Every finding on record at Golden Villa

Based on interview and record review, the facility failed to provide routine and emergency drugs and biologicals to its residents or obtain them under an agreement described in S483.70(f) and provide pharmaceutical services including procedures that assure the accurate acquiring, receiving, and dispensing of routine drugs and biologicals to meet the needs of each resident for 1 of 4 (Resident #32) resident reviewed for pharmacy services. The facility failed to administer (3) doses of allopurinol, (3) doses of Bystolic, and (3) doses of diltiazem for Resident #32 on 08/08/2026-08/10/2026. This failure could place residents at risk for not receiving the intended therapeutic benefit of prescribed medications. Findings included: Record review of an undated face sheet revealed Resident #32 was a [AGE] year-old made that admitted to the facility on [DATE] with diagnoses of history of pulmonary embolism (a sudden blockage in an artery of the lung, most often caused by a blood clot that travels from a deep vein in the leg), acute and chronic respiratory failure (occurs when the lungs cannot adequately oxygenate the blood or remove carbon dioxide, leading to dangerously low oxygen or high carbon dioxide levels), and hip replacement. Record review of an admission MDS assessment, dated 08/10/2026, revealed Resident #32 had a BIMS of 10, which indicated moderate memory impairment. Resident #32 required substantial assistance with toileting, dressing, and bed mobility. Resident #32 had shortness of breath at rest, when lying flat and with exertion. Resident #32 took anticoagulant (blood thinner) medications and diuretic (medication for the retention of fluid) medications. Record review of the comprehensive care plan, dated 08/10/2026, revealed a care plan titled Anticoagulation that indicated Resident #32 had atrial fibrillation(a common heart condition where the upper chambers of the heart beat fast and out of sync with the lower chambers), a pacemaker, and received anticoagulant medication. These conditions increased risk for irregular heart rhythm, bleeding, bruising, and fall related injury. Record review of discharge orders from the hospital, dated 08/07/2026, revealed Resident #32 had discharge orders for the following medications:allopurinol (treatment for gout (a build up of uric acid in joints)) 100mg dailyBystolic (blood pressure medication) 20 mg dailydiltiazem (heart rate control and blood pressure medication) 240mg daily Record review of Resident #32's MAR, with a start date of 08/07/2026, revealed the following:allopurinol 100mg daily start date 08/11/2026Bystolic 20mg daily with start date 08/11/2026diltiazem 240mg daily with start date 08/11/2026Attempted to contact RN A on 08/20/2026 at 9:00 a.m. and 2:40 p.m. with no return call. During an interview on 08/20/2026 at 10:00 a.m., the DON stated it was the facility policy when a new admission, such as Resident #32 admitted , the nurse would pull any medication not available from the emergency kit. He stated the emergency kit had most commonly used medications and some narcotics. The DON stated if a medication was not available in the emergency kit his expectation was for the staff to call the MD and get a medication that was equivalent to the missing medication or get an order to start the medication when it was available from the pharmacy. He stated in the case of Resident #32 the allopurinol, Bystolic and diltiazem were not in the emergency kit. He stated the nurse failed to contact the MD and get a therapeutic interchange for those medications and failed to get an order to hold those medications. The DON stated Resident #32 had no adverse effect from not receiving 3 doses of allopurinol, Bystolic, and diltiazem. He stated Resident #32's blood pressure and heart rate were monitored each shift for skilled services, and it was not outside of safe perimeters. He stated Resident #32 had no complaints related to joint pain or gout. During an interview on 08/20/2026 at 11:00 a.m., the MD stated Resident #32 was a very sick man. He stated he had a history of pulmonary embolism (a sudden and dangerous blockage in an artery in the lungs) and was non complaint with taking his blood thinner outside of the facility. He stated he was made aware of the 3 days of missed medication by the facility and stated there was no ill effect on the resident from missing 3 doses of allopurinol, Bystolic, and Diltiazem. He stated Resident #32's vital signs remained stable. The MD stated it was his expectation that medications ordered for the resident be available from the pharmacy by the time the next dose was due. He expected to be informed if medications were not available so he could adjust as needed to the resident's mediation list. He stated it was important to have medication available to keep levels therapeutic in the blood and maintain the effectiveness of the medications. During an interview on 08/20/2026 at 12:00 p.m., the Administrator stated it was his expectation that the pharmacy would deliver the medications for the residents by the morning following the admission if the admission was later in the day. He stated Resident #32 was admitted after 5 p.m. on 08/07/2026, so he expected his night medications and morning medications to be pulled from the emergency kit and the pharmacy to deliver before lunch the day after admitting. He stated he was unsure why the medications were not available from the pharmacy. Record review of the Providing Pharmacy Services policy, undated, reflected, [Pharmacy] will. provide pharmacy and prescription delivery services as specified by the pharmacy provider contract.provide a continuum of pharmaceutical services to the facility and essential medications and services for customers. Ensure that the facility's staff has access to medications, emergency service for medications, and drug information on a twenty-four (24) hour basis. if orders for medications are received from the physician when the pharmacy is closed, the facility may: remind the physician that the pharmacy is closed and that a delay in medication therapy can be prevented by using a drug that is included in the facility's back-up box.if there is no drug substitution, ask the physician if the drug therapy can be initiated the next morning. If a drug is considered essential and cannot be substituted or delayed, please contact [pharmacy] emergency number. The policy did not address medication administration and/or documentation. No further policy was provided upon exit of the facility.

Based on interviews and record reviews, the facility failed to provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service for 4 out of 13 dietary staff. (DA A, DA B, DA C, and DA D) The facility did not ensure DA A, DA B, DA C, and DA D had an appropriate, up to date Food Handler's Certificate before working with food or serving food to residents. This failure could place residents at risk of foodborne illness from food prepared in the kitchen. Findings Included: Record review of the Food Handler's Certificates of completion, provided by the DM on 8/3/26 at 1:30 PM revealed: DA A hired 6/20/2014. Food Handler's Certificate dated 10/25/23. The certificate indicated it was valid for 2 years. She had worked in the kitchen approximately 10 months without a current Food Handler's Certificate. DA B hired 2/1/2018. Food Handler's Certificate dated 10/11/2023. The certificate indicated it was valid for 2 years. She had worked approximately 10 months without a current Food Handler's Certificate. DA C hired 3/6/2024. Food Handler's Certificate dated 3/12/2024. The certificate indicated it was valid for 2 years. She had worked approximately 4 months without a current Food Handler's Certificate. DA D hired 5/11/2019, Food Handler Certificate dated 10/27/2022. The certificate indicated it was valid for 2 years. She had worked approximately 1 year and 9 months without a current Food Handler's Certificate. During an interview on 8/4/26 at 12:02 PM, the DM said dietary staff not having their Food Handler's Certificates up to date could cause food born illnesses if staff did not handle the food properly. She said dietary staff were responsible for keeping their Food Handler's Certificates up to date, but ultimately it was up to her to make sure they completed them timely. During an interview on 08/04/26 at 4:02 DA B stated her Food Handler Certificate had expired and she was unaware. She said it was up to date now (as of 8/4/26). She said it was important to ensure staff's Food Handler Certificates were up to date for food safety for the residents. During an interview on 8/4/26 at 4:10 PM, DA A said she did not know that her Food Handler's Certificate expired 2 years from the date she got it. She said she never really looked at it. She said she did not remember the DM telling her she needed to update it until today. During an interview on 8/4/26 at 4:15 PM, DA C said she had not updated her Food Handler's Certificate. She said she did not remember to update her Food Handler's Certificate and did not remember anyone telling her she needed to. She said it was important to keep it updated for the safety of residents. During an interview on 08/05/2026 at 8:58 AM the ADM provided the Preventing Foodborne Illness-Food Handling Policy. He said that was all he had. During an interview on 08/05/2026 at 10:40 AM, the ADM said he was the supervisor for the kitchen and the DM. He said all staff had been preparing for the survey for months. The DM told him she and the staff were working on the Food Handler's Certificates that needed to be updated, and she told him she would get them all up to date. He gave her his credit card to pay for them. He believed all the Food Handler's Certificates were up to date. He said he wanted it noted the DM was on a 60-day review plan before this survey began. The ADM said on Monday morning, 8/3/26, before the survey began, the DM told him all Food Handler's Certificates were up to date. He said all residents ate from the kitchen. During an interview on 08/05/2026 at 10:56 AM, the DON said staff not being trained properly could cause food born illnesses to residents. He said the DM was responsible for the kitchen and the ADM supervised her. During an attempted phone interview on 08/05/2026 at 12:36 PM, left a message for DA D to return call in regard to her expired Food Handler's Certificate. No return call was received. Record review of a Preventing Foodborne Illness - Food Handling Policy with a revision date of July 2014 indicated: Food will be stored, prepared, handled, and served so that the risk of foodborne illness is minimized.3. All employees who handle, prepare or serve food will be trained in the practices of safe food handling and preventing foodborne illness. Employees will demonstrate knowledge and competency in these practices prior to working with food or serving food to residents.

Based on observation, interviews and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen sanitation. In the refrigerator there were 2 opened/unsealed baggies with sliced turkey. They were not dated. There were 2 baggies of grated carrots that were not dated or labeled. There was one baggie of boiled eggs that was not dated or labeled. These deficient practices could place residents who received meals from the kitchen at risk for food borne illness. Findings included: During an initial tour of the kitchen and interview on 8/3/26 at 9:07 a.m. it was observed in the walk-in refrigerator, there were 2 baggies of what was labeled sliced turkey in the original packaging. The turkey was not dated, and the baggie was not sealed. There were 2 baggies of what the DM said were grated carrots that were not dated or labeled. There was 1 baggie of what the DM said were boiled eggs, that were not labeled or dated. The DM said whatever staff was using the item or food was responsible for making sure the item was sealed, dated, and labeled. But she said she was ultimately responsible for making sure it was done. She asked DA A if she had left the turkey opened, or undated. The DM asked her if she knew anything about the grated carrots or the boiled eggs. DA A said she would not do that and did not do that. During an interview on 8/4/26 at 12:02 PM, the DM said food not stored properly could cause foodborne illnesses to residents. She said staff usually check all food when a food truck comes in and they were unloading it. Their truck came this morning, and the last truck came Friday (7/31/26). She said all staff were responsible for making sure all food was sealed, labeled and dated, ultimately, she was responsible for the kitchen. During an interview on 08/05/2026 at 8:58 AM, the ADM provided the Preventing Foodborne Illness - Employee Hygiene and Sanitary Practices Policy. He said that was all he had. During an interview on 08/05/2026 at 10:56 AM, the DON said undated and unlabeled food in the refrigerator could cause a risk of food spoilage or infection control issues. He said the DM was responsible for the kitchen and the ADM supervised her. Record review of Preventing Foodborne Illness - Employee Hygiene and Sanitary Practices Policy, dated October 2008, provided by the ADM indicated: Policy Statement Food Services employees shall follow appropriate hygiene and sanitary procedures to prevent the spread of foodborne illness. Policy Interpretation and Implementation 1.All employees who handle, prepare of serve food will be trained in the practices of safe food handling and preventing foodborne illness. Employees will demonstrate knowledge and competency in these practices prior to working with food or serving food to residents.

Based on interview and record review the facility failed to ensure an accurate assessment was completed for 1 of 24 residents (Resident #7) reviewed for MDS accuracy. The facility did not ensure Resident #7's quarterly MDS assessment, dated 07/08/26, was accurately coded to reflect his antianxiety medication use. This failure could place residents at risk of not receiving care and services to meet their needs.The findings included: Record review of the face sheet, dated 08/05/26, reflected Resident #7 was a [AGE] year-old male who admitted to the facility on [DATE] with a diagnosis of myoclonus (uncontrollable movement that includes sudden, brief involuntary twitching, jerking, or spasm of a single muscle or a group of muscles). Record review of the quarterly MDS assessment, dated 07/08/26, reflected Resident #7 had clear speech, was understood by others, and was able to understand others. Resident #7 had a BIMS score of 8, which indicated moderately impaired cognition. The MDS reflected Resident #7 was not taking an antianxiety medication during the 7-day look back period. Record review of Resident #7's comprehensive care plan, dated 06/26/26, reflected no care plan was in place to address Resident #7's antianxiety use. Record review of the physician order report, dated 07/05/26 to 08/05/26, reflected Resident #7 had the following orders:1. On 07/01/26 to 07/08/26, Resident #7 had an order for clonazepam (antianxiety and anticonvulsant medication) 0.25 mg - Give 1 tablet by mouth twice a day as needed.2. On 07/08/26, Resident #7's order for clonazepam was changed from as needed to three times a day routinely. Record review of the MAR, dated July 2026, reflected Resident #7 received clonazepam 0.25 mg as needed five times during the 7 day look-back period (timeframe used in assessments or compliance processes to review and document a person's condition, behavior, or status immediately before a specific reference date). During an interview on 08/05/26 at 1:49 PM, MDS Coordinator K stated before she coded medications in Section N on the MDS assessment, she looked up the medication to ensure she was coding the medication in the correct category. She stated when she looked up clonazepam on the internet, she discovered that the medication was classified as an anticonvulsant medication. She stated she knew the medication was also classified as an antianxiety. She stated she should have coded the medication under both classifications, antianxiety and anticonvulsant. She stated she just overlooked it because she was focused on the anticonvulsant part. She stated the DON was responsible for making sure the MDS assessment was coded accurately. She stated it was important to ensure the MDS assessment was accurately coded for medications so a care plan could be developed and staff could monitor for side effects, which included increased falls and risk for poor nutrition. She stated it was important for continuity of care. During an interview on 08/05/26 at 2:14 PM, the DON stated MDS Coordinator K was responsible for making sure the MDS assessment was coded accurately. He stated it was important to ensure the medications were included on the MDS assessment to ensure a plan of care was developed and staff knew how to address Resident #7's anxiety. During an interview on 08/05/26 at 2:23 PM, the Administrator stated he expected the MDS assessments to be coded accurately and included all aspects of care each resident was receiving. He stated MDS Coordinator K was responsible for making sure the MDS assessment was coded accurately. The Administrator stated it was important to ensure the medication section was coded accurately so the staff were aware of how to care for each resident, to ensure resident safety, and to monitor for drug interactions. Record review of the MDS Policy for MDS assessment Data Accuracy, undated, reflected The purpose of the MDS policy is to ensure each resident receives an accurate assessment by qualified staff to address the needs of the resident who are familiar with his/her physical, mental, and psychosocial well-being. The RN is responsible for the coordination of each resident MDS assessment. By signing the assessment, the RN is certifying that each section was completed by the appropriate person and that the individual is qualified to determine the accuracy of the portion of the resident's assessment he/she completed.

