 was not provided with an admission agreement to elect ancillary services. SW #104 verified Resident #22 had not been provided with vision services since admission. 2. Review of the medical record for Resident #54 revealed an admission date of 07/30/25. Diagnoses included anoxic brain injury, dysphagia, hypertension, cerebellar ataxia, and cardiomyopathy. Review of the quarterly MDS assessment dated [DATE] revealed the resident had intact cognition. Review of a physician order dated 07/31/25 revealed orders for ancillary services including vision services. Review of the vision care plan dated 08/19/25 revealed an intervention for staff to arrange eye appointments if increased visual deficits were noted. Review of an ancillary services consent for treatment form dated 11/05/25 revealed the resident had consented to receive vision services. Review of a vision provider note dated 01/19/26 revealed the resident was ordered prescription eyeglasses and had received the eyeglasses sometime in February 2026. Interview on 06/01/26 at 3:18 P.M., Resident #54 revealed he had glasses, but they caused blurry vision. Resident #54 revealed he had not been seen by the eye care provider to fix the glasses. Interview on 06/02/26 at 9:58 A.M., SW #104 verified Resident #54 had reported concerns with his eyeglasses. SW #104 revealed she had emailed the vision provider on 03/25/26 and had not received a response from the provider. SW #104 revealed she had not attempted any further follow-up with the provider and the provider had not further assessed the resident's vision and/or eyeglasses. SW #104 verified the follow up with the vision provider was not timely. Review of the facility policy Ancillary Services, dated 01/01/25, revealed the facility would assist residents in obtaining ancillary services as needed including vision services.

Based on observation, review of the medical record, interview, and policy review, the facility failed to ensure timely and accurate pressure ulcer wound assessments, failed to ensure wound treatments were completed and accurately documented per physician orders. Additionally, the facility failed to ensure pressure ulcer prevention treatments were in place per physician orders. This affected two (#74, #2) of four residents reviewed for pressure ulcers. The facility identified seven residents with pressure ulcers. The facility census was 64. Findings include:1. Review of the medical record for Resident #74 revealed an admission date of 01/19/26 and a discharge date of 01/27/26. Diagnoses included acute and chronic respiratory failure with hypoxia, tracheostomy status, gastrostomy status, hypertension, abnormal weight loss, and type two diabetes mellitus. Review of an admission summary progress note dated 01/19/26 at 7:38 P.M. revealed the resident had an existing buttock wound and the dressing was dry and intact. Review of a skin risk assessment completed 01/19/26 revealed the resident was at high risk for skin breakdown. Review of the admission skin assessment dated [DATE] revealed the resident has a pressure ulcer to the coccyx. There was no assessment of the wound, no wound measurements, and the wound was not staged. Review of a physician order dated 01/20/26 revealed to cleanse the coccyx with normal saline, pat dry, apply nystatin cream, apply zinc oxide cream, leave open to air every shift for wound care.Review of the Treatment Administration Record (TAR) dated 01/20/26 revealed the wound treatment had been completed on the 12-hour day shift and 12-hour night shift by two different nurses. Review of a nurse's note dated 01/21/25 at 2:52 P.M. revealed the resident had asked the nurse to check his coccyx due to increased pain. The nurse observed a dressing dated 01/11/25 in place on the resident's coccyx which had not looked like an in-house facility dressing. The nurse removed the old dressing, and redness was observed around the area. The nurse then completed the wound treatment per physician orders. Review of a nurse practitioner wound care progress note dated 01/22/26 at 8:09 A.M. revealed the resident had a fungal rash to the bilateral buttocks and a new wound treatment was initiated. Interview on 06/03/26 at 11:55 A.M., Licensed Practical Nurse (LPN) #168 revealed when she went to complete the resident's wound treatment on 01/21/26, she found the resident had a dressing on his coccyx dated 01/11/26. LPN #168 revealed the area had not appeared infected. LPN #168 revealed she reported the incident to the Director of Nursing at the time. Interview on 06/03/26 at 1:44 P.M., the Director of Nursing (DON) revealed staff should have removed the hospital dressing, assessed, and measured the residents' wound upon admission to the facility then obtained treatment orders. The DON revealed the resident had no pressure ulcers prior to discharge to the hospital. The DON revealed the wound care provider saw the resident on 01/22/26 and noted the area was a fungal infection and not a pressure ulcer. Further interview with the DON revealed the nurses had incorrectly documented completing the resident's wound treatment on 01/20/26. 2. Review of the medical record for Resident #2 revealed an admission date of 05/16/25. Diagnoses included heart failure, anoxic brain injury, and contractures. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was never understood. The resident was dependent on staff for toileting, repositioning, and personal hygiene. The resident was at risk for skin breakdown. Review of the skin integrity care plan dated 05/20/25 revealed an intervention for heel boots per physician orders, and to float heels as tolerated. Review of a physician order dated 05/21/25 revealed an order for heel boots for protection every shift. Review of the TAR on 06/02/26 at 2:22 P.M. revealed Resident #2's heel boots for protection had been documented as in place.Observation on 06/02/26 at 2:22 P.M. during wound care for a stage three pressure ulcer to the coccyx and urinary catheter care for Resident #2 with Licensed Practical Nurse (LPN) #218 and Registered Nurse (RN) #119 revealed the resident had no heel boots in place. The resident's heels were observed resting directly on the mattress. Interview on 06/02/26 at 2:22 P.M., RN #119 verified the resident had no heel boots in place. RN #119 also verified she had incorrectly documented the resident's heel boots were in place. Review of the facility policy Wound Treatment Management, dated 01/08/25 revealed wound treatments would be provided per physician orders. The effectiveness of treatments would be monitored though ongoing assessment of the wound. There were no guidelines on assessing a wound. Review of the facility policy Pressure Injury Prevention Guidelines, dated 10/01/23, revealed interventions would be implemented in accordance with physician orders, including the type of prevention devices to be used and for task the frequency for performing them. The effectiveness of interventions would be monitored through ongoing assessment of the resident's wound. This deficiency represents non-compliance investigated under Complaint Number 2727019.

Based on observation, review of the medical record, interview, and policy review, the facility failed to ensure an indwelling urinary catheter securement device was in place per physician order. This affected one (#2) of two residents reviewed for urinary catheters. The facility identified 13 residents with urinary catheters. The facility census was 64. Findings include:Review of the medical record for Resident #2 revealed an admission date of 05/16/25. Diagnoses included heart failure, anoxic brain injury, and contractures. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was never understood. The resident was dependent on staff for toileting and personal hygiene. Review of the urinary catheter care plan revealed the resident's indwelling urinary catheter was indicated due to a coccyx wound per hospice. Interventions included to provide catheter care per facility policy and to ensure the catheter tubing was not under the resident's legs. There was no intervention documented for securing the urinary catheter tubing. Review of a physician order dated 05/13/26 revealed the resident had an indwelling urinary catheter. Review of a physician order dated 05/13/26 revealed an order for a catheter securement device, ensure placement and replace as needed. Observation on 06/02/26 at 2:22 P.M. of urinary catheter care for Resident #2 with Licensed Practical Nurse (LPN) #218 and Registered Nurse (RN) #119 revealed the resident had no urinary catheter securement device in place.Interview on 06/02/26 at 2:26 P.M., RN #119 verified the resident had no urinary catheter securement device in place. RN #119 also verified she had inaccurately documented the securement device was in place in the treatment administration record (TAR).Interview on 06/04/26 at 7:49 A.M., the Director of Nursing (DON) verified Resident #2 had an order for a urinary catheter securement device and staff should have made sure the securement device was in place. Review of the facility policy Catheter Care, dated 03/02/22, revealed residents with indwelling catheters would receive appropriate catheter care. Further review of the policy revealed no guidelines for the securement devices.

