Every finding on record at Etowah Landing

Based on observation, interviews, record review, and a review of the facility policy titled Cleaning and Disinfection of Resident-Care Items and Equipment, the facility failed to implement infection prevention and control practices for two of five sampled residents (R) (R50 and R23). In addition, the facility failed to ensure proper cleaning, disinfection, and separation of reusable resident care equipment for two of two units. This failure created the potential for cross-contamination and transmission of infection.Findings include: A review of the facility's policy titled, Cleaning and Disinfection of Resident-Care Items and Equipment, revised July 2014, documented Policy Statement: Resident- care equipment, including reusable items and durable medical equipment will be cleaned and disinfected according to current Centers for Disease Control (CDC) recommendations for disinfection and the Occupational Safety and Health Administration (OSHA) Bloodborne Pathogens Standard. 1. During an observation on 04/12/2026 at 2:50 PM, R50 was observed in bed, and the bed was in the lowest position. A catheter bag was observed hanging on the bed rail, resting on the floor. Licensed Practical Nurse (LPN) RR confirmed that the catheter bag was on the floor and confirmed that it should not be touching the floor. She was observed to move it to a position so that it was not resting on the floor. During an observation on 04/13/2026 at 9:50 AM, R50 was observed in bed, and the bed was in the lowest position. Again, the catheter bag was observed hanging on the bed rail, resting on the floor. Certified Nursing Assistant (CNA) LL confirmed that R50's catheter bag was on the floor. She stated that she knows it isn't supposed to be on the floor, but that it is probably because his bed must be in the lowest position. She stated that she has not even gotten to his room today to provide him with care. 2. During an observation outside of R23's room on 04/11/2026 at 9:41 AM, the privacy curtain was pulled and approximately 18 inches from the floor. The resident nearest the door was observed to have an oxygen (O2) concentrator actively on. The water bottle from the O2 concentrator was observed empty and on the floor. The Staffing Coordinator was interviewed at this time, and she confirmed that R23 has a tracheostomy (trach) and that the bottle on the floor should not be empty and should not be on the floor. During an interview with R23 on 04/11/2026 at 9:44 AM, he stated that he hasn't had a water bottle in a couple of weeks, and he has asked for the bottle to be replaced. During an observation and interview with the Respiratory Therapist (RT) on 04/11/2026 at 9:49 AM, she was observed to go into R23's room, remove the old water bottle, and replace it with a full bottle. Upon exiting the room, the RT confirmed that the water bottle should not be on the floor and that it should be changed daily. She confirmed that the bottle that she removed did not have a date or label as to when it was last changed. She stated that the resident was not on the respiratory caseload. He is on the nursing case load, so they should be providing the trach care and respiratory services to the residents. 3. Observation on 04/11/2026 at 8:15 AM, revealed the clean and soiled utility room was observed to be divided by a blue strip on the floor, intended to separate the clean and soiled equipment, with designated clean and soiled entrances. During the observation, used/dirty equipment was observed throughout both sides of the room, including oxygen concentrators, pulse oximeters, suction machines, folding chairs, IV poles, and vital sign machines. There was no method to distinguish clean from contaminated equipment. Further observation revealed that no equipment was covered, bagged, or labeled as clean, no cleaning or disinfectant supplies were present, and no Personal Protective Equipment (PPE) for use during the disinfectant process. Interview on 04/11/2026 at 8:50 AM with the weekend supervisor, Licensed Practical Nurse (LPN) CC verified the findings in the clean and soiled utility room. She stated that all equipment in the room was considered dirty at that time because she could not determine which items were clean and which were dirty. LPN CC stated the equipment would not be used until cleaned. The LPN CC further stated that cleaning supplies and bags would be placed on the soiled side of the room. She stated that the nurses and the respiratory therapist share responsibility for cleaning the equipment, and together they spot-check the room and clean it when necessary. Interview on 04/11/2026 at 9:30 AM with the Respiratory Therapist (RT) revealed while observing the clean and soiled utility room, the dirty equipment would not be on both sides of the clean and dirty room. She stated that normally the equipment would come in through the soiled entrance, be disinfected, then pushed to the clean side, and bagged, making it ready for use. The RT stated that cleaning the equipment was done with nursing staff and whoever could get to it first. She was unsure why the dirty equipment was combined with the clean and stated that she grabs a bottle of wipes from the office and bags from the PPE hanging apparatus, then returns the wipes to the office after cleaning the equipment. RT confirmed there was no indication of what was clean or dirty. 4. Observation and Interview on 04/11/2026 at 8:15 AM in the Spring Hall revealed two oxygen concentrators sitting beside a vending machine, and the resident common area, which were visibly soiled and dirty. The weekend supervisor, LPN CC confirmed the oxygen concentrators were dirty and needed to go to the soiled utility room. Additionally, an observation of two resident recliners and wedges was visibly soiled in the Spring hallway. LPN CC stated the process is to clean the recliners in the resident rooms before bringing them to the hallway, and that the wedges should have been bagged, tied, and taken to the soiled utility for cleaning. LPN CC confirmed the wedges were soiled and stated she would bag them and take the wedges to the soiled utility.

Based on observations, interviews, and record review, the facility failed to ensure a clean and homelike environment on two of three units (Meadows Unit and the Springs Unit) related to an unclean room and broken bathroom tissue holder, lack of use of proper bed linen, unclean packaged terminal air condition (PTAC) units, and lingering malodorous odors. The deficient practice had the potential to affect resident comfort and safety.Findings include:During multiple observations on 04/11/2026 and 04/12/2026, the Packaged Terminal Air Conditioners (PTAC) units in the Meadows Dining Room had a thick covering of dust buildup.During an observation on 04/11/2026 at 8:40 AM, the resident in room [ROOM NUMBER]A was observed lying in the bed with a flat sheet not visible on the mattress underneath her upper body. The flat sheet was observed on the bed, bunched up under the resident's lower body, buttocks, and lower extremities. During an observation on 04/11/2026 at 9:52 AM, the resident in room [ROOM NUMBER]C was observed sleeping on a mattress without a fitted sheet or standard linens in place. There was no fitted sheet or secured linen. A blue striped pillow was on the bed without a pillowcase. During multiple observations on 04/11/2026 at 10:16 AM, 04/11/2026 at 2:31 PM, and 04/12/2026 at 8:55 AM, the floor in room [ROOM NUMBER] was dirty with food particles and was sticky throughout the walking area; the wall was splattered with a brown substance behind the B bed, there was a strong urine odor in the room and bathroom, and the tissue holder in the bathroom was broken and/or missing a cover.During observations on 04/11/2026 at 10:16 AM, 04/11/2026 at 2:31 PM, and 04/12/2026 at 8:55 AM, the resident in 20A bed was observed lying in bed. The upper and lower mattresses were exposed. There was a flat sheet on the bed that had slid to the middle of the mattress and was bunched up under the resident.During an observation on 04/11/2026 at 10:24 AM, and 04/11/2026 at 2:30 PM, the resident in room [ROOM NUMBER]C was observed in her room lying in bed. There was a top sheet on the mattress being used as a fitted sheet, so it was halfway on the bed with the mattress exposed on the bottom and top. The resident was lying halfway on the bare mattress. The resident was determined not to be a resident interview candidate.During an interview on 04/12/2026 at 7:21 AM, CNA PP stated there were plenty of sheets and linens for the standard beds, but those sheets don't fit the larger beds or oversized beds. CNA PP stated, The flat sheet won't stay in place, the resident ends up sleeping on the bare mattress, and they stick to the mattress. That can't be comfortable. CNA PP verified that the resident in room [ROOM NUMBER]C was sleeping on the mattress without a fitted sheet and verified that the bed needed larger linens. During an interview with the resident in 20A bed on 04/12/2026 at 8:55 AM, he stated that he was told the facility doesn't have the fitted sheets for his bed (the resident has a bariatric bed). He further stated that the housekeeping staff doesn't clean his room every day. He confirmed that no one came in yesterday to clean his room.During an interview on 04/12/2026 at 9:00 AM, Certified Nursing Assistant (CNA) SS stated that they are sometimes short of linen, including the fitted sheets. She confirmed that the resident in room [ROOM NUMBER]A had a flat sheet on his bed.On 04/12/2026 at 9:04 AM, the Housekeeping Supervisor (HKS) stated that she had been in the position of HKS for almost four months. She stated that there are a total of eight housekeepers and two laundry aides. She stated that the staff has plenty of linen. An observation of the clean linen closet, the housekeeping laundry room, and the new supplies storage room with the HKS revealed that the facility had enough fitted sheets and other linen. The HKS revealed that the housekeeping staff are expected to clean each room at least once per day and that some of the rooms are cleaned twice a day.During an interview with the Staffing Coordinator on 04/12/2026 at 9:25 AM, she stated that she orders linen, and the facility has plenty of linen. The staff just choose to place the flat sheets on the beds when they make the bed. She stated that regular mattresses should have a fitted sheet, but air mattresses don't have fitted sheets. She confirmed that the mattresses in room [ROOM NUMBER]A and room [ROOM NUMBER]C were regular and should have a fitted sheet. During an observation and interview with the HKS on 04/12/2026 at 9:30 AM, she confirmed that room [ROOM NUMBER] was not clean and stated that the housekeeping staff was going to clean the room. Two housekeeping staff were observed entering room [ROOM NUMBER]. During an interview and observation with the Maintenance Director on 04/12/2026 at 9:38 AM, he stated that he has a maintenance book on the conference room door so that staff can place information related to areas of concern in the facility. He confirmed that the tissue holder in the bathroom of room [ROOM NUMBER] was missing a cover/broken. He stated that they have an Ambassador Program at the facility and that the Social Services Director was the Ambassador for room [ROOM NUMBER]. A review of the maintenance book revealed no entries related to the tissue holder needing repair. During an interview with CNA TT on 04/12/2026 at 10:00 AM, she stated that it is easier to put a flat sheet under the resident in room [ROOM NUMBER]C because she sometimes doesn't roll, and with her not feeling well, she thought it was easier to use the flat sheet. During a tour of the Meadows Dining Room on 04/12/2026 at 12:28 PM, the Maintenance Director verified that dirty filters were to be washed with soap and water monthly on a rotating basis and replaced quarterly. He provided a maintenance report that showed the PTAC serial numbers, but no documentation of which PTAC unit filters were cleaned or replaced.

Based on observations, record review, and interviews, the facility failed to ensure that three of seven medication and treatment carts (Springs Medication Cart #1, Springs Medication Cart #2, and Meadows Treatment Cart #1) were locked and secure when not in use. The deficient practice increased the risk of unauthorized access to medications and diversion.Findings include:During entry into the facility on [DATE] at 7:30 AM, the Springs Medication Cart #1 and the Springs Medication Cart #2 were observed unlocked and unattended. Two staff members were observed seated behind the Springs Nursing Station. During an observation on 04/11/2026 at 7:40 AM, during the initial tour of the facility, the Meadows Treatment Cart #1 was observed unlocked and unattended. At that time, Licensed Practical Nurse (LPN) AA confirmed that the treatment cart was left unlocked and unattended. She stated that the wound care nurse must have left it open the day before.A review of the Medication Cart/Storage document (undated) revealed that there are five medication carts and two treatment carts. A review of the Medication Storage Policy with a revised date of April 2007, documented that the facility shall store all drugs and biologicals in a safe, secure, and orderly manner. The nursing staff shall be responsible for maintaining medication storage AND preparation areas in a clean, safe, and sanitary manner. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing drugs and biologicals shall be locked when not in use, and trays or carts used to transport such items shall not be left unattended if open or otherwise potentially available to others.

Based on observations, staff and resident interviews, record review, and review of the facility policy titled Care of Fingernails/Toenails, the facility failed to ensure Activities of Daily Living (ADL) care was provided for two of eight sampled residents (R) (R2 and R9) related to fingernail care. The deficient practice placed R2 and R9 at risk of diminished quality of life.Findings include:1. During an observation on 04/11/2026 at 2:54 PM, and 04/12/2026 at 11:29 AM, R9's fingernails were observed to be long with a heavy accumulation of brown debris under the nail bed. A review of the electronic medical record (EMR) revealed that R9 was admitted to the facility on [DATE], with diagnoses included, but not limited to unspecified dementia, anxiety and depression.The Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed R9 was dependent on staff for the ability to maintain personal hygiene and maximum assistance with showering/bathing. A review of the care plan revised 02/26/2026, documented R9 required staff assistance for ADL care and specified to check nail length, trim and clean on bath day, and as necessary. Report any changes to the nurse.A review of the care record, progress notes and Kardex did not show documentation that R9 refused fingernail care. 2. During an observation on 04/11/2026 at 10:20 AM and 3:36 PM, R2 was observed in bed with long fingernails that were jagged, green and dirty. During an observation on 04/12/2026 at 9:16 AM, the wound care nurse demonstrated that R2's right hand was contracted and her fingers were bent with the fingernails digging into the palm of her hand. The fingernails on both hands were long, with rough edges and had debris under the nails and on the fingers. R2 stated her fingernails needed to be trimmed because of how my hands are.A review of the EMR revealed that R2 was admitted to the facility on [DATE]. Diagnoses included, but not limited to Non-Alzheimer's Dementia, diabetes, and pneumonia. The MDS comprehensive assessment dated [DATE] showed R2 was dependent on staff to maintain personal hygiene, bathing and grooming.A review of the care record, progress notes and Kardex did not show documentation that R2 refused fingernail care. An interview on 04/12/2026 at 11:30 AM, Licensed Practical Nurse (LPN) OO stated the Certified Nursing Assistant's (CNA's) should do nail care with shower or bathing. LPN OO stated if care was refused it was to be documented in the electronic health record. LPN OO verified R9's fingernails were overgrown with visible accumulation of brown debris beneath the nail beds. An interview on 04/12/2026 at 3:12 PM, the Director of Nursing (DON) stated if staff are unable to clean or clip fingernails, they should let the nurse know or document it and stated, I have not seen any documentation over the past couple of weeks to show any refusals for R2 or R9. The DON stated, R2 refused a shower on March 24 and once in February, but there was nothing documented about fingernails. An interview on 04/13/2026 at 8:56 AM, CNA KK stated both R2 and R9 required staff to complete ADL care for them including nail care. CNA KK asked R9 if he would like his nails cleaned and trimmed and he agreed. CNA KK stated R2 really doesn't refuse anything. An interview on 04/13/2026 at 8:56 AM, LPN QQ confirmed R9's fingernails were long, with thick debris on the side of the nailbed, and under the nails. LPN QQ stated that [referred to growth and debris] was over a while and the R9 deserved better. R9 agreed to have his nails cleaned and trimmed. A review of the facility policy titled Care of Fingernails/Toenails, with an effective date of 2001, revised October 2010, documented nail care includes daily cleaning and regular trimming. The procedure included soaking the hand in warm soapy water for approximately five minutes then rinse the hand with clear, warm water. Dry the hand with the towel, gently remove the dirt from around and under each nail, trim the fingernails in an oval shape, smooth the nails with a nail file or emery board. Documentation specified to include the date and time that nail care was given, the condition of the resident's nails and nail bed, and difficulties cutting the residents nails, any problems or complaints made by the resident, if the resident refused the treatment, the reason why and the intervention taken.

Based on observations, staff interviews, record review, and review of the facility policy titled Restorative Nursing Policy and Procedure, the facility failed to ensure that one of two sampled residents (R) (R2) received restorative services to prevent contractures and/or to prevent a decrease in range of motion (ROM) mobility. The deficient practice increased the risk that R2 would experience worsening contractures.Findings include: During an observation on 04/11/2026 at 10:20 AM, and 3:36 PM, R2 was observed in bed with the left hand visible on top of the blanket. R2's left hand was observed in a contracted, flexed position, with the fingers tightly drawn together. No splints were observed in the room. During an observation on 04/12/2026 at 9:16 AM, the wound care nurse demonstrated R2's lack of ROM in the right hand which was closed and contracted. R2's fingers were bent with the fingernails digging into the palm of her hand. No splints or washcloths were rolled in R2's hands. The wound care nurse confirmed no splints were in use or visible.A review of the electronic medical record (EMR) revealed that R2 was admitted to the facility on [DATE]. Diagnoses included Non-Alzheimer's Dementia, diabetes, and pneumonia. The Minimum Data Set (MDS) comprehensive assessment dated [DATE], showed R2 was dependent on staff to maintain personal hygiene, bathing and grooming. Review of the physician order dated 08/25/2025, instructed staff to clean bilateral hands and apply rolled washcloths daily and prn (as needed) and splint/cast: Check skin under/around splint for impairment, irritation, injuries, warm skin/fingers, skin color and document yes or no if issues noted; every day and night shift.A review of the restorative program progress note dated 03/23/2026, documented Resident continued on restorative nursing programs for passive range of motion (PROM) to bilateral lower extremities (BLE) and bilateral resting hand splints at night only for 6-8 hours, no signs or symptoms of skin redness or irritation noted. Requires total dependence from staff for both programs. Resident denies pain with PROM or splint, continue restorative plan of care.A review of the therapy progress note dated 01/13/2025, documented the recommendation for discharge from therapy to restorative nursing for continued bilateral upper extremity (BUE) range of motion to shoulders, elbows and wrists and splinting to bilateral hands for 6 hours at night.A review of the care record for April 2026 failed to show documentation that R2 received restorative nursing for splinting identified as staff will assist/cue resident with PROM 15 minutes a day, 7 days a week/physical prompts/ encouragement as needed to prevent contractures for 13 of 13 days reviewed in April. On 04/12/2026 at 7:01 AM, during an interview with Certified Nursing Assistant (CNA) II stated she worked 3rd shift. CNA II stated R2 was supposed to have a splint on her hand and confirmed R2 was not wearing the splint. She demonstrated the splint was in the nightstand drawer and not applied to R2's hands. On 04/12/2026 at 7:23 AM, during a telephone interview, CNA PP stated she was assigned to R2 and worked the night shift. CNA PP stated R2 did not refuse any care. CNA PP stated she did nothing with R2's hands.On 04/12/2026 at 7:53 AM, CNA HH stated range of motion/splinting for restorative was supposed to be done by the CNA assigned. CNA HH stated she has never heard of R2 refusing anything.On 04/12/2026 at 3:12 PM, the Director of Nursing (DON) stated R2 was evaluated monthly to determine if the current program should continue, change or be discontinued. The DON stated R2 was on the restorative program for passive range of motion to both upper extremities, and resting hand splints bilaterally at night. The assigned CNA was responsible for providing range of motion, putting the splints on and taking them off. R2's program was last updated 01/16/2025. The DON stated she was the restorative nurse and documented restorative program progress monthly. The DON stated care plan requires the CNA to document on the restorative nursing section to show what was done for the residents during their assigned shift. The DON confirmed no one signed off for splinting last night which meant no one did it. The DON stated the CNA should have done splinting and range of motion. The DON stated there was no documentation that showed R2 refused to wear the hand splints. The DON stated CNAs are trained in range of motion during the hire process but did not have any resident specific training regarding splinting or range of motion.During an interview on 04/12/2026, the Rehabilitation Director (RD) stated therapy did not provide CNA training for restorative, range of motion or splinting and that would fall to the nursing program. The RD stated R2 was being evaluated today. The last recommendation at that time was bilateral upper extremity (BUE) range of motion and splinting, BUE resting hand splints at night only for 6-8 hours. On 04/13/2026 at 8:53 AM, CNA LL stated she was assigned to care for R2. CNA LL stated she had not been trained on splinting or range of motion specific to R2 and had not put the splint on her.On 04/13/2026 at 8:56 AM, R2 was observed sleeping in bed, no washcloth or roll was observed in R2's visible left hand. Licensed Practical Nurse (LPN) RR assigned to R2 verified the resident was not wearing hand splints/roll.On 04/13/2026 at 8:59 AM, CNA KK stated R2 required total care and was unable to use her hands. CNA stated physical therapy would come in to do therapy. CNA KK stated she had not had training to perform range of motion or splinting for residents in general or specific to R2.On 04/13/2026 11:06 AM, the MDS Coordinator stated R2 was admitted with contractures and required restorative services to prevent the contractures from worsening. MDS Coordinator stated staff needed to keep R2's hands clean and dry and put rolled washcloths in both hands. R2 was supposed to get passive range of motion 15 minutes per day 7 days per week, and it should be done on day shift. If R2 refused splinting, there should be a note written by the DON.On 04/13/2026 11:30 AM, during an interview the DON stated the restorative program is reviewed once a year with all staff and upon hire. The therapy department is part of teaching what the different programs are. The staff person responsible would be the CNA for that resident for that shift. Therapy decided to re-evaluate R2 for the correct splints today after I showed them the splints we found.Review of the facility policy titled Rehabilitative Nursing Care, revised July 2013, documented under Policy Statement: 4. Rehabilitative nursing care is performed daily for those residents who require such service. Such program includes but is not limited to: . f. Assisting residents with their routine range of motion exercises; .h. Others as prescribed by the resident's Attending Physician.

Based on record review, resident and staff interviews, and facility policy review, the facility failed to send a written notification of hospital transfer to the resident and/or resident representative (RR) for three of three residents (Resident (R) 22, R56, and R62) reviewed for hospital transfer of 27 sample residents. This failed practice had the potential to affect the residents and their RR by not having the knowledge of where and why a resident was transferred and/or how to appeal the transfer, if desired. Findings include: Review of the facility's policy titled, Transfer or Discharge Documentation, an initiation date of 2001 and a revision date of 12/16, indicated .details of the transfer or discharge will be documented in the medical record and appropriate information will be communicated to the receiving health care facility or provider . When a resident is transferred or discharged from the facility, the following information will be documented in the medical record .That an appropriate notice was provided to the resident and/or legal representative. 1.Review of R22's electronic medical record (EMR) located under the Census tab revealed that R22 was discharged to the hospital on 2/6/2025 and returned to the facility on 2/11/2025. There was no record in the EMR of the facility providing a written notice of transfer to the resident or the RR. 2. Review of R56's Census tab in the EMR revealed R56 was originally admitted to the facility on [DATE]. Review of R56's Medical Diagnosis tab in the EMR revealed that R56 had diagnoses including metabolic encephalopathy, Alzheimer's disease, repeated falls, difficulty walking, and other lack of coordination. Review of the Care Plan under the Care Plan tab in the EMR revealed R56 had a focus with interventions related to a risk for falling initiated on 10/7/2022. Review of the MDS [Minimum Data Set] tab in the EMR revealed R56 had Discharge Return Anticipated MDS completed on 1/22/2025. Review of a nurse note, dated 1/21/2025 and located under the Progress Note tab in the EMR, revealed R56 had a witnessed fall in her room. The Occupational Therapist witnessed R56 slide from her bed, in the lowest position, onto her fall mat. The resident had hit her head on the nightstand and complained of hip pain. R56 was sent to the hospital for evaluation. Review of a Nursing Home to Hospital Transfer Form dated 1/21/2025 and supplied by the DON revealed R56 had gone to the hospital due to a fall. This form was given to the transportation personnel upon arrival at the facility. This was not provided to the resident or the RR. 3. Review of R62's undated admission Record located under the Profile tab in the EMR indicated R62 had originally been admitted to the facility on [DATE]. R62's diagnoses include resistance to multiple antimycobacterial drugs, dehydration, atrial fibrillation, dementia, depression, anxiety disorder, hypertension, heart failure, and chronic obstructive pulmonary disease. Review of R62's quarterly MDS located under the MDS tab in the EMR with an Assessment Reference Date (ARD) of 5/16/2025 indicated R62 was coded as having a Brief Interview for Mental Status (BIMS) score of 11 out of 15, which indicated R62 was moderately cognitively impaired. Review of R62's eInteract-Nursing Home to Hospital Transfer From, dated 4/14/2025 and located under the Assessment tab in the EMR reflected R62 had been transferred to the emergency room (ER) on 6/3/2025 at 10:45 am for altered mental status. Review of R62's eInteract-Nursing Home to Hospital Transfer From, dated 5/5/2025 and located under the Assessment tab in the EMR reflected R62 had been transferred to the ER on [DATE] at 11:12 am for fever. Review of R62's eInteract-Nursing Home to Hospital Transfer From, dated 5/20/2025 and located under the Assessment tab in the EMR, reflected R62 had been transferred to the ER on [DATE] at 7:15 pm for chest pain. Review of R62's eInteract-Nursing Home to Hospital Transfer From, dated 6/3/2025 and located under the Assessment tab in the EMR, reflected R62 had been transferred to the emergency room (ER) on 6/3/2025 at 11:21 am for chest pain. During an interview on 6/12/2025 at 12:23 pm, R62 was unable to recall if a written notification of hospital transfer was received. Review of R62's medical record revealed documentation of written notification of the reason for the transfer to the hospital could not be located. During an interview on 6/12/2025 at 10:31 am, the Director of Nurses (DON) stated that they send the interact form with the emergency personnel. The DON stated that they did not have a form to send to the residents or the family, but they called them. During an interview on 6/12/2025 at 10:35 am, the Social Services Director (SSD) stated that nursing did all of the transfer forms. The SSD also stated that she was not sure about a written transfer notice being sent to the family, but she sent a list of residents transferred to the ombudsman every month. During an interview on 6/12/2025 at 1:28 pm, the Assistant Director of Nurses (ADON) stated they called the resident's representative and documented in the nursing notes in the EMR.