Based on interview and record review, the facility failed to implement a comprehensive person-centered care plan to meet residents' medical, nursing, mental and psychosocial needs identified in the comprehensive assessment for 1 of 24 residents reviewed for comprehensive care plans. (Resident #7) The facility failed to ensure Resident #7's antianxiety medication usage was included in the comprehensive care plan. This failure could place residents at risk of not having individual needs met and a decreased quality of life. The findings included: Record review of the face sheet, dated 08/05/26, reflected Resident #7 was a [AGE] year-old male who admitted to the facility on [DATE] with a diagnosis of myoclonus (uncontrollable movement that includes sudden, brief involuntary twitching, jerking, or spasm of a single muscle or a group of muscles). Record review of the quarterly MDS assessment, dated 07/08/26, reflected Resident #7 had clear speech, was understood by others, and was able to understand others. Resident #7 had a BIMS score of 8, which indicated moderately impaired cognition. The MDS reflected Resident #7 was not taking an antianxiety medication during the 7-day look back period. Record review of Resident #7's comprehensive care plan, dated 06/26/26, reflected no care plan was in place to address Resident #7's antianxiety use. There was a care plan to address anticonvulsant medication usage but only included gabapentin for chronic pain. Record review of the physician order report, dated 07/05/26 to 08/05/26, reflected Resident #7 had the following orders:1. On 07/01/26 to 07/08/26, Resident #7 had an order for clonazepam (antianxiety and anticonvulsant medication) 0.25 mg - Give 1 tablet by mouth twice a day as needed.2. On 07/08/26, Resident #7's order for clonazepam was changed from as needed to three times a day routinely. During an interview on 08/05/26 at 1:49 PM, MDS Coordinator K stated a comprehensive care plan was not developed for the clonazepam (antianxiety and anticonvulsant medication) because Resident #7 had a care plan in place for anticonvulsant usage. She stated she was unaware the anticonvulsant care plan did not include clonazepam. MDS Coordinator K stated she was responsible for ensuring the care plans were updated and accurate. She stated she should have developed a care plan for the antianxiety medication usage. She stated it was important to ensure the comprehensive care plan accurately reflected the resident's' current status for communication with the staff and continuity of care. During an interview on 08/05/26 at 2:14 PM, the DON stated MDS Coordinator K was responsible for ensuring the care plans accurately reflected the resident's status. He stated he expected antianxiety medication to have been included on the comprehensive care plan. He stated it was important to ensure a plan of care was developed so the facility staff knew how to address Resident #7's anxiety. During an interview on 08/05/26 at 2:23 PM, the Administrator stated he expected the comprehensive care plan to have been up to date and reflected all aspects of care each resident was receiving. He stated MDS Coordinator K was responsible for making sure the care plan was completed and up to date. The Administrator stated it was important to ensure antianxiety medication was included on the comprehensive care plan, so the staff were aware of how to care for each resident, to ensure resident safety, and to monitor for drug interactions. Record review of the Care Plans, Comprehensive Person-Centered policy, dated December 2016, reflected The Interdisciplinary Team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. assessments of residents are ongoing and care plans are revised as information about the residents and the residents' condition changes.

Based on observation, interview, and record review the facility failed to ensure a resident who needed respiratory care was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals, and preferences for 1 of 2 residents (Resident #98), reviewed for respiratory care and services. 1. The facility failed to ensure Resident #98's oxygen was on 2 liters continuously on 8/4/2026 following return from hospital for respiratory failure with hypoxia on 8/3/2026. This failure could place residents at risk for developing respiratory complications. Findings included: 1. Record review of Resident #98's Face sheet dated 8/4/2026 indicated an [AGE] year-old male who was readmitted to the facility on [DATE]. Resident #98 had diagnoses which included acute on chronic respiratory failure with hypoxia (a condition in which a person with long-standing respiratory problems experiences a sudden decline that exceeds the body's compensatory mechanism), Atrial Fibrillation (an irregular heart rhythm that originates in the heart's upper chambers), acute on chronic systolic heart failure (a sudden worsening of symptoms in a patient with pre-existing chronic systolic heart failure), urinary tract infection (an infection in any part of the urinary system) and pneumonia (an infection that inflames the air sacs in one or both lungs, which may fill with fluid or pus leading to symptoms such as cough, fever, chills, and difficulty breathing). Record review of Resident #98's quarterly MDS dated [DATE] indicated he was able to make himself understood and understood others. Resident #98 had a BIMS score of 8 indicating Resident #98 was moderately impaired cognitively. Resident #98 required substantial assistance with toileting, bathing, and dressing upper and lower body. Resident #98's MDS did not indicate he was on oxygen. Resident #98 had oxygen order added on 7/20/2026 after MDS was completed. Record review of Resident #98's care plan dated 4/13/2026 indicated he had pulmonary hypertension, causing elevated pressure in the pulmonary arteries and increasing risk for right side heart strain, hypoxia (a serious medical condition where your body tissue does not get enough oxygen to function properly), dyspnea (shortness of breath), fatigue, edema (swelling caused by fluid trapped in body tissue) , and reduced activity tolerance. Interventions included to administer medications as ordered and monitor for side effects, administer oxygen only as ordered by the MD, assist with ADLs as needed to prevent overexertion, avoid tight clothing that may restrict circulation, avoid unnecessary exertion that my worsen hypoxia, and check oxygen saturation per order and observe for cyanosis (bluish or purplish color of the skin) or hypoxia. Record review of a nurse evaluation dated 8/3/2026 at 3:20 PM, indicated Resident #98 was readmitted to facility with diagnosis of Acute on Chronic hypoxia with respiratory failure. The nurse evaluation indicated Resident #98 was on 2 liters of oxygen and no oxygen saturation was documented on the LVN Record review of MAR dated 8/1/2026-8/31/2026 indicated Resident #98 had orders for Oxygen at 2 liters via nasal cannula every shift for Acute on Chronic systolic congestive heart failure (a sudden worsening of symptoms in a patient with pre-existing chronic systolic heart failure) started on 7/20/2026. Resident #98's oxygen saturation (refers to the fraction of hemoglobin binding sites occupied by oxygen in the blood with normal ranges 95-100% normal, mildly low 90-94% and below 90% hypoxemia which compromise organ function) was 96 % on 2 liters of oxygen between 6:00 AM and 6:00 PM on 8/3/2026 and 8/4/2026. Record review of Hospital records dated 8/3/2026 indicated Resident #98 was hospitalized from [DATE]-[DATE] for diagnosis of acute on chronic hypoxic respiratory failure. Resident #98's discharge records did not have oxygen listed. During an observation on 8/4/2026 at 1:56 PM, observed Resident #98 lying in bed with oxygen concentrator in the corner of his room with water bottle for humidifier dated 7/28/2026 with tubing on the floor. Resident #98 had received catheter care during observation. Resident #98's oxygen concentrator was not on during the catheter care. During an interview 8/4/2026 at 2:24 PM, LVN F reviewed Resident #98's records and said resident was on oxygen as needed while in the hospital. LVN F said she received Resident #98 back from the hospital on 8/3/2026. LVN F said Resident #98's oxygen saturation was 96% on room air. LVN F said Resident #98 was in the hospital for acute on chronic hypoxia with respiratory failure LVN F reviewed the paper MAR she had documented Resident #98's oxygen level was 96% on 2 liters of oxygen on 8/3/2026. LVN F said he was not wearing his oxygen yesterday. During an interview and observation on 8/4/2026 at 2:34 PM, the DON came over to LVN F while reviewing Resident #98's chart. The DON said Resident #98 should be wearing his oxygen at 2 liters. The DON took the pulse oximeter (a noninvasive method to measure the oxygen saturation of blood) and wanted to assess Resident #98. The DON entered Resident #98's room at 2:42 PM, applied the pulse oximeter and reading was 90% on room air. The DON asked Resident #98 to take some deep breaths. Resident # 98 denied feeling short of breath but complained of nausea. The DON asked Resident #98 if he wanted to take medication for nausea. At 2:46 PM, Resident #98's oxygen increased to 96% on room air. The DON asked LVN F to obtain new tubing and water for the concentrator and he set up Resident #98's oxygen and placed the nasal cannula with setting on 2 liters. During an interview on 8/5/2026 at 9:29 AM, RN H said a resident who returns from the hospital who had oxygen should have their oxygen saturation level checked within 30 minutes of returning to the facility. RN H said the skin assessment could be completed within 24 hours. RN H said if a resident had oxygen prior to hospitalization, the resident should have oxygen on when they return unless the hospital discontinued the orders. RN H said if she was unsure, she would clarify with the Physician. RN H said a resident could go into respiratory distress or be sluggish if they were not wearing their oxygen as ordered. RN H said if a resident's oxygen saturation were greater than 90% on room air, she would notify the Physician to see if the resident still needed the oxygen. RN H said if a resident had a history of respiratory distress or hypoxia, she would assume they need their oxygen. RN H said the nurse was responsible for clarifying orders and following oxygen orders. During an interview on 8/5/2026 at 12:15 PM, ADON G said the nursing staff on the night shift changed out the oxygen tubing and nebulizer tubing was changed on Tuesday and Wednesdays. ADON G said the Administration/dept heads followed up on Fridays to ensure the tubing was changed. ADON G said Resident #98 takes his oxygen off. ADON G acknowledged the concentrator was not on at the time the oxygen tubing was identified on the floor and not running. ADON G said Resident #98 refused his oxygen when he returned to the facility. ADON G said he was not sure if the nurse documented the refusal. ADON G said the nurse should have documented Resident #98's refusal to wear oxygen upon returning. ADON G said the resident could cause desaturation (when blood oxygen levels are low) if he was not wearing his oxygen, resulting in hypoxia or respiratory failure. ADON G said the resident returned to the facility with diagnoses of pneumonia and urinary tract infection with retention. ADON G said the facility reviewed the high-risk residents on Thursdays. ADON G said he expected the nurse to clarify orders if they were not sure if a resident should resume oxygen orders. ADON G said the nurse should attempt to reapply oxygen if the resident refused and the physician should be notified. ADON G said the physician was not notified. ADON G said the nurse was responsible for ensuring Resident #98 had oxygen or clarified orders for oxygen. During an interview on 8/5/2026 at 1:02 PM, the DON said he expected oxygen to resume on Resident #98 upon returning from the hospital. The DON said Resident #98 did not refuse the oxygen. The DON said he expected the concentrator to be on if he took off his oxygen on his own. The DON said he expected the nurse staff to clarify orders with Physician or notify MD if a resident continued to refuse oxygen. There was no documentation indicating the resident refused. The DON said he expected the tubing to not be on the ground and to be in bag. The DON said oxygen tubing on the floor could cause infection. The DON said if a resident did not resume his oxygen following hospitalization, the resident could desaturate, have worsening breathing issues resulting in negative effects. The DON said everyone was responsible, but the nurse assigned to Resident #98 was responsible for the orders being followed. Record review of a facility policy titled Oxygen Administration revised October 2010 indicated .purpose of this procedure is to provide guidelines for safe oxygen administration. Preparation.1. Verify that there is a physician's order for this procedure.2. Review the resident's care plan to assess for any special needs.3. Assemble the equipment and supplies as needed.General guidelines.1. Oxygen therapy is administered by way of an oxygen mask, nasal cannula.b. nasal cannula is a tube that is placed approximately one-half inch into the resident's nostrils.Assessment.before administering oxygen, and while the resident is receiving oxygen therapy.signs or symptoms of cyanosis (blue tone to the skin or mucous membranes).signs of hypoxia (rapid breathing, rapid pulse rate, restlessness, confusion).signs and symptoms of oxygen toxicity (tracheal irritation, difficulty breathing, or slow, shallow rate of breathing).Vital signs.lung sounds.Steps in the procedure.turn on oxygen .adjust the oxygen delivery device.securely anchor the tubing.observe the resident upon setup.Documentation.date and time.name and title of individual who performed.the frequency and duration of the treatment.reason for as needed administration.all assessment data obtained before, during and after.how the resident tolerated.