Based on review of the medical record, interview, and policy review, the facility failed to ensure ongoing communication with the dialysis center. This affected one (#22) of one resident reviewed for dialysis services. The facility identified one resident receiving dialysis services. The facility census was 64. Findings include:Review of the medical record for Resident #22 revealed an admission date of 02/09/26. Diagnoses included end stage renal disease, type two diabetes mellitus, atrial fibrillation, and hypertension.Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had intact cognition and was receiving dialysis services. Review of the care plan dated 02/09/26 revealed the resident had end stage renal disease requiring dialysis treatment. One intervention included for staff to communicate with the dialysis center staff regarding the resident's plan of care, laboratory values, and diet/fluid restriction recommendations. Review of the physician orders dated 02/10/26 revealed the resident attended dialysis three times a week on Monday, Wednesday, and Fridays. Review of a physician order dated 04/28/26 revealed the resident attended dialysis three times a week on Tuesdays, Thursdays, and Saturdays. Review of the dialysis communication forms dated 04/03/26 through 04/30/26 revealed there were no dialysis communication forms for 04/06/26, 04/10/26, 04/13/26, 04/15/26, 04/17/26, 04/20/26, 04/24/26, and 04/27/26. Also, the dialysis communication forms dated 04/08/26, 04/22/26, 04/29/26 revealed no returned communication from the dialysis center.Review of the dialysis communication forms dated 05/02/26 through 05/30/26 revealed there were no dialysis communication forms for 05/16/26, 05/19/26, 05/21/26, and 05/30/26. Review of the dialysis communication forms dated 05/12/26, 05/14/26, 05/26/26, and 05/28/26 revealed no returned communication from the dialysis center. Interview on 06/04/26 at 7:49 A.M., the Director of Nursing (DON) verified Resident #22's missing dialysis communication forms and the communication forms lacking documentation of a response to treatment from the dialysis center. Review of the facility policy Dialysis Care, last revised 01/2016, revealed there would be a source of communication between the facility and the dialysis unit with each visit and staff would utilize the dialysis communication form. Further review of the policy revealed that in the event the dialysis unit refused and/or failed to provide communication with the resident visit, staff would document in the clinical record, the dialysis unit had not provided any communication on the communication form provided.

Based on review of the medical record, staff interview, resident interview, and policy review, the facility failed to ensure dental services were provided to residents. This affected two (#22, #54) of three residents reviewed for dental services. The facility census was 64. Findings include:1. Review of the medical record for Resident #22 revealed an admission date of 02/09/26. Diagnoses included end stage renal disease, type two diabetes mellitus, atrial fibrillation, and hypertension.Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had intact cognition. Review of the dental care plan dated 02/10/26 revealed an intervention for staff to arrange for periodic dental consults and follow up visits by dentistry as scheduled and as needed. Review of the medical record revealed the resident had no signed admission agreement and no documentation of acceptance or refusal of offered ancillary services upon admission. Further review of the medical record revealed no documentation the resident had received dental services. Review of a physician order dated 02/10/26 revealed orders for a dental consult as needed. Interview on 06/01/26 at 10:42 A.M., Resident #22 revealed she had no teeth and her old dentures no longer fit. Resident #22 revealed she told staff she needed to see a dentist shortly after she was admitted to the facility.Interview on 06/02/26 at 9:53 A.M., Social Worker (SW) #104 revealed during the admission process there was a form in the admission packet for residents to elect ancillary services including dental and vision. SW #104 revealed there was no social worker in the facility when Resident #22 was admitted . SW #104 also revealed the resident admitted during a management transition at the facility. SW #104 revealed Resident #22 was not provided an admission agreement to elect ancillary services. SW #104 verified Resident #22 had not been provided dental services since admission. 2. Review of the medical record for Resident #54 revealed an admission date of 07/30/25. Diagnoses included anoxic brain injury, dysphagia, hypertension, cerebellar ataxia, and cardiomyopathy. Review of the quarterly MDS assessment dated [DATE] revealed the resident had intact cognition. Review of a physician order dated 07/31/25 revealed orders for ancillary services including dental services. Review of the dental care plan dated 08/19/25 revealed an intervention for staff to arrange for periodic dental consults. Review of an ancillary services consent for treatment form dated 11/05/25 revealed the resident had consented to receive dental services. Interview on 06/01/26 at 3:18 P.M., Resident #54 revealed he had not been provided dental services in the last eight months. Interview on 06/02/26 at 9:58 A.M., SW #104 verified Resident #54 had not been provided routine dental services. Review of the facility policy Ancillary Services, dated 01/01/25, revealed the facility would assist residents in obtaining routine and emergency ancillary services as needed including routine and emergency dental services.

Based on observation, record review and staff interview, the facility failed to ensure adaptive equipment was provided to residents during meals. This affected two (#6 and #12) residents observed during meal service. The facility identified five (#6, #12, #20, #31, and #49) residents used assistive devices with meals. The facility census was 64. Findings include:1. Review of the medical record for Resident #6 revealed an admission date of 05/08/18 with diagnoses of parkinsonism, dementia, and multiple sclerosis.Review of the quarterly Minimum Data Set (MDS) assessment, dated 02/15/26, revealed Resident #6's cognition was not assessed. Resident #6 required partial/moderate assistance for eating.Review of the current physician order dated 04/23/26 revealed Resident #6 was on a mechanical soft diet with thin liquids, with crust to be removed from sandwiches, and cups with lids.Review of the current physician order dated 04/24/25 revealed Resident #6 should be provided built-up utensils and scoop dish/individual bowls as needed for all meals.Review of the care plan initiated 12/18/18, and updated 05/13/26, revealed Resident #6 was at risk for alteration in nutrition and/or hydration related to history of aspiration or potential for aspiration, type II diabetes mellitus, dysphagia, hypertension, Parkinson's disease, dementia, assistance with meals, use of adaptive equipment, tremors, vitamin deficiency, therapeutic/mechanically altered diet. Interventions included to provide adaptative equipment as ordered (02/15/23).Continuous observations on 06/01/26 from 11:59 A.M. through 12:40 P.M. revealed residents being served the noon meal in the dining room.Observation on 06/01/26 at approximately 12:17 P.M. revealed Resident #6's arm shook as she used a standard fork to feed herself penne pasta. Resident #6 had an uncovered glass of red beverage. Interview on 06/01/26 at 12:21 P.M. with Activities Recreation Director (ARD) #164 and concurrent review of Resident #6's physician orders, confirmed Resident #6 should have cups with lids, should have built up utensils, and should have food in individual bowls or on a scoop plate. Further interview and concurrent observation of Resident #6 confirmed the drink was uncovered, her meal came on a standard plate and standard utensils were provided. Observation on 06/02/26 at 7:22 A.M. revealed residents gathered in the dining room for the breakfast meal. Observation on 06/02/26 at 7:24 A.M. and concurrent interview with Director of Rehabilitation (DOR) #195 of Resident #6 confirmed Resident #6 received breakfast food in bowls with a covered cup, and regular utensils. Concurrent review of Resident #6's physician orders with DOR #195 confirmed Resident #6 should have built-up utensils with meals. DOR #195 proceeded to the kitchen to request built-up utensils.Observation on 06/02/26 at 7:28 A.M. revealed Certified