Based on record review, staff interview, and facility policy review, the facility failed to ensure one 27 sampled residents (R) (R287) was free from significant medication errors when R287 did not receive diltiazem (Cardizem), a blood pressure medication, as ordered by the physician on 10 days. This failure had the potential to cause adverse reactions of high blood pressure. Findings include: Review of the facility's policy titled, Administering Medications, revised December 2012, revealed Medications must be administered in accordance with the orders . Review of R287's admission Record located in the Profile tab of the electronic medical record (EMR) revealed R287 was admitted to the facility on [DATE] for a 14-day respite stay, with diagnoses including heart disease, dementia, and hypertension. R287 discharged home on [DATE]. Review of R287's Physician Orders located under the Orders tab of the electronic medical record (EMR) and dated 10/1/2024, revealed R287 was to receive diltiazem, 120 milligrams (mg), two tablets to equal 240 mg once daily for the treatment of hypertension (high blood pressure). Review of R287's pharmacy Consultation Report, dated 10/2/2024, located under the Scanned Documents tab of the EMR, revealed the recommendation to change the immediate release formulation of diltiazem to the extended-release formulation, diltiazem 24-hour extended release 240 mg once daily. The recommendation was accepted by the physician and signed on 10/3/2024. Review of R287's Physician Orders located under the Orders tab of the EMR and dated 10/3/2024, revealed R287 was to receive diltiazem 24-hour extended release, 240 mg capsule once daily. The medication was entered into the computer by the Director of Nursing (DON) on 10/3/2024 but scheduled not to begin until 10/14/2024 and the old order for diltiazem 120 mg, two tablets (immediate release) once daily was discontinued on 10/3/2024. Review of R287's Medication Administration Record (MAR), dated October 2024, located under the Orders tab of the EMR, revealed no documentation that R287 had received diltiazem on 10/4/2024 through 10/13/2024 as ordered by the physician. It also showed documentation of R287's vital signs that included R287's blood pressure was 128/68 on 10/2/2024 and 10/3/2024 and increased to 140/97 on 10/4/2024. Review of R287's Progress Notes tab revealed no documentation that the medication was discontinued or held by the physician. During an interview on 6/11/2025 at 11:05 am, the Director of Nursing (DON) reviewed R287's clinical record and confirmed that diltiazem 24-hour extended release, 240 mg, should have been started on 10/4/2024 instead of 10/14/2024 and should have been administered once daily. The DON stated that she made an error and entered a start date of 10/14/2024 instead of 10/4/2024, and considered diltiazem to be a significant medication and should have been administered.

Based on observations, record review, interviews, and review of the policy titled Care Plans, Comprehensive Person-Centered, the facility failed to follow the care plan related to trach supplies for three residents (R) (R68, R70, R76). In addition, the facility failed to develop a person-centered care plan for three residents (R23) for Post Traumatic Stress Disorder (PTSD) and anti-coagulant use; R38 for the use of psychotropic medications, and R51 for PTSD. The sample size was 37. On February 9, 2024, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment, or death to residents. The facility's Administrator and Director of Nursing (DON) were informed of the Immediate Jeopardy (IJ) on February 9, 2024, at 2:39 pm. The noncompliance related to the immediate jeopardy was identified to have existed on June 21, 2023. At the time of exit on 2/12/2024, an acceptable Immediate Jeopardy Removal Plan had not been received, therefore the Immediate Jeopardy remained ongoing. Findings: Review of policy titled Care Plans, Comprehensive Person-Centered, revised December 2016, policy statement indicated a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Policy Interpretation and Implementation: Number 2. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. Additionally, the care plan would be updated based on ongoing assessments of the resident and any changes in condition the resident experienced during their care. 1. Review of the Electronic Medical Record (EMR) for R68 revealed he was admitted to the facility on [DATE] with multiple diagnoses, including tracheostomy status, acute respiratory failure with hypercapnia (increased carbon dioxide), dependence on respirator status. Review of the most recent Admission Minimal Data Set (MDS) for R68 dated 1/8/2024 revealed a Brief Interview for Mental Status (BIMS) was not recorded, with documentation that resident is rarely/never understood. Section O revealed the resident received oxygen therapy, suctioning, invasive mechanical ventilator, non-invasive mechanical ventilator, tracheostomy care. Review of the care plan for R68 created on 1/4/2024 revealed a focus on tracheostomy related to impaired breathing mechanics. Interventions to ensure that trach ties are secured at all times; monitor/document for restlessness, agitation, confusion, and (increased heart rate) tachycardia, and bradycardia (slow heart rate); monitor/document respiratory rate, depth, and quality, check and document every shift/as ordered, O2 (oxygen) as ordered, change tubing weekly, provide good oral care daily and as needed (PRN), provide paper and pencil if needed, work with resident to develop communication system that will work in an emergency, reassure resident to decrease anxiety, suction as necessary. Tube out procedures: Keep extra trach tube and obturator at bedside. If tube is coughed out, open stoma with hemostat. If tube cannot be reinserted, monitor/document for signs of respiratory distress. If able to breathe spontaneously, elevate head of bed (HOB) to 45 degrees and stay with the resident. Obtain medical help immediately. Observation on 2/9/2024 at 8:05 am revealed R68 lying semi-Fowler in the bed. The ventilator has minimal condensation in the tubing. A pulse oximeter is connected to the resident, displaying a good waveform and reading. A suction machine is at the bedside. Further observation revealed that R68 does not have an obturator visible at the bedside and no emergency tracheostomy supplies at the bedside. The respiratory therapist in the room confirmed this finding. 2. Review of the EMR for R70 revealed he was admitted to the facility on [DATE] with multiple diagnoses, including tracheostomy status (a surgical procedure to open a direct airway through an incision in the trachea [windpipe]), acute respiratory failure with hypoxia (low oxygen), dependence on respirator (ventilator) status. Review of the Annual MDS assessment dated [DATE] revealed BIMS was coded as five, indicating severe cognitive impairment. Section O revealed the resident received oxygen therapy, suctioning, invasive mechanical ventilator, and tracheostomy care. Review of the care plan for R70 created on 12/29/2023 revealed a focus on tracheostomy related to impaired breathing mechanics. Interventions to ensure that trach ties are secured at all times; monitor/document for restlessness, agitation, confusion, tachycardia, and bradycardia; monitor/document respiratory rate, depth, and quality, check and document every shift/as ordered, O2 as ordered, change tubing weekly, provide good oral care daily and PRN, provide paper and pencil if needed, work with resident to develop communication system that will work in an emergency, reassure resident to decrease anxiety, suction as necessary. Tube out procedures: Keep extra trach tube and obturator at bedside. If tube is coughed out, open stoma with hemostat. If tube cannot be reinserted, monitor/document for signs of respiratory distress. If able to breathe spontaneously, elevate HOB 45 degrees and stay with the resident. Obtain medical help immediately. Observation on 2/9/2024 at 8:45 am of R70 shows the resident lying supine in bed with clean linens and well groomed. R70 is ventilator-dependent and attached to a pulse oximeter with a heart rate and oxygen saturation reading displaying good waveform. The ventilator tubing has minimal condensation. A suction machine is at the bedside. There was no visible obturator at the resident's bedside and no emergency tracheostomy supplies. Observational tour on 2/9/2024 at 8:50 am, Registered Respiratory Therapist (RRT) AA revealed she was unable to locate emergency tracheostomy supplies at the bedside for three residents (R68, R70, and R76). She indicated there were some supplies in the supply closet but was unable to locate the appropriate trach sizes for the residents with tracheostomies. Surveyor accompanied RRT AA to a Respiratory Cart where she located some respiratory supplies (gauze, gloves, masks, suction, saline, and adapters), but cart did not have any tracheostomy tubes or obturators in it. RRT AA further revealed she had been employed in the facility since November 2023 and had not been informed regarding the need to have emergency trach supplies at each residents bedside. 3. Review of the EMR for R76 revealed she was admitted to the facility on [DATE] with multiple diagnoses including tracheostomy status, respiratory failure unspecified whether with hypoxia or hypercapnia, dependence on respirator status, and unspecified chronic obstructive pulmonary disease (COPD). Record review of the most recent Quarterly MDS for R76 dated 1/24/2024 revealed resident is rarely/never understood. Section O revealed the resident received oxygen therapy, suctioning, invasive mechanical ventilator, and tracheostomy care. Record review of the care plan for R76 created on 10/18/2023 revealed a focus on tracheostomy related to impaired breathing mechanics. Interventions to ensure that trach ties are secured at all times; monitor/document for restlessness, agitation, confusion, and tachycardia, and bradycardia; monitor/document respiratory rate, depth, and quality, check and document every shift/as ordered, O2 as ordered, change tubing weekly, provide good oral care daily and PRN, provide paper and pencil if needed, work with resident to develop communication system that will work in an emergency, reassure resident to decrease anxiety, suction as necessary. Tube out procedures: Keep extra trach tube and obturator at bedside. If tube is coughed out, open stoma with hemostat. If tube cannot be reinserted, monitor/document for signs of respiratory distress. If able to breathe spontaneously, elevate HOB 45 degrees and stay with the resident. Obtain medical help immediately. Observation on 2/9/2024 at 8:30 am revealed that R76 was lying supine in the bed connected to a ventilator with minimal condensation visible in the tubing. R76 has a pulse oximeter connected to the finger with a good waveform and reading. Further observation revealed there was no obturator visible at the bedside and no emergency tracheostomy supplies. This observation was confirmed by the RRT AA at the bedside. Interview on 2/11/2024 at 1:33 pm, Director of Respiratory Therapy ([NAME]) stated he could view a resident's care plan through the EMR system and used the care plan during his shifts to identify a resident's individualized needs while providing care. He added resident care plans were adjusted as needed based on a resident's change in condition. The [NAME] explained that if an intervention needed to be added, removed, or modified, he would alert Licensed Practical Nurse (LPN) JJ to update the care plan. Interview on 2/12/2024 at 1:40 pm, Registered Nurse (RN) EE indicated she reviews the resident's care plan at the beginning of her shift to see if there were any changes or updates related to the resident's care or needs. RN EE explained that the care plan provided specific individualized information about care, such as vent settings, suctioning needs, and communication. She added that if she needed to modify the care plan to reflect any new changes, she would notify LPN JJ to make the required changes. 46691 4. Review of the clinical record revealed R23 was admitted to the facility on [DATE] with diagnoses including diabetes, hypertension (HTN), depression, and post-traumatic stress disorder (PTSD). Review of the Admission MDS for R23 dated 1/15/2024 revealed a BIMS of six, indicating severe cognitive impairment. Section I revealed the resident has diagnoses of atrial fibrillation (a-fib) and Post Traumatic Stress Disorder (PTSD). Review of the February 2024 Clinical Physicians' Orders revealed an order dated 1/11/2024 for apixaban oral tablet (a medication used to help prevent strokes or blood clots) 5 milligram (mg) one tablet twice a day; and an order dated 1/12/2024 for Enteric Coated Aspirin (medication used to help prevent strokes or blood clots) 81 mg once daily. Review of the care plan initiated on 1/11/2024 did not have focus areas or interventions specific to R23's use of anticoagulant medications or his diagnosis of PTSD. Interview on 2/10/2024 at 1:30 pm, Licensed Practical Nurse (LPN) HH, stated the diagnosis of PTSD and the resident's triggers for PTSD, should be on the resident's care plan, so the nursing staff would be aware of the triggers for PTSD. She further stated the use of anticoagulant medications should also be on the resident's care plan with interventions to follow. Interview on 2/11/2024 at 9:50 am with Registered Nurse (RN) MDS Coordinator II, verified that R23 has a diagnosis of PTSD, and confirmed there was not a care area addressing triggers for PTSD. During further review, RN MDS Coordinator II revealed there was not a care plan area or interventions for anticoagulant use. She stated the MDS Coordinator was responsible for ensuring the care plans were updated quarterly with each MDS assessment. Interview on 2/11/2024 at 10:00 am, the Director of Nursing (DON) stated her expectation is for the residents care plans to be accurate to reflect the residents current conditions, and that the staff follow the care plan, because it is a tool to inform staff of resident care areas. During further interview, she stated R23's care plan should have been developed for PTSD and for the use of anticoagulants, because those were admitting diagnoses when he admitted to the facility.She indicated the MDS Coordinator was responsible for ensuring the care plans were updated and were person-centered for each resident. 5. Review of the clinical record revealed R51 was admitted to the facility on [DATE] with diagnoses including diabetes, hypertension (HTN), depression, and post-traumatic stress disorder (PTSD). Review of the Quarterly MDS for R23 dated 12/20/2023 revealed a BIMS of five, indicating severe cognitive impairment. Section I revealed the resident has diagnosis of Post Traumatic Stress Disorder (PTSD). Review of the care plan revised 1/4/2024 revealed there was not a care plan focus area for PTDS identifying triggers for PTD on the care plan. Interview on 2/10/2024 at 9:10 am, Certified Nursing Assistant (CNA) FF stated she was unaware of R51's diagnosis of PTSD or his triggers related to PTSD. She stated CNAs were normally made aware of resident diagnoses and needs by the nurse or by looking at the care plan. Interview on 2/10/2024 at 9:50 am, Licensed Practical Nurse (LPN) GG confirmed R51 had a diagnosis of PTSD. She stated the care plan should identify things that may trigger PTSD and verified there was not a care plan addressing PTSD or triggers identified on R51's care plan. Interview on 2/10/2024 at 1:30 pm, LPN HH revealed a diagnosis of PTSD and the resident's triggers should be on the resident's care plan so the nursing staff would be aware of the diagnosis and the triggers. Interview on 2/10/2024 at 9:50 am, RN MDS Coordinator II revealed a diagnosis of PTSD would be considered part of the behavior care plan. She further stated if the resident exhibited behaviors related to PTSD, a care area would be developed for PTSD. She verified there was not a care area for PTSD nor triggers for R51's PTSD diagnosis on the care plan. She stated the care plans was reviewed and updated at least quarterly with each MDS assessment. Interview on 2/11/2024 at 10:00 am, the DON stated her expectations were for the diagnosis of PTSD to have a care plan area with interventions and for the care plan to include the residents' PTSD triggers. She stated staff should be aware of a resident's PTSD triggers to aid in providing proper care related to PTSD and the care plan was a tool to inform staff of resident concerns. 35180 6. Review of the clinical record revealed R38 was admitted to the facility on [DATE] with diagnoses including dementia, urinary retention, dysphagia, gout, hypertension (HTN), and anxiety disorder. Review of the Significant Change MDS OBRA Assessment, dated 3/2/2023, Section V, Care Area Assessment (CAA) Area, revealed psychotropic medications was triggered as a care area for R38. Review of the Physician Orders (PO) dated 12/22/2023 revealed an order for lorazepam (a medication used to treat anxiety) 1 mg/milliliter (ml) every 4 hours as needed (PRN) for anxiety. A review of R38's Medication Administration Record (MAR) revealed the resident received lorazepam 1mg per mL topically on the following dates and times: 12/22/2023 at 6:03 pm, 12/23/2023 at 8:03 am, 1:05 pm, and 8:18 pm, 12/25/2023 at 8:00 pm, 12/26/2023 at 8:01 pm, 12/27/2023 at 1:56 am, 12/30/2023 at 9:12 am, 1/4/2024 at 12:34 pm, 1/5/2024 at 8:45 am and 9:09 pm, 1/10/2024 at 4:40 pm and 8:45 pm, 1/11/2024 at 4:00 am, 1/12/2024 at 8:00 pm, 1/13/2024 at 8:36 pm, 1/14/2024 at 3:35 pm, 1/16/2024 at 1:55 am, 1/17/2024 at 8:59 am, 4:26 pm and 8:42 pm, 1/18/2024 at 2:00 am and 8:02 pm, 1/19/2024 at 8:17 pm, 1/23/2024 at 8:06 pm, 1/24/2024 at 00:30 am and 7:43 pm, 1/28/2024 at 4:12 pm, 1/29/2024 at 8:24 pm, 2/3/2024 at 8:59 am, 2/5/24 at 7:50 pm, and 2/8/2024 at 8:00 pm. Review of R38's care plan revealed R38 did not have a care plan developed for psychotropic medication. During an interview on 2/10/2024 at 12:11 pm with the Director of Nursing (DON), she acknowledged that R38 did not have a care plan developed addressing the use of psychotropic medications, and stated she should have had one. 44168