Based on observations, interviews, and record review, the facility failed to ensure all drugs were stored in a locked compartment and only accessible by authorized personnel for 1 of 1 (Resident #34) residents reviewed for medication storage and 1 of 9 of medication carts. 1. The facility failed to keep medication being administered under the direct observation of the person administering medications. Resident #34 had in his possession a bottle of prescription strength Nystatin Topical Powder 100,000 units per gram. 2. The facility failed to ensure Medication Cart #1 was secured on 8/3/2026 at 11:40 AM. This failure could place residents at risk of having access to unauthorized medications, leading to harm or drug diversions. Findings included: 1. Record review of Resident #34's face sheet, dated 10/18/24, indicated she was an [AGE] year-old female, admitted to the facility on [DATE]. Her diagnoses included Dementia (an umbrella term for a decline in mental ability severe enough to interfere with daily life), Psychotic Disturbance (a mental state where a person loses touch with reality), and Mood Disturbance (persistent, severe shifts in a person's emotional state, commonly seen in conditions like major depression and bipolar disorder). Record review of Resident #34's Quarterly MDS assessment, dated 05/20/26, indicated she had a BIMS score of 07, which indicated severe cognition impairment. The MDS further indicated she had dementia and required maximal assistance with activities of daily living. Record review of Resident #34's care plan indicated that a problem initiated on 10/19/2024 revealed that Resident #34 had cognitive impairment with potential for behavioral issues related to Dementia. During an interview and observation on 08/03/2026 at 9:14 a.m. it was observed that Resident #34 had a bottle of prescription strength Nystatin Topical Powder 100,000 units per gram sitting on her bedside dresser. The bottle cap was off and the powder was exposed. Resident #34 said she did not know what it was for or if she actually used that medication. She said she did not know how long it had been there. During an interview on 08/05/2026 at 12:50 p.m. the Director of Nurses said it was the responsibility of nurses and any staff that observed medication in a resident's room to ensure that it was taken and stored properly. He said that residents could potentially misuse medications that are within their reach. During an interview on 08/05/2026 at 1:08 p.m. the Administrator said that it was the responsibility of all staff to ensure that residents' medications were not left in residents' rooms and it was the responsibility of the staff that provided the medication to ensure it was stored properly after use. He said that there is potential for a resident to misuse a medication if it was freely available. 2. During an observation on 8/3/2026 at 11:40 AM, a medication cart identified as medication cart #1 for hall 300/600 was unlocked and unattended in the middle of the hall located in front of the dining hall entrance. All drawers were able to open. The Administrator came over to the medication cart #1 and was looking for the nurse. The Administrator found LVN F, and she returned to her medication cart. There were multiple residents and staff members in hallway assisting residents in the dining room for lunch. During an interview on 8/3/2026 at 11:43 AM, LVN F returned to Medication cart #1. LVN F said she could see her medication cart #1 from the dining room, but the drawers were not facing the dining hall. LVN F said she did not realize her medication cart was unlocked. LVN F said she was checking on a resident. LVN F said a resident or visitor could take medication from her cart or cut themselves on needles in the medication cart. LVN F said she was responsible for ensuring her medication cart was locked. LVN F identified the medication cart was for halls 300 and 600. During an interview and observation on 8/5/2026 at 9:24 AM, LVN J reviewed medication cart for hall 300 and 600. The medication cart for hall 300/600 had insulin (a hormone produced by the pancreas that regulates blood sugar by enabling cells to absorb glucose for energy and storage), lancets (small, sharp medical devices used to obtain blood samples), insulin syringes (single-use disposable medical device designed for accurate insulin dosing) and alcohol swabs in the top drawer. Review of second drawer revealed 2 narcotic lock boxes and prescription blister packets (are pre-organized medication with the exact dose ordered), the third drawer revealed breathing treatments (therapies designed to help improve lung function and alleviate respiratory issues), vitamins and over the counter medications and the fourth drawer revealed overflow of lancets and insulin syringes. During an interview on 8/5/2026 at 9:24 AM, LVN J said the nurse assigned to the medication cart was responsible for ensuring the cart was secured and locked. LVN J said the only time the medication cart should be unlocked was when the nurse was administering medications or treatments. LVN J said the nurse assigned should not leave their medication cart unattended and unlocked while in a resident room, even if the medication cart was in the hall. LVN J said the cart should not be unlocked. LVN J said a resident or visitor could take medications out of the medication cart. LVN J said a resident or visitor could have an allergic reaction or cause them harm by making them sick if they took medication that was not prescribed to them. During an interview on 8/5/2026 at 9:29 AM, RN H said the nurses were responsible for ensuring the medications carts were locked. RN H verified the assigned nurse was responsible for the medication cart. RN H said a resident or visitor could take medication that was not prescribed to them. RN H said a resident or visitor could have an allergic reaction, anaphylaxis (a severe, potentially life-threatening allergic reaction), or lower blood pressure if a person took a blood pressure medication. RN H said taking medication not prescribed could also cause death. RN H said medication carts should only be unlocked when the nurse was using the cart to pass medications and standing directly in front of the medication cart. During an interview on 8/5/2026 at 12:15 PM, ADON G said the medication cart was the nurses and MAs were responsible for keeping the medication cart locked. ADON G said the ADM and the Administrative Department heads also watch for unlocked medication carts. ADON G said the medication carts should only be unlocked while passing medications. ADON G said the medication cart should not be unlocked in the hallway. ADON G said a resident could try to take medications from the medication cart. ADON G said it depended on what medication was taken as to what could happen. ADON G said if medication were taken, it could make a resident sick and cause harm such as having too much of a medication in their system or the medication could throw off the resident's electrolytes. ADON G said anytime a nurse leaves their medication cart, it must be locked. ADON G said the assigned nurse was responsible for their medication cart. During an interview on 8/5/2026 at 1:02 PM, the DON said he expected the nurse to keep the medication cart locked when not in use. The DON said the medication cart should be locked anytime the nurse is away from the cart. The DON said the nurse assigned to the medication cart was responsible. The DON said a medication diversion could occur; a resident or visitor could digest a medication not prescribed to them making them sick, overdose or cause an allergic reaction. During an interview on 8/5/2026 at 1:37 PM, the Administrator said he expected the nurse to keep the medication cart locked and secure. The Administrator said he saw where the medication cart was parked in the hallway and said it should not have been parked there. The Administrator said an unlocked cart could cause a drug diversion; a dementia resident could get in the unlocked medication cart and take out medications not prescribed. The Administrator said the nurse was the first line of defense. The Administrator said a medication taken out the medication cart and taken could cause harm such as interact with other medications, an allergic reaction or kill them. The Administrator said the nurse administration was responsible for ensuring the medication carts were locked. Review of the facility's policy titled Pharmacy Services Policy undated indicated .The facility will provide and obtain pharmaceutical services to meet the needs of each resident. Medications will be provided safely, accurately, and in accordance with physician orders, federal regulations, and state law.Procedures.3. Medication storage. Medications will be stored securely in locked medication rooms, carts, or automated dispensing systems.controlled substances will be stored in double-locked systems.refrigerated medications will be stored at proper temperatures and monitored daily.

Based on observation, interview and record review the facility failed to ensure nurse staffing data was posted daily and readily accessible to residents and visitors with all required information for the facility reviewed for nurse staffing posting. The facility failed to post the required current daily staffing information since February 2026. This failure could place residents, families, and visitors at risk of not being informed of the census and number of staff working each day to provide care on all shifts. The findings included: During an observation and interview on 08/04/26 beginning at 3:26 p.m., the nurse staffing was not posted anywhere in the facility. The DON stated it was normally posted where the Resident Rights poster was hanging. The Administrator stated he was unable to find the nurse staffing postings. The Administrator stated the Staffing Coordinator was responsible for completing the nurse staffing daily and posting it in a visible area. During an interview on 08/05/26 at 2:07 p.m., Staffing Coordinator L stated she recently started her position in February 2026. She stated when she took over the position, it was not explained that she was responsible for completing the nursing staff posting. She stated she had not posted the nurse staffing sheet, since she started at the facility. She stated she completed the posting for 08/04/26 and 08/05/26 and would continue to complete them going forward. She stated it was important to ensure the nurse staffing was posted daily so the residents' and the residents' families would know the staffing levels for that day. She stated the facility staff could also be made aware of the staffing levels and management could ensure the facility was staffed appropriately. During an interview on 08/05/26 at 2:14 p.m., the DON stated the Staffing Coordinator recently started her position and had not been informed she was responsible for completing the nurse staff posting. He stated he believed he had seen the staffing hanging on the wall in the last few weeks but was unsure when it was dated. He stated it was important to ensure the nurse staffing was posted because it places the residents' and residents' families at ease when they were able to see exactly how much staffing was scheduled for that day. He stated having the staffing posted gave everyone an idea of what the staffing levels looked like. During an interview on 08/05/26 at 2:23 p.m., the Administrator stated he was unsure when the last time the nurse staffing was posted. He stated the previous Staffing Coordinator left around January or February 2026. He stated the Staffing Coordinator was responsible for ensuring the nurse staffing was posted. He stated the DON was responsible for monitoring to ensure the nurse staffing was posted. He stated it was important to ensure the nurse staffing was posted because it gave the staff an idea of the staffing levels, management was able to ensure the staffing levels were appropriate, and to ensure the facility was staffed according to the facility assessment. Record review of the Posting Direct Care Daily Staffing Number policy, dated July 2016, reflected Our facility will post, on a daily basis for each shift, the number of nursing personnel responsible for providing direct care to residents.