Nursing Assistant (CNA) #172 provided a built-up spoon to Resident #6 and Resident #6 said the hot cereal was too hot. Further observation revealed CNA #172 handed Resident #6 a standard fork and offered eggs. Continued observation revealed DOR #195 returned to Resident #6 with foam grips that slipped onto standard utensils and Resident #6 said I remember these.2. Review of the medical record for Resident #12 revealed an admission date of 06/26/13 with diagnoses of Alzheimer's disease, neuralgia and parkinsonism. Review of the quarterly MDS assessment, dated 02/03/26, revealed Resident #12's cognition was not assessed. Further review revealed Resident #12 required supervision or touching assistance for eating.Review of the care plan, initiated 09/12/22, revealed Resident #12 had an alternation in nutrition and/or hydration related to dementia/Alzheimer's disease, chronic kidney disease stage 3, congestive heart failure, hypertension, Parkinson's disease, feeding dependent, under hospice care, mechanically altered diet. Resident #12 used adaptive equipment at meals due to tremors. Interventions included to provide adaptive equipment as ordered (02/15/23).Review of the physician order, initiated 03/23/24 and discontinued 06/02/26, revealed Resident #12 should use a sippy cup with meals and snacks every shift to prevent spilling on herself. Review of the current diet order, dated 12/17/24, revealed Resident #12 received a pureed diet with thin liquids.Continuous observations on 06/01/26 from 11:59 A.M. through 12:40 P.M. revealed residents being served the noon meal in the dining room.Observation on 06/01/26 at 12:38 P.M. revealed CNA #137 sitting next to Resident #12 and attempting to assist Resident #12 with eating. Resident #12 had two bowls of pureed food and an uncovered cup of chocolate milk. Concurrent interview with CNA #137 and review of Resident #12's physician orders revealed Resident #12 should receive drinks in a sippy cup. CNA #137 confirmed Resident #12's drink was not in a sippy cup. Observation on 06/02/26 at 7:22 A.M. revealed residents gathered in the dining room for the breakfast meal. Further observation revealed CNA #182 was sitting next to Resident #12 encouraging her to eat breakfast. Resident #12 had a regular cup filled with red drink. Interview on 06/02/26 at 7:31 A.M. with CNA #182 confirmed Resident #12's red drink was in a regular cup, not a sippy cup. Concurrent review of Resident #12's physician orders with CNA #182 confirmed Resident #12 had an order for a sippy cup with meals and snacks.

Based on medical record review, observation, staff interviews, and review of facility policy, the facility failed to ensure the residents received timely incontinence care and received appropriate incontinence care by the facility policy. This affected one (Resident #505) of one resident observed for incontinence care. The facility census was 63. Findings include:Review of the medical record for Resident #505 revealed they were admitted on [DATE]. Diagnoses included Lewy body dementia, hypertension, anxiety, muscle weakness, and abnormal posture.Review of the Minimum Data Set 3.0 (MDS) assessment dated [DATE] revealed Resident #505 was cognitively impaired and did not display any behaviors at the time of the assessment. He was always incontinent of bowel and bladder.Review of the physician orders for Resident #505 revealed the absence of an order for brief liners.Review of the care plan dated 01/09/25 for Resident #505 revealed an intervention for incontinence care every two hours and as needed.Observation on 01/05/26 at 10:45 A.M. of incontinence care for Resident #505 provided by Certified Nurse Assistants (CNA) #102 and CNA #103 revealed the resident appeared to have a dry brief. Continued observation revealed the resident had two briefs on, one on top of the other, and the brief next to his skin was saturated with urine.Interview on 01/05/26 at 10:50 A.M. with CNA #102 revealed she was unsure how long Resident #505 had a wet brief against his skin as she was unaware the resident had two briefs on. She indicated her every two-hour brief checks since beginning her shift at 7:00 A.M. consisted of checking the outer brief. CNA #102 verified the facility policy prohibited double briefing residents and brief liners could only be used if ordered by a physician.Interview on 01/05/26 at 11:05 A.M. with the Director of Nursing (DON) confirmed double briefing residents was not permitted and brief liners could only be utilized if ordered by a physician. The DON confirmed Resident #505 did not have an order for brief liners.Review of the facility policy titled Perineal Care dated 01/08/25 revealed the facility would provide perineal care to incontinent residents to promote cleanliness, prevent infection, and prevent skin breakdown.This deficiency represents non-compliance investigated under Complaint Number 2647291.

Based on medical record review, staff interviews, review of facility policy, the facility failed to ensure residents were free from significant medication errors when they incorrectly transcribed physician orders and failed to administer medication as physician ordered. This affected one (Resident #501) of three residents reviewed for medication administration. The facility census was 63. Findings include:Review of the medical record for Resident #501 revealed they were admitted on [DATE] with diagnoses including chronic respiratory failure with hypoxia, emphysema, and rheumatoid arthritis.Review of the Minimum Data Set 3.0 (MDS) assessment dated [DATE] revealed Resident #501 was cognitively intact. 1. Review of Resident #501's hospice physician orders dated 10/16/25 revealed an order for 0.25 milliliter (mL), equal to five milligrams (mg), of morphine solution 20 mg per one mL, to be administered by mouth every four hours.Review of the medication administration record for October 2025 for Resident #501 revealed an order was incorrectly entered on 10/16/25 for 0.25 mL of morphine solution 20 mg per five mL, equivalent to one mg per dose instead of the ordered five mg per dose, to be administered by mouth every four hours.Review of the controlled medication count sheet for October 2025 for Resident #501's morphine revealed a printed pharmacy label indicating morphine solution of 20 mg per five mL was dispensed to the facility to be administered at 1.25 mL per dose; equivalent to five mg per dose as ordered. The dose printed on the pharmacy label had been changed by hand to 0.25 mL per dose. The controlled medication count sheet revealed this dispensed medication was administered at 0.25 mL per dose, equivalent to one mg per dose instead of the ordered five mg per dose, on 14 occasions on 10/16/25, 10/17/25, and 10/18/25.Interview on 01/06/26 at 9:00 A.M. with the Director of Nursing (DON) confirmed Resident #501 was given one mg of morphine, instead of the ordered five mg of morphine, on 14 occasions on 10/16/25, 10/17/25, and 10/18/25.2. Review of hospice physician orders for Resident #501 revealed an order dated 10/18/25 for 0.5 mL, equal to ten mg, of morphine solution 20 mg per one mL, to be administered by mouth every two hours.Review of the medication administration record for October 2025 for Resident #501 revealed an order was incorrectly entered on 10/18/25 for 0.5 mL of morphine solution 20 mg per five mL, equivalent to two mg per dose instead of the ordered ten mg per dose, to be administered by mouth every two hours.Review of the controlled medication count sheet for October 2025 for Resident #501's morphine revealed a printed pharmacy label indicating morphine solution 20 mg per five mL was dispensed to the facility. Further review of this controlled medication count sheet revealed this dispensed medication was administered at 0.5 mL per dose, equivalent to two mg per dose instead of the ordered ten mg per dose, on 14 occasions on 10/18/25, 10/19/25, and 10/20/25.The progress note dated 10/20/25 for Resident #501 written by Registered Nurse #106 revealed Resident #501 was administered incorrect doses of morphine at two mg instead of the ordered ten mg.Interview on 01/06/26 at 9:00 A.M. with the DON confirmed Resident #501 was given two mg of morphine, instead of the ordered ten mg of morphine, on 14 occasions on 10/18/25, 10/19/25, and 10/20/25.Review of the facility policy titled Medication Administration dated 08/22/22 revealed the facility would administer medications as ordered by the physician.This deficiency represents non-compliance investigated under Complaint Number 2647291.