Based on observations, record review, staff interviews, review of the Policies and Procedures for Nursing Facility Services, the facility failed to ensure emergency tracheostomy supplies were at the bedside for three of 15 sampled residents (R) (68, 70, 76). In addition, facility failed to change the oxygen nasal cannula (N/C) tubing per physician orders or as needed for R49, failed to provide ongoing training for staff working on the ventilator unit, and failed to ensure a Registered Nurse (RN) worked on the ventilator unit for at least 12 hours per day. On February 9, 2024, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment, or death to residents. The facility's Administrator and Director of Nursing (DON) were informed of the Immediate Jeopardy (IJ) on February 9, 2024, at 2:39 pm. The noncompliance related to the immediate jeopardy was identified to have existed on June 21, 2023. At the time of exit on 2/12/2024, an acceptable Immediate Jeopardy Removal Plan had not been received, therefore the Immediate Jeopardy remained ongoing. Findings Include: Review of the document titled Part II - Policies and Procedures for Nursing Facility Services; Georgia Department of Community Health, Division of Medical Assistance dated July 1, 2014, Chapter 800, Section 804: Mechanical Ventilation Services, 804.5 Nursing Facility Staffing, Equipment and Requirements revealed durable medical equipment and supplies to meet the needs of the ventilator-dependent resident to include but not be limited to: Number 5. Supplies required to support the equipment such as suction catheters, tracheostomy supplies, and oxygen. 1. Review of the electronic medical record (EMR) revealed R68 was admitted to the facility on [DATE] with multiple diagnoses, including tracheostomy status, acute respiratory failure with hypercapnia (increased carbon dioxide), and dependence on respirator status. Review of the Admission Minimum Data Set (MDS) assessment dated [DATE], Section O documented the resident received oxygen therapy, suctioning, and tracheostomy care. Review of the care plan dated 1/4/2024 revealed the resident has a tracheostomy related to impaired breathing mechanics. Interventions to care include ensure that trach ties are secured at all times. Tube out procedures: Keep extra trach tube and obturator at bedside. If tube is coughed out, open stoma with hemostat. If tube cannot be reinserted, monitor/document for signs of respiratory distress. If able to breathe spontaneously, elevate HOB 45 degrees and stay with the resident. Obtain medical help immediately. Review of the February 2024 Order Summary Report revealed an order dated 1/12/2024 for Shiley 6 flex, change inner cannula daily, trach care every shift and as needed, without orders for whether the trach is to be cuffed or uncuffed, or emergency management if the trach should become dislodged. Observation on 2/9/2024 at 8:05 am revealed R68 lying semi-Fowler in the bed, A suction machine is at the bedside. There are no visible emergency tracheostomy supplies or obturator at the resident's bedside. These observations were confirmed by the Registered Respiratory Therapist (RRT) AA at the bedside. Observation on 2/10/2024 at 9:15 am in the room of R65, revealed emergency tracheostomy supplies and an obturator visible at the bedside. 2. Review of the EMR revealed R70 was admitted to the facility on [DATE] with diagnoses including tracheostomy status, acute respiratory failure with hypoxia, and dependence on respirator (ventilator). Review of the Annual MDS assessment dated [DATE], Section O documented the resident received oxygen therapy, suctioning, and tracheostomy care. Review of the care plan initiated on 12/29/2023 revealed resident has a tracheostomy related to impaired breathing mechanics. Interventions to care include ensure that trach ties are secured at all times. Tube out procedures: Keep extra trach tube and obturator at bedside. If tube is coughed out, open stoma with hemostat. If tube cannot be reinserted, monitor/document for signs of respiratory distress. If able to breathe spontaneously, elevate HOB 45 degrees and stay with the resident. Obtain medical help immediately. Review of the February 2024 Order Summary Report revealed an order dated 12/30/2023 for Shiley 6 flex, trach care every shift and as needed, without orders for whether the trach is to be cuffed or uncuffed, or emergency management if the trach should become dislodged. Observation on 2/9/2024 at 8:45 am R70 lying supine in bed. There are no visible emergency tracheostomy supplies or obturator at the resident's bedside. These observations were confirmed by the RRT AA at the bedside. Observation on 2/10/2024 at 9:00 am, R70 continues to lay supine in the bed connected to a ventilator with a pulse oximeter connected to the finger. Further observation revealed emergency trach supplies and obturator have been placed at the bedside. 3. Review of the EMR revealed R76 was admitted to the facility on [DATE] with diagnoses including tracheostomy status, respiratory failure unspecified whether with hypoxia or hypercapnia, dependence on respirator status, and chronic obstructive pulmonary disease (COPD). Review of the quarterly MDS assessment dated [DATE], Section O documented the resident received oxygen therapy, suctioning, and tracheostomy care. Review of the care plan initiated on 10/18/2023 revealed resident has a tracheostomy related to impaired breathing mechanics. Interventions to care include ensure that trach ties are secured at all times and suction as necessary. Tube out procedures: Keep extra trach tube and obturator at bedside. If tube is coughed out, open stoma with hemostat. If tube cannot be reinserted, monitor/document for signs of respiratory distress. If able to breathe spontaneously, elevate HOB 45 degrees and stay with the resident. Obtain medical help immediately. Review of February 2024 Order Summary Report revealed an order dated 12/7/2023 for trach orders: 7 Luer Lock, cuffed, trach care every shift and as needed, and ventilator settings PS 10/+6/405/36%. There are no orders for emergency management if the trach should become dislodged. Observation on 2/9/2024 at 8:30 am in the room of R76, revealed no emergency trach supplies or obturator were at the bedside. This observation was confirmed by the RRT AA at the bedside. Observation on 2/10/2024 at 9:40 am revealed that R76 is connected to a ventilator with a pulse oximeter in place. Further observation revealed emergency trach supplies and obturator have been placed at the bedside. Observational tour on 2/9/2024 at 8:50 am, Registered Respiratory Therapist (RRT) AA revealed she was unable to locate emergency tracheostomy supplies at the bedside for three residents (R68, R70, and R76). She indicated there were some supplies in the supply closet but was unable to locate the appropriate trach sizes for the residents with tracheostomies. Surveyor accompanied RRT AA to a Respiratory Cart where she located some respiratory supplies (gauze, gloves, mask, suction, saline, and adapters), but cart did not have any tracheostomy tubes or obturators in it. RRT AA further revealed she had been employed in the facility since November 2023 and had not been informed regarding the need to keep emergency trach supplies at each residents bedside. Interview on 2/9/2024 at 10:00 am, Administrator indicated the facility had tracheostomy supplies in another supply building, and staff were looking for sizes to fit the resident's tracheostomies. Administrator stated he was reaching out to outside resources, from sister facilities or the local hospital, for emergency tracheostomies supplies needed for the residents. Interview on 2/9/2023 at 12:10 pm, RRT AA stated that she and other therapists searched the facility inventory for emergency supplies and tracheostomy tubes for current residents and revealed an extensive list of supplies needed for the residents in the facility. During further interview, RRT AA stated that someone from the facility was going to borrow these supplies from the hospital. Interview on 2/10/2024 at 9:15 am, the Director of Respiratory Therapy ([NAME]) stated staff could find some tracheostomy supplies in the resident rooms, and stated there was a supply closet down the hall that has tracheostomy supplies. During further interview, the [NAME] stated he was unsure why obturators were not kept at residents bedside. Interview on 2/11/2024 at 1:30 pm, the Director of Nursing (DON) revealed her expectation was for all the staff to know what tracheostomy supplies are needed for each resident, and where the extra supplies are located. During further interview, she stated staff working on the ventilator unit should be educated and trained to work on the ventilator unit. The DON provided education for the ventilator unit staff, consisting of nine Licensed Practical Nurses, one Registered Nurse, one Infection Preventionist, one Minimum Data Set Registered Nurse, and one Registered Respiratory Therapist. The DON confirmed this was all the education staff received regarding the ventilator unit, equipment, and supplies. Interview on 2/11/24 at 2:50 pm, RN EE revealed she started working at the in January 2024. She revealed she has not received any training from the facility regarding ventilator alarms, the need for emergency tracheostomy supplies to be kept at bedside or end tidal CO2 monitoring for the residents. 46691 Review of the document titled Part II - Policies and Procedures for Nursing Facility Services; Georgia Department of Community Health, Division of Medical Assistance dated July 1, 2014, Chapter 800, Section 804: Mechanical Ventilation Services, 804.5 Nursing Facility Staffing, Equipment and Requirements revealed providers of mechanical ventilation services will provide the following as part of or in addition to the requirements for traditional facility care: Licensed nursing services on the ventilator unit 24 hours a day; at least 12 hours a day must be provided by a Registered Nurse. Nursing services will be provided in an appropriate ratio according to patient acuity, not to exceed a ratio of 1:10 nurses per ventilator-dependent resident. Review of an undated document on facility letterhead documented Staffing levels for the 15-bed Ventilator Unit: One Registered Nurse, One Licensed Practical Nurse, One Respiratory Therapist, Two Certified Nursing Assistants; 24 hours a day, 7 days a week. Review of the Licensed Nursing schedules for the ventilator unit for November 2023, December 2023, and January 2024 revealed the nurse assigned to work on the ventilator unit was notated with the letter L for Licensed Practical Nurse or RN for Registered Nurse. Further review of the nursing schedules revealed there was not 12 hours of RN coverage on the ventilator unit for each day. November 2023 schedule had 15 of 30 days with RN coverage for 12 hours; December 2023 schedule had 10 of 31 days without RN coverage; and January 2024 schedule had 16 of 31 days without RN coverage for 12 hours. Interview on 2/10/2024 at 12:30 pm, the Director of Nursing (DON) confirmed that there was not an RN scheduled to work on the ventilator unit 12 hours daily for the months of November 2023, December 2023, or January 2024. During further interview, she stated she was unaware that an RN must work on the ventilator unit for 12 hours daily, but thought an RN just had to be in the building. She stated the facility only had two RN's employed by the facility, to work on the ventilator unit. Interview on 2/11/2024 at 1:16 pm, DON reported that the education binder for 2023 is missing. She stated the Staff Development Coordinator (SDC) left the facility in October 2023, so they are having to start fresh this year, with herself and the Infection Preventionist (IP) currently providing trainings. During further interview, the DON indicated that a lot of the training is talking and utilizing YouTube videos. Interview on 2/11/2024 at 2:10 pm, the Administrator stated he was unaware that an RN was required to be assigned to the ventilator unit for at least 12 hours each day. He stated it was not easy to find RN's willing to work on the ventilator unit. 36200 4. Review of EMR revealed R49 was admitted to the facility on [DATE] with diagnoses that included but was not limited to acute respiratory failure with hypercapnia, obstructive sleep apnea (OSB), and chronic obstructive pulmonary disease (COPD) with acute exacerbation. Review of the Admission MDS assessment dated [DATE] revealed a BIMS of 15, indicating no cognitive impairment. Section O revealed the resident received oxygen therapy. Review of the care plan for R49 documented the resident has altered respiratory status and difficulty breathing related to pulmonary edema ad sleep apnea. Interventions to care include keep head of bed elevated for shortness of breath, oxygen as ordered and change tubing weekly. Review of February 2024 Order Summary Report revealed an order dated 12/2/2023 to change oxygen and nebulizer tubing weekly and label and date the tubing every Saturday. Review of February 2024 electronic Medication Administration Record (eMAR) revealed oxygen tubing was changed on 2/10/2024. However, the date on the tubing was not legible and the tubing remained pink throughout the duration of the survey. During an observation on 2/9/2024 at 3:46 pm, R49 was noted to be in bed in her room with oxygen in use via nasal cannula (N/C). The oxygen tubing was noted to have a pink tint. The date on the oxygen tubing was not legible. During an observation on 2/10/2024 at 10:42 am, R49 was in bed asleep. The oxygen N/C continued to have a pink tint to the oxygen tubing. During an interview on 2/10/2024 at 2:00 pm, R49 was observed in bed with oxygen N/C in place. She reported that the tubing has been changed a few times since her admission in December, but she revealed it had been a while. The tape with the date on the tubing was not legible. The oxygen tubing remained pink throughout the duration of the survey. During an interview and observation on 2/11/2024 at 2:00 pm, the Assistant Director of Nursing (ADON) in R49's room, confirmed the oxygen tubing was pink. She stated that the oxygen tubing could be changed anytime during the seven-day period. During further interview, the ADON stated she was unsure why the oxygen tubing was pink and confirmed she was unable read the date on the oxygen tubing. A request for the policy for Oxygen Administration was requested but it did not address changing the tubing.

44168 Based on observations, record review, staff interviews, review of Policies and Procedures for Nursing Facility Services and review of job descriptions for the Administrator and the Director of Respiratory Operations ([NAME]), the facility administration failed to provide monitoring and oversight for the Mechanical Ventilation Unit (MVU) by ensuring the respiratory ventilator equipment was functioning appropriately with audible alarms, and monitoring end title carbon dioxide (ETCO2) for six of six sampled ventilator dependent residents (R) (R281, E, F, R68, R70, R76). In addition, administration failed to ensure emergency tracheostomy supplies were available at the bedside for three of 15 residents (R) (R 68, R70, R76) reviewed for tracheostomy care. On February 9, 2024, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment, or death to residents. The facility's Administrator and Director of Nursing (DON) were informed of the Immediate Jeopardy (IJ) on February 9, 2024, at 2:39 pm. The noncompliance related to the immediate jeopardy was identified to have existed on June 21, 2023. At the time of exit on 2/12/2024, an acceptable Immediate Jeopardy Removal Plan had not been received, therefore the Immediate Jeopardy remained ongoing. Findings Include: Review of the document titled Part II - Policies and Procedures for Nursing Facility Services; Georgia Department of Community Health, Division of Medical Assistance dated July 1, 2014, Chapter 800, Section 804: Mechanical Ventilation Services, 804.5 Nursing Facility Staffing, Equipment and Requirements revealed durable medical equipment and supplies to meet the needs of the ventilator-dependent resident to include but not be limited to: Number 2. Pulse oximetry monitors. Number 3. End tidal CO2 analyzers. Number 4. An audible, redundant external alarm system is located outside the patient room to alert caregivers of ventilator failure. Review of the undated document titled Nursing Home Administrator revealed the responsibilities are defined as: lead and direct the overall operation of the facility in accordance with resident needs, federal and state government regulations, and company policies/procedures to maintain quality of care for the residents while achieving the facility's business objectives. Works with facility management staff and consultants in planning all aspects of operations, including setting priorities and job assignments. Conducts regular rounds to ensure resident needs are being addressed and monitors operations of all departments. Demonstrates knowledge of all state rules and regulations and provides adequate instruction regarding such rules and regulations to appropriate staff. Review of the document titled Director of Respiratory Operations revealed the responsibilities are defined as: train and support all RT, RN and CNA staff, for up to date policy and procedures for care of respiratory patience{sic}. evaluate RT, RN, and CNA staff monthly, so proper care can be administered. educate and implement central supply inventory for par levels. educate and implement tracking of all mechanical equipment inventory. educate and implement tracking of equipment that are out for repair. Will educate and implement central supply. work as a team with the Regional Director, Administrator, clinical department and admissions personal{sic}. 1. Administration failed to ensure that ventilator equipment functioned appropriately with audible alarms and failed to provide monitoring of ETCO2 for ventilator dependent residents, in accordance with Policies and Procedures for Nursing Facility Services. R281 had a decline in condition that resulted in death after being found unresponsive when staff did not hear audible ventilator alarms from outside the room. Cross Refer F908 Interview on 2/9/2024 at 8:10 am, Registered Respiratory Therapist (RRT) AA revealed she has been employed at the facility since November 2023. She stated the audible alarms for the ventilators have not worked since she has been employed, and further stated they do not alarm outside the resident rooms. During further interview, she stated staff can be in one room providing care for a resident, and if other staff are not in the hallway, a resident could be in distress in another room, when staff can't hear the alarms, places the residents at risk for death. Interview on 2/9/2024 at 8:30 am, Director of Nursing (DON) stated she was aware the alarms were not working, and indicated the facility was planning to contact the ventilator company by phone next week, to discuss what to do about the alarms. She stated RT OO has previously reported alarm concerns. During further interview, she reported she is unsure when the system went out, but stated staff were doing more frequent rounds on the ventilator residents and denies any complications. The DON denies any complications with residents since the alarms have been out. A phone interview on 2/9/2024 at 10:44 am, Operations Respiratory Therapist (ORT) revealed he comes to the facility every couple of weeks and was not aware the alarms were not working. During further interview, the ORT stated he does not take oversight or responsibility for the facility, that he leaves that up to the local Respiratory Therapists and the Director of Respiratory Therapy ([NAME]). Interview on 2/9/2024 at 11:07 am, Administrator indicated there is a scheduled phone call with a technology company because the monitors were having issues. He stated he was not sure when the auditory alarms on the ventilators stopped working. During further interview, the Administrator stated he did not realize they were supposed to alarm in the hallways. Interview on 2/12/2024 at 3:00 pm, Administrator stated he was not aware of the CO2 monitoring requirement until after reviewing the policies and procedures for requirements to operate a Mechanical Ventilator Unit. During further interview, he stated the facility will rent a CO2 monitoring device to perform every 30 minute CO2 checks for the ventilator residents and has ordered CO2 cables for the ventilator machines to be delivered overnight. 2. Administration failed to maintain emergency tracheostomy supplies at the bedside in the event of accidental dislodgement of trach tube. Cross Refer F695 Observational tour on 2/9/2024 at 7:50 am, Registered Respiratory Therapist (RRT) AA revealed she was unable to locate emergency tracheostomy supplies at the bedside for three residents (R68, R70, and R76). She indicated there were some supplies in the supply closet but was unable to locate the appropriate trach sizes for the residents with tracheostomies. Surveyor accompanied RRT AA to a Respiratory Cart where she located some respiratory supplies (gauze, gloves, mask, suction, saline, and adapters), but cart did not have any tracheostomy tubes or obturators in it. RRT AA further revealed she had been employed in the facility since November 2023 and had not been informed regarding the need to have emergency trach supplies at each residents bedside. Interview on 2/9/2024 at 10:00 am, Administrator indicated the facility had tracheostomy supplies in another supply building, and staff were looking for sizes to fit the resident's tracheostomies. Administrator stated he was reaching out to outside resources, from sister facilities or the local hospital, for emergency tracheostomies supplies needed for the residents. Interview on 2/10/2024 at 9:15 am, the [NAME] stated staff located some tracheostomy supplies in resident rooms, and revealed there is a supply closet down the hall that has some stock items, and an outside building with extra tracheostomy supplies. He stated he was unsure why obturators were not kept at the bedside. During further interview, he stated the end tidal CO2 monitors had not been connected to the ventilators since his employment in June 2023, 3. Facility Administrator and Director of Respiratory Therapy failed to perform duties of their job descriptions that facilitated medical care to the residents of the facility. 4. Administration failed to implement care plan interventions that addressed emergency care and supplies at bedside for residents admitted with a tracheostomy. Cross Refer F656

Based on observations, record review, interviews, and review of the Policies and Procedures for Nursing Facility Services, the facility failed to ensure that ventilator machines had properly functioning heart rate and pulse oximetry alarms that were audible outside resident rooms. In addition, the facility failed to ensure end tidal carbon dioxide (ETCO2) analyzers were implemented for measuring ETCO2 of ventilator residents This deficient practice affected six of six residents (R) (R281, RE, RF, R70, R68, R76) sampled for mechanical ventilators and CO2 monitors. On February 9, 2024, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment, or death to residents. The facility's Administrator and Director of Nursing (DON) were informed of the Immediate Jeopardy (IJ) on February 9, 2024, at 2:39 pm. The noncompliance related to the immediate jeopardy was identified to have existed on [DATE]. At the time of exit on [DATE], an acceptable Immediate Jeopardy Removal Plan had not been received, therefore the Immediate Jeopardy remained ongoing. Findings include: Review of the document titled Part II - Policies and Procedures for Nursing Facility Services; Georgia Department of Community Health, Division of Medical Assistance dated [DATE], Chapter 800, Section 804: Mechanical Ventilation Services, 804.5 Nursing Facility Staffing, Equipment and Requirements revealed durable medical equipment and supplies to meet the needs of the ventilator-dependent resident to include but not be limited to: Number 2. Pulse oximetry monitors. Number 3. End tidal CO2 analyzers. Number 4. An audible, redundant external alarm system is located outside the patient room to alert caregivers of ventilator failure. 1. Review of the Electronic Medical Record (EMR) revealed R281 was admitted to the facility on [DATE] with diagnoses including acute respiratory failure with hypoxia, dependence on respirator status and chronic obstructive pulmonary disease (COPD) with exacerbation. Review of the Admission Minimal Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) was not scored and indicated resident is rarely/never understood. Section O revealed the resident received suctioning and invasive mechanical ventilator. Review of the care plan initiated [DATE] documented the resident is ventilator dependent related to respiratory failure. Interventions to care include head of bed elevated unless providing care, maintain spare trach at bedside, maintain ventilator settings as ordered, monitor oxygen (O2) saturation while on mechanical ventilator support, observe for indications of tube obstruction. Review of the [DATE] Order Summary Report revealed a ventilator order dated [DATE], with no settings identified. Review of the Progress Note dated [DATE] at 11:45 am written by Licensed Practical Nurse (LPN) HH documented writer called [hospital] and [resident] had expired. Review of the Progress Note dated [DATE] at 4:00 am written by Registered Nurse (RN) MM documented duty nurse went to his room check on him founded{sic}that he was not taking any breath. Notified RT called 911 as he was fullcode {sic} started CPR. NO response noted. EMT here at 4:10 am, resident not responded to CPR and defibrillation, transferred to hospital 4:20 am. Notified duty oncall{sic}, failed to call his son via phone. Review of the Progress Note dated [DATE] at 5:59 pm written by Registered Respiratory Therapist (RRT) AA documented Resident took himself off the vent. When I got in the room him {sic}saturation in the 80s. I placed him back on the vent and his saturation was still not increasing. He kept saying he could not breath. I lavaged {sic}suctioned him five times but there was no mucus plug. His O2 saturation started to finally increase back up to 95% once he calmed down. Review of the Progress Note dated [DATE] at 1:30 pm revealed RRT CC documented, [resident] continues to take himself off the vent. Changed sat probe to wrap aroundfinge. {sic} Bagged with 100% O2. SXED. Given Rxs. Sedation given. Still active. Sat now 97 to 93. Rhonchi noted. Review of the Progress Note dated [DATE] at 9:23 am written by LPN NN documented resident vent disconnected, reconnected, informed RT of findings. Interview on [DATE] at 7:45 am, RRT AA confirmed R281 was ventilator dependent, with O2 saturation in the ,d+[DATE]% range. She stated she was in the Respiratory Department when the nurse came in and stated, I think he is dead, blue, and I didn't hear the alarms. During continued interview, she revealed that no alarms were heard at that time. Upon arrival to the room, RRT AA stated she began bagging the resident, and CPR was started; 911 was called while staff were alternating doing CPR for effective compressions. RRT AA stated the saturation never recovered, nor did a pulse, and the resident was transferred to the hospital. Interview on [DATE] at 6:30 pm, RRT CC stated he arrived in the R281 room to find he was blue and didn't have a heart rate. He stated that he began bagging the resident, but the O2 saturations were undetectable. He stated 911 was called, and the resident was transferred to the hospital, where he was pronounced dead. Interview on [DATE] at 11:00 am, the Interim Administrator revealed he was aware of R281's history of pulling at his ventilator tubing. He stated the resident was moved closer to the nurse's station and the facility implemented increased documentation/rounding due to his history of pulling the ventilator tubing off. Interview on [DATE] at 11:45 am, Director of Nursing (DON) stated she was unaware R281 needed increased monitoring, or documentation, and stated she was not aware the reason he was moved to another room was due to him pulling at the ventilator tubing. During further interview, she revealed she believed the reason he was moved was due to needing his room for an admission. Interview on [DATE] at 12:45 pm, Director of Respiratory Tyherapy ([NAME]) stated that the respiratory ventilator checks went from every six to every four hours for R281. The [NAME] stated he was not aware of the resident being moved due to the frequently taking off his tubing from the tracheostomy. 2. Record review of the EMR revealed R E was admitted to the facility on [DATE] with diagnoses including acute respiratory failure with hypoxia (low oxygen), dependence on respirator status, and tracheostomy status (a surgical procedure to open a direct airway through an incision in the trachea [windpipe]). Review of the Discharge MDS assessment dated [DATE] revealed BIMS was not scored and documented resident was unable to respond. There is no additional data available due to resident being discharged to acute hospital with anticipated return. Review of the care plan for R E initiated on [DATE] documented resident is ventilator dependent related to respiratory failure. Interventions to care include head of bed elevated unless providing care, maintain spare trach at bedside, maintain ventilator settings as ordered, and suction as needed. Review of the [DATE] Order Summary Report revealed ventilator orders dated [DATE] for CPAP+PS/PEEP 8/FIO2 50%. Review of the Progress Note dated [DATE] at 4:56 am written by RRT OO documented RT observed resident was in respiratory distress. Sats were at 30% HR 121. RT immediately began to bag resident at 100% FI02. Additional staff arrived at the bedside. Resident became alert to verbal stimuli. Once Sats were at 95% resident was tried on the ventilator again, but immediately desatted {sic} to 87%. Resident was then bagged and EMT personal {sic} was called and transported without issue. Interview on [DATE] at 9:34 am Nurse Practitioner (NP) reported that the ventilator alarms were not working in [DATE] when she first began working at the facility, but stated she doesn't remember when they started working again. The NP further revealed she is aware R E went out to the hospital a few weeks ago due to pulling off his ventilator. Interview on [DATE] at 1:00 pm, the DON confirmed R E remained in the hospital, with bilateral pneumonia, septic shock, on an intravenous drip for hypotension and currently in the intensive care unit on the ventilator with an FIO2 of 60%. 3. Review of the EMR revealed R F was admitted to the facility on [DATE] with diagnoses including tracheostomy status, acute respiratory failure with hypoxia or hypercapnia, dependence on respirator status, and obstructive sleep apnea. Review of the admission MDS assessment dated [DATE] revealed a BIMS of 99 documenting resident is moderately impaired. Section O revealed the resident received oxygen therapy, suctioning, invasive mechanical ventilator, and tracheostomy care. Review of the care plan initiated on [DATE] documented resident is ventilator dependent related to respiratory failure. Interventions to care include head of bed elevated, maintain spare trach at bedside, maintain ventilator settings as ordered, and routine trach change by respiratory care. Review of the [DATE] Order Summary Report revealed ventilator orders dated [DATE] for day shift - PS [DATE], night shift - PS [DATE]. Resident was discharged from facility on [DATE]. 4. Review of the EMR revealed R70 was admitted to the facility on [DATE] with diagnoses including tracheostomy status, acute respiratory failure with hypoxia, and dependence on respirator (ventilator) status. Review of the Annual MDS assessment dated [DATE] revealed BIMS was coded as five, indicating severe cognitive impairment. Section O revealed the resident received oxygen therapy, suctioning, invasive mechanical ventilator, and tracheostomy care. Review of the care plan initiated on [DATE] revealed the resident is ventilator dependent related to respiratory failure. Interventions to care include head of bed elevated unless providing care, maintain spare trach at bedside, maintain ventilator settings as ordered, and routine trach change by respiratory care. Review of the February 2024 Order Summary Report revealed an order dated [DATE] for ventilator setting - SIMV 400ml, +5, rate 12. Review of the Progress Note dated [DATE] at 9:04 am revealed RN EE documented Resident is trach/vent dependent. Observation on [DATE] at 7:05 am revealed R70 lying supine in bed and is ventilator dependent. The ventilator is on with current settings as ordered, and the ventilator tubing has minimal condensation. A suction machine is at the bedside. Further observation revealed no audible alarms could be heard outside the resident's room, and there is not an end-tidal CO2 monitor measuring exhaled CO2. The ventilator monitor or pulse oximeter does not display a CO2 reading. These observations were confirmed by the RRT AA at the bedside. Observation on [DATE] at 8:57 am, revealed lights above resident rooms do not indicate different distress codes. The DON and surveyor walked to the Nurse's Station to view the monitoring system. The RRT was in a resident room to test the alarm and monitoring system, and there was no change noted on the monitor, and no alarms heard, after the test was performed by the Therapist. Interview on [DATE] at 8:57 am, the DON reported part of the problem is the monitoring is not indicating when there is an issue with the resident. She reported she is unsure when the system went out, but she has the staff making frequent rounds. Phone interview on [DATE] at 10:44 am, Operations Respiratory Therapist (ORT) revealed he comes to the facility every couple of weeks and was not aware the alarms were not working. During further interview, he stated the facility has a call set up with the manufacturer of the alarm system to add more transmitters. He stated the system should pick up the receptors from the resident's room to the nurse station monitor and the one in the hall. Observation on [DATE] at 9:00 am revealed R70 continues to lay supine in the bed dependent on ventilator support. Audible ventilator alarms are now heard outside the resident's room. Pulse oximeter is connected to the finger; however, there is no evidence that exhaled CO2 is being monitored. Observation on [DATE] at 10:00 am revealed R70 is lying semi-Fowlers in the bed on the ventilator with suction equipment available at bedside. The ventilator audible alarms can be heard outside the resident's room. There is no evidence of ETCO2 being monitored. Observation on [DATE] at 1:00 pm revealed R70's ventilator does not have the capability for end-tidal CO2 monitoring to measure exhaled CO2. The ventilator monitor or pulse oximeter does not display a CO2 reading. Interview on [DATE] at 1:45 pm, the [NAME] verified the facility does not currently have the capability to monitor ventilator residents exhaled CO2 at this time. The [NAME] stated that he looked through the equipment in the respiratory department and found plastic adapters that appeared to fit some cables at one time. 5. Review of the EMR revealed R68 was admitted to the facility on [DATE] with multiple diagnoses, including tracheostomy status, acute respiratory failure with hypercapnia (increased carbon dioxide), and dependence on respirator status. Review of the Admission MDS assessment dated [DATE] BIMS was unscored and indicated severe cognitive impairment. Section O revealed the resident received suctioning, invasive mechanical ventilator, and non-invasive mechanical ventilator. Review of the care plan dated [DATE] revealed the resident is ventilator dependent related to respiratory failure. Interventions to care include keep head of bed elevated unless providing care or patient request, maintain spare trach at bedside, maintain ventilator settings as ordered, and monitor tube for obstruction. Review of February 2024 Order Summary Report revealed an order dated [DATE] for ventilator settings - [DATE]. Review of the Progress Note dated [DATE] at 10:47 am written by Assistant Director of Nursing (ADON) documented Vent with weaning trials not successful at this time, trach with moderate suctioning required. Observation on [DATE] at 8:05 am revealed R68 lying semi-Fowlers in the bed with ventilator connected to the resident's tracheostomy. The ventilator currently does not have the capability for the alarms to be heard outside the resident's room. RRT AA was in the residents room and confirmed the alarms were not audible. There is no evidence of CO2 monitoring at this time. Observation on [DATE] at 9:20 am, the Administrator, LPN DD, and surveyor were standing at the nurse's station, located halfway down the hall, and Certified Nursing Assistant (CNA) BB was standing at the nurse's station when RRT AA went into a ventilated resident's room and made the alarm go off. None of the above-mentioned individuals could hear the alarm from where they were standing. Observation on [DATE] at 9:15 am revealed R68 in bed lying supine. The ventilator alarms can be heard outside the resident's room today, but there is no CO2 monitoring at this time. Observation on [DATE] at 8:30 am revealed that R68 continues to be ventilator dependent. There is no evidence of CO2 monitoring at this time. Interview on [DATE] at 9:15 am, [NAME] revealed he has been employed since [DATE]. He stated the alarms for the ventilator have never worked. He stated the end tidal CO2 monitors had not been connected to the ventilators since his employment. He stated he thinks there are pieces to the monitor in the facility, but he is not sure exactly what is in the building. 6. Review of the EMR revealed R76 was admitted to the facility on [DATE] with diagnoses including tracheostomy status, respiratory failure unspecified whether hypoxia or hypercapnia, dependence on respirator status, and chronic obstructive pulmonary disease (COPD). Review of the quarterly MDS assessment dated [DATE] revealed a BIMS was unscored the resident is rarely/never understood, staff assessment-severely impaired. Section O revealed the resident received suctioning and invasive mechanical ventilator. Review of the care plan dated [DATE] revealed the resident is ventilator dependent related to respiratory failure. Interventions to care include maintain spare trach at bedside, maintain ventilator settings as ordered, monitor tube misplacement every two hours, and observe for indications of tube obstruction. Review of February 2024 Order Summary Report revealed an order dated [DATE] ventilator settings PS 10/+[DATE]%. Review of the Progress Note dated [DATE] at 9:01 am written by RN EE documented Excessive secretions noted, required oral/trach suction. Suctioning, trach/vent care done by Respiratory Therapist. Observation on [DATE] at 8:30 am revealed R76 lying supine in her bed connected to a ventilator with minimal condensation visible in the tubing. Further observation revealed the ventilator alarms are not audible outside the resident's room and there is no evidence of CO2 monitoring. RRT AA was in the room and confirmed these findings. Observation on [DATE] at 9:40 am revealed that R76 continues to be on a ventilator and connected to a pulse oximeter. The ventilator alarms were now able to be heard outside the resident's room. Observation on [DATE] at 9:00 am revealed that R76's ventilator audible alarms can be heard outside the resident's room. There is no evidence of CO2 monitoring for R76. Interview on [DATE] at 8:10 am, RRT AA revealed she has been employed at the facility since [DATE]. She stated the audible alarms for the ventilators have not worked since she has been employed, and further stated they do not alarm outside the resident rooms. During further interview, she stated staff can be in one room providing care for a resident, and if other staff are not in the hallway, a resident could be in distress in another room, when staff can't hear the alarms, places the residents at risk for death. Interview on [DATE] at 10:56 am, Maintenance Director revealed he didn't know the monitors were not alarming. He reported he made an adjustment to one of the ventilators, and it is now working. He revealed testing the alarms is not a part of his regular monitoring of the machines, and only tests them as problems arise. During further interview, the Maintenance Director stated he does not log any information about maintenance of the machines/alarms. He denies he has received any training for the alarm system. Interview on [DATE] at 1:30 pm, DON revealed her expectation was for all the staff working on the ventilator unit to be up to date with education. The DON further stated she has shown each staff member where the cables are for the ventilators, instructed them not to turn the volume down, and to contact herself or the Administrator if there are any issues.