Based on observation, interview, and record review the facility failed to ensure all drugs and biologicals used in the facility were labeled and stored in accordance with professional standards for 2 of 8 medication carts (200 Hall Medication Cart and 300 Hall Medication Cart) reviewed for drugs and biologicals. The facility failed to ensure the 200 Hall Medication Cart and the 300 Hall Medication Cart were properly secured when Medication Aide A left the facility and left them unlocked and unattended on 06/12/2026. This failure could place residents at risk of not receiving drugs and biologicals as needed, medication errors, medication misuse, and drug diversion.Findings included: During an observation and interview on 06/12/2026 at 3:52 PM, 200 Hall Medication Cart and 300 Hall Medication Cart were noted at the nurse's station unlocked and unattended. Staff members were observed walking by the unlocked medication carts. A resident was also observed standing next to the unlocked medication carts. The DON approached the medication carts and locked them. The DON stated he was not aware that the medication carts were left unlocked and unattended. The DON said he was unsure of who the medication carts were assigned to. The DON went to get the master keys from his office and the Staffing Scheduler. When the DON opened the 200 Hall Medication Cart, the keys for the medication carts ( 200 Hall and 300 Hall) were noted to be in the top drawer. The DON and Staffing Scheduler counted both carts. The DON then said Medication Aide A was assigned to both medication carts. The DON said he did not see a problem with the two medication carts being unlocked and unattended because the medications carts were now locked and had been counted down. During an interview on 06/12/2026 at 04:10 PM, the Staffing Scheduler said MA A had told her she had an emergency and had to leave the building and would be right back. The Staffing Scheduler said she was responsible for oversight of the MA. The Staffing Scheduler said she expected Medication Aide A to have counted down the assigned medication carts with the charge nurse and hand over the keys prior to leaving the facility. The Staffing Scheduler said she had not realized the MA A had left the facility without following the proper procedures. The Staffing Scheduler said she expected all staff to ensure the medication carts were locked when unattended. The Staffing Scheduler said the medication cart keys were to stay secured by the assigned staff member to prevent misappropriation and/or a drug diversion. The Staffing Scheduler said it was important to ensure the medication carts were locked when leaving unattended to prevent misappropriation, drug diversion, or residents not receiving their medications timely. The Staffing Scheduler said she believed the ADON conducted random rounds to check to ensure the medication carts were secured. During an interview on 06/12/2026 at 04:20 PM, the ADON said the nurses were responsible for ensuring the medication carts were locked. The ADON said if the medication cart was left unlocked somebody could access the medications or treatments in it. The ADON said the clinical staff did random walk throughs in the halls to verify the medication carts were locked appropriately. During an interview on 06/12/2026 at 4:55 PM, MA A said she had a family emergency and had to leave the facility quickly. MA A said she should have counted the medication carts down with the charge nurse and turned over the keys to her at that time but did not. MA A said it was important for the medication cart to be locked because they had dementia patients, and someone could go and take stuff. MA A said that it was dangerous for the medication cart to be left unlocked. During an interview on 06/12/2026 at 04:50 PM, the Corporate Consult Regional Nurse said medication carts should be locked when not within eyesight. The Corporate Consult Regional Nurse said she expected DON/ADONS to monitor for proper storage of medications and locked medication carts by walking down the hallways daily, and providing education if errors were observed. The Corporate Consult Regional Nurse said unlocked medication carts could result in somebody getting into the medication cart, medications getting stolen, and a resident who did not know could take medications they should not be taking. During an interview on 06/12/2026 at 04:55 PM, the Administrator said he expected the staff to follow the rules and lock the medication carts when leaving unattended. The Administrator said unlocked medication carts placed the residents at risk of taking the medications and the staff could also take the medications as well. Record review of the facility's policy, Storage of Medications, dated 04/2017, indicated, The facility shall store all drugs and biologicals in a safe, secure, and orderly manner. 7. 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 interviews and record review, the facility failed to ensure the facility assessment was reviewed and updated as necessary, and at least annually, to include the resident population, diseases, conditions, physical and behavioral health needs, cognitive status, acuity of the resident population, and other pertinent information for 1 of 1 facility.The facility failed to include any resident disease, conditions, physical and behavioral health needs, cognitive status, and acuity of the resident population as well as the number of staff to care for the resident population on the Facility Assessment.This failure could affect residents by not having the necessary resources to ensure appropriate care was provided.Findings included: Record review of the facility assessment dated [DATE] revealed, .The Facility Assessment is required by the nursing home Requirements of Participation to identify and analyze the facility's resident population and identify the personnel, physical plant, and environment and emergency response resources needed to competently care for the resident during day-to-day operation, including nights and weekends, and emergencies. The section titled Resident Acuity section did not indicate an outline of the acuity of their resident population. The section titled Special Treatments and Conditions did not indicate any information concerning the resident population. Part 3: Facility Resources Needed to Provide Competent Support and Care for our Resident Population Every Day and During Emergencies in the section titled Staff Planning did not indicate the number of nurse aides needed for the day shift, evening shift and the night shift. During an interview on 05/19/2026 at 1:09 p.m., the Administrator stated he must have overlooked adding the resident acuity information and the number of nurse aides needed to provide the care. He stated the purpose of the facility assessment was to give a summary of the types of residents they cared for and give a base for how many different staff it would take to care for the different levels of acuity in the facility. He stated it was an important tool for the facility to use to provide care that promoted quality of life for the residents, and though it was not looked at every day for staffing purposes, it was a guide to the facility on how many people to staff in the different positions, like nurses and CNAs on each shift. He stated he did not feel missing the information affected the facility because they still staffed based on resident need. An undated policy titled 'Facility Assessment' revealed the facility assessment includes a detailed review of the resident population. This part of the assessment includes: a. Resident census data from the previous 12 months;b. Resident capacity of the facility and its occupancy rate for the past 12 months;c. Factors that affect the overall acuity of the residents, such as the number and percentage of residentswith:(1) Need for assistance with ADLs;(2) Mobility impairments;(3) Incontinence (bowel or bladder);(4) Cognitive or behavioral impairments; and(5) Conditions or diseases that require specialized care (e.g., dialysis, ventilators, wound care). The facility assessment also includes a detailed review of the resources available to meet the needs of the resident population. This part of the assessment includes: e. All personnel, including:(1) Directors;(2) Managers;(3) Regular employees (full and part time);(4) Contracted staff (full and part time); and(5) Volunteers.

Based on interview and record review, the facility failed to provide or obtain laboratory services to meet the needs of 1 of 5 (Resident #1) residents reviewed for laboratory services.The facility failed to obtain a urinalysis with culture and sensitivity (a laboratory test that grows and identifies bacteria or yeast in a urine sample to diagnose a urinary tract infection. The sensitivity test is then performed on the cultured germs to determine which specific antibiotic, or antifungal medication will effectively treat the infection) for Resident #1 per physician's order placed on 12/18/26.This failure could place residents at risk of delays in treatment, and/or deterioration in condition Findings include:Record review of a face sheet dated 05/18/26 revealed Resident #1 was an [AGE] year-old female admitted to the facility on [DATE] with the diagnoses including dementia, coronary artery disease, and chronic kidney disease.Record review of a quarterly MDS assessment dated [DATE] revealed Resident #1 had a BIMS score of 07, which indicated severe cognitive impairment. The MDS indicated Resident #1 required supervision or touching assistance with ADLs.Record review of a care plan last revised on 04/13/26 revealed Resident #1 experienced symptoms of fatigue, weakness, and confusion related to anemia. There was an intervention to obtain lab reports and report to physician as ordered.Record review of physician's orders dated 12/18/25 revealed Resident #1 had an order for a urinalysis with culture and sensitivity.Record review of the health record on 05/09/26 revealed Resident #1 had no lab results for the ordered urinalysis with culture and sensitivity.During an interview on 05/19/26 at 1:50 p.m., the DON said he was on vacation in December 2025. He said ultimately, he was the one responsible for making sure urinalysis and lab work were followed through with. He said he was not aware that Resident #1 had an order. He said normally those orders came through their morning meetings. He said he was not sure why it had not been done. He said it was important to follow orders to improve resident outcomes. He said the doctor wrote those orders as a diagnostic test and it was their responsibility to carry those orders out.During an interview on 05/19/26 at 1:58 p.m., the Administrator said they had been unable to find the urinalysis results for Resident #1 that were ordered on 12/18/25. He said he was not sure if she had refused or what had happened. He said he could not find any documentation about the urinalysis except for the order. He said it was important for any order to be completed so they knew how to treat the resident. He said it was super important for the well-being of the resident and quality of care.Record review of the Lab and Diagnostic Test Results - Clinical Protocol facility policy last revised September 2012 indicated, .The physician will identify and order diagnostic and lab testing based on diagnostic and monitoring needs.The staff will process test requisitions and arrange for tests .A nurse will review all results.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards in 1 of 1 kitchen reviewed for food service safety.The facility failed to ensure frozen food items were stored properly in their walk-in freezer.This failure could place residents at risk of foodborne illness and food contamination.Findings include:Findings include:During an observation on 05/18/26 at 10:15 a.m., in the walk-in freezer there was a thin ice buildup on the ceiling of freezer. On the left top shelf, there were bags of food items with thick frost build-up. The bags were stuck together into one lump and could not be pulled apart to check dates or labels. In the center of the freezer, there were three stacks of boxes approximately 5 - 6 feet high on top of plastic milk crates and a cart with boxes on it. The stacks of boxes and cart were blocking access to the shelves in the freezer.During an interview on 05/19/26 at 1:04 p.m., Dietary Aide A said they had problems with the freezer for years. She said they need a day to actually get everything out and clean it. She said one person could not clean it by themselves. She said to access the shelves they had to pull out all three stacks of boxes and the cart with boxes. She said the bags of food on the shelves were covered with frost and frozen together. She said there was no way to check the dates on the bags. She said the food could very well be freezer burned and there was no way to tell with them covered in frost and stuck together. She said she could not say if the bags of food on the shelves were bad or good.During an interview on 05/19/26 at 1:11 p.m., the Dietary Manager said the freezer was a disaster. She said they had not had time to clean it. She said they had only been adding food to the freezer. She said she was aware of the frost buildup on the bags of foods on the shelves and not being able to pull the bags apart to check for dates or labels. She said it was important to make sure all foods were accessible to make sure they were not freezer burnt. She said if freezer burnt food or out of date food were served to a resident, it could make them sick. When asked how they functioned in the freezer she said, very carefully.During an interview on 05/19/26 at 1:35 p.m., the DON said it was important to serve fresh foods. He said mealtime was one of the favorite times for the residents. He said it was important for the food to be rotated out in the freezer to prevent spoilage and infection.During an interview on 05/19/26 at 1:58 p.m., the Administrator said everything in the freezer should be unpacked, labeled, and stored in the right order. He said there should not be any boxes in the freezer. He said he would expect for the freezer to be defrosted. He said he was not sure why it was not, because it was a self-defrosting freezer. He said food that was not stored properly could change the food quality and nutritional value.Record review of the Sanitization facility policy last revised October2018 indicated, .The food service area shall be maintained in a clean and sanitary manner.All kitchens, kitchen areas and dining areas shall be kept clean.The Food Services Manager will be responsible for scheduling staff for regular cleaning of kitchen and dining areas. Food service staff will be trained to maintain cleanliness throughout their work areas during all tasks, and to clean after each task before proceeding to the next assignment.

Based on observations, interviews and record review, the facility failed to maintain clinical records on each resident that were complete and accurately documented in accordance with accepted professional standards and practices for 1 (Resident #1 of 14 residents reviewed for accuracy and completeness of clinical records. 1.The facility failed to document the blood pressure and heart rate for parameters established by the physician for administering Resident #1's carvedilol (blood pressure medication) 8 PM dose from 3/1/26-3/19/26. This failure could place residents receiving blood pressure medications at risk of experiencing unsafe drops in blood pressure and heart rate.Findings included:Record review of Resident #1's face sheet dated 3/25/26 indicated she was [AGE] years old and admitted to the facility on [DATE]. Resident #1 had diagnoses including heart failure, heart disease, and hypertension (high blood pressure).Record review of Resident #1's admission MDS assessment dated [DATE] indicated she had a BIMS of 9, which indicated she had moderate cognitive impairment. The MDS indicated Resident #1 required substantial staff assistance for most ADLs.Record review of Resident #1's undated Care Plan indicated the resident had hypertension, which placed her at risk for stroke (blockage or bleed of blood vessels in the brain, killing brain cells), heart disease . required monitoring, medication management, lifestyle support, and safety interventions. The interventions included administering antihypertension medications (lower blood pressure) as ordered, check and document blood pressure per MD order, hold (do not give) medication and notify MD per facility protocol if blood pressure was below ordered parameters.Record review of Resident #1's Physician Order Report dated 3/01/26 - 3/31/26 revealed an order for carvedilol 3.125 mg 1 tablet by mouth every 12 hours at 8 AM and 8 PM, with special instructions to hold (not give) for systolic blood pressure (top number) less than 105, diastolic blood pressure (bottom number) less than 60, and a heart rate less than 60, with a start date of 2/24/26. There was an order to monitor vital signs daily-if medication was held, notify the nurse- hold parameters per medication once daily between 6 AM to 6 PM, with a start date of 2/24/26.Record review of Resident #1's Nursing MAR dated 3/01/26-3/31/26 revealed an order for carvedilol 3.125 mg 1 tablet by mouth every 12 hours at 8 AM and 8 PM, with special instructions to hold for systolic blood pressure less than 105, diastolic blood pressure less than 60, and a heart rate less than 60, with a start date of 2/24/26. There were no blood pressures or heart rates documented for the 8 PM dose administration from 3/01/26 through 3/19/26.During an interview on 3/25/26 at 11:20 AM, the DON said when a medication, such as a blood pressure medication, with vital sign (blood pressure and heart rate) parameters set by the physician, the vital signs would be documented on the MAR. The DON said there was not a place for a second set of vital signs related to Resident #1's 8 PM carvedilol dose on the 3/1/26-3/31/26 MAR and there should have been. The DON said there were vital signs on some of the nurses' notes in the night shift section, but there was no real way to tell what time the vital signs were taken in context to the medication being administered. The DON said Resident #1's MAR was missing a place for the documentation of the second dose (8 PM) of carvedilol and the vital signs that were documented on nurse's notes were not timed, so there again, there was no way to know when the vital signs were taken in context to the medication being administered.During an interview on 3/25/26 at 3:39 PM, MA A said she had worked at the facility since 1994. MA A said she normally worked the 2 PM to 10 PM shift. MA A said when she administered medications with parameters for blood pressure and pulse rates, she documented the blood pressure and pulse rate on the MAR. MA A said if the medication was ordered more than once daily there would be a place to document the blood pressure and heart rate with each medication administration on the MAR. MA A said if the resident's blood pressure or pulse was out of parameters and the medication was not given, there would be a circle around her initials to indicate it was not given. MA A observed Resident #1's MAR for the month of March 2026 and said there was not a place to document her blood pressure or pulse for her Carvedilol 8 PM dose. MA A said the S was her initial on the MAR. MA A said she knew she had checked Resident #1's blood pressure and pulse before she administered her carvedilol 8 PM dose. MA A said if the blood pressure and heart rate were not documented, it was like she did not check the resident's blood pressure of pulse (heart rate). MA A said if the blood pressure and pulse were not documented, there was no way to tell if the medication was given within the parameters set by the physician. MA A said if the blood pressure and pulse were not documented, they would not be able to see how many times the resident's blood pressure or pulse were low and the medication was given. MA A said if the medication was given without checking the blood pressure or pulse, they could be out of parameters, and the resident's blood pressure could drop and could place the resident in serious danger.During an interview on 3/25/26 at 3:53 PM, the DON said when it was discovered there was no place to document the blood pressure and heart rate on Resident #1's MAR for her 8 PM carvedilol dose, they started an audit of all the MARs and was prepping an in-service for nursing and will get that tightened up. The DON said once they go to the electronic medical record, it would eliminate a lot of the issues with the paper charts. The DON said if the staff were not checking the resident's blood pressure and/or heart rate when administering blood pressure medications, they would not know if the medication needed to be held (not given) and it could bottom out the resident's blood pressure, cause injuries, falls, and it needed to be fixed. The DON said he thought there may have been an issue with the way their orders linked blood pressure medication and vital signs in their system and somehow may have unlinked.Record review of the facility's policy titled Administering Medications dated revised April 2019, indicated . Medications were administered in a safe and timely manner, and as prescribed . medications were administered in accordance with prescriber orders . the following information was checked/verified for each resident prior to administering medications . vital signs, if necessary .