Based on medical record review, observation, staff interviews, review of facility policies, and review of protocols from Centers for Disease Control and Prevention, the facility failed to ensure infection prevention measures were maintained during wound care. This affected one (Resident #503) of one resident observed for wound care. The facility census was 63.Findings include:Review of the medical record for Resident #503 revealed they were admitted on [DATE] with diagnoses including surgical aftercare on the respiratory system, pulmonary embolism, and traumatic subdural hemorrhage.Review of the Minimum Data Set 3.0 (MDS) assessment dated [DATE] revealed Resident #503 was cognitively impaired and did not display any behaviors at the time of the assessment. He was bedbound and dependent on staff for all care.Review of the physician order dated 12/04/25 for Resident #503 revealed a wound care order to cleanse the distal midline abdominal wound with normal saline, pat dry, apply alginate, and cover with an absorbent silicone dressing once daily and as needed.Observation on 01/05/26 at 10:10 A.M. revealed Licensed Practical Nurse (LPN) #101 performed the dressing change for Resident #503. LPN #101 did not change her gloves after removing the soiled dressing and cleansing the wound before applying the clean dressing. LPN #101 did not disinfect the scissors prior to cutting the alginate and placing it in the wound bed.Interview on 01/05/26 at 10:15 A.M. with LPN #101 confirmed she did not change her gloves after removing the soiled dressing and before applying the clean dressing to Resident #503's abdominal wound, nor did she disinfect the scissors prior to cutting the alginate and placing it in the wound bed.Interview on 01/05/26 at 10:30 A.M. with the Director of Nursing (DON) revealed gloves should be changed after removing a soiled dressing and before applying a clean dressing to a wound, and scissors should be disinfected prior to cutting any dressing items during wound care.Review of the facility policy titled Wound Treatment Management dated 12/01/21 revealed the facility would provide wound treatments in accordance with current standards of practice.Review of the facility policy titled Infection Prevention and Control Program dated 01/07/25 revealed the facility would maintain an infection prevention program that would help prevent infections. All reusable equipment would be cleaned.Review of Centers for Disease Control and Prevention (CDC) protocols revealed bandage scissors should be disinfected prior to use and gloves should be changed when moving from a dirty site to a clean site.This was an incidental finding discovered during the course of the complaint investigation.

Based on medical record review, staff interview, and review of facility policy, the facility failed to initiate a baseline care plan. This affected one resident (#19) of one resident reviewed for baseline care plan. The facility census was 63. Findings include: Review of the medical record for Resident #19 revealed an admission date of 09/30/25 with diagnoses of intracranial hemorrhage, respiratory failure, and chronic obstructive pulmonary disease (COPD).Review of the admission Minimum Data Set (MDS) assessment dated [DATE] for Resident #19 revealed she was severely cognitively impaired, dependent for all care, and was at risk for development of pressure ulcers.Review of the medical record for Resident #19 revealed no baseline care plan was developed.Interview on 11/13/25 at 4:24 P.M. with Regional Registered Nurse (RRN) #500 verified Resident #19 did not have a baseline care plan upon admission.Review of the facility policy titled, Baseline Care Plan, revised 06/24 revealed the facility will develop and implement a baseline for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. The baseline care plan will be developed within 48 hours of a resident's admission.

Based on medical record review, resident and staff interview, and facility policy review, the facility failed to conduct quarterly care plan conferences are required. This affected three (#12, #24, and #32) of three residents reviewed for care planning conferences. The facility census was 60. Findings include: 1. Review of the medical record revealed Resident #12 was admitted on [DATE]. Diagnoses included chronic obstructive pulmonary disease, hemiplegia and hemiparesis following cerebral infarction, alcoholic cirrhosis of the liver without ascites, generalized idiopathic epilepsy and epileptic syndromes, muscle weakness, bipolar disorder, hyperlipidemia, and major depressive disorder mild. Review of the Minimum Data Set (MDS) assessment, dated 07/04/24, revealed the resident was moderately cognitively impaired. Review of care conference documentation revealed no care conferences were completed. 2. Review of the medical record revealed Resident #24 was admitted on [DATE]. Diagnoses included acute and chronic respiratory failure with hypoxia, paralysis of vocal cords and larynx, chronic obstructive pulmonary disease, essential (primary) hypertension, anxiety disorder, heart failure, anemia, and unspecified atrial fibrillation. Review of the MDS assessment, dated 07/24/24, revealed the resident was moderately cognitively impaired. Review of the care plan conference summaries, dated since admission, revealed Resident #24 had one care conference completed on 03/29/24. Interview on 08/07/24 at 8:55 A.M. with Social Services #398 verified Resident #12 had no care conferences and Resident #24 did not have a quarterly care plan conferences. 3. Review of the medical record revealed Resident #32 was admitted on [DATE]. Diagnoses included chronic obstructive pulmonary disease, dyspnea, benign prostatic hyperplasia with lower urinary tract symptoms, anxiety disorder, depression, carpal tunnel syndrome, essential hypertension, hyperlipidemia, and paroxysmal atrial fibrillation. Review of the MDS assessment, dated 06/29/24, revealed the resident was cognitively intact. Review of care conference documentation revealed no care conferences were completed. Interview on 08/09/24 at 9:20 A.M. with Resident #32 revealed he had not had any care conferences since admission. Interview on 08/07/24 at 8:34 A.M. with Social Services #398 revealed Resident #32's resident representatives were reluctant to meet and the resident has refused to attend. Social Services #398 verified there were no documented refusals for Resident #32 to attend care conferences. Social Services #398 reported due to no resident or resident representative interest, no care conferences have been held for Resident #32. Review of a policy titled, Comprehensive Care Plans,: dated January 2023, revealed the comprehensive care plan will be prepared by an interdisciplinary team including the resident and the resident's representative. The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment.

Based on observation, medical record review, staff interview, and facility policy, the facility failed to ensure medications were administered by route ordered by the physician, which resulted in four medication errors out of 28 opportunities for a medication administration error rate of 14.28 percent (%). This affected one (#4) of three residents observed during medication administration. The facility census was 65. Findings include: Observation on 03/12/24 at 8:18 A.M. noted Licensed Practical Nurse (LPN) #200 obtaining Resident #4 medications from medication cart. Medications included Abilify 2 milligram (mg) tablet, Lexapro 5 mg tablet, Metoprolol 25 mg tablet, Plavix 75 mg tablet. LPN #200 placed the tablets into a medication cup and proceeded to Resident #4 room. LPN #200 then proceeded to place each tablet into Resident #4 mouth followed by a drink of water. Once medications were consumed LPN #200 departed the room. Review of Resident #4 medical record identified the following physician medication orders and associated route of administration. On 02/21/24 Abilify 2 mg via Gastrostomy tube (G-Tube) given one time daily for anxiety disorder. On 02/19/24 Lexapro 5 mg via G-Tube given one time daily for anxiety and depression. On 02/19/24 Metoprolol 25 mg give 100 mg via G-Tube one time daily for hypertension. On 02/21/24 Plavix 75 mg via G-Tube one time daily related to history of transient ischemic attack and cerebral infarction. On 03/12/24 at 1:27 P.M. interview with LPN #200 during review of medical record confirmed Resident #4's medications were ordered to be administered via G-Tube and not by mouth (PO). Review of the medication administration policy revised 08/22/22 revealed staff should review the Medication Administration Record (MAR) to identify medication to be administered. Compare medication source (bubble pack, vial, etc.) with MAR to verify medication name, form, dose, route and time. Administer medications as ordered. Sign MAR after administered. Report and document any adverse side effects of refusals. This deficiency represents non-compliance investigated under Complaint Number OH00151380.