Based on observations, staff interviews, and review of the facility's policies, the facility failed to have a hands-free trash receptacle at the hand washing sink, failed to ensure the exhaust hood filters were clean and free from grease build-up, and failed to properly label and date opened food items. These failures had the potential to affect 69 residents receiving an oral diet. Findings include: 1. Observation on 2/9/2024 at 9:45 am during the initial tour of the kitchen with the Dietary Manager (DM), revealed the hand washing sink near the main entrance to the kitchen, adjacent to the dish room, revealed the only trash receptable available to dispose of used paper towels was a large 50-gallon trash can covered with a lid. Continued observation revealed the DM lifting the dirty trash bin lid to dispose of a used paper towel. Interview on 2/9/2024 at 9:45 am, the DM confirmed that the only trash receptacle near the hand washing sink near the main entrance to the kitchen, was a 50-gallon trash can covered with lid, and the lid would need to be touched in order to dispose of used paper towels. The DM could not explain why a hands-free trash bin was not available at the hand washing sink. 2. Observation on 2/9/2024 at 9:48 am, the exhaust hood filters revealed a layer of grease build-up. The exhaust hood was above a four-burner stove and free-standing oven. Interview on 2/9/2024 at 9:48 am, the DM confirmed that there was grease build-up on the exhaust hood filters. She stated that the dietary department recently became responsible for cleaning the filters. She stated maintenance had been cleaning them every two weeks. During further interview, the DM stated that the exhaust hood is scheduled to be cleaned this weekend. Interview on 2/11/2024 at 1:30 pm, the Maintenance Director stated that he is ultimately responsible for cleaning the exhaust hood filters in the kitchen. He stated that the filters should be cleaned at least once a week, and confirmed they have not been cleaned. He stated that he does not keep a log of when the filters had been cleaned. During further interview, the Maintenance Director revealed that he prefers to clean the hood filters himself, due to the need to use a ladder to remove the filters. He stated he does not want to place anyone at risk of falling. 3. Review of the policy titled Food Storage: Dry Goods revised 2/2023, revealed storage areas will be neat, arranged for easy identification, and date marked as appropriate. Review of the policy titled Food Storage: Cold Foods revised 2/2023, revealed all foods will be stored wrapped or in covered containers, labeled and dated, and arranged in a manner to prevent cross contamination. Observation on 2/9/2024 at 9:56 am, during the initial tour of the kitchen, inside the two-door stand up refrigerator revealed a clear plastic container containing Mixed Fruit labeled on the top lid with a date of 1/30/2024. There was also a rectangle shaped steam table pan containing cheese sauce that had a label stating Cheddar Cheese dated 1/28/2024. Interview on 2/9/2024 at 9:56 am, the DM verified the container with the mixed fruit was dated 1/30/2024. She stated that the date on the mixed fruit was wrong, that the fruit was just placed in the container yesterday. The DM confirmed that the pan containing the cheddar cheese sauce was dated 1/28/2024. The DM stated that she thought the discard date for the cheese sauce should be the same as that for shredded cheese, which is to discard three to four weeks after opening. Observation on 2/9/2024 at 10:05 am, in the dry storage area revealed three large clear plastic containers on a shelf containing elbow macaroni, rigatoni noodles, and rice that had no label or open date on them. Further observation revealed a large white plastic bin with wheels containing sugar with no label or open date. Interview on 2/9/2024 at 10:05 am, the DM confirmed that the pasta and rice containers had no label or open date on them. She stated that she expects the dietary staff to label and date food items once taken out of the package and placed in a container. The DM confirmed that the white plastic bin containing sugar had no label or open date on it. During further interview, the DM stated that she does not expect staff to date the sugar bin once the sugar has been taken out of the original package. She stated the sugar bin is cleaned once per month and stated that is when new sugar is placed. The DM verified the last documented date for cleaning the sugar bin was 6/13/2023. Observation on 2/9/2024 at 10:10 am, the outside building with kitchen refrigeration and freezer storage revealed a two door stand up freezer next to the milk chest refrigeration, had a white frosted plastic bag containing a white circular food item with no label or date. Interview on 2/9/2024 at 10:10 am, DM confirmed the white frosted plastic bag with the circular food item did not have a label or date om it. She stated the dietary staff should have placed a label and dated the product before storing the food item. Observation on 2/11/2024 at 9:20 am, the two-door stand up refrigerator inside the kitchen revealed a clear plastic circulator container containing two bags of opened shredded cheese. Continued observation revealed the label on the top lid stated Mixed Fruit 2/8/2024. Interview on 2/11/2024 at 9:20 am, the DM confirmed that the lid to the container storing opened bags of shredded cheese was labeled Mixed Fruit and dated 2/8/2024. The DM stated the dietary staff failed to remove a previous label from the container lid, and she expects staff to place appropriate labels on the containers.

Based on observations, staff interviews, review of the Policies and Procedures for Nursing Facility Services, and review of the policy titled Healthcare Management-Legionella Infection Control, the facility failed to develop and implement a water management plan to include policies and procedures for the prevention and spread of Legionella and other opportunistic pathogens in the building water system. In addition, the facility failed to designate a clean and dirty room on the ventilator unit to reduce the cross contamination of respiratory therapy equipment. The census was 93. Findings include: Review of the document titled Healthcare Management-Legionella Infection Control dated 7/22/2021 revealed Legionella bacteria is found in [NAME] environment. The bacteria can become a health concern when it grows in building water systems such as: o Shower heads and sink faucets. o Cooling towers found in centralized air- cooling systems. o Decorative fountains o Hot water tanks and heaters. o Large complex plumbing systems. o Medical equipment such as a C- PAP machine. The facility will implement a water management program to reduce the building's risk for growing and spreading Legionella. Elements of a water management program are to: o Establish a water management program team. The team should include someone who understands accreditation standards and licensing requirements. The infection control person, a clinician with expertise in infectious diseases. Risk management o Describe the building water systems using text and floor diagrams. Be sure to include descriptions of water sources relevant to patient care areas, Clinical support areas, and components and devices that can expose patients to contaminated water. o Identify areas where Legionella could grow and spread. Prevent any water stagnation. o Decide the way control measures should be applied and how to monitor them. Control measures and limits should be established for each control point. And measure your control points weekly. Water should be measured throughout the system to ensure that changes that may lead to Legionella growth are not occurring. o Water heaters should be maintained at an appropriate temperature. (Equal or greater to 124 degrees). o Decorative fountains should be kept free and clear of debris, including biofilm. o Disinfectant and other chemical levels in coolant towers and hot tubs should be continuously maintained and monitored. o Establish ways to intervene when control limits are not met. You should also develop an ongoing dialogue with your drinking water provider so that you are aware of changes that may affect your building's water supply. o Make sure the program is running as designed and is effective. Document and communicate all the activities. 1. The facility could not provide any documentation regarding the water management plan, including an assessment for the identification of where Legionella could grow and spread or measures to prevent the growth of opportunistic waterborne pathogens, and how to monitor. Review of the daily water temperature logs provided by the Maintenance Director revealed there were no temperatures logged for the months of January 2023 through January 2024. The facility did not have a log for flushing water lines in areas that had increased risk for the growth of Legionella. Interview on 2/10/2022 at 9:40 am, the Maintenance Director revealed he checks the water temperature in resident rooms monthly. He presented a book titled [facility name] Treatment that had pictures of a temperature stick dated 2/10/2024. There were no other dates or pictures of temperatures in the [facility name] Treatment book. The Maintenane Director was asked for the policy and procedures for measures to prevent the growth of Legionella and other opportunistic waterborne pathogens in the building water systems, and he reported it should all be in the book. He confirmed there was no plan in place for prevention of Legionella or other bloodborne pathogens in the [facility name] Treatment Book. 44168 2. Review of the document titled Part II - Policies and Procedures for Nursing Facility Services; Georgia Department of Community Health, Division of Medical Assistance dated July 1, 2014, Chapter 800, Section 804: Mechanical Ventilation Services, 804.5 Nursing Facility Staffing, Equipment and Requirements revealed in order to maintain quality standards and reduce cross contamination, the facility policy and procedure for cleaning and maintaining equipment must include a designated soiled utility room which will be used to clean soiled Respiratory Therapy equipment, as well as a separate area to store clean equipment. The ventilator unit must have a designated clean and dirty room. This area may not be a mixed use area. It must be separated from storage and or office space. Observation on 2/9/2024 at 11:53 am of the ventilator unit revealed the facility does not have a dirty and clean room for disinfecting and cleaning equipment. Observation of dirty respiratory equipment is the respiratory office. Interview on 2/9/2024 at 1:30 pm, Registered Respiratory Therapist (RRT) AA indicated the dirty equipment from the ventilator unit is brought into the respiratory department to be cleaned, and then taken back out for use. During further interview, RRT AA revealed there was not a separate door to take the cleaning equipment from the department, back on the unit. She stated the room in the respiratory department was used by all the staff. Interview on 2/9/2024 at 1:00 pm, Administrator stated the respiratory equipment was cleaned in the respiratory department, on the opposite side of the room. He confirmed there was only one entrance to the room to bring the dirty equipment in and to take clean equipment out. Interview on 2/10/2024 at 12:30 pm, Director of Respiratory Therapy ([NAME]) stated the dirty respiratory equipment was now being covered with a plastic bag and moved from the vent unit through the hall to a room designated for cleaning. He stated the room still does not have a separate dirty and clean side.

Based on observations, interviews, and review of the policy titled Cleaning and Disinfection of Resident Care Items and Equipment, the facility failed to ensure that it maintained a clean and comfortable home-like environment for two of 30 sampled residents (R) (R54 and R63). Specifically, the facility failed to upkeep the cleanliness of resident wheelchairs related to dirt and hair build up. Findings: Review of the policy titled Cleaning and Disinfection of Resident Care Items and Equipment revised July 2014, revealed the policy is resident care equipment, including reusable items and durable medical equipment will be cleaned and disinfected according to current CDC recommendations for disinfection and the OSHA Bloodborne Pathogen Standard. Observation on 2/10/2024 at 12:15 pm revealed a thick gray buildup and hair on the undercarriage of the wheelchair for R63. Observation on 2/10/2024 at 1:34 pm revealed R54 sitting in her wheelchair near the front nurse's station. There was a thick gray build-up noted to the wheel spokes and undercarriage of the wheelchair. Interview on 2/11/2024 at 11:17 am, the Maintenance Director stated resident wheelchairs should be cleaned monthly. He reported that night shift staff have washed wheelchairs before, but the Director of Nursing (DON) may be able to provide more information on the schedule. Interview 2/11/2024 at 11:25 am, DON reported that nursing and housekeeping staff are responsible for cleaning resident wheelchairs. During further interview, she indicated that a certain number of wheelchairs should be cleaned weekly on the night shift, but she was unsure of the specific number or which wheelchairs were to be cleaned. During a brief walking tour on 2/11/2024 beginning at 11:26 am, the DON confirmed R63 was observed sitting in her wheelchair with hair, dirt, and thick gray buildup on the undercarriage of her wheelchair; and R54 was observed sitting in her wheelchair in the hallway with thick gray buildup and dirt on the undercarriage and wheel spokes of her wheelchair.

Based on observation and interviews, the facility failed to ensure the environment was free from potential accident hazards by not ensuring that a portable oxygen tank was stored securely in resident (R) 233's room of 43 resident rooms. Findings include: Review of medical record revealed R233 was admitted to the facility on [DATE] with diagnoses that included but was not limited to chronic congestive heart failure (CHF) and chronic obstructive pulmonary disease (COPD). Observation on 2/9/2024 at 3:35 pm, in R233's room was a free-standing portable oxygen tank sitting unsecured on the floor, near the wall by the television. Observation on 2/9/2024 at 3:55 pm, Licensed Practical Nurse (LPN) LL exited room of R233. During an observation and interview on 2/9/2024 at 3:59 pm, LPN KK confirmed the oxygen tank in R233's room was unsecured. She acknowledged that the oxygen tank should not have been sitting directly on the floor and then removed the oxygen tank from the room. Interview on 2/9/2024 at 4:00 pm, LPN LL stated that she had just exited R233's room but denied that she saw the unsecured oxygen tank sitting on the floor. Interview on 2/11/2024 at 3:43 pm, the Director of Nursing (DON) and the Administrator both denied knowledge of portable oxygen tanks sitting unsecured in any residents' rooms. The DON stated that the portable oxygen tanks should sit in a stand.

Based on record review, staff interview, and review of the policy titled Antipsychotic Medication Use, the facility failed to ensure that psychotropic medications including antianxiety medications were not ordered as needed (PRN) beyond 14 days unless clinically indicated for two of five residents (R) (R8 and R38) reviewed for unnecessary medications. Findings are: Review of the policy titled Antipsychotic Medication Use revised 12/2016, revealed Policy Interpretation and Implementation: Number 15. as needed (PRN) psychotropics medications would not be utilized beyond 14 days unless the healthcare practitioner provided a documented rationale for the extended order and had evaluated the resident for the appropriateness of that medication. 1. Review of the clinical record revealed R8 was admitted to the facility on [DATE] with diagnoses including fibromyalgia, osteoarthritis, congestive heart failure (CHF), hypertension (HTN), hypothyroidism, and anxiety disorder. Review of the Physician Orders (PO) dated 1/18/2023 revealed an order for alprazolam (a medication used to treat anxiety) 0.5 milligram (mg) one tablet by mouth every 24 hours as needed (PRN). Further review of the PO did not indicate that the use of the PRN medication had been re-evaluated by the physician for continued use. The order had no end date. Review of R8's Medication Administration Record (MAR) for January 2024, revealed as needed alprazolam was administered 11 times and February 2024, revealed as needed alprazolam was administered 5 times. 2. Review of the clinical record revealed R38 was admitted to the facility on [DATE] with diagnoses including dementia, urinary retention, dysphagia, gout, hypertension (HTN), and anxiety disorder. Review of the Physician Orders (PO) dated 12/22/2023 revealed an order for lorazepam (a medication used to treat anxiety) 1 mg/milliliter (ml) every 4 hours as needed (PRN). Further review of the PO did not indicate that the use of the PRN medication had been re-evaluated by the physician for continued use. The order had no end date. Review of R38's Medication Administration Record (MAR) for December 2023 revealed PRN lorazepam was administered eight times; January 2024 PRN lorazepam was administered 20 times, and February 2024, revealed PRN lorazepam was administered three times. Interview on 2/10/2024 at 12:11 pm, the Director of Nursing (DON) stated that all psychotropic medications were supposed to have a 14-day stop date. The DON acknowledged there was no stop date for R38s alprazolam and R8s Lorazepam. She stated she was responsible for chart audits to ensure stop-dates were in place, and she stated this was an oversight.

Based on observations, interviews, and review of the policies titled, Storage of Medications and Administering Medications, the facility failed to ensure that one of four medication carts was locked and secured when the carts were out of view of the nurse and failed to ensure that six containers of multi-use ophthalmic drops on one of four carts were labeled with the open date. The Deficient practice had the potential to allow unauthorized staff, visitors, and residents access to unsecured medications. Findings include: Review of the undated policy titled Storage of Medications revealed the policy statement for the facility is to store all drugs and biologicals in a safe, secure, and orderly manner. Policy interpretation and implementation number 7 stated: Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing drugs and biologicals shall be locked when not in use, and trays or carts used to transport such items shall not be left unattended if open or otherwise potentially available to others. Review of the policy titled Administering Medications with a revision date of December 2012, revealed the policy statement of: Medications shall be administered in a safe and timely manner, and as prescribed. Policy interpretation and implementation number 9 stated: The expiration/beyond use date on the medication label must be checked prior to administering. When opening a multi-dose container, the date opened is recorded on the container. An observation on 1/3/2023 at 10:05 a.m. on the Springs Hall revealed that one medication cart located in the hallway outside of the nursing unit to be unlocked. The cart was facing the hallway with the drawer handles facing the hallway. One resident was observed propelling themself in a wheelchair past the cart. At 10:35 a.m. Licensed Practical Nurse (LPN) DD approached the cart and verified she was responsible for the cart and that she left it unattended and unlocked. LPN DD stated she had left the cart for a few minutes. An observation on 1/4/2023 at 2:30 p.m. of a medication cart on the Meadows Hall with LPN EE, revealed the cart to contain six open containers of multi-dose ophthalmic drops without open dates labels. The following were open and without an open date label: 1. latanoprost ophthalmic solution .005% 2. Timolol GFS ophthalmic solution 0.5%, 3. fluorometholone 0.1% ophthalmic solution 4. Tobramycin 0.3%/Dexamethasone 0.1% ophthalmic solution 5. Tobramycin 0.3%/Dexamethasone 0.1% ophthalmic solution 6. Tobramycin 0.3%/Dexamethasone 0.1% ophthalmic solution On 1/4/2023 at 2:35 p.m., LPN EE verified the ophthalmic solutions were open and without an open dated labeled on the container or box. LPN EE revealed she was unaware that ophthalmic medications should have an open date written on them when opened. An interview on 1/4/2023 at 3:15 p.m. with the Director of Nursing (DON) revealed her expectations are for all medication carts and medication storage rooms to be locked and secured when unattended and only accessed by authorized nurses. Further revealed her expectation are for ophthalmic medications containers to be labeled with the open date when opened. She also revealed she provided education on 11/2/2022 that included medication cart audit (date opened OTC, medication refrigerator dates, nurses to lock the medication cart when not in use, medication door must be locked). Record review of the in-service sign in sheet revealed 54 signatures. The DON revealed she plans to provide further in-service about security of the medication carts and labeling of opened multi-dose ophthalmic solutions to nursing staff.