Based on observation, interview, and record review, the facility failed to ensure a resident who was unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming and personal and oral hygiene for 1 of 3 residents (Resident #1) reviewed for quality of life. The facility failed to provide Resident #1 incontinent care, after she had an episode of bowel incontinence on 02/11/2026. This failure could place residents at risk of not receiving the services and care needed, decreased self-esteem, and a decreased quality of life.Findings included: Record review of a face sheet dated 02/11/2026 indicated Resident #1 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included Alzheimer's disease (progressive disease that destroys memory and other important mental functions), dementia (loss of memory, language, problem solving and other thinking abilities that were severe enough to interfere with daily life), and anxiety disorder (mental illness defined by feelings of uneasiness, worry and fear). Record review of Resident #1's Comprehensive MDS assessment dated [DATE] indicated she understood others and others understood her. The MDS assessment indicated Resident #1 had a BIMS score of 5, which indicated her cognition was severely impaired. The MDS assessment indicated Resident #1 required substantial/maximal assistance with toileting, dressing, and personal hygiene. Record review of Resident #1's care plan revised 02/08/2026 indicated she required substantial/maximal assistance with ADLs. Resident #1's care plan indicated she required assistance of 1 staff member for toileting to toilet her every 2 hours and as needed and perform incontinent care after each incontinent episode. During an observation and interview on 02/11/2026 at 10:18 AM, Resident #1 was sitting in her wheelchair in her room her pajama pants were stained brown from her crotch area, and there was an odor of stool. Resident #1 was fidgeting and attempted to grab some clean clothes laying on her bed. Resident #1's verbalizations were incomprehensible. Hospitality Aide A was sitting with Resident #1 in her room, and she said Resident #1 needed to be changed because she had a bowel movement. Hospitality Aide A said she told NA B Resident #1 had an incontinent episode and needed to be changed about an hour ago, and she was waiting for her to come change her. During an observation and interview on 02/11/2026 at 10:45 AM, LVN C said NA B was on break. LVN C said NA B had not told her Resident #1 required incontinent care before she went to break. LVN C said NA B should have reported to her Resident #1 needed incontinent care, and she would have done it or asked for another CNA to do it. LVN C said the residents not being provided incontinent care promptly could result in skin breakdown. LVN C said she had to find a CNA to provide the incontinent care for Resident #1. LVN C said she was going to have to give Resident #1 a shower. LVN C and the ADON showered Resident #1 because she had stool all over her front perineal area. During an interview on 02/11/2026 at 11:23 AM, Resident #1's family member said often when they observed Resident #1's dirty clothing it was soaked in urine. During an interview on 02/11/2026 at 2:27 PM, NA B said she was providing care for Resident #1, but she was not aware Resident #1 needed incontinent care before she went on her break. NA B said she went to break before 11, checked on Resident #1 before she went to break, and Resident #1 did not need incontinent care. NA B said incontinent care should be provided promptly because it could cause bed sores or the residents' skin could be bad. During an interview on 02/11/2026 at 5:29 PM, the DON said his expectations were that before any break was completed the residents care should be provided. The DON said Resident #1 should have been provided incontinent care when Hospitality Aide A reported to NA B she needed it. The DON said not providing prompt incontinent care could result in the residents having skin issues and it could also be a dignity issue. During an interview on 02/11/2026 at 5:50 PM, the Administrator said his expectations were incontinent care should be provided before the staff went on break. The Administrator said he expected incontinent care to be provided promptly, and all staff should be assisting with ensuring it happened. The Administrator said managers were supposed to provide oversight to ensure incontinent care was being provided. The Administrator said not providing incontinent care promptly could result in skin breakdown. Record review of the facility's policy dated, 11/28/2017, titled, QUALITY OF LIFE ADL CARE PROVIDED FOR DEPENDENT RESIDENTS, indicated, To appropriately address resident and facility practices that would affect the resident's ability to attain and maintain his/her highest practicable well-being. A resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene.

Based on interview and record review, the facility failed to not use any individual working in the facility as a nurse aide for more than four months on a full-time basis unless that individual completed a training and competency evaluation program for 2 of 3 Nurse Aides (NA B and NA D) reviewed for nursing services. The facility failed to ensure NA B and NA D were certified within the required time of four months. This failure could place residents at risk for receiving inappropriate care from an individual whose skill level was not known. Findings included: Record review of the undated Employee Data Calendar for NA D indicated NA D's date of hire was 01/03/2024. Record review of NA D's Certificate of Completion for the LTCR Nurse Aide Training and Competency Evaluation Program indicated it was completed on 12/31/2024. Record review of the undated Employee Data Calendar for NA B indicated NA B's date of hire was 11/12/2024. Record review of NA B's Certificate of Completion for the LTCR Nurse Aide Training and Competency Evaluation Program indicated it was completed on 02/16/2025. During an interview on 02/11/2026 at 2:25 PM, NA D said she worked at the facility full-time and provided care to the residents such as incontinent care and bathing. NA D said she could not remember when she completed her NA training, but it was sometime last year. NA D said she had not tested to become a CNA, and she did not have a test date scheduled. During an interview on 02/11/2026 at 2:27 PM, NA B said she worked full-time and provided care to the residents such as incontinent care and bathing. NA B said she did not remember when she completed her NA training. NA B said she had not taken the test to become a CNA, and she did not have a test date scheduled. During an interview on 02/11/2026 at 5:39 PM, the DON said the Administrative Assistant was responsible for ensuring the NAs were certified when they were supposed to. The DON said the NAs had up to one year to get certified. The DON said it was important for the NAs to be certified within the required timeframe to ensure they were competent. During an interview on 02/11/2026 at 5:44 PM, the Administrative Assistant said she and the staffing coordinator were responsible for ensuring the NAs were certified within the required timeframes. The Administrative Assistant said they had been without a staffing coordinator, and one was hired today. The Administrative Assistant said she was not sure what the required timeframe was for the NAs to get certified. The Administrative Assistant said it was important for the NAs to become certified within the required timeframe to ensure the residents were receiving the proper care and their training was correct. During an interview on 02/11/2026 at 5:58 PM, the Administrator said the DON and the Administrative Assistant kept a spreadsheet to ensure the NAs were certified within the required timeframe. The Administrator said the NAs had two years to become certified from when they completed their skills training. The Administrator said it was important for the NAs to be certified within the required timeframe because they would be required to repeat the NA class and would not be allowed to continue to work as NAs. Record review of the facility's policy revised, September 2011, titled, Nurse Aide Qualifications and Training Requirements, indicated, Nurse Aide is defined as any individual providing nursing or nursing-related services to residents in our facility who is not a licensed health professional. 3. In keeping with the Omnibus Budget Reconciliation Act of 1987 (OBRA), our facility will only employ those nurse aides who meet the requirements set forth in the federal and state statutes concerning the staffing of long-term care facilities. 4. Our facility will not use any individual as a nurse aide for more than four (4) months full-time, temporary, per diem, or other basis, unless: a. That individual is competent to provide nursing and nursing related services; and b. That individual has completed a training program and competency evaluation program, or a competency evaluation program approved by the state; or c. That individual has been deemed competent as provided in S483.150(a) and (b) of the Requirements of Participation.

Based on observation, interview, and record review, the facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition for 1 of 4 resident raised toilet seat reviewed for essential equipment (Resident #1). Resident #1's raised toilet seat had a missing anti-slip rubber foot. This failure could result in resident falls and injury while the raised toilet seat. Record review of an undated face sheet, revealed Resident #1 was a [AGE] year-old female that admitted on [DATE]. Resident #1 had diagnoses of dementia (an umbrella term for a decline in mental ability severe enough to interfere with daily life, affecting memory, thinking, language, and problem-solving), COPD (a group of diseases that cause airflow blockage and breathing-related problems), and anxiety. Record review of a quarterly MDS assessment dated [DATE] revealed Resident #1 had a BIMS score of 07, which indicated moderate cognitive impairment. The MDS also indicated Resident #1 required supervision for transfer from to and from the toilet. The MDS further indicated that a walker was Resident #1's primary mode of mobility. Record review of a care plan dated 08/21/2025 revealed Resident #1 was at risk for falls related to being in a new environment. Fall interventions listed for Resident #1 increased monitoring and raised toilet seat. During an observation and interview on 12/09/2025 at 10:15 a.m., it was noted that Resident #1 had a sitter for monitoring related to the falls. Resident #1 was noted to have a raised toilet seat. The right front leg of the raised toilet seat was noted to be missing the anti-slip rubber foot on the left front leg. Resident #1 was unable to tell how long the rubber foot had been missing. Upon touching the raised toilet seat, it was noted to rock slightly when weight was applied to the left side of the raised seat. During an observation on 12/09/2025 at 1:00 p.m., Resident #1's raised toilet seat continued to be missing the anti-slip rubber foot on the left front leg of the seat. During an interview on 12/09/2025 at 2:00 p.m., the maintenance director stated there was no specific schedule to check equipment for function and safety. He stated the system for fixing broken equipment was for the staff to leave the information about the broken item on one of two clipboards he had in the facility. He stated he checked them and made repairs twice daily. The maintenance director stated there was no record of the missing anti-slip foot on the raised toilet seat. During an interview on 12/09/2025 at 1:15 p.m., the DON stated it was important for all residents to have functioning equipment. The DON stated non-functioning equipment could result in serious injury from falls and other accidents. The DON stated the maintenance man was responsible for making monthly checks on equipment, as well as completing any work orders. During an interview on 12/09/2025 at 2:30 p.m., the Administrator stated it was the maintenance director's responsibility to maintain all equipment in the facility. The Administrator stated it was important to have functioning equipment for all residents for safety. The Administrator stated they had no policy on the functioning of essential equipment.

Based on observations, interviews, and record review the facility failed to follow established policy regarding smoking areas and smoking safety for the 1 of 1 facility reviewed for smoking. The facility failed to ensure NA A did not smoke a vape in the facility on 11/13/25 while standing beside the nurse's station. This failure could place residents and staff at risk of unsafe smoking and injury.Findings include:During an observation on 11/13/25 at 11:24 AM, NA A vaped while standing between the nurse's station and the resident sitting area where residents were sitting at the time. When NA A vaped a cloud of fumes went in the air around her. NA A turned around as the vape fumes went in the air and observed this surveyor standing around from her and rushed down the hallway. During an interview on 11/13/25 at 11:33 AM, NA A said she did not remember, and she did not believe that she did vape when she was standing at the nurses. NA A said she did utilize vapes, and she smoked cigarettes, but the facility did not allow the staff to vape in the facility. NA A said she was not an expert at what the risk was for vaping in the facility. During an interview on 11/13/25 at 11:35 AM, the Regional Nurse said the facility was a smoke free facility and she had manager go find NA A and write her up and begin in-servicing with the staff. During an interview on 11/13/25 at 3:10 PM, CNA B said she was not aware of any staff smoking or using vapes in the facility and the facility is a non-smoking facility. CNA B said none of the residents smoke at the facility. CNA B said if she was aware of any staff using vapes in the facility she would have reported it to the administrator. During an interview on 11/13/25 at 3:15 PM, Resident #1 and Resident #2, who resided on the hall NA A worked on, said they have never had any issues with the vapes being used by staff or residents in the facility. During an interview on 11/13/25 at 3:19 PM, LVN C said she had not had any problems with any staff vaping recently but when she first started about a year ago, she was unsure of some hearsay of staff using vapes. LVN C said she had no problems since. LVN C said the facility was a non-smoking facility. LVN C said she was sure there was a risk for using a vape around residents, but she honestly was not sure what the risk was. During an interview on 11/13/25 at 3:21 PM, LVN D said she was not aware of the vape being used but the staff was allowed to go outside to the shed to smoke and use them. She said the failure placed a risk for residents breathing in the fumes and causing problems. During an interview on 11/13/25 at 3:23 PM, the DON said he has never had anyone use a vape in the facility. The DON said no residents smoked and if they do smoke, they offer the patch or try to get them relocated to the sister facility. The DON said facility staff are allowed to smoke but out back in the designated smoking area. The DON said the failure of staff vaping in the facility placed a risk for the infection control spread through the fumes for staff and other residents. During an interview on 11/13/25 at 3:32 PM, the Regional Director of Operations said no staff should be using any smoking products in the facility. The Regional Director of Operations said the facility did have a designated place for the staff to smoke in the back of the facility. The Regional Director of Operations said the failure of staff vaping in the facility could have aggravated breathing for the residents. Record review of the undated facility policy Smoking Area indicated: The Facility is a non-smoking facility for residents/visitors.Smoking is never permitted inside the building, including electronic cigarette products.