Based on medical record review, staff interview, and facility policy, the facility failed to ensure medications were obtained and administered as ordered by the physician resulting in significant medication errors. This affected one (#13) of six sampled residents reviewed for medication administration. The facility census was 65. Findings include: Resident #13 readmitted from the hospital on 02/16/24 with the diagnosis including, chronic respiratory failure, dependence on respirator, chronic obstructive pulmonary disease, gastrostomy tube, and tracheostomy. According to the minimum data set assessment dated [DATE] Resident #13 was assessed with moderately impaired cognition, dependent on staff for the completion of activities of daily living, experienced constant pain with pain medication administration including opioid administration. Review of Resident #13's physician orders noted the following medications ordered on 02/16/24; Metoprolol Tartrate Tablet 25 milligrams (mg) give one tablet via gastrostomy tube (G-Tube) two times a day for hypertension, MagOx 400 Oral Tablet give 400 mg via G-Tube two times a day for supplement, Seroquel Oral Tablet give 50 mg via G-Tube one time a day for anxiety, Trazodone Oral Tablet 50 mg via G-Tube one time a day for insomnia, Donepezil Oral Tablet give 10 mg via G-Tube one time a day for anxiety, Lasix Oral Tablet give 20 mg via G-Tube one time a day for congestive heart failure, Apixaban Oral Tablet give 5 mg via G-Tube two times a day for venous thromboembolism (VTE) prophylaxis, Lipitor Oral Tablet give 10 mg via G-Tube one time a day for hyperlipidemia. On 02/21/24 Sertraline 50 mg via G-Tube once daily for major depression was ordered. Review of the medication administration record (MAR) from February 2024 noted the following medications documented as being omitted and not given as ordered; Metoprolol Tartrate Tablet 25 milligrams (mg) MAR scheduled to be given at bedtime omitted dose 02/18/24. MagOx 400 mg MAR scheduled to be given at morning upon rising and at bedtime missed morning dose on 02/18/24 and bedtime dose on 02/22/24. Seroquel 50 mg MAR scheduled to be given at bedtime missed doses on 02/17/24, 02/18/24, 02/19/24, 02/20/24. Trazodone 50 mg MAR scheduled to be given at bedtime missed doses on 02/18/24, 02/19/24, 02/20/24. Donepezil 10 mg MAR scheduled to be given at bedtime missed doses on 02/18/24, 02/19/24, 02/20/24. Lasix 20 mg MAR scheduled to be given at morning upon rising missed 02/19/24 dose. Apixaban Oral Tablet 5 mg MAR scheduled to be given at morning upon rising and at bedtime missed bedtime doses on 02/18/24, 02/20/24, 02/21/24 and missed morning doses on 02/21/24, 02/22/22. Lipitor Oral Tablet 10 mg MAR scheduled to be given at bedtime missed doses on 02/17/24, 02/18/24, 02/19/24, 02/20/24. Sertraline 50 mg ordered on 02/21/24 MAR scheduled to be given in morning upon rising missed dose on 02/22/24. Further review of the medical record lacked documentation indicating the physician was notified of the medications being omitted (missed) or a second pharmacy being contacted in an attempt to obtain the medications. On 03/13/24 at 8:55 A.M. interview with the Director of Nursing (DON) during a review of Resident #13's medical record revealed the facility had difficulty obtaining certain medications for the resident on the listed dates. The DON stated the pharmacy reported lack of supply leading to the medications not being obtained. The DON further verified the physician was not notified of the medications not being obtained or administered and lack of a secondary pharmacy being contacted in an attempt to obtain Resident #13 medications. Review of the medication administration policy revised 08/22/22 revealed staff should review the Medication Administration Record (MAR) to identify medication to be administered. Compare medication source (bubble pack, vial, etc.) with MAR to verify medication name, form, dose, route and time. Administer medications as ordered. Sign MAR after administered. Report and document any adverse side effects of refusals. Review of medication reordering policy dated revised 01/01/2024 revealed the facility will utilize a systematic approach to provide or obtain routine and emergency medications and biological's in order to meet the needs of each resident. Acquisition of medications should be completed in a timely manner to ensure medications are administered in a timely manner. If a medication is not available to be administered and not in the emergency kit the nurse will notify the pharmacy, physician, resident and or responsible party. This deficiency represents non-compliance investigated under Complaint Number OH00151380.

Based on the unprecedented global pandemic that resulted in the Presidential declaration of a State of National Emergency dated 03/13/20, review of guidance from the Centers for Disease Control (CDC) and Prevention website related to preparing for Coronavirus Disease 2019 (COVID-19) and responding to COVID 19 for nursing homes and health care facilities, surveyor observations, medical record reviews, staff interviews, review of the facility census sheet which included a detailed record of the residents COVID 19 status and location in the building, review of facility infection control line listing for COVID-19 testing of residents, review of the policy for considerations for cohorting COVID-19 residents in post-acute care facilities, the facility failed to implement effective and recommended infection control practices to prevent the spread of COVID-19 including: ensuring residents were cohorted correctly in accordance with facility policy following COVID-19 outbreak testing and ensuring Personal Protective Equipment (PPE) was changed between care of residents who were quarantined for exposure to COVID-19. This resulted in Immediate Jeopardy for nine residents (#01, #02, #03, #04, #05, #06, #07, #08, #09) who were COVID-19 negative and remained on the COVID-19 positive unit. The nine residents later tested positive for COVID-19. Additionally, four residents (#10, #11, #12, #13) who were negative for COVID-19 and quarantined for exposure to COVID-19, were placed in Immediate Jeopardy when staff members provided care without changing PPE between each resident. The facility census was 57. On 10/05/20 at 4:58 P.M., the Administrator and Director of Nursing (DON) were notified Immediate Jeopardy began on 09/28/20 when the facility failed to move residents in accordance with their policy and the latest CDC guidelines dated 06/25/20, after receiving results for COVID-19 initial outbreak testing. On 09/28/20, the facility was informed 34 residents and 23 staff members had tested positive for COVID-19. After receiving the results on 09/27/20, the facility began setting up designated units to separate positive and negative cases and completed the movement of residents on 09/28/20. On 10/01/20, nine residents who were negative for COVID-19 continued to reside on the positive COVID-19 unit. Seven of the nine identified residents had a roommate who was positive for COVID-19. Observations were made of staff in the positive COVID-19 unit providing direct care to both positive and negative residents wearing the same PPE between all residents. On 10/02/20, the facility received the results of their second round of outbreak testing. The nine identified residents who had previously been negative were found positive for COVID-19. The Immediate Jeopardy continued 10/05/20 when four residents in the quarantine unit were provided direct care by staff without changing PPE between the four residents. The quarantine unit was designated by the facility for residents who were negative for COVID-19 but exposed to [MEDICAL CONDITION]. The quarantine unit included two rooms with double occupancy. Both double occupancy rooms had two residents in each room. Staff were instructed by the facility to provide care to residents who were quarantined in the same room while wearing the same PPE between residents. The Immediate Jeopardy was removed on 10/06/20 at 5:35 P.M. when the facility established three separate units; one for negative residents, one for positive residents and one for quarantined residents, based on the residents COVID-19 status, changed the facility practice pertaining to PPE when caring for quarantined residents, and initiated a COVID-19 policy for cohorting residents. The deficiency remained at a Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) until it was corrected on 10/21/20 when the facility implemented the following corrective actions: · On 09/27/20, the facility started receiving COVID-19 laboratory results from