Based on staff interviews, clinical record review, and review of facility policy titled, Admission Criteria, the facility failed to perform PASARR Level II screening for two of two residents (R), R#68, R#5, diagnosed with mental disorders. These failures to prescreen residents prior to admission to the facility may result in the failure to identify residents who have or may have mental disorders (MD), intellectual disorders (ID), or a related condition. Findings include: Review of the facility policy titled, Admission Criteria, dated March 2017, revealed the following: Policy Interpretation and Implementation: #8) Nursing and medical needs of individuals with mental disorders or intellectual disabilities will be determined by coordination with Medicaid Pre-Admission Screening and Resident Review program (PASARR) to the extent practicable. #9) Potential residents with mental disorders or intellectual disabilities will only be admitted if the State mental health agency has determined (through preadmission screening program) that the individual has a physical or mental condition that requires the level of services by the facility. Review of the electronic medical record (EMR) for R#68 revealed he was a [AGE] year old male admitted to the facility on [DATE] with diagnoses to include post-traumatic stress syndrome (PTSD) and adjustment disorder with anxiety. Review of the EMR for R#68 revealed a PASARR Level I assessment was approved before admission (2/17/2021) but there was no Level II PASARR assessment on file. Review of the EMR for R#5 revealed she was a [AGE] year old female admitted to the facility on [DATE] with diagnosis to include schizoaffective disorder. Review of the EMR revealed a PASARR Level I assessment was approved before admission but there was no Level II PASARR assessment on file. In an interview with the Social Services Director (SSD) on 1/4/2023 at 6:20 p.m., she stated the facility had five residents with PASARR level II approvals. She confirmed neither R#68 nor R#5 had a PASARR Level II assessments but should have based on their diagnoses. She stated she has only been on staff since September of 2022 and had not done an audit to determine which residents should be assessed. She stated she would conduct an audit when the new psych services company starts this month.

Based on observations, record review, resident and staff interviews, and review of the facility policies titled Care Planning-Interdisciplinary Team and Care Plans, Comprehensive Person-Centered the facility failed to develop and implement a comprehensive person-centered care plan that included measurable objectives and timeframes to meet a resident's medical needs and included the resident's goals and desired outcomes in regards to oxygen administration for two of two residents (R) (R#82 and R#12) and failed to implement care plan interventions for one resident (R#14) related to Activities of Daily Living (ADL) fingernail maintenance. Findings include: Review of the undated facility policy titled, Care Planning-Interdisciplinary Team revealed the policy statement of: Care Planning/Interdisciplinary team is responsible for the development of an individualized comprehensive care plan for each resident and A comprehensive care plan for each resident is developed with seven (7) days of completion of the resident assessment Minimum Data Set (MDS). Review of the policy titled, Care Plans, Comprehensive Person-Centered with a revision date of December 2016, revealed the policy statement of: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs is developed and implemented for each resident. The policy interpretation and implementation section revealed: 8.b. The comprehensive, person-centered care plan will: Describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. 1. A review of the clinical record for R#82 revealed an admitted [DATE] with diagnoses including but not limited to: hemiplegia and hemiparesis following cerebral infarction, hypertension, chronic kidney disease, muscle weakness. Review of the most current quarterly MDS dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 10 indicating a moderate cognitive impairment. In addition, MDS revealed the resident was receiving oxygen before living at the facility. Review of physician orders revealed an order for oxygen with a start date of 11/21/2022 to use as needed for shortness of breath (SOB) at 2, 3, or 4 liters per minute (LPM) via nasal cannula (NC). An observation on 1/3/2023 at 10:35 a.m. revealed oxygen on at 3.5 LPM via NC, with the NC on his forehead, 1/4/2023 at 10:55 a.m. revealed R#82 lying in bed with oxygen on at 3.5 LPM via nasal cannula (NC) with NC on upper right corner of mattress, and on 1/5/2023 at 9:50 a.m. revealed R#82 lying in bed with oxygen on at 3.5 LPM via NC with the NC lying in the bed beside R#82. During an interview on 1/5/2023 at 2:40 p.m. with Licensed Practical Nurse (LPN) DD, she revealed she looks at the Medication Administration Record (MAR) and physician orders for oxygen needs and looks at the care plan maybe once a month if she sees a change written in the Pertinent Charting 24-hour Report notebook kept at the nurse's station. During an interview on 1/5/2023 at 2:50 p.m. with LPN FF, she revealed she checks the MAR for oxygen needs and looks at the care plan maybe every two weeks. She checks the Pertinent Charting 24-hour Report notebook every day prior to beginning work. During an interview on 1/5/2023 at 3:20 p.m. with the Director of Nursing (DON), she revealed it is the Unit Manager's responsibility to initiate the care plan on admission and auditing care plans. The nurses and interdisciplinary team can update the care plan. The DON also revealed the clinical team has a morning meeting every day where missing or incorrect interventions should be discussed if needed. 2. Review of the clinical record for R#12 revealed he was admitted to the facility on [DATE] with diagnoses including but not limited to acute on chronic diastolic (congestive) heart failure, chronic atrial fibrillation, and chronic obstructive pulmonary disease (COPD). Review of the admission MDS dated [DATE] revealed a BIMS score coded as 3 indicating severe cognitive impairment. Further review revealed section O for special treatments documentation of oxygen use while in the facility was answered positively. Review of care plan dated 11/10/2022 did not address the use of oxygen. Review of physician orders revealed new orders for oxygen were written on 1/5/2023. No orders for oxygen prior to this date were found. Nurses' notes dated 10/25/2022 revealed an entry, recorded by LPN GG, at 3:12 p.m. revealed a drop in oxygen saturation to 82% for R#12. LPN GG called the physician and documented receiving a verbal order for oxygen at 2 LPM via NC but did not write the verbal order received. Further review of nurse's notes dated 10/25/2022 through 1/4/2023 revealed multiple entries recorded by various nursing staff of R #12 being on oxygen at 2 LPM via NC. An observation 1/3/2023 at 10:30 a.m. revealed R #12 with oxygen on at 3.5 LPM via NC without humidification. The oxygen tubing was not labeled. An observation 1/4/2023 at 8:40 a.m. revealed R#12 sitting up in bed, stating he enjoyed his breakfast, and they were about to bathe him. Observed clean linens neatly stacked on the nightstand. Observed R#12 was receiving oxygen at 3.5 LPM via NC without humidification and the oxygen tubing was not labeled. An observation 1/5/2023 at 8:50 a.m. revealed R#12 receiving oxygen at 3 LPM via NC without humidification and the oxygen tubing was not labeled. During an interview on 1/5/2023 at 10:25 a.m. with LPN GG, she revealed that all residents who are receiving oxygen must have an order for the intervention, states nurses check residents' oxygen saturation every shift as ordered by physician. She went on to indicate that the respiratory therapist is responsible for maintaining the oxygen concentrator and changing of filters but was uncertain of how often this should occur. During an interview on 1/5/2023 at 10:29 a.m. with Registered Respiratory Therapist (RRT) HH, she confirmed that it is the responsibility of the respiratory therapist to maintain and change filters for all the oxygen concentrators on a weekly basis. She was not certain what day of the week this facility does this. She confirmed that every resident receiving oxygen has an order. She also confirmed there was no order for oxygen recorded in the medical record for R#12. During an Interview on 1/5/2023 at 10:32 a.m. with the DON, she confirmed that the respiratory therapists are responsible for maintaining oxygen concentrators and change filters on a weekly basis. She further stated the respiratory therapists are responsible for reviewing orders and making recommendations to the physician regarding oxygen needs and humidification for oxygen use. She confirmed R #12 did not have an order for oxygen and the care plan did not address use of oxygen. 3. A review of the clinical record for R#14 revealed an admitted [DATE] with diagnoses including muscle weakness, other lack of coordination, difficulty in walking, unspecified dementia, type 2 diabetes mellitus with hyperglycemia. Review of the most recent quarterly MDS dated [DATE], revealed a BIMS score coded as 13, indicating R#14 is cognitively intact. The MDS revealed R#14 required supervision of one person for personal hygiene. Review of the care plan dated 11/1/2022, revealed R#14 had an ADL self-care performance deficit and required assistance with care to meet her needs. Interventions included to check nail length and trim and clean on bath day and as necessary and to report any changes to the nurse. Observations on 1/3/2023 at 11:10 a.m., 1/4/2023 at 8:45 a.m., and 1/4/2023 at 11:15 a.m. revealed R#14 with long, jagged fingernails with brown discoloration on all fingernails and to have facial hair on chin, upper lip, and cheeks. Interviews on 1/3/2023 at 11:10 a.m., 1/4/2023 at 8:45 a.m., and 1/4/2023 at 11:15 a.m. with R#14 revealed he would like to have his face shaven at least two times a week and would like to have fingernails trimmed and cleaned weekly. R#14 revealed he had asked for his face to be shaved and his nails to be trimmed. During an interview on 1/4/2023 at 9:25 a.m. with Certified Nursing Assistant (CNA) AA, she revealed the shower team provides showers/baths and included facial shaving and nail care. She revealed she provides bed baths to residents that are bed bound and nail care and facial shaving was provided with the bed baths. She revealed refusal of cares are reported to the nurse and documented in the electronic medical record (EMR). During an interview on 1/4/2023 at 11:25 a.m. with CNA BB, she revealed she was part of the shower/bath team. She further revealed male residents are offered to have their face shaven on shower/bath days and that fingernail care is included in cares received on shower/bath days. She revealed refusal of cares, including ADL cares, are documented in the EMR and reported to the nurse. During an interview on 1/4/2023 at 11:30 a.m. with Registered Nurse (RN) CC, she revealed residents are offered a shower/bath two times a week and facial shaving and nail cares are provided on shower/bath days and as needed. She revealed refusal of cares should be documented in the EMR and reported to the nurse. An observation on 1/4/2023 at 11:30 a.m. of R#14 with RN CC, verified R#14 to have obvious facial hair on their chin, upper lip, and cheeks and to have long, jagged fingernails with brown discoloration on all fingers. R#14 revealed to RN CC he would like to have his face shaved and his fingernails trimmed and cleaned. Record review of the shower log for October, November, and December 2022 revealed documentation that R#14 received a shower two times a week during the last three months. There was no specific area for nail care or facial shaving documentation. During an interview on 1/5/2023 at 9:00 a.m. with the DON, she revealed her expectations are for residents to have fingernail care provided and for male residents to be offered to have face shaved on shower/bath days and as needed. She further revealed residents with a diagnosis of diabetes mellitus receive fingernail care provided by a nurse and that nail care should be provided and documented as provided or refused. She revealed her expectations are for care plans to be followed. The DON verified that R#14 had obvious facial hair on chin, upper lip, and cheeks and fingernails were long, jagged with brown discoloration. She also verified the care planned interventions for R#14 including ADL and nail cares should be provided. Cross reference F677 46691 Resident #14 Activities of Daily Living 1/3/23 11:10 am Observation and interview of R#14 , revealed resident propelling self in a wheelchair into his room. Was dressed and had facial hair visible on chin, cheeks, and upper lip. Observed fingernails to be long, jagged, and with brown discoloration. Resident revealed he does have his face shaven when receives a shower and revealed receives a shower two times a month. Revealed would like a shower more often and for face to be shaved at least two times a week and fingernails to be trimmed. 1/4/23 8:45 a.m. Observation and interview of R#14 revealed sitting in his room in a wheelchair. Was dressed and had visible facial hair on chin, upper lip and cheeks. Observed fingernails to be long, jagged, and with brown discoloration under nails. Toenails observed to be within normal length and smooth. Resident revealed cannot remember the last time he had a shower or face was shaved and would like for his face to be shaved at least two times a week. Revealed he required assistance with bathing and personal cares. 1/4/23 11:15 a.m. Observation and interview of R#14 revealed resident sitting in a wheelchair in his room. Dressed and groomed with facial hair observed on chin, upper lip and cheeks. Fingernails observed to be long, jagged, and with brown discoloration. Resident revealed he did get a shower this morning but did not have his face shaved or fingernails trimmed or cleaned. R#14 is a [AGE] year old male admitted on [DATE] Quarterly MDS dated [DATE] revealed: C - BIMS score of 13 E - no behaviors exhibited G - required limited assistance of one person for bed mobility, transfers, dressing; supervision of one person for locomotion, eating, personal hygiene; extensive assistance of one person for toileting; ambulation did not occur; required physical assistance of one person in part of bathing activity. J - did not receive scheduled or prn pain medication and no pain was reported during the 5 day look back period. O - received occupational therapy for 5 of 7 days Physician's orders include (not all inclusive): 10/14/22: Behavioral Monitoring: Has resident had behaviors of yelling, cursing, resisting care, delusions, hallucinations, hitting this shift? Monitor for and document if noted adverse reactions - every day and night shift 10/11/22: Skilled OT to tx 5-7 x week x 4 weeks for therapy exercise, therapy activity, neuro [NAME] and self care/ADLS Diagnosis include (not all inclusive): MUSCLE WEAKNESS (GENERALIZED) OTHER LACK OF COORDINATION DIFFICULTY IN WALKING UNSPECIFIED DEMENTIA TYPE 2 DIABETES MELLITUS WITH HYPERGLYCEMIA Care plan dated 11/1/22 revealed (not all inclusive): Focus: The resident has an ADL self-care performance deficit r/t recent lengthy hospitalization . Had a fall with fracture and had surgical nailing repair to rt hip. Here for therapy and regain as much of prior function as possible. Goal: The resident will improve current level of function in transfers and ambulation through the review date. Interventions: BATHING/SHOWERING: Check nail length and trim and clean on bath day and as necessary. Report any changes to the nurse. DRESSING: Allow sufficient time for dressing and undressing. DRESSING: Assist the resident to choose simple comfortable clothing that enhances the resident's ability to dress self. EATING: The resident is able to feed self with set up assist ORAL CARE ROUTINE SPECIFY brush rinse mouth with wash. Encourage the resident to use bell to call for assistance. Monitor/document/report PRN any changes, any potential for improvement, reasons for self-care deficit, expected course, declines in function. Praise all efforts at self care. PT/OT evaluation and treatment as per MD orders. Focus: The resident has Diabetes Mellitus Goal: The resident will have no complications related to diabetes through the review date. Interventions include: Diabetes medication as ordered by doctor. Monitor/document for side effects and effectiveness. Dietary consult for nutritional regimen and ongoing monitoring. Discuss meal times, portion sizes, dietary restrictions, snacks allowed in daily nutritional plan, compliance with nutritional regimen. Fasting Serum Blood Sugar as ordered by doctor. Offer substitutes for foods not eaten. Refer to podiatrist/foot care nurse to monitor/document foot care needs and to cut long nails. Record review of the nurses notes revealed no documented refusal of ADLS or showers. 1/4/23 at 3:00 p.m. a record review of the shower log in the electronic medical record (EMR) revealed resident did not receive a shower from 12/25/22 to 1/3/22. Revealed one refusal of a shower on 11/25/22. 1/4/23 at 9:25 a.m. an interview with [NAME], CNA revealed she had worked at the facility for 3 weeks. Revealed during orientation, she received training to include ADL cares, abuse and neglect, PPE use, infection control, fire safety. She revealed there was a shower team of CNAs who provide showers and baths. Revealed residents have scheduled shower/bath two times a week and as needed. Revealed she provides bed baths to bed bound residents daily as needed. 1/4/23 at 11:25 a.m. an interview with [NAME], CNA revealed she had worked at the facility for 3 weeks. Revealed during orientation, she received training to include ADL cares, infection control, PPE use, abuse, and revealed she had completed multiple training modules in the Relias program. She further revealed she is on the shower/bath team and follows the schedule for resident showers. She revealed residents are scheduled for shower/bath two times a week and may receive shower/bath as requested on other days. She revealed males are offered to have their face shaved and hair and fingernail care is included in cares received with showers. She further revealed ADL cares and refusal of cares are reported to the nurse and documented in the (EMR). 1/4/23 at 11:30 a.m. an interview with [NAME], RN revealed residents are scheduled for showers/baths two times a week and that males should be offered to have their face shaved and hair and fingernail care is provided for all residents on shower days. She further revealed ADL cares are to be documented in the EMR and refusal of cares are to be documented and reported to the nurse. Observation of R#14 with RN [NAME] verified him to have obvious facial hair on chin, upper lip and cheeks and fingernails to be long, jagged and to have brown discoloration. 1/4/23 at 1:50 p.m. an interview with [NAME] Brown, Director of Nursing (DON) revealed residents are scheduled to have a shower two times a week and as needed or requested. She further revealed males should have their face shaved as requested and that fingernail care is provided on shower days and as needed. She revealed residents with diagnosis of diabetes mellitus have fingernail care provided by the nurse and toenail care provided by a podiatrist. She revealed her expectations are for residents to receive showers and ADL cares as scheduled and for cares and refusal of cares to be documented in the EMR. 1/5/23 at 9:00 a.m. during an interview with [NAME] Brown, DON, the shower log documentation was reviewed and she verified R#14's documentation revealed he did not receive a shower from 12/25/22 to 1/3/22. She further stated she thinks he did receive a shower during the time frame and contacted a unit nurse and stated R#14 received a shower on 12/28/22 and printed a shower log to contain 12/28/22 documented as resident received a shower. Further interview verified resident had obvious facial hair on chin, upper lip and cheeks and long, jagged, brown discolored fingernails on 1/3/23/and 1/4/23. Based on observation, resident and staff interviews and record, the facility failed to provide ADL care, specifically fingernail care and facial grooming related to shaving for R#14. 47146 Resident #12 Respiratory Care 01/03/23 10:30 AM Resident resting quietly with eyes open, Oxygen at 3.5 lpm via NC with no humidification, oxygen tubing not labeled, brief record review revealed no order for oxygen. 1/4/23 08:40 AM R 12 observed sitting up in bed after eating breakfast states he enjoyed his breakfast. Bed linens appeared clean, resident reports he is about to get his bath. Clean linens, towels, and clothing stacked neatly on residents night stand. 01/05/23 08:50 AM Observed resident resting quietly with eyes closed, oxygen at 3 lpm via NC no humidification, oxygen tubing not labeled. 01/05/23 10:25 AM Interview with [NAME] LPN revealed residents on oxygen have an order for the intervention, states they check O2 saturations every shift as ordered by the physician. States the respiratory therapy is responsible for maintaining the oxygen concentrator and changing filters. 01/05/23 10:29 AM Interview with Lavonda Fowler RT confirmed that respiratory therapist is responsible to maintain concentrators and change filters weekly. She confirmed there is no order on chart for R #12. 01/05/23 10:32 AM Interview with Director of Nursing confirmed respiratory therapist (RT) is responsible for maintain concentrators and change filters weekly, the RT is also responsible for reviewing orders and make recommendations to physician regarding oxygen needs and humidification for oxygen. She confirmed R #12 does not have an order for oxygen. Confirmed oxygen is not care planned. Record Review: Admission MDS dated [DATE] C - Cognitive Patterns: BIMs score of 03 indicating severe impairment. G - Functional Status: Total Dependence with 2 person assist for bed mobility, toilet use, dressing, bathing; Extensive assistance with personal hygiene with 2 person assist; Independent with eating J - Health Conditions: no shortness of breath recorded on this MDS. O - Special Treatments, Procedures, and Programs: treatments, procedures, and programs that were performed during the last 14 days prior to MDS assessment: Oxygen was marked as received while resident of the facility. Respiratory therapy not received in previous 7 days of MDS assessment. Physician's orders: Evaluate resident for SOB with laying flat, attempting to lay flat, or with activities, new or worsening malaise (general feeling of discomfort, illness, or uneasiness), new dizziness, diarrhea, sore throat, or new loss of smell or taste every shift. Pertinent diagnoses: Acute on chronic diastolic (congestive) heart failure, chronic atrial fibrillation, chronic obstructive pulmonary disease (COPD) Care plan dated 11/10/22 no findings on care plan to support use of oxygen. Nurses Notes Reviewed:On 10/25/22 Nurse note entry by [NAME] LPN at 1512 recorded spo2 of 82% and a call to physician (Dr. Sighn) and new orders received and implemented at this time. 02 on at 2 lpm. Stat neb tx ordered, legs elevated and lasix ordered and given. Resident is stable and resting comfortably at this time. VSS Spo2 at 95%, P 69, r16, bp 115/89. There after multiple intermitted entries recorded by various nursing staff of Resident on O2 at 2LPM via NC.

Based on observations, resident and staff interviews and record review, the facility failed to provide activities of daily living (ADL) cares, specifically nail care and facial shaving, for one of 48 residents (R) (R#14) sampled that required assistance for ADLS, including showers and nail care. These failures caused R#14 to go unshaven and to have long, unkept/unclean fingernails. Findings include: The facility did not provide a policy, procedure, or formal guidelines for ADL cares. A review of the clinical record for R#14 revealed admitted [DATE] with diagnoses including muscle weakness, other lack of coordination, difficulty in walking, unspecified dementia, type 2 diabetes mellitus with hyperglycemia. Review of the most recent quarterly Minimum Data Set (MDS) dated [DATE], revealed Brief Interview for Mental Status (BIMS) coded as 13, indicating R#14 is cognitively intact. The MDS revealed R#14 required supervision of one person for personal hygiene. Review of the care plan dated 11/1/2022, revealed R#14 had ADL self-care performance deficit and required assisted care to meet needs. Interventions included to check nail length and trim and clean nails on bath day and as necessary and to report any changes to the nurse. Observations on 1/3/2023 at 11:10 a.m., 1/4/2023 at 8:45 a.m., and 1/4/2023 at 11:15 a.m. revealed R#14 with long, jagged fingernails with brown discoloration on all fingernails and to have facial hair on chin, upper lip, and cheeks. Interviews with R#14 on 1/3/2023 at 11:10 a.m., 1/4/2023 at 8:45 a.m., and 1/4/2023 at 11:15 a.m. revealed he would like to have his face shaven at least two times a week and would like to have his fingernails trimmed and cleaned weekly. R#14 revealed he had asked for his face to be shaved and his nails to be trimmed. Interview on 1/4/2023 at 9:25 a.m. with Certified Nursing Assistant (CNA) AA revealed the shower team provides showers/baths and includes facial shaving and nail care. She revealed she provides bed baths to residents that are bed bound and nail care and facial shaving is provided with the bed bath. She revealed refusal of cares are reported to the nurse and documented in the electronic medical record (EMR). Interview on 1/4/2023 at 11:25 am with CNA BB revealed she is part of the shower/bath team. She further revealed male residents are offered to have their face shaven on shower/bath days and that fingernails care is included in cares received on shower/bath days. She revealed refusal of cares, including ADL cares, are documented in the EMR and reported to the nurse. Interview on 1/4/2023 at 11:30 a.m. with Registered Nurse (RN) CC revealed residents are offered a shower/bath two times a week and facial shaving and nail care are provided on shower/bath days and as needed. She revealed refusal of cares should be documented in the EMR and reported to the nurse. Observation on 1/4/2023 at 11:30 a.m. of R#14 with RN CC verified R#14 to have obvious facial hair on chin, upper lip, and cheeks and to have long, jagged fingernails with brown discoloration on all fingers. R#14 revealed to RN CC he would like to have face shaved and fingernails trimmed and cleaned. Record review of the shower logs for October, November and December 2022 revealed documentation that R#14 received a shower two times a week during the last three months. There was no specific area for nail care or facial shaving documentation. Interview on 1/5/2023 at 9:00 a.m. with the Director of Nursing (DON) revealed her expectations are for residents to have fingernail care provided and for male residents to be offered to have face shaved on shower/bath days and as needed. She further revealed residents with a diagnosis of diabetes mellitus receive fingernail care provided by a nurse and that nail care should be provided and documented as provided or refused. The DON verified that R#14 had obvious facial hair on chin, upper lip, and cheeks and fingernails were long, jagged with brown discoloration.