Based on observation, interview, and record review the facility failed ensure staff provided pharmaceutical services such as dispensing and administering all drugs to meet the needs of each resident for 3 of 4 staff reviewed for pharmacy services. (LVN A, LVN B, and MA) 1.On 06/20/25, 5 clear medication cups were found with 5 different residents' medications in a resident's room. 2.On 06/24/25, LVN A's medication cart had 15 clear medication cups with 15 different resident names written on them and their medications pre- popped from the medication blister pack in those cups. 3.On 06/24/25, LVN B's medication cart had 2 paper medication cups with two different resident names written on the bottom of the cups with pre popped medication from the medication blister pack in those cups. 4.On 06/24/25, MA C's medication cart had 3 clear medication cups with no names on them with , but resident medications were pre popped from the medication blister pack in the cups. These findings could place residents at risk of receiving the wrong medications. Findings included: 1. Record review of an employee concern form dated 6/20/25 indicated the Administrator had received a report that medications were found in cups stacked within each other. It appeared the medication were intended to be administered and somehow forgotten. The Medical Director was notified and identified residents were put-on 24-hour monitoring for any changes, the responsible parties were notified, and in service education on Medication Administration was conducted. Classroom meetings were scheduled for 6/24/25. During an interview on 6/24/25 at 6:40 a.m. the Administrator said he had written an employee concern about medications found in a room. He said they had identified the residents and their medications. He said the nurse they thought was responsible had been terminated. They had called the physician, the families and placed the residents in question on a 24-hour monitoring. He said he had not seen the medications himself but understood there was a picture floating around. Record review of an in-service training report dated 6/20/25 indicated the topic was Medication Administration. When administering medications to residents it is your responsibility to ensure the resident takes the prescribed medications. It is the facility policy to never leave medications at bedside unattended for the resident to take later. This deficient practice could possibly put the residents at risk for medical complications. Record review of a picture dated 6/20/25 at 1:27 a.m. showed 5 different clear cups of medications with medications sitting on a bed side table. The clear cups had residents' names written on them. 2.During an observation and interview on 6/24/25 at 5:10 a.m. LVN A said she had the medication cart for 300 hall, 500 hall, and 600 hall. Observation of the top drawer of the medication cart were stacked cups of medications in different compartments in the drawer. LVN A said she had pre popped the medications from the medication blister pack. She said medications for the 300- hall with 5 different cups with 5 different resident names written on them. The cups had various shapes, sizes, colors, and numbers of medications. The cups she displayed for the 500-hall were 7 different cups with different resident names. The cups had various shapes, sizes, colors, and numbers of medications. The 600-hall had 3 different medication cups with three different resident names. The cups had various shapes, sizes, colors, and numbers of medications. LVN A said she knew she was not supposed to pre pop the medications. During an interview on 6/24/25 at 5:15 a.m. the ADON said the staff should not pre pop medications from the blister pack before they were ready to administer them. She said resident medications should not be dispensed prior to the time of administration . 3.During an observation and interview on 6/24/25 at 5:28 a.m. LVN B said she was finished passing medications. Observation of the top drawer of the 100-hall medication cart revealed there were two white paper medication cups with one pill each in the cups. She said they were her last two morning medications. LVN B had the names written on the bottom of the cups. She said she had tried to give the medications but was unable to do so and had not disposed of them yet. She said she was not supposed to pre pop medications from the blister pack prior to administration. 4.During an observation and interview on 6/24/25 at 10:20 a.m. MA D was passing medications on the 500 hall. Observation of top drawer of her medication cart had 3 clear cups of resident medications with no names. She said they were medications for 3 of the residents on the hall. She also said she knew she was not supposed to pre pop the medications from the blister pack prior to administration. Record review of an in service dated 6/24/25 indicated the MA was educated on medication pass and proper steps for medication administration. The MA was not to pre pop medications ever. That was against regulations, provide privacy, obtain vitals, and administer medication at the time of medication pass. Pre popping medications could cause a medication error or a mistake to happen. It was signed by MA C. Record review statement dated 6/24/25 indicated the DON had verbally educated LVN A and LVN B that pre preparing medication was not allowed at the facility. Both nurses verbalized their understanding, and the statement was signed by the DON. Record review of the facility Administering Medications policy last revised April 2019 indicated medications are administered in a safe and timely manner as prescribed. The individual administering the medications checked the label three times to verify the right resident, the right medication, right dosage, right time, and right method(route) of administration before giving the medications.

Based on observation, interview, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards in 1 of 1 kitchen reviewed for food service safety. 1. The facility failed to ensure all food items were labeled and dated in the walk-in cooler and the walk-in freezer. 2. The facility ensure that the Activity Director Assistant wore a hair net when entering the kitchen and 2 male staff members wore facial hair coverings while assisting with meal preparation. 3. The facility failed to the shelf above the stove top and parts of the oven were clean. These failures could place residents at risk of foodborne illness and food contamination. Findings include: Record review of an R. D. (Registered Dietician) Consultation Report dated 12/30/24 indicated, .Oven, microwave, range top need cleaning . Record review of a Summary Report of Meeting dated 03/31/25 indicated 9 dietary staff members were trained on Food Safety, Menus and Nutritional Adequacy, Infection Control Practices, and Employe Hygiene. The training indicated, .Uses hair restraints and beard guards properly .Practices the first-in, first-out method of inventory rotation .Keeps the refrigerator/freezer clean .Wraps, dates, and labels all foods properly .Demonstrates personal responsibility for maintaining safe and sanitary conditions .Cleans and sanitizes food surfaces thoroughly . During an observation on 06/02/25 at 8:50 a.m., revealed a foul smell in the walk-in cooler. Inside the cooler were 15 foam bowls with lids that were not dated or labeled. Some of the bowls contained a fluffy white food item and some contained unknown fruits. There was 1 small plastic food container containing a round bread with an unknown meat and a yellow slice of an unknown food item inside. There was one plastic container with an unknown cubed meat with no date or label. There was one plastic bag containing unknown chopped nuts with no date or label. During an observation and interview 06/02/25 at 8:56, revealed inside the walk-in freezer there were 2 plastic bags containing unknown oblong brown food item with no date or label. There was 1 bag with an unknown breaded food item with no date or label. There was 1 plastic bag containing a light brown square food item with no date or label. There was 1 plastic bag with an unknown beige food item with no date or label. There was 1 plastic bag with an unknown beige stick shaped food item with no date or label. There was 1 bag of beige, small, unknown smaller food sticks with no date or label. The dietary manager said there was a female staff member that usually kept everything dated or labeled in the freezer and she had been out for surgery. She said there had been a male worker that would not listen that had been doing the job. She said he had just quit, and the other staff worker would be back and take care of the freezer. During an observation on 06/03/25 at 10:45 a.m., revealed both doors on the front of the oven had a brown, greasy build up around the handles and along a long metal piece above the oven doors. There was a brown greasy build up around two of the knobs above the oven door. There was a large brown area built up on the backsplash behind the stove top. There was a dirty greasy build up on the shelf above the stove. There appeared to be drops of grease hanging from the shelf above the stove. The drops were over the stove top where food was being prepared. During an observation on 06/03/25 at 10:49 a.m., Activity Director Assistant entered approximately 4 feet into the kitchen while food was being prepared without a hairnet on. During an interview on 06/03/25 at 10:53 a.m., the Activity Director Assistant said she did not know she had to wear a hair net when she was just stepping into the kitchen. She said she stepped in the kitchen every day without a hairnet to carry in menus. She said no one had ever told her that she had to wear a hair net and did not know where they were. During an interview on 06/03/25 at 11:00 a.m., Dietary Aide D said dietary staff had told the Activity Director Assistant that she needed to wear a hair net in the kitchen in the past. During an observation and interview on 06/03/25 at 11:17 a.m., revealed Dietary Aide E present in the kitchen assisting with meal service. He had a mustache and hair on his chin. He did not have on a facial hair covering. He said he did not wear a facial hair covering because it made him sweat. He said, I am not all about getting all sweaty. It makes me itch. During an observation and interview on 06/03/25 at 11:21 a.m., revealed Dietary Aide F present in the kitchen assisting with meal service. He had a mustache and hair on his chin. He did not wear a facial hair covering. He said he never wore a facial hair covering. He said the only time he wore anything on his face was when he had a cold, and he would wear a mask . During an observation and interview on 06/04/25 at 9:40 a.m., revealed both doors on the front of the oven had a brown, greasy build up around the handles and along a long metal piece above the oven doors. There was a brown greasy build up around two of the knobs above the oven door. There was a large brown area built up on the backsplash behind the stove top. There was a dirty greasy build up on the shelf above the stove. There appeared to be drops of grease hanging from the shelf above the stove. The drops were over the stove top where food was being prepared. The drops were easily wiped off with a finger and were wet and greasy to the touch. [NAME] G was cooking the noon meal on the stove under the shelf. She said the drops were caused by steam from the cooking meal. During an interview on 06/04/25 at 9:44 a.m., the Dietary Manager said she expected all facility staff to wear hair nets as soon as they enter the kitchen. She said they used to have beard coverings. She said she had not realized Dietary Aide F even had facial hair. She said she had personally told all staff, including the Activity Director Assistant to not enter the kitchen without a hairnet. She said there used to be a sign on the door that said, Kitchen Employees Only. She said staff not wearing hair coverings could cause hair to get into the resident's food. She said when it rained water puddled in the walk-in cooler. She said the water came in from somewhere outside of the cooler. She said she felt like the water reacted with the floor and caused the foul smell. She said the floor was rusty in places. She said the staff member that usually cleaned the cooler just started back after being on leave and she had just not had a chance to do everything. She said the foam bowls in the cooler was food that had been prepared for the next meal and been placed in the cooler to keep the food cool. She said she thought it was whipped cream and some fruit. She said the foam bowls should have been dated and labeled. She said the cooks were responsible for dating and labeling the foods as they were put away. She said she expected all food to be dated and labeled. She said food not being dated, staff would not know how long it had been in there. She said food not being dated would need to be thrown away and if served it could cause a resident to get sick. She said food not being labeled could cause residents to get spoiled food. She said all equipment including the stove, oven, and the shelf above the stove should be wiped off and cleaned daily. She said the staff that stocked the kitchen, and the cooks should be keeping the equipment clean. She said she did have a cleaning schedule and it was hanging right outside of her door. She said equipment not being clean could make a resident sick and cause their food to be contaminated. During an observation on 06/04/25 at 11:50 a.m., revealed a cleaning schedule hanging on the wall outside of the Dietary Manager's office. The cleaning schedule was for 05/26/25 - 06/08/25. The daily cleaning schedule included cleaning the refrigerator and range. The schedule did not indicate documentation that any staff had completed any daily cleaning task for 05/26/25 - 06/04/25. The weekly cleaning schedule included Range top, Refrigerators - Clean and organize, Freezer - Clean and organize, and undershelves - clean. The schedule did not indicate documentation that any staff had completed any weekly cleaning task for 05/26/25 - 06/04/25. During an interview on 06/04/25 at 1:20 p.m., the Administrator said he expected staff to follow the policy for hairnets. He said no one wants to find a hair in their food. He said once a staff member enters the kitchen, they should have on a hair net. He said he had never heard about water leaking into the walk-in cooler. He said dietary staff were responsible for storing food according to policy. He said they learn all of this when they got their certificates. He said food items not having a date could cause out of date items to be served and cause food borne illness. He said food not having a label could cause staff to not know what the food was. He said it could cause a resident to be served something they dislike or have an allergy too. He said he expected everything in the freezer to be dated and labeled. He said not knowing how long a food item had been in the freezer could lead to freezer burn and ruin the nutritional value of the food. He said the cook was supposed to clean the oven every shift and they had to keep the grease build up off of the equipment. He said grease build up could cause a fire. Record review of a Food Receiving and Storage facility policy last revised 07/2014 indicated, .Foods shall be received and stored in a manner that complies with safe food handling practices .Food Services, or other designated staff, will maintain clean food storage areas at all times .All foods stored in the refrigerator or freezer will be covered, labeled and dated (use by date) . Record review of a Preventing Foodborne Illness - Employee Hygiene and Sanitary Practices facility policy dated 10/2008 indicated, .Food Services employees shall follow appropriate hygiene and sanitary procedures to prevent the spread of foodborne illness .Hair nets or caps and/or beard restraints must be worn to keep hair from contacting exposed food, clean equipment, utensils and linens . Record review of a Sanitation of Food Service Department facility policy dated 2005 indicated, .The Food service staff shall maintain the sanitation of the food service department through compliance with a written, comprehensive cleaning schedule .A cleaning schedule shall be posted weekly for all cleaning tasks, and employees will initial tasks as completed . Review of a 2022 Food Code for the U.S. Food and Drug Administration indicated, .2-402 Hair restraints .food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food .Annex 4. Establish First-In-First Out (FIFO) Procedures. Product rotation is important for both quality and safety reasons. First-In-First-Out (FIFO) means that the first bath of product prepared and placed in storage should be the first one sold or used. Date marking food as required by the Food Code facilitates the use of a FIFO procedure in refrigerated, ready-to-eat, TCS (temperature control storage) foods. The FIFO concept limits the potential for pathogen growth, encourages product rotation, and documents compliance with time/temperature requirement .