the testing performed on 09/24/20, with results continuing through 09/28/20. Based on the testing, 30 of 54 residents were identified as positive for COVID-19, 13 of 54 residents were identified as negative but exposed to COVID-19, and 11 of 54 residents were found to be negative and not exposed. Additional PPE stations were made available throughout the unit. · On 09/28/20, the facility activated the Congregate Care Unified Response Team (CCURT) with a telephone call to Team Member #25. The coordinated call took place at 4:30 P.M. · On 09/28/20, all guidance provided was followed and calls were placed to recommended staffing agencies. The Ohio National Guard was activated and responded to immediate staffing needs with response in place by 8:30 P.M. · On 10/01/20, the laboratory results were received for testing performed on 09/29/20. Resident rooms were cleaned and sanitized to prepare for room moves based on CDC guidelines requiring 12-24 hours between sanitation and resident move in. Barrier walls were constructed to isolate negative and not exposed residents from the rest of the population. Additional PPE stations were made available throughout all units. · On 10/02/20, resident room moves were made to accommodate cohorting of residents as a result of the 09/24/20 and 09/29/20 laboratory results. Barrier walls applied to all negative but exposed rooms. Additional PPE stations were made available throughout all units. All resident records were reviewed by the DON, Infection Preventionist (IP) #50, Minimum Data Set (MDS) Nurse #15 and the Administrator to accommodate necessary room changes. · On 10/03/20, resident room changes were made to accommodate additional residents identified as positive and negative but exposed from testing on 09/29/20. Based on the room moves 43 of 57 residents were identified as positive for COVID-19 and cohorted on identified COVID positive unit; Seven of 57 residents were identified as negative but exposed to COVID-19 and cohorted on a negative but exposed unit and seven of 57 residents tested were found to be negative and not exposed and cohorted in a negative and not exposed unit. Zipper barriers were applied to the entrances of all rooms housing negative but exposed residents. Additional PPE stations were made available throughout all units. All changes mentioned under this paragraph were completed by the DON, Social Services Director #10, and Housekeeping Supervisor #55. · On 10/05/20, the DON and Administrator revised the policy on PPE usage in cohorted negative but exposed rooms. Staff education began on 10/05/20 and continued on 10/06/20, when all staff were educated on the revised policy for PPE usage in cohorted negative but exposed rooms. All staff education was via one or more of the following formats: text, email, phone calls, Relias training, and On shift. Staff will not be permitted to work without receipt of acknowledgment regarding education. PPE equipment was placed inside and outside of all rooms with cohorted residents testing negative but exposed. PPE usage audits were being completed daily on varying shifts for four weeks. Retesting of all previously negative staff and residents is to be completed on 10/06/20, and then weekly thereafter. · Interviews on 10/20/20 from 11:35 A.M. to 11:39 A.M. with Licensed Practical Nurse (LPN) #60, and State tested Nurse Aide ' s (STNA) #70 and #80, verified they had received in-service education on PPE usage via computer and in-person. The topics covered were the type of PPE to be utilized when on the quarantine and the COVID-19 units. · Review of the facility audit records for PPE usage from 10/06/20 to 10/19/20 verified one audit was completed by the Infection Preventionist or designee each day during the period reviewed. No concerns were identified. · Review of the facility COVID-19 testing records for 10/06/20 and 10/13/20 verified all staff and residents in the facility had been tested . Findings include: Review of the facility census sheet which included a detailed record of the residents COVID-19 status and location in the building dated 09/28/20, revealed the facility had set up a designated COVID-19 negative area in the 300 unit. All other units of the building (units 100 and 200) were dedicated to positive residents. Nine Residents (#01, #02, #03, #04, #05, #06, #07, #08, #09) who were identified COVID-19 negative on the bed board remained in units 100 or 200 as of 09/28/20. The bed board dated 10/01/20, revealed the nine identified residents continued to reside in the same rooms they occupied on 09/28/20. Seven residents (#01, #04, #05, #06, #07, #08, #09) of the nine negative residents were identified on both the 09/28/20 and 10/01/20 bed board as having a roommate who was confirmed positive for COVID-19. The 09/28/20 and the 10/01/20 bed board were absent for evidence of any additional units being set up for residents with a negative testing status who were exposed to COVID-19. The bed board dated 10/02/20, revealed Residents (#01, #02, #03, #04, #05, #06, #07, #08, #09) were all confirmed positive for COVID-19. The bed board dated 10/02/20, revealed the facility had set up a quarantine unit for COVID-19 negative but exposed residents which was located at the end of the 200-unit hallway. The bed board from 10/03/20 revealed four residents (#10, #11, #12, #13) tested negative for COVID-19 but were quarantined for an exposure. The 10/03/20 bed board also identified Residents #10 and #11 as roommates and Residents #12 and #13 as roommates. Review of the COVID-19 Outbreak Line Listing, revealed the facility had completed two rounds of COVID-19 outbreak testing. Initial outbreak testing for all residents took place on 09/24/20, and all results were received by the facility on 09/28/20. The results of testing concluded 32 residents were positive for COVID-19. The second round of testing for all residents was conducted on 09/29/20 and results were reported to the facility on [DATE]. The results indicated an additional 11 residents were positive for COVID-19, bringing the facility total to 43 residents. The line listing verified Residents #01, #02, #03, #04, #05, #06, #07, #08, and #09 had initially tested negative during the first round of testing, then tested positive for COVID-19 during the second round of testing. Interview on 10/01/20 at 9:25 A.M. with the Executive Director (ED), revealed the facility was notified on 09/24/20 that a resident who had been transferred to the hospital had tested positive for COVID-19. The ED stated the facility began outbreak testing protocol and began testing all residents and staff that same day. The results of the testing were reported to the facility on [DATE] and all results were received by 09/28/20. The results indicated 34 residents and 23 staff members were positive for COVID-19. The ED stated after receiving the test results, the staff separated negative residents from positive residents by creating dedicated units and residents were moved based on the test results. The ED confirmed the facility had finished the movement of residents to their dedicated areas on 09/28/20. Interview on 10/01/20 at 9:38 A.M. with IP #50, revealed the facility had set up two units in the building to separate their positive and negative COVID-19 cases. The negative COVID-19 unit was in the 300 unit and separated by a plastic barrier in the hallway. The residents on this unit had a negative testing status and did not have any exposure to COVID-19. IP #50 stated the 100 and 200 units were designated for positive residents but also housed residents who were tested negative but exposed to COVID-19. IP #50 stated residents with an exposed status were presumed positive and deemed safe to isolate with residents with a positive COVID-19 status. Observation on 10/01/20 between 9:25 A.M. and 9:45 A.M., during an initial tour, revealed all clinical staff in the facility were wearing an N95 masks, a face shield or goggles, and isolation gowns throughout the building. Review of the medical record for Resident #01 revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Further review of the medical record revealed Resident #01 received two COVID-19 tests. The results of the initial COVID-19 test collected on 09/24/20, was reported to the facility on [DATE], and was negative. Results of a second COVID-19 test collected on 09/29/20, was reported to the facility on [DATE] at approximately 11:47 P.M. and was positive. Resident #01 shared a room with Resident #15. Review of the medical record for Resident #15 revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Further review of the medical record revealed Resident #15 had received a COVID-19 test on 09/24/20. The results of the test were positive and reported to the facility on [DATE]. Review of the medical record for Resident #04 revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Further review of the medical record revealed Resident #04 received two COVID-19 tests. The results of the initial COVID-19 test collected on 09/24/20, was reported to the facility on [DATE] and was negative. Results of a second COVID-19 test collected on 09/29/20 and reported to the facility on [DATE] was positive. Observation on 10/01/20 at 12:05 P.M. in the 100 unit of the building revealed State tested Nursing Assistant (STNA) #20 entered the room of Resident #01 who was negative, and Resident #15 who was positive, wearing an N95, goggles, isolation gown, and gloves. STNA #20 began assisting Resident #15 with moving her tray table and call light near the resident and adjusting the blankets on the resident ' s bed. STNA #20 then went to the bedside of Resident #01 and began to assist the resident with eating. STNA #20 did not perform hand hygiene or change any of the PPE she was wearing between care of the two residents. Interview on 10/01/20 at 12:23 P.M. with STNA #20, revealed she was assigned to the 100 unit and four rooms on the 200 unit that day. STNA #20 verified while caring for Resident #01 and Resident #15, hand hygiene was not performed, and PPE was not changed between the residents. STNA #20 stated she had not changed the N95, goggles, or isolation gown she was wearing at all since she arrived for her shift that morning. STNA #20 stated she was instructed to wear the same PPE for the entire shift while caring for all residents unless the PPE became soiled or damaged. Observation on 10/01/20 at 12:33 P.M. in the 100 unit of the building, revealed LPN #30 entered room [ROOM NUMBER] wearing an N95, a face shield, and isolation gown. LPN #30 assisted Resident #14 with adjusting the blankets on the bed and obtaining personal items from the tray table. LPN #30 then exited the resident ' s room wearing the same PPE she entered with and continued back to her medication cart in the hallway where she performed hand hygiene. At approximately 12:37 P.M., LPN #30 entered Resident #04 ' s room wearing the same N95, face shield, and isolation gown she had worn in Resident #14 ' s room. LPN #30 assisted Resident #04 with taking a drink and placing the call light beside the resident. During an interview with LPN #30 on 10/01/20 at 12:40 P.M. she stated her assignment that day was the 100 unit and two rooms on the 200 unit. LPN #30 verified she had been wearing the same PPE throughout her shift between all residents and was told only to change it if it became soiled or damaged. LPN #30 also stated she was aware residents in her care were both negative and positive for COVID-19 but was told by the management team to maintain the same PPE she had on between all residents. Interview with IP #50 on 10/01/20 at 2:35 P.M., confirmed staff assigned to the 100 and 200 units were utilizing the same PPE for the duration of their shift in order to conserve supply. IP #50 verified staff were instructed to wear the same PPE between all residents including those who ' s COVID-19 status was negative but remained on the COVID-19 positive unit. Review of the list of residents in transmission-based precautions dated 10/05/20, provided by the facility, revealed Residents #10, #11, #12, and #13, were in droplet isolation precautions. Observation on 10/05/20 at 12:35 P.M., of the facility ' s quarantine area designated for residents exposed to COVID-19, revealed isolation bins with PPE supplies were located outside of each resident room. Signs were posted on each resident door in the quarantine area regarding transmission-based precautions. The signs stated staff were to don a clean gown, facemask, and gloves prior to providing care for residents in those rooms. Interview with LPN #60 on 10/05/20 at 3:57 P.M., revealed her assignment for that day included the area dedicated to residents quarantined for exposure to COVID-19. LPN #60 stated the required PPE for residents who were exposed and in quarantine was an N95, isolation gown, gloves, and eye protection. LPN #60 stated when caring for quarantined residents who were together in the same room, she was wearing the same PPE between both residents. LPN #60 stated it was her understanding that once she donned the proper PPE prior to entering the room, she was considered clean and could provide care to both residents without changing PPE between them. LPN #60 verified there were two rooms on the quarantine unit that had double occupancy. LPN #60 verified Residents #10 and #11 were roomed together and Residents #12 and #13 were roomed together with the same COVID-19 exposure status. Interview with the DON on 10/05/20 at 4:40 P.M., verified the staff were told that when caring for residents in quarantine with a negative test result and exposure that were in the same room, the same PPE could be used between both residents because both residents had already been exposed to COVID-19. Review of the facility policy titled, Considerations for Cohorting COVID-19 Patients in Post-Acute Care Facilities dated 08/03/20, revealed the plan for cohorting residents during an outbreak of COVID-19 indicated four different cohorts. Cohort #1 was for COVID-19 positive residents, Cohort #2 for COVID-19 negative but exposed residents, Cohort #3 for COVID-19 negative and not exposed residents, and Cohort #4 for new admissions and readmissions. The policy indicated Cohort #1 was to consist of both symptomatic and asymptomatic residents who test positive for COVID-19. Cohort #1 was to be on a separate closed unit if feasible. Cohort #2 was to consist of symptomatic and asymptomatic residents who test negative for COVID-19 with an identified exposure to someone who was positive. Exposed individuals would be quarantined for 14 days regardless of the test results. The guidelines for Cohort #2 stated residents who test negative for COVID-19 could be incubating and later test positive. Cohort #3 would consist of residents who test negative for COVID-19 with COVID-19 like symptoms and were thought to have no known exposures. Review of the CDC website COVID-19 guidelines titled, Use of Testing to Inform the Response to COVID-19 in Nursing Homes (https://www.cdc.gov/coronavirus/2019-ncov/hcp/nursing-homes-responding.html), dated 04/30/20, revealed if testing capacity allows use of facility wide testing following identification of newly identified [DIAGNOSES REDACTED]-CoV-2 infected residents or healthcare personal could be particularly important. Facility wide testing can help identify a symptomatic or pre-symptomatic resident with COVID-19 to guide movement into COVID-19 designated spaces. Review of the CDC website COVID-19 guidelines titled, Infection Control for Nursing Homes( https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html) dated 06/25/20, revealed when extended use of gowns was implemented as part of crisis strategies, the same gown should not be worn when caring for different residents unless it was for the care of residents with confirmed COVID-19 who were cohorted in the same area of the facility and these residents were not known to have any co-infections (e.g., Clostridioides difficile). Further review of this section of the CDC revealed the facility should have a plan for how residents in the facility who develop COVID-19 will be handled (e.g., transfer to single room, implement use of Transmission-Based Precautions, prioritize for testing, transfer to COVID-19 unit if positive) and have a plan for how roommates, other residents, and HCP who may have been exposed to an individual with COVID-19 will be handled (e.g., monitor closely, avoid placing unexposed residents into a shared space with them). Review of the CDC website COVID-19 guidelines titled, Responding to COVID-19, dated 04/30/20, revealed responding to residents newly infected with [DIAGNOSES REDACTED]-CoV-2 includes ensuring the resident was isolated and cared for using all recommended COVID-19 PPE. The resident should be placed in a single room if possible pending results of [DIAGNOSES REDACTED]-CoV-2 testing. Cohorting residents on the same unit based on symptoms alone could result in inadvertent mixing of infected and non-infected residents (e.g., residents who have fever, for example, due to a non-COVID-19 illness could be put at risk if moved to a COVID-19 unit). If cohorting symptomatic residents, care should be taken to ensure infection prevention and control interventions are in place to decrease the risk of cross-transmission.