Based on record review, staff and Ombudsman interviews, review of facility policy titled Enteral Nutrition revised (MONTH) 2014, and review of the Georgia Nurse Practice Act (chapter ,[DATE]) the facility failed to provide care and services in accordance with facility policies and that met professional standards related to providing a dinner tray to one resident (R) (R#1) with a Physician order to have nothing by mouth (NPO). Failure to provide services according to professional standards resulted in R#1 choking on food, aspirating, then a cardiopulmonary arrest and an eleven (11) day admission to an Intensive Care Unit, where he was maintained on life support, with an endo tracheal tube, then a [MEDICAL CONDITION], and remained unresponsive due to suspected [MEDICAL CONDITIONS]. R#1 was transferred to a Long Term Acute Care Unit (LTAC) where he expired twenty-seven (27) days later. The sample included ten (10) residents. On (MONTH) 25, 2019 a determination was made that a situation in which the non-compliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents. The Administrator and the Director of Nursing (DON) were informed of the Immediate Jeopardy (IJ) on (MONTH) 25, 2019 at 10:44 a.m. The noncompliance related to the Immediate Jeopardy identified to have existed on (MONTH) 22, 2019 when staff failed to follow the Physician's orders for nothing by mouth (NPO) for resident (R) (R#1) who was newly admitted to the facility and was served a dinner tray which resulted in R#1 choking on a food item and R#1 went into [MEDICAL CONDITION]. The facilty had not provided a Removal Plan at the time of the exit on (MONTH) 29, 2019 therefore the IJ is ongoing. The immediate jeopardy is outlined as follows: Resident #1 was admitted to the facilty on (MONTH) 22, 2019 with a feeding tube and written Physician's orders to have nothing by mouth (NPO). Nursing failed to follow the physicians orders and served the resident a tray from the kitchen. Shortly after the tray was delivered R#1 was found to be in severe respiratory distress choking on a food item. The incident resulted in R#1 going into [MEDICAL CONDITION] and Cardiopulmonary Resuscitation (CPR) was started Emergency Medical Service (EMS) arrived and transported R#1 to the emergency room (ER) where R#1 was intubated and admitted to Intensive Care Unit (ICU) and later transferred to a Long Term Acute Care (LTAC) facilty where R#1 expired on (MONTH) 2, 2019. The immediate jeopardy was related to the facility's noncompliance with the program requirements as follows: C.F.R. 483.21 Services Provided Meet Professional Standards (F 658 Scope and Severity: J) C.F.R. 483.25 Quality of Care (F 684 Scope and Severity: J) C.F.R. 483.70(d)(1)-(3) Governing Body ( F 837 Governing Body Scope and Severity:J) Additionally, Substandard Quality of Care was identified with the requirements at C.F.R. 483.25 Quality of Care (F 684 Scope and Severity :J). Findings include: Review of the Georgia Nurse Practice Act, chapter ,[DATE], revealed that licensed and registered nurses are required to: assess their patients in a systematic, organized manner; initiate nursing actions to assist the patient to maximize his/her health capabilities; evaluate with the patient the status of any goals as a basis for reassessment and reordering of priorities; function within the legal boundaries of nursing practice; and determine that care performed is based on the orders/directions of a licensed physician or other similarly licensed professional. Review of the facility policy titled Enteral Nutrition revised (MONTH) 2014 revealed on page 8 in part, #11. The Nurse will confirm that there are appropriate orders for oral (PO) intake or restrictions for nothing by mouth (NPO), as appropriate. Review of the clinical record for R#1 revealed he was admitted to the facility on (MONTH) 22, 2019 after being transferred from a local hospital with [DIAGNOSES REDACTED]. A nurse's report sheet dated (MONTH) 22, 2019 and timed 12:20 p.m. revealed the hospital nurse had reported that R#1 also had a [DIAGNOSES REDACTED]. Review of the printed transfer orders that were sent with R#1, from the transferring hospital revealed an order for [REDACTED].>Review of the facility Physician orders dated (MONTH) 22, 2019 revealed an order for [REDACTED]. Review of the Progress Notes for R#1 revealed on (MONTH) 22, 2019, LPN DD began to document medication order notes in the Electronic Medical Record (EMR) for R#1 at 2:49 p.m. At 4:15 p.m. LPN DD documented an admission note revealing R#1 was jaundiced and alert to person and place. LPN DD also documented that R#1's PEG tube was intact. Continued review of the Progress Notes for R#1 revealed on (MONTH) 22, 2019 at 6:00 p.m. R#1 was in bed, had no pulse and no respirations. Cardiopulmonary Resuscitation (CPR) was initiated and 911 was called. At 6:05 p.m. Emergency Medical Technicians (EMT) arrived, CPR continued and R#1 was transferred to the local hospital Emergency Department (ED). Review of the Hospital Record for R#1 revealed on (MONTH) 22, 2019 an ED Physician documented in History of Present Illness that according to (EMS) R#1 was found choking on food at the nursing home, had a [MEDICAL CONDITION] at that time. Patient did receive CPR at nursing home staff . patient was reportedly eating a biscuit, his room mate reportedly stated that the patient put the entire biscuit in his mouth. On Reexamination and Reevaluation the ED Physician documented he had seen and reexamined R#1 several times . the patient's brother does express concern over the fact that the patient is supposed to be nothing by mouth and receiving everything via PEG tube and yet he choked on a biscuit. (sic) The ED Physician's final [DIAGNOSES REDACTED]. After admission to the Intensive Care Unit (ICU) the care of R#1 was transferred to a Physician Hospitalist service. The Hospitalist History and Physical dated (MONTH) 23, 2019, revealed R#1 had been brought to the hospital after apparently choking on a food item with subsequent CPR . The Hospitalist documented on the Discharge Summary dated (MONTH) 6, 2019 that R#1 had apparently gone into [MEDICAL CONDITION] after choking on a biscuit. According to EMS, patient was choking on food at the nursing home, had a [MEDICAL CONDITION] at that time. Review of the Expiration Summary from the Long Term Acute Care (LTAC) unit where R#1 was a patient from (MONTH) 6, 2019 until his death on (MONTH) 2, 2019, revealed that R#1 had a prolonged ventilator course and required [MEDICAL CONDITION] and PEG tube placement at the hospital and was transferred to the LTAC unit for ongoing management of [MEDICAL CONDITION]. He was suspected to have [MEDICAL CONDITIONS]. During his hospitalization he remained dependent on the ventilator and his mentation did not improve. [MEDICAL CONDITION] medicine recommended that the chances of weaning R#1 from mechanical ventilation were almost nil. The hospital Ethics Committee was consulted due to R#1 suffering with prolonged ventilator support and requiring Vasopressor support (medication to maintain blood pressure) as well. Infectious Disease was following the patient. On the date of expiration patient continued to require increased amount of vasopressors, full ventilator support and in spite of that he passed away on (MONTH) 2, 2019 at 3:12 a.m. An interview with Unit Manager II was conducted on (MONTH) 29,2019 at 11:09 a.m. She revealed she had never been told that R#1 had been given food. The Unit Manager stated she had been at home at approximately 6:15 p.m. on Friday (MONTH) 22, 2019 when she received a call from LPN DD. LPN DD told the Unit Manager that R#1, who had just been admitted that after noon, had a cardiopulmonary arrest and had been transferred to a hospital with CPR in progress. LPN DD also told her that food was in the room and R#1 may have eaten something. Unit Manager II stated she called the former Director of Nurses (DON) and was told the DON would report this to the Corporate Regional Vice President, and the former Administrator, and would complete an incident report and initiate an investigation. Continued interview with Unit Manager II on (MONTH) 29, 2019 at 1:40 p.m. revealed that she was told by the former DON on (MONTH) 1, 2019 to give LPN DD a disciplinary write up related to not following Physicians orders on (MONTH) 22, 2019. She stated she was never told what order LPN DD did not follow and she had not asked what the write up was related to specifically. The Unit Manager revealed she assumed it was for LPN DD allowing R#1 to possibly get into food that was left in his room. Unit Manager DD confirmed she had never discussed anything related to the disciplinary write up with the former DON or the former Administrator who did not start an incident report and had never asked the staff to provide written statements or questioned them regarding R#1 eating food that was in the room because she was not told to do any of this. The Unit Manager confirmed that there is no incident report or investigation because no one initiated an incident report or investigation. The Unit Manager acknowledged that R#1 was bed bound so food in the room would not be a concern unless the food that was in the room was directly in front of him. The Unit manager also confirmed that disciplinary write ups are not given to employees for the possibility of Physician orders not being followed. She stated she had no knowledge of this. An interview was conducted on (MONTH) 29, 2019 at 4:37 p.m. with LPN DD related to R#1's brief stay at the facility. LPN DD stated she remembered R#1 and the events that had occurred prior to his cardiopulmonary arrest. LPN DD revealed she had received report from a hospital nurse for R#1 shortly after noon on (MONTH) 22, 2019. She stated she had been informed that R#1 had a history of [REDACTED]. LPN DD revealed that one of the Certified Nursing Assistants (CNAs) had told her when dinner trays came that R#1 said he was hungry, and she had made a terrible mistake. She stated she did not check Physician orders but had gone to the kitchen and told the staff that a resident on the unit with a regular diet had dropped his tray and she needed a replacement. They gave her a regular diet tray and she had taken it back to the(NAME)wing and given it to the CNA. She stated she saw the CNA take it into the room. She stated she had said the tray was for someone else because she had not confirmed all the Physician orders yet, the dietary department had not received any information for R#1 and it would just be faster to say it was for someone that already had a diet order for. LPN DD revealed she did not remember what the CNA's name was, and did not actually see R#1 set up with the dinner tray, but she knows he did receive the food. LPN DD would not say how she knows that but repeated she just knows. LPN DD stated she was called to the room because R#1 had been found with no pulse or respirations. LPN DD stated she does not remember much more about the code, but she did not see the dinner tray near R#1, the CNA's had started CPR, and she did not notice if any food had been consumed from the tray or if there was food in his mouth. Interview with the former DON on (MONTH) 29, 2019 at 5:04 p.m. related to any investigation of the circumstances surrounding the admission and transfer of R#1 and the disciplinary write up of LPN DD. The DON revealed she had given the corporation her thirty day notice at the end of (MONTH) and her last day was to be (MONTH) 22, 2019. The former DON revealed she continued to come to the facility to help out but was not functioning as DON. She stated she was called by Unit Manager II on the night of (MONTH) 22, 2019 and told that R#1 had required CPR and transfer to the hospital and that there had been food in the room. The DON acknowledged that R#1 was immobile and that she was not sure why food in the room would be a concern unless it had been served to him. The DON stated she had told Unit Manager II to initiate an incident report, begin collecting statements from staff involved. The former DON revealed she had informed the former Administrator, the new DON, the new Administrator. The DON revealed she could not remember if she had informed the Corporate Regional Vice President, but if she had not the former Administrator should have done this. The DON stated she had no knowledge of LPN DD not following Physician orders on (MONTH) 22, 2019 and had never told the unit Manager to give LPN DD a disciplinary write up on (MONTH) 1,2019 or any other date. The former DON revealed she had not started any kind of investigation, but she had requested hospital record from the hospital R#1 was admitted to after he required CPR at the facility. She stated she did not remember the date she requested the hospital record. The DON revealed she had reviewed the hospital records and determined there were no concerns for R#1 choking on food. Interviews on (MONTH) 29, 2019 with the current DON at 10:50 a.m., the current Administrator at 11:00 a.m., the former Administrator at 1:24 p.m., the Corporate Regional Vice President at 12:43 p.m. and Corporate Co-Owner/Vice President KK at 5:22 p.m. revealed they were not informed by anyone that R#1 had been admitted to the facility on (MONTH) 22, 2019 and had a cardiopulmonary arrest at 6:00 p.m., or any situation related to a nurse not following Physician orders on Feburary 22, 2019 and providing a dinner tray to R#1 who was NPO. They all stated there was no incident report or investigation and they had had no knowledge of this situation until a State Surveyor began to investigate at the facility on (MONTH) 23, 2019. Cross Refer to F 837 and F 684

Based on observation, record review, staff interviews, and facility policy review entitled Interdepartmental Notification of Diet (Including Changes and Reports), the facility failed to ensure that one (1) out of 10 sampled residents were protected from not following physician orders. Resident (R) R#1, was a new admission, who was ordered nothing by mouth (NPO), and was given a dinner tray after admission. After R#1 received his dinner tray, he choked on a piece of bread, requiring Cardiopulmonary resuscitation (CPR) to be performed due to [MEDICAL CONDITION], and transportation to the hospital emergency room (ER) and then Intensive Care Unit (ICU ) requiring mechanical ventilation and tracheotomy. On (MONTH) 25, 2019 a determination was made that a situation in which the non-compliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents. The Administrator and the Director of Nursing (DON) were informed of the Immediate Jeopardy (IJ) on (MONTH) 25, 2019 at 10:44 a.m. The noncompliance related to the Immediate Jeopardy identified to have existed on (MONTH) 22, 2019 when staff failed to follow the physician's orders [REDACTED].#1) who was newly admitted to the facility and was served a dinner tray which resulted in R#1 choking on a food item and R#1 went into [MEDICAL CONDITION]. The facilty had not provided a Removal Plan at the time of the exit on (MONTH) 29, 2019 therefore the IJ is ongoing. The immediate jeopardy is outlined as follows: Resident #1 was admitted to the facilty on (MONTH) 22, 2019 with a feeding tube and written physician's orders [REDACTED]. Nursing failed to follow the physicians orders and served the resident a tray from the kitchen. Shortly after the tray was delivered R#1 was found to be in severe respiratory distress choking on a food item. The incident resulted in R#1 going into [MEDICAL CONDITION] and Cardiopulmonary Resuscitation (CPR) was started Emergency Medical Service (EMS) arrived and transported R#1 to the emergency room (ER) where R#1 was intubated and admitted to Intensive Care Unit (ICU) and later transferred to a Long Term Acute Care (LTAC) facilty where R#1 expired on (MONTH) 2, 2019. The immediate jeopardy was related to the facility's noncompliance with the program requirements as follows: C.F.R. 483.21 Services Provided Meet Professional Standards (F 658 Scope and Severity: J) C.F.R. 483.25 Quality of Care (F 684 Scope and Severity: J) C.F.R. 483.70(d)(1)-(3) Governing Body ( F 837 Governing Body Scope and Severity:J) Additionally, Substandard Quality of Care was identified with the requirements at C.F.R. 483.25 Quality of Care (F 684 Scope and Severity :J). Findings include: R#1 was admitted to the facility on (MONTH) 22, 2019 at 2:16 p.m. with a [DIAGNOSES REDACTED]. The resident was later transferred out of the facility to a local hospital by Emergency Medical Services( EMS) on (MONTH) 22, 2019 at 6:23 p.m. Review of the Admissions Report dated (MONTH) 22, 2019 at 12:20 p.m., revealed that R#1 had a [DIAGNOSES REDACTED]. Review of the Nursing Admission Screening/History dated (MONTH) 22, 1019 at 12:59 p.m., revealed that the resident was alert to person, place, time and situation at time of admission. Continued review revealed that he has some short term memory problems, looked thin and anxious, and appeared jaundice in color. Review of continuing assessment revealed that his throat was clear, and pink; his mouth was pink, moist and lips were pink with tongue being moist and pink. All extremities were within normal limits (WNL) for range of motion (ROM). Review of the Progress Note dated (MONTH) 22, 2019 at 6:00 p.m., revealed R#1 in bed without a pulse, and/or respirations. Continued review revealed that CPR was started along with 911 being called. Further review indicated that at 6:05 p.m., Emergency Medical Services (EMS) arrived with CPR being continued and R#1 was transferred to the ER at a local hospital. Review of the Transfer Form V 4.1 dated Feburary 22, 2019 revealed that resident was transferred to a local hospital on (MONTH) 22, 2019 at 6:23 p.m., related to respiratory arrest. Continued review revealed that R#1 was NPO, had trouble swallowing and was receiving [MEDICATION NAME] (fiber-fortified tube feeding formula) 1.5 at 55 milliliters (ml)/20 hours (hr). Review of the Admitting Physician order [REDACTED]. Review of the Diet Order and Communication Form dated (MONTH) 22. 2019 with an unknown time, revealed that the resident was NPO with peg feeding. Review of the History and Physical from the local Medical Center dated (MONTH) 6, 2019 revealed that the resident was recently sent back from a Skilled Nursing Facility (SNF) today for respiratory distress. The patient was recently admitted to the hospital and was discharged earlier today for further rehab as he had a non-ST elevation [MEDICAL CONDITION] infarction (MI) with right lower lobe pneumonia and [MEDICAL CONDITION]. The patient was found to be in severe respiratory distress at the nursing facility with low oxygen saturations and subsequently sent back to the hospital. The patient came to theER on a nonrebreather and was placed on a Bi-level positive airway pressure ([MEDICAL CONDITION]). Subsequently, the patient is being admitted for further management to intensive care unit (ICU). Review of the Local Medical Center EMS report dated (MONTH) 22, 2019 revealed that EMS responded to a [AGE] year old male, [MEDICAL CONDITION], on arrival EMS supervisor was on scene and had already intubated (process of inserting a tube through the mouth and into the airway). Staff states that they were unsure how long patient had been unresponsive, but had checked on the patient a few minutes before and he was conscious alert and now, patient is pulseless. Patient was administered [MEDICATION NAME] (medication used to treat life-threatening allergic reactions) three times. Though CPR was being continued, R#1 had no change during rhythm check. R#1 had to be ventilated (having an opening to allow air to pass out) at a rate of 8 to 10 breaths per minute. During further review, R#1's systems were not assessed, such as mental status, skin, HEENT (head/face, eyes, and/or neck/airway), chest, abdomen, back, pelvis, neurological, and/or extremities. Review of the Final Report Emergency Department (ED) note-Physician from a local Medical Center dated Feburary 22, 2019 revealed that resident was brought into the ED due to choking on food at the nursing home, according to EMS. Patient did receive CPR by nursing home staff and he cannot be assessed secondary to patient's clinical status, but R#1 does have a peg tube. Patient was reportedly eating a biscuit, his roommate reportedly stated that the patient put the entire biscuit in his mouth. He had weak and thread peripheral pulses, with no spontaneous respiratory activity. Diffuse inspiratory crackles bilaterally when receiving bagged ventilations, slightly worse on the right. Patient seen and reexamined several times, and stabilized on a treatment course. Discussed findings and prognosis with patient's brother, who was at R#1's bedside, he voices understanding, and appreciative of care. Review of the Impression and Plan (page 6 of 7) revealed a [DIAGNOSES REDACTED]. R#1 was admitted to the hospital. Review of the local Medical Center Discharge Summary dated (MONTH) 6, 2019 revealed that the resident had presented to theER on (MONTH) 23, 2019 from the nursing home after patient had apparently gone into [MEDICAL CONDITION] after choking on a biscuit. According to EMS, patient was found choking on food at the nursing home, and had a [MEDICAL CONDITION] at that time. Patient did receive CPR by nursing home staff and was brought to the ER. In the ER, patient was emergently intubated and admitted to ICU for [REDACTED]. He remained unresponsive and neurology determined he had suffered [MEDICAL CONDITIONS] (occurs when the brain is deprived of oxygen) from the [MEDICAL CONDITION]. Eventually, had a [MEDICAL CONDITION] placed on (MONTH) 4, 2019 and subsequently accepted for transfer to a local Long Term Acute Care (LTAC) for further care. Review of the LTAC Discharge Summary dated (MONTH) 24, 2019 revealed that resident was admitted on (MONTH) 6, 2019 and expired on (MONTH) 2, 2019. admitted from a Medical Center after coming to the ER suffering [MEDICAL CONDITION]. He was intubated, and kept on a ventilator. R#1 was suspected to have [MEDICAL CONDITIONS]. Due to his prolonged vent course, trach, and peg tube and he was transferred to a LTAC center in hopes to vent weaning (remove the ventilator); however, no improvement, resident had poor prognosis. Depict increased amounts of vasopressors (medication given for septic shock), and full ventilation support, the resident passed on (MONTH) 2, 2019 at 3:12 a.m. Interview with Licensed Practical Nurse (LPN)/Treatment Nurse AA on (MONTH) 24,2019 between 10:32 a.m.-10:40 a.m., revealed that he was the manager on duty for this particular weekend. Continued interview revealed that when he was told about the resident's condition, he entered the room and CPR was being completed. There was two nurses and two Certified Nursing Assistants (CNA) in the room. He took over chest compressions, which he continued until EMS arrived, and one of the other nurses DD was giving report to EMS. He took the lead once he entered the room. Stated an ambo bag was applied , lifted head, and resident's chest raised and fell without any problems. The incident did occur during supper time; however, he did not recall seeing a dinner tray for this resident, but for other residents in the room. When EMS arrived, they took over and resident was transported. He did the initial skin/wound assessment earlier that day, and said that the resident was a pale yellow, indicating that the R#1 looked very sick. Continue to say that R#1 had to be vented at a local Medical Center and just got extubated (removed) a few days prior to being admitted to the facility. Interview with LPN, DD, over the phone, on (MONTH) 24, 2019 at 1:50 p.m., revealed that she found the resident non-response with no pulse, and called a code blue while she went to get the crash cart. Continued interview revealed that another nurse called 911, and EMS arrived within minutes of being called. She started doing chest compressions, and when EMS arrived they took over, and placed a devise for [MEDICAL CONDITION] with continuous mechanical chest compressions on R#1. EMS did Intubate resident and transported him to a local hospital. She confirmed that R#1 was NPO, so stated that there was no dinner tray delivered to him. Interview with ER admitting physician CC, on (MONTH) 24, 2019 at 4:16 p.m. via the phone, revealed that he is fairly sure that he saw some biscuit that particular evening because he stated that he is newly divorced and is learning to cook, which he had made some biscuits and brought for dinner that evening, which he gave away. He continued to state that if the resident had not gotten over the pneumonia that too could have caused the [MEDICAL CONDITION] because of the shock to his body. Stated that EMS would still have been able to Intubate even if there was a foreign object in the throat which would just push the object down further. Confirms that he should do a better job of documenting of what the foreign object was, which he usually does, but does not remember documenting in this particular case. Interview with the Registered Dietitian (RD) BB on (MONTH) 24, 2019 at 3:25 p.m., revealed that with every meal usually, there is a roll, and/or slice of bread that is served to the residents. Could not confirm if a biscuit was served that evening (February 22, 2019) of the particular incident. Stated that when a new resident comes to the facility, the nurse after taking off the orders, will fill out a diet slip for dietary with the appropriate diet. During another interview at 4:03 p.m., confirmed that there was no dietary slip received in dietary that particular day, and if there is no slip, then a new admit resident would not receive a tray without a slip from nursing. Interview with CNA EE, on (MONTH) 24,2019 between 5:00 p.m.-5:10 p.m., revealed that this particular resident came in around dinner time, when she was in his room showing him the call light, he stated that he was hungry, so she left the room and told the nurse DD, who went to the kitchen and obtained him a tray. Continued interview revealed that when she returned to the room to check on him, his head was flat on the bed, and he was reaching for the tray, which was on the nightstand and did contain a roll. Stated that she put his head up, moved the tray to an over bed table, which she had to go get, and R#1 grabbed the roll off the tray; however, could not confirm if he ate anything prior to this. Said that when she left the room, R#1 was doing well, and a few minutes later she heard the code blue for that resident. Confirmed that she was unaware of his NPO status and said that the nurses give information on newly admitted residents, including diet orders. Confirmed that upon getting to the facility and starting her shift, rounds were completed, as they are everyday, but this resident had not been admitted as of that time, stating he came in around dinner time. Interview with cook FF, on (MONTH) 25, 2019 at 7:40 a.m., that she has been at the facility for the past [AGE] years, and normally works 5:30 a.m.-1:30 p.m.; however, on (MONTH) 22, 2019, worked over due to call out until about 7:30 p.m. Continued interview revealed that nurse DD came back to the kitchen requested a dinner tray for another resident, who was on a regular diet, stating that this resident dropped his tray. Stated that on the tray that evening would have been a piece of meat, vegetables, and bread, mostly likely a dinner roll. She confirmed that the nurse DD never mentioned that the tray was for R#1, and the kitchen never received a diet communication sheet. She stated that she knew he was NPO, so he would have not received a tray. Stated that if staff come back to the kitchen and request a tray for a resident that is newly admitted , then the kitchen staff asks about a diet communication sheet prior to giving that tray. If staff come back to the kitchen and request another tray for an existing resident, then the kitchen staff fixes that particular residents tray again per their diet order. Interview with CNA GG on (MONTH) 25,2019 between 8:00 a.m.-8:15 a.m. over the telephone, revealed that she has been working on the ,[DATE] shift for about six to seven months. Continued interview revealed that she was here that particular evening; however, did not see R#1 receive a dinner tray, but knows he received a tray. Said that the resident came in around dinner time. Confirmed that she knew that he received a tray was because of what happened, code blue being called. She was the one that gathered all other CNA's to his room, while another CNA called the code blue. She confirmed that she was the one that dug a piece of roll out of his throat during the code blue. Went on to state that nurse DD, while performing CPR, R#1's chest was not rising, so CPR was stopped. This is when he was turned to his side and she dug a piece of roll out of his mouth, and CPR was continued. Stated that the ambulance came within minutes, and took over and the resident was transported out of the facility. Confirmed that nurse DD got tired while performing CPR, and she took over CPR, while LPN/Treatment Nurse was in the room, but all he did was holler for the crash cart. Stated that there has been no roommate changes, and confirmed that nurse DD got all the CNA's together that evening to let them know that this particular resident was NPO after he arrived on the unit. Confirmed that upon admission of a new resident, it is the nurses who let them know of the orders, including diet orders. Interview with LPN HH, on (MONTH) 25, 2019 at 8:38 a.m., revealed that when a newly admitted resident comes to the facility, after orders are taken off, a diet communication slip is filled out, and sent to the kitchen. Continued interview revealed that a copy is made and put into the resident's chart, along with being put into the computer. Interview with LPN/Unit Manager (UM) on (MONTH) 25, 2019 at 8:40 a.m., revealed that after the orders are taken off, then a diet communication slip is filled out, sent to the kitchen, and placed into the medical records box, which then is scanned into the computer. The facility has been electronic charting since around (MONTH) (YEAR). During another interview on (MONTH) 25, 2019 at 9:30 a.m., revealed that she has been the UM for the past five years and confirmed that the information on the SBAR and transfer form was obtained from nursing notes. Confirmed that she was not here at the time of this particular incident. However, received a call from nurse DD who said that there was food in the resident's room, but unsure if resident ate anything. Went on to state that R#1 coded, CPR was started, EMS was called and R#1 was transported out of the facility. Confirmed that she notified the previous DON about this incident. Confirmed that she made sure the paperwork was completed. She recalls that she was here at the time R#1 was admitted ; however, was not here at this particular incident. Said that she normally works 8:00 a.m.-4:30 p.m., but has to be flexible in her hours due to what is going on the unit. Since this incident, there has been no further incidents of this kind and she is unaware of the time that she left that particular day. Said that is the nurses responsibility to inform the CNA and dietary of any diet orders upon admit. Interview with the DON on (MONTH) 25, 2019 between 8:42 a.m.-8:48 a.m., revealed that both her and the Administrator has only been in the facility since (MONTH) 26 2019, and she does not know of anything that happened that particular evening (February 22, 2019). Confirmed that since she has arrived, there has been no other incidents of this kind. Review of facility policy Interdepartmental Notification of Diet (Including Changes and Reports) with revised dated of (MONTH) 2008, revealed that when a new resident is admitted , or a diet has been changed, the Nurse Supervisor shall ensure that the Food Services Department receives a written notice of the diet order. Continued review revealed that the Food Services Department will also be notified verbally if the diet change or report occurs one hour or less before a scheduled meal, or if circumstances indicate that the written procedures will not be adequate to ensure service at the next meal. Refer to F658 and F837