Based on observation, interview, and record review, the facility failed to provide food that was palatable and attractive for 7 of 8 residents (Resident's #9, #11, #33, #42, #49, #57, and #84) reviewed for palatable food. The facility failed to provide food that was palatable and attractive to Resident #9, #11, #33, #42, #49, #57, and #84 who complained the food was bland, mushy, and overcooked, and the same foods were served over and over. These failures could place residents who ate food from the kitchen at risk of weight loss, altered nutritional status, and diminished quality of life. The findings included: 1. Record review of a face sheet dated 06/04/25 revealed Resident #9 was an [AGE] year-old female and was admitted to the facility on [DATE] with diagnoses of dementia (memory loss), risk for protein-calorie malnutrition, and vitamin deficiency. Record review of the quarterly MDS assessment dated [DATE] revealed Resident #9 was understood and understood others. The MDS revealed Resident #9 had a BIMS score of 11, which indicated moderate cognitive impairment. During an interview on 06/02/25 at 9:57 AM, Resident #9 stated the food was not served appealing. Resident #9 stated the vegetables were cooked too long and were full of water. Resident #9 stated the fried food were cooked hard and tough to eat. Resident #9 stated her bacon that morning was tough to chew, and she threw it back up . Resident #9 stated the facility staff were aware of the food complaints but nothing the food had not gotten better. 2. Record review of a face sheet dated 06/03/25 revealed Resident #11 was a [AGE] year-old female and was admitted to the facility on [DATE] with diagnoses of stroke, protein-calorie malnutrition, and vitamin deficiency. Record review of an annual MDS assessment dated [DATE] revealed Resident #11 was understood and understood others. The MDS revealed Resident #11 had a BIMS score of 10, which indicated moderate cognitive impairment. During an interview on 06/02/25 at 11:39 a.m., Resident # 11 said the food was terrible. She said there was no taste to it, and it was always overcooked. She said she was tired of being served the same things over and over. 3. Record review of a face sheet dated 06/03/2024 revealed Resident #33 was a [AGE] year-old female and was admitted to the facility on [DATE] with diagnoses of heart failure, vitamin deficiency, and unspecified nutritional deficiency. Record review of a quarterly MDS assessment dated [DATE] revealed Resident #33 was understood and understood others. The MDS revealed Resident #19 had a BIMS score of 14 which indicated the resident had intact cognition. During an interview on 06/02/25 at 9:45 a.m., Resident #33 said the food was not good. She said they talk about it every council meeting. She said they serve the same thing over and over. She said the staff do not honor their likes and dislikes. She said the dietician did bring her some seasoning, but it has not helped. She said the other night they were served Reuban sandwiches and people just do not like that. She said usually the food was way over cooked. 4. Record review of a face sheet dated 06/04/25 revealed Resident #42 was an [AGE] year-old female and was admitted to the facility on [DATE] with diagnoses of dementia (memory loss), protein-calorie malnutrition, and vitamin deficiency. Record review of the quarterly MDS assessment dated [DATE] revealed Resident #42 was understood and understood others. The MDS revealed Resident #42 had a BIMS of 07, which indicated severe cognitive impairment. During an interview on 06/02/25 at 9:57 AM, Resident #42 stated the food was terrible and the staff did not try to make it better. Resident #42 stated it was not fit to eat, and she was unable to tell what the food was at times. Resident #42 stated the vegetables were cooked too long and were full of water. Resident #42 stated she rarely received a hot meal. During an observation and interview on 06/02/25 at 12:05 p.m., Resident #42 was sitting up in bed with a meal tray in front of her. Resident #42 said she was not going to eat because her roommate was going to bring her back a burger. The squash, vegetables had standing liquid on the tray (approximately 0.5 inches) and appeared mushy. Resident #42 stated the temperature of the food felt fine. 5. Record review of a face sheet dated 06/03/25 revealed Resident #49 was a [AGE] year-old female and was admitted to the facility on [DATE] with diagnoses of depression, vitamin deficiency, and protein-calorie malnutrition. Record review of an admission MDS assessment dated [DATE] revealed Resident #49 was understood and understood others. The MDS revealed Resident #27 had a BIMS score of 09 which indicated the resident had moderate impaired cognition. During an interview on 06/02/25 at 10:00 a.m., Resident #49 said the food was just not good. She said she does not eat chicken, corn dogs, and hot dogs but she was still served those items. She said the food did not taste good. 6. Record review of a face sheet dated 06/03/25 revealed Resident #57 was an [AGE] year-old male and was admitted to the facility on [DATE] with diagnoses of stroke, unspecified protein-calorie malnutrition, and anemia (a condition characterized by a lower-than-normal number of red blood cells, or a reduced amount of hemoglobin in red blood cells, resulting in a reduced oxygen-carrying capacity of the blood). Record review of a quarterly MDS assessment dated [DATE] revealed Resident #57 was understood and understood others. The MDS revealed Resident #57 had a BIMS score of 7 which indicated the resident had severely impaired cognition. During an interview on 06/02/25 at 10:05 a.m., Resident #57 said the food did not taste good at all. He said they serve the same thing over and over and he really gets tired of it. 7. Record review of a face sheet dated 06/04/25 revealed Resident #84 was a [AGE] year-old female and was admitted to the facility 02/06/25 with diagnoses of pressure ulcers (wounds) and protein calorie malnutrition. Record review of the quarterly MDS assessment dated [DATE] revealed Resident #84 was understood and understood others. The MDS revealed Resident #84 had a BIMS score of 11, which indicated moderately impaired cognition. During an interview on 06/02/25 at 11:13 a.m., Resident #84 stated the facility repeated the same foods over and over again. Resident #84 stated the facility served mashed potatoes with every meal. Record review of the grievance log, dated between December 2024 and May 2025, revealed the following: 1. On 12/30/24 Resident #292 was unhappy with the food quality. Resident #292 stated the food had no flavor and was very bland. 2. On 03/25/25 Resident #74 stated she was unhappy with the flavoring of the foods, and everything tasted like [an Italian restaurant]. 3. On 04/18/25 Resident #44 stated the breakfast was awful and too much junk was sent out. He said it was wasteful. 4. On 04/21/25 Resident #27 stated she was unhappy the kitchen did not send her preferred list for supper. 5. On 05/01/25 Resident #61 stated her burger for supper had cheese and she did not want cheese on her burger. 6. On 05/19/25 Resident #44 stated eggs were no good over the weekend . Record review of the resident council minutes, dated between December 2024 and May 2025, revealed the following: 1. On 12/30/24, old business discussed revealed hall trays were being served cold to residents. The minutes reflected the issue was resolved as in-service education was provided. 2. On 01/20/25, new business discussed revealed all residents stated they were sick of eating the same food over and over, every day. The cook over seasoned the food or does not season the food at all. Beans and soup were served cold, right out of the can. 3. On 02/27/25, new business discussed revealed dietary staff were still serving the same food over and over. The cook cooked veggies to mush and burned grilled cheese, cookies, and rolls. The minutes revealed no one liked the chicken cordon blue, or to eat English peas for every meal. 4. On 03/31/25, new business discussed revealed the seasoning on the food items such as greens and vegetables were too hot for them to eat. The minutes revealed dietary staff to pay closer attention to their cards before sending out trays such as dislikes. 5. On 04/30/25, new business discussed revealed a few residents were not getting what they asked for during lunch and dinner. 6. On 05/29/25, new business discussed revealed breakfast had become one of the least favorite meals of the day. Same food was served a lot. During a resident council group interview on 6/3/2025 at 10:29 a.m. with Resident's #33, #49, #55, #58, #61 revealed the kitchen serves chicken two or three times a day. The resident council said the kitchen serves instant mashed potatoes and green beans too much. The resident council said the vegetables were mushy and were so hot that you could not eat them as if they were overcooking the vegetables until they fell apart. They said the kitchen staff were not paying attention to items that were disliked as they served the items anyway. Resident #61 stated she did not like cheese, and she was constantly served cheese. The resident council said food tasted fine, but they did not like the variety, consistency, and texture of the food. During an observation and interview on 06/03/25 at 12:00 p.m., a meal tray was sampled with the Dietary Manager and 5 surveyors. The tray consisted of country fried steak, Brussel sprouts, mashed potatoes, a roll, and pudding with marshmallows and graham crackers. The country fried steak with white gravy had good flavoring but the breading was soggy. The Brussel sprouts were mushy and overcooked. The Dietary Manager said she agreed the breading on the steak was soggy and the Brussel sprouts were mushy and over cooked. When asked if the facility served mashed potatoes every day, the Dietary Manager said they did almost every day. She said the potatoes were fortified. During an interview on 06/04/25 at 9:44 a.m., the Dietary Manager said she talked to residents about their preferences and their food concerns . She said, there are some that you just cannot please. She said she was aware of complaints from resident council and there had been grievances concerning food complaints. She said she had talked to the cooks, and they had been in-serviced by the dietician. She said the cooks, just don't listen. She said a resident not liking the food could cause them to lose weight. During an interview on 06/04/25 at 11:42 a.m., the Dietary Manager said she did not have a food palatability policy. During an interview on 06/04/25 at 1:07 p.m., the Administrator stated he was aware of the food complaints made by the residents. The Administrator stated the facility recently hired a new cook that was working hard to improve the food taste and quality. The Administrator stated he believed the food has gotten better since the new cook has started. The Administrator stated the Dietician was providing education and going over meal preparation with the dietary staff. The Administrator stated the facility had started serving more fresh fruits and added seasoning packets to the meal trays. The Administrator stated the Dietary Manager was responsible for overseeing the day-to-day activities in the kitchen. The Administrator stated it was important to ensure the food tasted and looked appetizing to ensure the resident's nutritional needs were met. The Administrator stated meals were also part of the resident's socialization activities and it was important for the residents to enjoy the meal services. Record review of a Summary Report of Meeting held by the dietician on 03/31/25 indicated 9 staff members were in-service on menus and nutritional adequacy. The in-service indicated, .menus are developed and is prepared to meet resident choices including nutritional, religions, cultural, and ethnic needs while using national guidelines . Record review of an In-service held by the dietician on 10/15/24 indicated, .recipes must be followed to ensure that foot item is tasty, cooked properly, and is appealing .