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, staff interviews, review of an employee personnel file, review of facility policy on Do Not Resuscitate orders, review of the emergency medical squad report, and review of in-service documentation, the facility failed to provide the necessary care and services when staff did not initiate Cardiopulmonary Resuscitation (CPR) for one resident (#82) who was found without vital signs and was a Full Code status. This resulted in Immediate Jeopardy for one of four residents reviewed who expired in the facility. The facility identified 11 current residents who were a Full Code status. The facility census was 58. On [DATE] at 4:47 P.M., the Administrator and Chief Executive Officer (CEO) were notified Immediate Jeopardy began on [DATE] at 10:05 P.M. when Resident #82 was found without vital signs and Registered Nurse (RN) #100 failed to initiate CPR. The Immediate Jeopardy was removed and the deficient practice was corrected on [DATE] when the facility implemented the following corrective actions: · On [DATE], the Director of Nursing (DON) initiated an investigation of Resident #82's medical event and self-identified an opportunity for improvement with regard to cardiopulmonary resuscitation. An internal Quality Assurance Performance Improvement (QAPI) plan was implemented. · On [DATE] and [DATE], the DON obtained witness statements and/or interviews from all nurses and State tested Nurse Aides (STNA) on duty, including RN #100. · On [DATE], the DON provided RN #100 a final written warning for failure to immediately implement CPR. On [DATE], RN #100's employment was terminated due to an unrelated situation. · On [DATE], the DON initiated in-service education for all licensed nurses on CPR protocols, with emphasis on immediate implementation of CPR for residents with a Full Code status who were found without vitals. In-service education was complete for all licensed nurses on [DATE]. · On [DATE], the DON, MDS nurse and assistant MDS nurse reviewed all residents' clinical records to validate each resident's code status was accurate and correctly documented. · Interviews on [DATE] at 4:55 P.M. with RN #106 and on [DATE] at 1:20 P.M. and 1:25 P.M. with Licensed Practical Nurse (LPN) #103 and LPN #105 respectively revealed they were knowledgeable about the procedure to follow to initiate CPR. Findings include: Review of Resident #82's medical record revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of the resident's Advanced Directive noted the resident was a full code. Review of Resident #82's Advance Directives/Medical Treatment Decisions form dated [DATE] identified the resident did not choose to formulate an advanced directive at that time. Full Code was handwritten above the resident's signature. Review of the Advance Care Planning form dated [DATE], noted the resident was a full code. Review of Resident #82's plan of care dated [DATE] included a focus area which identified the resident requested all life saving measures be taken. Interventions included if the resident experiences cardiopulmonary arrest, begin CPR and continue until the pulse and respirations are restored or until relieved by rescue personnel. Review of a nursing progress note dated [DATE] at 11:29 P.M. documented RN #100 was called into Resident #82's room by State Test Ready Nurse Aide (STRNA) #110 because something was wrong with the resident. The note indicated when RN #100 entered into the room and called the resident's name, there was no response. The note documented RN #100 checked Resident #82's vitals and there was no sign of life. RN #100 found no heart or lung sounds. The nursing progress note documented the resident was absent of vitals and his eyes and mouth were open, but he was not breathing. RN #100 called 911 emergency transport due to the resident's code status of Full Code. The note documented the emergency medical service (EMS) arrived and administered CPR to Resident #82 until a physician called the time of death at 10:55 P.M. Review of the local EMS report dated [DATE] revealed the EMS was notified at 10:21 P.M. to respond to the nursing facility for emergency services. The EMS was 10:24 P.M. dispatched and in route at 10:25 P.M. The report noted they were at Resident #82's bedside at 10:29 P.M. The EMS report narrative noted when the first paramedic arrived to the scene the resident was being bathed by two staff members. The narrative noted the paramedic initiated CPR on Resident #82 and emergency medications were administered. The report documented the resident's color was pale and the extremities were described as cold. The report noted one of the paramedics called the coroner and explained the resident was terminal with [MEDICAL CONDITION] which had gone to the lungs. The physician stated resuscitation efforts could be terminated. The time of death on this report was 10:55 P.M. Review of the undated facility investigation revealed STRNA #110's statement noted on [DATE] at 10:05 P.M., Resident #82's skin color was not right and he wasn ' t responsive. The STRNA immediately informed RN #100 who went to the resident's room. Further review of the facility investigation included a statement from RN #100 which noted the nurse had checked on Resident #82 at 9:00 P.M., before she went into a mandatory facility meeting. The statement noted the third shift STNAs completed their first rounds about 10:05 P.M. STRNA #110 reported Resident #82 did not look right, as his color was off and he appeared to be unresponsive. RN #100 stated she went right to the resident's room to assess him. The resident was absent of vital signs and the nurse went out and called 911 because she knew the resident had a Full Code status. RN #100' s statement indicated the emergency medical technicians (EMT) arrived about two minutes ' later and initiated resuscitation attempts. RN #100 indicated no vital signs were maintained during the EMT's attempts and the emergency personnel contacted the emergency room (ER) physician who called the time of death at 10:55 P.M. Interview with LPN #104 on [DATE] at 2:33 P.M. revealed an aide had reported to the nurse the resident wasn ' t right and found he was without vital signs. When asked about documentation regarding where CPR had been initiated, LPN #104 confirmed there was none. LPN #104 then stated the nurse was no longer working at the facility as she was fired. Interview on [DATE] at 5:20 P.M. by telephone with STRNA #110 revealed when she started her assignment for the night, Resident #82 was already gone. She stated the resident's condition was discovered at shift change. STRNA #110 stated she notified RN #100 and when the nurse went into Resident #82's room she stated he was gone. STRNA #110 stated she did not observe the nurse conduct CPR on the resident. Interview with STNA #111 was conducted by telephone on [DATE] at 5:45 A.M. STNA #111 stated they had been providing care to the roommate and when finished, they checked on Resident #82 and ran and got the nurse. STNA #111 stated the nurse came to check the resident and stated he's gone . She stated she then began to clean up the resident because that is what she always do when a resident passes away. She said the ambulance people then showed up. STNA #111 stated she did not observe the nurse conduct CPR on the resident. Interview on [DATE] at 8:55 A.M. with the DON revealed she had received a text from the nurse (RN #100) at approximately 10:30 P.M. on [DATE]. The DON stated she was notified the resident had died by the RN and had asked the RN what the resident's code status was. The DON stated she had asked RN #100 if she started CPR on the resident and the RN stated she had not because he was already gone. The DON stated she then had the nurse write a statement as well as the aides. Review of the medical records for Resident #12, Resident #69, and Resident #102 were reviewed for code status upon their death in the facility. All were found to have had a Do Not Resuscitate (DNR) code status. The facility identified no other residents with a Full Code status who had expired in the facility since [DATE]. Review of the undated facility policy titled Do Not Resuscitate (DNR) Orders revealed CPR will be initiated for all residents when appropriate, unless a physician has issued a DNR order for the resident. The policy documented CPR will be initiated if the resident is not a DNR Comfort Care or DNR Comfort Care-Arrest status. Regardless of the presence of signs and symptoms of death, CPR will be initiated on all residents, unless directed otherwise by a physician or Emergency Medical Services personnel.