Based on record review, Ombudsman, staff, Administrator, and Corporate co-owner/Vice President interview it was determined that the of the facility's Governing Body failed to ensure a process was in place to identify risk and exposures and effective communication between the Governing body, the facility Administrator and the staff. This failure resulted in regulatory risk to include Standards of Professional Practice related to following MD orders and Quality of Care, when one resident (R), R#1 choked on food from a dinner tray that was delivered to him shortly after admission. R#1 had hospital transfer orders, dated (MONTH) 22, 2019 and admission orders [REDACTED]. R#1 became pulseless and apneic (without respirations) after choking and subsequently required intubation, mechanical compressions and administration of code medications. He was transferred to a local Emergency Department and admitted to the local hospital's Intensive Care Unit. These failures resulted in Immediate Jeopardy. The sample size was ten residents. On (MONTH) 25, 2019 a determination was made that a situation in which the non-compliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents. The Administrator and the Director of Nursing (DON) were informed of the Immediate Jeopardy (IJ) on (MONTH) 25, 2019 at 10:44 a.m. The noncompliance related to the Immediate Jeopardy identified to have existed on (MONTH) 22, 2019 when staff failed to follow the physician's orders [REDACTED].#1) who was newly admitted to the facility and was served a dinner tray which resulted in R#1 choking on a food item and R#1 went into [MEDICAL CONDITION]. The facilty had not provided a Removal Plan at the time of the exit on (MONTH) 29, 2019 therefore the IJ is ongoing. The immediate jeopardy is outlined as follows: Resident #1 was admitted to the facilty on (MONTH) 22, 2019 with a feeding tube and written physician's orders [REDACTED]. Nursing failed to follow the physicians orders and served the resident a tray from the kitchen. Shortly after the tray was delivered R#1 was found to be in severe respiratory distress choking on a food item. The incident resulted in R#1 going into [MEDICAL CONDITION] and Cardiopulmonary Resuscitation (CPR) was started Emergency Medical Service (EMS) arrived and transported R#1 to the emergency room (ER) where R#1 was intubated and admitted to Intensive Care Unit (ICU) and later transferred to a Long Term Acute Care (LTAC) facilty where R#1 expired on (MONTH) 2, 2019. The immediate jeopardy was related to the facility's noncompliance with the program requirements as follows: C.F.R. 483.21 Services Provided Meet Professional Standards (F 658 Scope and Severity: J) C.F.R. 483.25 Quality of Care (F 684 Scope and Severity: J) C.F.R. 483.70(d)(1)-(3) Governing Body ( F 837 Governing Body Scope and Severity:J) Additionally, Substandard Quality of Care was identified with the requirements at C.F.R. 483.25 Quality of Care (F 684 Scope and Severity :J). Finding include: Review of the undated face sheet for R#1 revealed he was admitted to the facility on (MONTH) 22, 2019. The [DIAGNOSES REDACTED]. Review of the clinical record for R#1 revealed on (MONTH) 22, 2019 at 12:20 p.m. a nurse received report for R#1. The nursing report included a [DIAGNOSES REDACTED]. An admission assessment dated (MONTH) 22, 2019 revealed R#1 was alert and oriented and unable to ambulate. Review of the electronic medical record Progress Notes for R#1 revealed Licensed Practical Nurse (LPN) DD had first documented admission medication orders at 2:49 p.m. and documented that the medications were to be given by PEG tube. Further review revealed an admission note documented at 4:15 p.m. that R#1 had no signs of distress and his PEG tube was intact. The following day on (MONTH) 23, 2019 at 2:44 p.m. LPN DD documented that on (MONTH) 22, 2019 at 6:00 p.m. R#1 was in bed, had no pulse, no respirations, 911 was called and at 6:05 p.m. the Emergency Medical Technicians had arrived and R#1 was transferred to an emergency room . Review of the transfer record Physician orders [REDACTED].#1 was transferred from revealed R#1 was to have nothing by mouth. The facility Physician orders [REDACTED].>A review of the eInteract transfer form dated (MONTH) 22, 2019 time 6:23 p.m. by Unit Manager LPN II revealed R#1 was not ambulatory. On (MONTH) 29, 2019 at 10:50 a.m. an interview was conducted with the current Director of Nurses (DON). She revealed that she entered the facility for orientation with the current Administrator on (MONTH) 26, 2019. The DON revealed the former DON was in the building to orient her for that week. She stated no one told her anything about a resident that choked on food with an order to be NPO and was transferred to the hospital the day he was admitted . The DON revealed she had not heard about this concern until a surveyor began to investigate last week. The DON revealed she would have expected the former DON to give her this information and to have an incident report and an investigation. The DON revealed there is no incident report on paper or in the Electronic Medical Record (EMR) system. She stated she was not told of any outstanding issues by anyone at the facility. The DON stated she started her own investigation on (MONTH) 23, 2019 and has interviewed staff and has written statements. Copies were requested, and the DON agreed to provide them. The DON revealed she was told by LPN DD, the admitting nurse for R#1 that LPN DD had gone to the kitchen to get a tray for R#1 because he said he was hungry and had told the dietary staff she had dropped a dinner tray and she just needed another one. She stated that LPN DD has a Performance Improvement Plan initiated by the Unit Manager, for not following orders on (MONTH) 22,2019. A copy of the personnel file for LPN DD was requested and the DON agreed to provide this. The DON revealed she had suspended LPN DD. On (MONTH) 29,2019 at 11:00 a.m. the Administrator joined the interview and revealed she had also started employment for the facility on (MONTH) 26, 2019 and was not given any information about any resident who had required CPR a few hours of admission, went to the hospital and expired. The Administrator revealed she had not been given any information about outstanding issues and learned of this concern with the DON, when the State Surveyor began to investigate last week. A review of the Payroll Detail Report for the former DON revealed she was in the building on [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE] for eight (8) hours each day. An interview was conducted with Unit Manager II on (MONTH) 29, 2019 at 11:09 a.m. related to her knowledge of R#1's admission to and brief stay at the facility. The Unit Manager confirmed she is responsible for the Meadows Wing where R#1 was a resident. The Unit Manager stated she was not in the building when dinner trays were being served on Friday, (MONTH) 22, 2019 and had left at approximately 4:30 p.m. that day after entering orders into the computer that she had received from the Admissions Department prior to R#1's arrival. The Unit Manager revealed that the orders are not accepted into the EMR until the charge nurse receives a paper copy when the resident arrives and confirms all the orders on the EMR. Then the orders are considered complete and final. She stated that she was at home on the evening of (MONTH) 22, 2019 and received a call from LPN DD saying that R#1 had been observed with no pulse or respirations at approximately 6:00 p.m. and that he might have gotten into some food that was in the room. The Unit Manager revealed she was not given any other details , but had assumed since R#1 had a [DIAGNOSES REDACTED]. The Unit Manager acknowledged that R#1 was not ambulatory and not able to transfer himself out of the bed, get to food out of the reach of his bed, then return to the bed and eat the food. She acknowledged the only food he could access would be food that was placed directly in front of him. Unit Manager II stated she called the former DON after the call from LPN DD and was told by her that the former DON was going to initiate an investigation and that the former DON would complete an incident report, call the former Administrator, and call the Regional Vice President. The Unit Manager revealed she had not heard anything more about this incident until she was told by the former DON on (MONTH) 1, 2019 to give LPN DD a written disciplinary action related to not following Physicians orders on (MONTH) 22, 2019. The Unit Manager revealed she had never been given any information by the former DON related to what order was not followed and the write up did not include any additional information. The former DON was called by the Unit Manager last week when the State Surveyor was here investigating the concern. The former DON told her she was initiating a request. The Unit Manager revealed she was told by the former DON that it was in her office in a manila envelope. She stated she gave this information to the DON and Administrator and they had searched the former DON's office multiple times from top to bottom and the investigation could not be found. They had searched for an incident report as well and that could not be found. An interview was conducted on (MONTH) 29, 2019 at 12:43 p.m. with the Corporate Regional Vice President, related to notification of a resident who was admitted to the facility on (MONTH) 22, 2019 and was transferred to the local hospital a few hours later with CPR in progress. The Corporate Regional Vice President confirmed that is her position, but she is also Administrator at another facility. She stated that she should have been notified of this but does not consider herself responsible for this facility because she is Administrator somewhere else. The Corporate Regional Vice President revealed she was never notified of this situation until the surveyor arrive last week. She denied being notified by the former DON of this issue and indicated she will discuss any problems with the facility management but is not part of the Governing Body or chain of command. She revealed she was not sure who the Governing Body is, because the Administrator does have final responsibility for anything that happens in the facility, but the two owners of the corporation can be called for any problems. An interview was conducted with the former Administrator on (MONTH) 29, 2019 at 1:24 p.m. related to his knowledge of the admission of R#1 on (MONTH) 22, 2019 and his transfer to the hospital with CPR in progress a few hours later. The former Administrator revealed he had not been informed of any information surrounding this incident until the State Surveyor began to investigate last week. The former Administrator revealed he had attended the morning clinical stand up meeting on (MONTH) 25, 2019 and the former DON was there, and this was his last day as Interim Administrator, and her last day as DON. He revealed the new DON and Administrator were not there because they did not start until the next day. He revealed the former DON had never called him regarding this incident and there was no mention of this from her or the Unit Manager in the clinical stand up meeting or by telephone. The former Administrator revealed he should have been notified of this incident by the DON or it should have been brought to everyone's attention in the clinical stand up meeting by Unit Manager II. The former Administrator revealed he has reviewed his notes and his email history from (MONTH) 22, 2019 through (MONTH) 1, 2019 and has no indication that anyone informed him of this. He stated this should have been reported to the state and an investigation should have been initiated. A review of morning meeting attendance sheets revealed the former DON signed in (MONTH) 21, 2019 and (MONTH) 22, 2019, and signed into morning meeting on (MONTH) 27, 2019 and (MONTH) 28, 2019 . There were no further signatures on the roster by the former DON from (MONTH) 22, 2019 through (MONTH) 5,2019. The former Administrator signed the roster for morning meeting on (MONTH) 25, 2019 as a consultant, and on (MONTH) 5, 2019 as a consultant. There were no additional signatures on morning meeting rosters from (MONTH) 22, 2019 through (MONTH) 5, 2019 by the former Administrator. An interview with LPN Unit Manager II was conducted on (MONTH) 29, 2019 at 1:40 p.m. related to reporting of the events of R#1's admission and stay at the facility. The Unit Manager revealed she does not remember being told that LPN DD did not follow Physicians orders, and confirmed that is what is documented on the Performance Improvement Plan dated (MONTH) 1, 2019, with her signature and the signature of LPN DD. She stated the DON may have found something with her investigation. The Unit Manager revealed she had assumed the order that was not followed was related to R#1 possible getting into some food that was in the room and choking on it. The Unit Manager acknowledged that R#1 was not capable of getting into any food that was not directly in front of him, and that disciplinary write ups are not given for possibly not following Physician orders. The Unit Manager confirmed her signature was present on the disciplinary write up dated (MONTH) 1, 2019 and that she was told that day by the DON to present the write up to LPN DD. The Unit Manager confirmed that LPN DD had been given a disciplinary write up in (MONTH) for administering [MEDICATION NAME] to a resident when the order had been discontinued over two weeks before the last administration. The Unit Manager revealed she did not question anyone about the cardiorespiratory arrest of R#1 or file an incident report, or mention this in morning meeting, or tell the new DON and Administrator about it because the former DON had told her she would take care of all that. The Unit Manager confirmed that LPN DD was disciplined for not following Physician orders [REDACTED]. The Unit Manager revealed she does not remember if the former DON was in the morning meeting on (MONTH) 25, 2019, but the former Administrator was there and she assumed he was still the Administrator on that day because the new Administrator and DON were not in the building yet. A review of disciplinary Individual Performance Improvement Plans in the personnel file of LPN DD revealed on [DATE] at 9:00 a.m. and 5:00 p.m., [DATE] at 10:00 a.m., [DATE] at 2:00 p.m., [DATE] at 12:00 p.m., [DATE] at 10:00 a.m., [DATE] at 10:00 a.m., [DATE] at 12:00 p.m. and [DATE] at 6:00 p.m. [MEDICATION NAME] was given to a resident without an order, [MEDICATION NAME] order had been discontinued on [DATE]. There were no signatures or date on the Performance Improvement Plan. The Performance Gap was documented to be a Medication Error, the Expected Result was staff will pay closer attention to Medication Administration Records/ Treatment Administration Records (MARs/TARs) when administering medication. The Developmental Process was documented to be education via DON. The Measurement of Expected Results was documented Unit Manager (UM) will monitor Narcotic Boxes for discontinued medications, with a Target date of Immediately. Hand written on the Performance Improvement Plan was a note to please sign education attached. An education roster dated [DATE] was included. The topic was detailed as follows: Always make sure you check the MARs/TARs before giving a medication to ensure there is an active order for the medication. There is no signature on the education roster. It is blank. An additional Individual Performance Plan for LPN DD was reviewed dated (MONTH) 22, 2019. The description of event was documented as follows: No (sic) following MD orders. The date of the meeting on the Plan was (MONTH) 22, 2019. The Performance Gap was documented as Unsatisfactory Performance. The Expected Result was all MD orders will be followed. The Developmental Process was education by UM's. The Measurement of Expected Results was to spot check as needed, with a Target Date of Immediately. This was signed by Unit Manager II and LPN DD as acknowledged and completed. There was no documentation of suspension in the personnel file, or any statements by LPN DD related to R#1. The Ombudsman arrived and was interviewed on (MONTH) 29, 2019 at 2:45 p.m. The Ombudsman revealed she was called by a family and named the family of R#1. She stated the family had told her that they received a call from an anonymous staff person on (MONTH) 20, 2019 that R#1 had choked on food he had been given at the nursing home. They were aware of this already but felt the issue was being covered up because the call from the nursing home they received on (MONTH) 22, 2019 after R#1 had coded revealed he had respiratory distress and staff initiated CPR and he was on his way to the hospital. The Corporate Regional Vice President called at (MONTH) 29, 2019 at 4:09 p.m. and asked if she could send the disclosure of owner ship instead of information about the Governing Body because there was no Governing Body. She stated the facility is owned by a Limited Liability Company (LLC) and the Administrator answers to owners if there are any problems. The Corporate Regional Vice President revealed she calls the two owners on a daily basis. An interview was conducted on (MONTH) 29, 2019 at 4:37 p.m. with LPN DD related to her recollection of the admission and transfer of R#1 on (MONTH) 22, 2019. LPN DD revealed she had just been terminated that day and would admit to me that she made a horrible mistake. She stated she had told the Unit Manager (UM) when she called her after R#1 left for the hospital with CPR in progress that there had been food in the room and R#1 may have eaten some of it. LPN DD revealed she had taken report for R#1 and the report included the information that he had previously had aspiration pneumonia, was NPO and had a new PEG tube with orders for feedings to be provided through the tube, but had forgotten this information. LPN DD then stated she had been told by a Certified Nursing Assistant (CNA) that R#1 said he was hungry and without remembering R#1 was NPO, or checking his orders had walked to the kitchen and requested a tray for another resident who received a regular diet and told them that that other resident had dropped his tray. LPN DD revealed she had done this because she had not yet confirmed the orders for R#1 and it would be easier for her to just get a tray for another resident and give it to R#1. She had returned to the floor and had given the tray, still with the plate covered to the CNA that had told her that R#1 was hungry, she stated she could not remember the CNA's name, and observed the CNA go to R#1's room with the tray. When she was called to the room because R#1 needed CPR she did not observe the tray near him and did not notice if any food was missing or if there was food in his mouth. LPN DD revealed she knows the resident did get the tray and would not reveal how she knows this. An interview was conducted on (MONTH) 29, 2019 at 5:04 p.m. with the former DON related to being told R#1 had been transferred to the hospital on (MONTH) 22, 2019 with CPR in progress a few hours after he was admitted . The former DON revealed she had written her notice at the end of (MONTH) due to personal issues and it was effective on (MONTH) 22, 2019. She stated that she was no longer DON after that day when she left, but she had stayed to help out. The former DON stated she was not in the building at all on (MONTH) 1, 2019 and did not remember if she was in the building to attend morning meeting on (MONTH) 25, 2019. She stated Unit Manager II had called her the evening of (MONTH) 22, 2019 and said a new patient had to go to the hospital soon after admission. She stated she was told LPN DD had started CPR and the wound care nurse LPN AA had assisted with CPR. She stated she was aware R#1 came in with a recent insertion of a PEG tube, was NPO and was completely dependent on the staff for mobility and transfers. The former DON stated she was told R#1 had a tray in his room . The former DON revealed she was told the tray was untouched. The former DON denied doing any form of investigation and then confirmed she had requested the record from the hospital R#1 was transported to after he had a cardiopulmonary arrest on (MONTH) 22, 2019. The former DON acknowledged she had reviewed this record and did not find any reference to choking on food and determined that he must not have choked on food. The former DON denied any knowledge of a CNA clearing food from the mouth of R#1 during ventilations with an Ambu bag because of inadequate chest rise and said she had not investigated the incident at all because she had told the Unit Manager II to investigate the incident, get staff interviews, and make an incident report. The former DON confirmed that if there was food in the room the resident would not be able to get to the food because he was immobile and if there was any food obstructing his airway it would have had to be placed right in front of him. The former DON revealed she had notified the former Administrator of the cardiopulmonary arrest of R#1, and does not remember if she called the Corporate Regional Vice President. She stated she does remember telling the new DON and the new Administrator. The former DON denied any interviews, denied any investigation, denies telling anyone that investigative results related to R#1's cardiopulmonary arrest being placed in a manila envelope that was lost, denied completing any incident report, and denied ever telling the Unit Manager II to complete a disciplinary write up for LPN DD for not following physician orders [REDACTED]. The former DON revealed she had instructed Unit Manager II to complete and incident report and begin collecting statements of staff on duty on (MONTH) 22, 2019 related to the incident with R#1. Record review of the hospital record for R#1 revealed the following references to him choking on food: February 22, 2019 a hospital Emergency Department (ED) Physician's note documented under the heading of Impression and Plan with a [DIAGNOSES REDACTED]. The Reexamination and Evaluation documented the concern of the brother of R#1 related to the resident choking on food when he was supposed to receive only tube feedings and nothing by mouth. The ED Physician's Final Report dated (MONTH) 22, 2019 was reviewed and under History of Present Illness the ED Physician documented that according to EMS the patient was found choking on food at the nursing home and that patient was reportedly eating a biscuit and his room mate told EMS that the patient put the entire biscuit in his mouth. The Hospitalist documented on the discharge summary dated (MONTH) 6, 2019 that R#1 had apparently gone into [MEDICAL CONDITION] at the nursing home after choking on a biscuit and eventually had a [MEDICAL CONDITION] placed by Pulmonology on (MONTH) 4, 2019. A History and Physical dated Feburary 23, 2019 by the hospitalist revealed that R#1 was brought to ED after apparently choking on a food item with subsequent CPR being done as well as interventions by EMS with a subsequent return rhythm. A review of the resignation dated (MONTH) 23, 2019 of the former DON revealed the effective date was (MONTH) 22, 2019. A call was placed to the Corporate Co- owner of the facility KK on (MONTH) 29, 2019 at 5:22 p.m. and an interview was conducted. He revealed he was not informed about any resident admitted on (MONTH) 22, 2019 that choked on food, had a cardiopulmonary arrest and was transferred to the hospital with CPR in progress the same day he was admitted , until a State Surveyor came to investigate on (MONTH) 23, 2019. The Corporate Co -Owner revealed the former Administrator and the Corporate Regional Vice President who is Administrator at another facility should have been notified right away and he also should have been notified immediately. The Corporate Co -Owner revealed he thinks the notifications, investigations and reports were missed because the situation occurred while the facility was in the midst of changing the DON and Administrator. Corporate Co -Owner KK revealed that there is no Governing Body Policy, but the chain of command should be Administrator, Regional Vice President then the owners. He stated that he has an organizational chart and he will send that and a disclosure of ownership. He revealed that every one with responsibility, including the owners, the Regional Vice President and the former Administrator would take their responsibility. Review of the disclosure of ownership of the facility sent by Co -Owner KK revealed the facility is at the bottom of the chart with one of two Managers listed as Co-Owner KK. Next up on the chart is the name of the Corporation identifying the corporation as an LLC. Next there are four names listed at the top of the algorithm with 25% after each name. One of the names is Co-Owner KK. On (MONTH) 29, 2019 at 5:10 p.m. the current DON was again requested to provide a copy of her investigation and she revealed she would copy it now and give it to the surveyor. A job description for the Corporate Regional Vice President was requested and the DON revealed she and the Administrator were both told they are to report anything of any concern or out of the ordinary or any adverse out comes to her, but they do not have a job description for the Corporate Regional Vice President and were in the process of obtaining a job description from her. An interview was conducted with LPN AA on (MONTH) 29, 2019 at 5:33 p.m. related to his recollection of providing CPR for R#1. LPN AA wound care nurse revealed he remembered that he was in facility on (MONTH) 22, 2019 and was providing wound care in another room when a CNA came to get him and said there was a code. He remembered providing a skin assessment for the resident who was coding, R#1. He went to the room and 2 CNA's were providing CPR and LPN DD was standing in the doorway. He revealed she was a seasoned nurse who had been involved in codes multiple times in the facility but she looked very upset. The crash cart was in the room and he asked how long they had been giving CPR and was told ,[DATE] minutes, an ambulance was in parking lot from just dropping off another resident and they came right in. LPN AA had observed a CNA having trouble giving ventilations with the ambu bag and had taken it from her and given two breaths with the ambu bag when he heard LPN DD tell the female paramedic the resident might have gotten some food. He revealed he was shocked that LPN DD had not given him this information before he gave the two breaths with the ambu bag because if he had known that he would have checked the residents mouth for food. He looked in residents' mouth when the paramedic opened R#1's mouth to intubate and did not see food. R#1 had looked jaundiced when the skin assessment was done, and as he was receiving CPR R#1 looked white around his mouth and eyes. He remembers the former DON asking him for a written statement possibly on (MONTH) 26, 2019 and he provided one to her. LPN AA revealed any time there is a significant change in a residents condition or they go to the hospital he understands the Unit Manager is told, she tells the DON who tells the Administrator, and he tells whoever is next in command. He revealed the statement he had written for the DON had also been provided to the Unit Manager on (MONTH) 22, 2019 when she asked for a written statement and it had disappeared. He revealed he had made a copy of the statement and left it in his office on (MONTH) 26, 2019 and that too had disappeared. He revealed he had save the second copy on his computer and had hand written from the saved copy a statement for the current DON and had given that to her and he did not remember the date but it was after the State Surveyor began investigating last week. Requested he provide me the statement he prepared for the DON. He agreed to do this. A review of the above mentioned undated statement, on plain paper, no letterhead, and no date of the event provided to the surveyor from LPN AA revealed a description of the occurrences he explained during his interview above. A post survey telephone call was made on (MONTH) 1, 2019 at 9:56 a.m. to the current Administrator related to the request for the Corporate Regional Vice President's job description. The current Administrator revealed she had found out yesterday that there is no one in that position and there is no job description for that position. The current Administrator and Current DON revealed they had been told to report any concerns or adverse or unusual events to the Corporate Regional Vice President by the former Administrator, and gave her name, but that must have been incorrect because now they have been told there is no one with that position. The current Administrator stated she would have the Corporate Co-Owner call me when he gets to the facility today. A post survey conference call was received from the former Administrator and the Corporate Co-Owner KK, who were both at the facility on (MONTH) 1, 2019 at 12:08 p.m. The Corporate Co-Owner and the former Administrator revealed there is no one in the position of Corporate Vice President and there never has been. The former Administrator revealed he was never notified of what happened to R#1, but if he had been notified he would have notified the owners because there was no Regional Vice President, and there is no job description for the position, they are developing one now and are going to hire someone soon for the position. Co-Owner KK revealed the former Administrator would oversee the two facilities that are owned by the corporation for now. Co -Owner KK revealed he did not think there was any system failure that caused the former Administrator and the owners to not be notified of the admission and transfer of R#1 with CPR in progress, and did not think any system failure would account for there being no incident report, investigation or education of the staff involved. He stated that it was just one nurse who had acted without regards for Physician orders [REDACTED]. He stated he had read a written statement from the nurse and she had confessed in the written statement to getting R#1 a tray when he was NPO and that she had knowledge that he received the tray, choked on the food and had a cardio [MEDICAL CONDITION] arrest. Corporate Co-Owner KK revealed that none of that is a system failure.

Based on observations, record reviews, review of manufactures' patient manuel, and staff interviews, it was determined that the facility failed to properly administer oxygen therapy for two (2) residents, #1, and #2, and provide appropriate nursing care to prevent harm for resident #2, in a survey sample of twelve (12) residents. This resulted in harm to two resident and the likelihood of possible serious harm to (2) other residents who utilized oxygen concentrators and 4 other resident who received respiratory therapy. It was therefore determined that an immediate and serious threat to resident health and safety existed from March 30, 2009 until April 16, 2009, at which time the facility took action to correct the deficient practice and abate the jeopardy situation. Findings include: 1. The Progress Note dated 3/11/2009 revealed that resident #1 had [DIAGNOSES REDACTED]. The resident's care plan identified as a problem ineffective breathing pattern related to Chronic [MEDICAL CONDITION] Disease and to use oxygen as ordered. The physician's orders [REDACTED]. The Interdisciplinary Progress Notes on 3/30/09 documented that at 12:00 p.m. the certified nursing assistant went into the resident's room and found the resident to be blue and unresponsive. The notes documented the oxygen saturation (O2 sat) was 57% at 4 liters/minute of oxygen via nasal cannula, a blood pressure or pulse could not be obtained, no rise or fall of the resident's chest was observed; therefore facility staff notified the hospice nurse. The notes further documented at 1:00 p.m. the hospice nurse arrived and found the oxygen concentrator humidifier bottle not connected correctly and corrected the problem. It was further documented that the resident was monitored and at 3:00 p.m. the resident's skin was noted to be warm, dry and pink, with capillary refill in less than 3 seconds, the resident was alert and talking, and the O2 stat had improved to 94 % with oxygen being administered at 4 liters per nasal canula . In addition, the documentation in the Interdisciplinary Progress Notes on 3/30/09 at 12:00 p.m. and 3:00 p.m. revealed that the resident was receiving oxygen at 4 liters/per minute instead of the 3 1/2 liters that was ordered when the resident was using an oxygen concentrator. An interview with nurse "AA" revealed that on 3/30/2009 he/she was contacted by the facility because resident #1 was experiencing respiratory distress. It was further stated that upon the nurses arrival in the resident's room he/she observed the humidifier on the oxygen concentrator was not bubbling and found that it was not properly connected to the oxygen concentrator. It was acknowledged that the resident was not receiving adequate oxygen. 2. The History and Physical for resident #2 dated 4/7/2009 was reviewed and documented that the resident's [DIAGNOSES REDACTED]. The resident's assessment dated [DATE] revealed that the resident was totally dependent for all ADLs. The physician's orders [REDACTED]. The Nurse's Notes on 4/12/09 at 10:00 p.m. revealed a pulse oximetry of 86% and oxygen was started at 2 liters and the O2 Sat increased to 95%. Observation of the resident on 4/15/09 at 12:25 p.m. revealed that the resident had a nasal cannula and the oxygen concentrator was set on 2 liters per minute. Further observation revealed that the tubing connected to the nasal cannula was on the floor connected to an adaptor; however the tubing from the oxygen concentrator was not connected to the other end of the adapter resulting in the resident receiving no oxygen. It was also observed that the humidifier was not bubbling. An interview with nurse "BB" at 12:35 p.m. revealed that the resident was not receiving oxygen because the oxygen saturation was low. Nurse "BB" observed the oxygen administration system and observed no problems. The surveyor then pointed out to the nurse that the oxygen tubing was not connected to the oxygen concentrator. The nurse connected the oxygen tubing, however did not note that the humidifier was not bubbling. At 2:20 p.m. observation of the oxygen system with the administrative nurse "CC", it was pointed out to the nurse that the humidifier was not bubbling. Upon checking the humidifier, it was found that it was not properly connected to the oxygen concentrator. On 4/15/2009 at 1:45 p.m., during observation of resident #2 with licensed staff nurse " FF" , this staff person said the resident had a pressure ulcer in the left nares caused by pressure from the nasal cannula the length and depth of the nasal cannula. When the staff person went to remove the nasal cannula it was stuck, and upon removal bleed profusely. The staff person said the resident should have on a mask not a cannula. Further said the wound care nurse was suppose to put suave on it, but none was observed to be on the resident. The staff member further mentioned that this was discussed in the morning meeting but no physician notification nor orders had been obtained. Staff person " FF " removed the nasal cannula and when the bleeding stopped and applied a oxygen mask to the resident. During the survey, the nurse's notes for resident #1 revealed that she/he was experiencing respiratory distress and the oxygen system was not connected properly. In addition, resident #2 was observed with a nasal cannula connected to tubing that was not connected to the oxygen concentrator and with a left nares ulcer caused by pressure from the nasal cannula and staff had not implemented any interventions. This reflected a failure in the facility's system for the care, treatment and administration of oxygen therapy. A review of the Millennium Respironics Patient Manual includes instructions on how to use the oxygen concentrators that included a section with a guide on troubleshooting. The guide had a list of problems; one of the problems listed was if limited oxygen flow to the user was noted , the probable cause was either faulty oxygen tubing, cannula or mask, and/or humidifier. One solution listed was to inspect and/or replace the items if necessary. The facility staff did not utilize this guide to determine if the equipment was in proper working order. The facility submitted the following plan of action on April 16, 2009 outlining immediate interventions employed by the facility to remove any further concerns surrounding the above issues: 1. All day shift RN and LPN nursing staff, LPN from night shift and RN weekend supervisor were re-educated on 4/16/09 prior to 5:00 p.m. on the proper set-up, use, and care of oxygen concentrators. The remaining licensed staff will be re-educated by Monday, April 20, 2009. All CNAs will be re-educated by Monday, April 20, 2009 on the proper functioning of oxygen concentrators and instructed to notify nursing staff when a problem exists. 2. Monitoring of the residents receiving oxygen will be done through daily observation and tracking by LPN or RN nursing staff, by use of the oxygen audit tool. 3. The treatment nurse, an LPN, will be responsible for daily monitoring during the day shift of the function of the oxygen concentrators, changing the tubing and nasal cannulas/masks every seven days and PRN, and for washing the concentrator filters weekly. The tubing or humidifier bottle will be dated indicating the day the tubing and humidifier were changed. 4. New employees will be educated during orientation to the facility for the proper set-up, use and monitoring of the oxygen concentrators and required to give return demonstration. This education and return demonstration will be required annually to ensure the safety of residents receiving oxygen from concentrators. 5. The DON, or ADON in her absence, will be responsible for monitoring oxygen therapy and ensuring that the residents are receiving the prescribed oxygen by review of the audit tool in the clinical stand up meeting. The supervisor will review the audit tool for compliance on the weekends. 6. Oxygen compliance will be monitored weekly for two weeks and then monthly through the Quality Management Meeting. 7. The Clinical Services Department follows standards as outlined in the 6 th Edition Perry- Potter Clinical Nursing Skills & Techniques for oxygen concentrators. Even though the facility had implemented the interventions referenced above, to ensure that these actions remain in effect and effective, there was insufficient time to assess long-term to continued correction of the deficient practice. Therefore, noncompliance continues, but the scope and severity level will be reduced to the " G " level.

Based on observation, record review, resident interview, and staff interview, the facility failed to ensure that three (3) residents ("A", #4 and #7) who had been assessed and care planned to receive thickened liquids, on the survey sample of nine (9) residents, received thickened liquids per their care plans. The failure of staff to ensure that these residents received thickened liquids represented the likelihood for serious harm for these residents. It was therefore determined that an immediate and serious threat to resident health and safety existed on March 25, 2009, and continues. Findings include: 1. Record review for Resident "A" revealed that the March 2009 physician's orders [REDACTED]. However, during an observation conducted on 03/25/2009 at 8:50 a.m., Resident "A" was observed to be seated in a wheelchair in his/her room by his/her bed. A cup containing unthickened water was sitting on an over-bed table directly in front of the resident within his/her reach, and a pitcher of unthickened water was sitting on the window sill, within the resident's reach. During an interview conducted at the time of the 03/25/2009, 8:50 a.m. observation referenced above, Resident "A" indicated that the unthickened water was his/hers. During an observation conducted on 03/25/2009 at 9:40 a.m., Certified Nursing Assistant (CNA) "CC" was observed providing the resident a pitcher containing unthickened water. Cross refer to F365, example 1, for more information regarding Resident "A". 2. Record review for Resident #7 revealed a March 2009 Dysphagia Initial Plan Of Treatment (Evaluation) which documented that the resident had a [DIAGNOSES REDACTED]. However, during observations conducted on 03/25/2009 at 08:51 a.m., 12:55 p.m., and 2:15 p.m., the resident was observed in the room in the bed, and a water pitcher containing unthickened water was observed on the cabinet located directly in front of the resident's bed. Cross refer to F365, example 2, for more information regarding Resident #7. 3. Record review for Resident #4 revealed that the resident's Interdisciplinary Care Plan contained a 03/14/2009 entry referencing the resident's nutritional risk, with Approaches which included the use of thickened liquids. However, the resident's March 2009 Nursing Assistant Care Card did not identify that the resident needed thickened liquids. During an interview conducted on 03/25/2009 at 1:30 p.m., Corporate Nurse "AA" stated that the facility's protocol was for CNAs to identify residents who were to receive thickened liquids by referencing resident Nursing Assistant Care Cards. Cross refer to F365, example #5, for more information regarding Resident #4. Based on the above, the facility failed to provide a functional system which ensured that residents who were care planned to receive thickened liquids received thickened liquids. This failure represented the likelihood for serious harm for these residents.

Based on observation, record review, resident interview, facility document review, and staff interview, the facility failed to ensure that six (6) residents ("A", #1, #2, #4, #5 and #7) who had been assessed to need thickened liquids, on the survey sample of nine (9) residents, received thickened liquids to meet their individual needs. The failure of staff to ensure that these residents received thickened liquids represented the likelihood for serious harm for these residents. It was therefore determined that an immediate and serious threat to resident health and safety existed on March 25, 2009, and continues. Findings include: 1. Record review for Resident "A" revealed that the March 2009 physician's orders [REDACTED]. The resident's current Interdisciplinary Care Plan referenced a 12/17/2008 entry identifying the resident to be a nutritional risk, with the Approaches including the provision of thickened liquids as ordered. However, the resident's current Nursing Assistant Care Card failed to indicate that the resident was to receive thickened liquids. During an observation conducted on 03/25/2009 at 8:50 a.m., Resident "A" was observed to be seated in a wheelchair in his/her room by his/her bed. During this observation, a cup containing unthickened water was sitting on an over-bed table directly in front of the resident within his/her reach, and a pitcher of unthickened water was sitting on the window sill to the right of the resident, within the resident's reach. During an interview conducted at the time of the 03/25/2009, 8:50 a.m. observation referenced above, Resident "A" indicated that the unthickened water was his/hers. During an additional observation conducted on 03/25/2009 at 9:40 a.m., Certified Nursing Assistant (CNA) "CC" was observed providing the resident a pitcher containing unthickened water. During an interview with CNA "CC" conducted on 03/25/2009 at 2:30 p.m., CNA "CC" stated that earlier in the day, she had filled Resident "A"'s water pitcher with unthickened water and ice, further stating that if a resident had a pitcher, that indicated the resident could receive unthickened water. 2. Record review for Resident #7 revealed a March 2009 Dysphagia Initial Plan Of Treatment (Evaluation), which was signed by both the speech language pathologist and the physician, which documented that the resident had a [DIAGNOSES REDACTED]. The resident's current Interdisciplinary Care Plan referenced a 03/06/2009 entry identifying that the resident was to receive a pureed diet with nectar-thickened liquids. However, the resident's current Nursing Assistant Care Card failed to indicate that the resident was to receive thickened liquids. During observations conducted on 03/25/2009 at 08:51 a.m., 12:55 p.m., and 2:15 p.m., the resident was observed in the room in the bed, and a water pitcher containing unthickened water was observed on the cabinet located directly in front of the resident's bed. 3. Record review for Resident #5 revealed a Weekly Speech Therapy Progress Summary, signed and dated by the speech language pathologist on 03/23/2009, which documented that the resident had been evaluated for dysphagia and that a recommendation was made for nectar-thickened liquids. A 03/23/2009 Physician's Telephone Order sheet documented a physician's orders [REDACTED]. However, during an observation conducted on 03/25/2009 at 12:20 p.m., the resident had a pitcher, one-half full of ice and non-thickened water, on the over-bed table directly adjacent to the bed. Additionally, the resident's current Nursing Assistant Care Card failed to identify that the resident was to receive thickened liquids. During an interview conducted on 03/25/2009 at 2:30 p.m., CNA "CC" stated that Resident #5 had a water pitcher, therefore earlier in the day, she had filled Resident "A"'s water pitcher with unthickened water. During interviews conducted on 03/25/2009 at 8:40 a.m. and 1:30 p.m. with Medication Nurse "BB", when asked to identify the residents who were to receive thickened liquids on the unit upon which he administered medications, he provided the names of Resident #3, Resident #4, and Resident #6, but failed to name Resident #5. During an interview conducted on 03/25/2009 at 4:00 p.m., Nurse "BB" acknowledged that he had previously been unaware that Resident #5 was to receive thickened liquids, but had been made aware that the resident was to receive thickened liquids since the previous interviews. 4. Record review for Resident #1 revealed a 01/02/2009 Dysphagia Initial Plan Of Treatment (Evaluation), signed by the speech language pathologist, and signed and dated by the physician on 01/03/2009, which documented that the resident had a [DIAGNOSES REDACTED]. The resident's diet order on the February 2009 physician's orders [REDACTED]. However, during an interview conducted on 03/25/2009 at 3:15 p.m., Hospice Nurse "GG" stated that she had given this resident unthickened soft drinks in the past. 5. Record review for Resident #4 revealed a 02/26/2009 Dysphagia Initial Plan of Treatment (Evaluation), signed by both the speech language pathologist and the physician, which documented that the resident had a [DIAGNOSES REDACTED]. The resident's Interdisciplinary Care Plan contained a 03/14/2009 entry referencing the resident's nutritional risk, with Approaches which included the use of thickened liquids. However, the resident's March 2009 Nursing Assistant Care Card did not identify that the resident needed thickened liquids. 6. Record review for Resident #2 revealed that the December 2008, and January, February, and March 2009 physician's orders [REDACTED]. However, during an observation conducted on 03/25/2009 at 5:30 p.m., the resident received a pureed diet, but the tea, coffee, and water on the resident's diet tray were thickened. During an interview conducted on 03/25/2009 at 6:00 p.m., Nurse "FF" stated that the resident should have been receiving thickened liquids, further indicating that the order specifying thin liquids was incorrect. During an interview conducted on 03/25/2009 at 1:30 p.m., Corporate Nurse "AA" stated that the facility had no nursing policies related to thickened liquids, but that the facility's protocol was for CNAs to identify residents who were to receive thickened liquids by referencing resident Nursing Assistant Care Cards. During an interview conducted on 03/25/2009 at 4:30 p.m., the Dietary Manager stated that at 8:00 p.m. nightly, dietary staff sent six-ounce glasses of thickened water, coffee, and fruit juice to the nursing units. The Dietary Manager stated that no thickener was provided to the nursing units, and that nursing staff could only obtain thickened liquids by going to the kitchen, before the kitchen closed at 8:00 p.m., to obtain the pre-thickened liquids. During an observation conducted on 03/25/2009 at approximately 4:40 p.m., no thickener or thickened liquids were observed on either nursing unit. Additionally, during an observation conducted on 03/25/2009 at approximately 4:45 p.m., all of the facility's medication carts were observed, and no thickener was available on any of the carts. Based on the above, the facility failed to provide a functional system which ensured that residents who had been assessed and/or care planned to need thickened liquids, and who had been ordered by the physician to receive thickened liquids, received thickened liquids. This failure represented the likelihood for serious harm for these residents.