Based on observation, interview, and record review the facility failed to ensure adequate supervision was provided to prevent accidents for 1 of 6 residents (Resident #1) reviewed for accidents. The facility did not prevent Resident #1 who had a history of wandering from leaving the facility unsupervised. On or about 07/28/2024, Resident #1 was found approximately 50 feet away from the entrance of the facility around 4:00 AM. The facility failed to ensure Resident #1 received adequate supervision to prevent elopement. The facility failed to investigate resident #1's three separate elopements that occurred in July 2024, October 2024, and January 25, 2025. The facility failed to put interventions in place to prevent Resident #1 from eloping. This failure resulted in an identification of an Immediate Jeopardy (IJ) at 4:48 PM. on 01/30/2025. While the IJ was removed on 01/31/2025, the facility remained out of compliance at a potential for more than minimal harm with a scope identified as isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. These failures could place residents at risk of accidents, injury, or death. Findings included: Record review of a face sheet dated 11/26/2024 indicated Resident #1 was [AGE] year-old female, admitted to the facility on [DATE], with diagnoses including transient cerebral ischemic attack (brief blockage of blood flow to the brain), pain, dementia (degenerative brain disease - loss of memory, language) and urinary tract infection. Record review of the comprehensive MDS dated [DATE] indicated Resident #1 had a BIMS of 06 and was severely cognitively impairment. Resident #1's MDS indicated wandering behavior was not exhibited. Resident #1 required supervision for eating, maximal assistance for toileting, showering, dressing and personal hygiene. Resident #1 required touching and supervision for ambulation and transfers. Record review of the care plan dated 06/19/2024 indicated Resident #1 experienced wandering with the interventions of clear pathways, avoid over stimulation and equipped with a device that alarms when wanders. Record review of the consolidated physician orders dated 01/01/2025 - 01/31/2025 indicated Resident #1 had an order for a wander guard with daily functional checks with a start date of 05/01/2024. Record review of the elopement assessment dated [DATE] indicated Resident #1 was a moderate risk for elopement with a score of 14. Record review of an elopement risk book titled Happy Feet kept at the nurses' station indicated Resident #1 was identified as an elopement risk. Record review of the facility's Incidents and Accidents Reports dated 06/01/2024 - 01/27/2025 did not indicate any elopements. Record review of Resident #1's chart did not indicate incidents of elopement, exit seeking behaviors, or notification to her family or physician regarding any elopements or exit seeking behaviors. Record review of unsigned progress note dated 07/29/2024 at 10:00 AM indicated Resident #1 was COVID positive and weak. Record review of progress noted dated 07/29/2024 at 09:30 PM signed by LVN N indicated Resident #1 was being sent to the emergency room per physician orders due to weakness. Record review of the schedule dated 07/27/2024 for 6 PM to 6 AM indicated the following: LVN K - 6PM - 6AM LVN B - 6PM - 6AM LVN E - 6PM - 6AM CNA A - 2PM - 6AM CNA F - 2PM - 6AM CNA G - 10PM - 3:30AM Record review of the wander guard bracelet daily checklist dated 07/2024 to 01/2025 indicated no issues. Record review of the alarm door battery monthly checklist dated 02/2024 - 01/2025 indicated no issues. During an interview on 01/28/2025 at 11:30 AM, Resident #1 said she got in trouble by the staff for going outside. Resident #1 said she could not remember when those incidents occurred, or which staff member got on to her for going outside of the facility. Resident #1 stated she did not want to talk about it and looked away from the surveyor. During an interview on 01/28/2025 at 11:35 AM, Resident #1's roommate said Resident #1 had gotten out of the facility at least three times that she could recall. Resident #1's roommate said she usually tried to get out at nighttime. Resident #1's roommate said Resident #1 would wait for someone to go out of the door and then she walked out behind them. Resident #1's roommate said she had seen the staff bring Resident #1 back to the room and put her to bed after she had been outside of the facility. Resident #1's roommate stated she overheard staff talking to Resident #1, when she was returned to the room. Resident #1's roommate said she was unable to recall the staff involved or the dates of those incidents, but it was more than a month ago. During a telephone interview on 01/28/2025 at 01:40 PM, Resident #1's family member stated they had not received any calls from the facility regarding incidents of elopement or exiting seeking behaviors. During an interview on 01/28/2025 at 03:36 PM, CNA A stated she had worked at the facility for over a year. CNA A said she worked the 2 PM to 6 AM shift. CNA A said Resident #1 got out of the facility and was found out in the grass by one of the kitchen aides when reporting to work between 4 AM or 5 AM. CNA A said that the kitchen aide had told one of the nurses that a resident was laying on the ground in the grass beside the parking lot when she entered the facility that morning. CNA A said she later saw LVN B assist Resident #1 to her room. CNA A said Resident #1 had ambulated with her rollator back to her room. CNA A said she always redirected a resident if they were too close to the doors. CNA A said if she had any difficulty with redirecting or felt like the resident's safety was in jeopardy, she would immediately report to the nurse. CNA A stated the nurses were responsible for the reports and notifying the family and doctor, but all staff were responsible for the safety of the residents. CNA A said communicating the residents' needs was very important, so the right care was given to the residents. During an interview on 01/28/2025 at 09:00 PM, an anonymous staff member stated Resident #1 had a significant change of condition on 07/29/2024, after it was reported she was found outside in the early hours of 07/28/2024 by staff. During a telephone interview on 01/29/2025 at 09:15 AM, the Transportation Aide stated she had completed the wander guard checks daily with the remotes to the doors and 3 days weekly of the resident at the doors. The Transportation Aide stated she took over checking the wander guard system sometime in July 2024 when the facility received the new upgraded system. The Transportation Aide stated there had been some issues when the upgraded system was installed because it would not stay programmed. The Transportation Aide stated the issue with the wander guard system may have occurred in July 2024. During an interview on 01/29/2025 at 09:45 AM, the Administrator stated he wanted to be clear that the facility had not had any elopement incidents. During an observation and interview on 01/29/2025 at 10:15 AM, the Maintenance Supervisor stated when he checked the door alarms on the 200 hall, it alarmed when the door was opened but the alarm tuned off within 1 minute prior to deactivating it. The Maintenance Supervisor stated it appeared the red metal box of the alarm, which hung on the door, had been damaged, and he did not know how it was damaged. The Maintenance Supervisor stated the system was not working correctly, and that could result in an elopement. The Maintenance Supervisor said it could result in an elopement because the alarm could turn off before the staff were alerted a resident went out, and the resident leaving would go unnoticed. The Maintenance Supervisor stated the door alarm batteries are checked monthly. During a telephone interview on 01/29/2025 at 10:50 AM, LVN E stated she worked at the facility as needed. LVN E stated she had worked on 07/27/2024 on the 6 PM to 6 AM shift. LVN E stated around 4:30 AM - 5:00 AM, a female kitchen aide entered the facility and said, there was a resident outside lying in the grass. LVN E stated she and a male CNA followed the kitchen aide approximately 50 yards outside of the facility's entrance door to the left side of the building to Resident #1, who was lying in the grass. LVN E stated Resident #1 was lying in a grass area between the sidewalk and parking lot with the rollator slightly positioned on top of her. LVN E stated Resident #1 appeared confused but had no complaints of pain or any visible injuries. LVN E stated she left the two staff members with Resident #1 and went inside the facility to get LVN B. LVN E stated LVN B was Resident #1's nurse. LVN E stated she assisted LVN B and the male CNA to get Resident #1 off from the ground and back into the facility. LVN E stated at the beginning of her shift around 7:00 PM on 07/27/2024 , she had noted Resident #1 was in the hall. LVN E stated LVN B reminded Resident #1 that she was COVID positive and walked Resident #1 back to her room at that time. LVN E stated she could not identify the male CNA by name or the kitchen staff aide because it was a large facility and she had only worked on an as needed basis. LVN E recalled that the male CNA identified Resident #1 once they were outside. LVN E remembered the male CNA stated Resident #1 did not reside on the hall he was working, and he was not familiar with her baseline status. LVN E stated Resident #1 had on the wonder guard bracelet. LVN E stated no alarms had gone off in the facility. LVN E said the alarms were very loud and noticeable. LVN E stated the nurses had a key and the key had to be inserted and the code entered to turn the alarms off once activated. LVN E stated she offered to help LVN B, but she declined her offer. LVN E stated it was important to document the incident in the resident's chart and complete an incident report, as well as report the incident to the DON, family, and physician. LVN E said the importance of following the protocol was for continuity of the resident's care. LVN E stated the incident would need to be investigated to determine how the resident exited the facility, and new interventions should be updated to be specific for that resident. LVN E stated she had not completed the incident report regarding Resident #1 because LVN B stated she would take care of it. During an interview on 01/29/2025 at 11:57 AM, Kitchen Aide C stated she had worked at the facility for approximately three years. Kitchen Aide C stated she arrived at work on a Sunday around 5:00 AM when Resident #1 was ambulating with a rollator on the sidewalk with staff members. Kitchen Aide C stated she recognized Resident #1 from previously working the halls. Kitchen Aide C said that Kitchen Aide D told her she had found Resident #1 out by the parking lot when she arrived at work. Kitchen Aide C could not remember the exact date but recalled it was on a Sunday several months back. Attempted telephone interview on 01/29/2025 at 12:15 PM to Kitchen Aide D. A voice message was left requesting a call back. (Kitchen Aide D was no longer employed at the facility.) During an interview on 01/29/2025 at 12:17 AM, the Administrator stated there are no recorded videos of the facility. The Administrator stated the videos record over and over after a 24-hour period. During an interview and observation on 01/29/2025 at 03:35 PM, the maintenance supervisor tripped the alarm on hall 200 by opening the door. The alarm remained on until the key and code were entered appropriately. Attempted telephone call on 01/29/2025 at 06:46 PM to Kitchen Aide D. A voice message was left requesting a call back. (Kitchen Aide D was no longer employed at the facility.) During a telephone interview on 01/29/2025 at 06:49 PM, CNA F stated he heard the kitchen aide (he did not know the kitchen aide's name) tell LVN E that a resident was lying outside on the ground. CNA F stated he and LVN E followed the kitchen aide outside and found Resident #1 lying on the grass with her rollator toppled over her. CNA F stated LVN E assessed the resident and then went back into the facility and got LVN B. CNA F stated they assisted Resident #1 off the ground. CNA F stated Resident #1 walked back to the facility using her rollator. CNA F stated Resident #1 seemed confused but was not injured. CNA F stated LVN B took Resident #1 back to her room. Attempted telephone interview on 01/29/2025 at 07:00 PM to Kitchen Aide D. A voice message was left requesting a call back. (Kitchen Aide D was no longer employed at the facility.) During an interview on 01/29/2025 at 07:35 PM, LVN B stated she had worked at the facility for 2 years on the 6 PM to 6 AM shift. LVN B stated she had never had a resident leave out of the facility or exit seek. LVN B stated the alarms may activate but the residents turned away from the door or she had redirect them to another activity, but the residents had never gone outside of the facility. LVN B stated if a resident went outside of the facility that would be considered an elopement. LVN B stated if a resident got outside the facility that could result in serious harm even death due to being hit by a vehicle in the parking lot or the roadway. LVN B stated if a resident left out of the facility or exhibited exit seeking behaviors, it would be documented in the resident's chart, an incident report would be completed, and the family and physician would be notified. LVN B stated the purpose of documenting incidents and notifications was so the physician and the facility staff would know how to take care of the resident appropriately. LVN B said an elopement should be reported to the DON for further investigation to prevent the situation from happening again. LVN B stated Resident #1 had not exhibited exit seeking behaviors. LVN B stated Resident #1 had not been outside the facility. LVN B denied any incidents of Resident #1 being outside of the facility for an undetermined time or being found outside by the kitchen staff. LVN B denied she had assisted LVN E or CNA F when Resident #1 was found outside in the parking lot. LVN B stated Resident #1 had never gone outside of the facility without their knowledge. LVN B stated she had no idea why the other staff reported her involvement with Resident #1 outside of the facility because she had no recollection of that situation. LVN B stated that one time Resident #1 had gone outside the facility but only to the picnic table. LVN B stated this incident had occurred in the month of October 2024 around the time she was doing morning rounds at 6:00 AM. LVN B stated Resident #1 had used the door on hall 5 to exit the facility and had sat down at the picnic table when she and the CNA reached her. LVN B said she and other staff had followed see Resident #1 exit the building and had followed her out. LVN B stated she never lost sight of Resident #1 and she was approximately 10 steps away from the door on hall 5. LVN B stated CNA G had assisted her to get Resident # 1 back into the building to her room. LVN B said she placed Resident #1 into her bed after she changed her socks because they were covered in grass, washed the mud from her legs, combed out Resident #1's hair because it was wet, and changed her gown because the bottom of it was soaked. LVN B stated she had filled out an incident report and documented in Resident #1's chart and notified her doctor and family member. LVN B was unable to locate the documented incident report or documentation in Resident #1's chart regarding the incident. LVN B stated she may not have documented anything because she was exhausted and needed to get home for sleep so she could return for the following night shift. LVN B said Resident #1 was fine, so there was really not anything to report anyway. During an interview on 01/29/2025 at 08:15 PM, CNA G stated he had not assisted LVN B with Resident #1 in changing her gown or socks after Resident #1 had been outside of the facility. LVN B stated he had no information about that incident. CNA G stated he was not at work when that incident occurred. CNA G stated that on Saturday, January 25th, 2025, Resident #1 had opened the door on hall 200 and had gone out the door. CNA G stated that the alarms went off. CNA G said he saw Resident #1, LVN B, and LVN H at the corner of the building about 5 steps outside the door leading Resident #1 back into the building. CNA G stated that incident occurred around 7:00 PM, and he had spent the remainder of his shift until 10:00 PM on 1:1 with Resident #1 per the instruction of LVN B. CNA G stated LVN B placed Resident #1 back in the bed. CNA G said Resident #1 had not attempted to get out of bed during the 1:1 care. CNA G said he could not think of any times he had personally been involved with Resident #1 eloping. During an observation and interview on 01/29/2025 at 08:35 PM, LVN B stated if CNA G was not who helped her with Resident #1 when she sat at the picnic table back in October 2024, she could not remember who had helped her. LVN B said she remembered Resident #1 at the corner of the building approximately 5 steps outside the door, when LVN B and LVN H had guided Resident #1 back inside the building. LVN B denied any 1:1 care provided by CNA G. LVN B stated Resident #1 was fine, and that incident was not considered exit seeking behaviors or elopement because she had been able to redirect Resident #1 and had never lost sight of Resident #1. LVN B stated Resident #1 was not hurt, and she was fine. LVN B stated she was sure she had notified Resident #1's family but guessed she did not document it. LVN B stated she should have documented the incident and notified the doctor and family. LVN B stated if she had not reported and documented the events, the doctor would not know Resident #1 required a more secured unit, which could cause potential harm to the resident. During an observation of the picnic table located outside of hall 500 approximately 10 ft. from the door, LVN B agreed there was no grass in the area only dirt and concrete. During an interview on 01/29/2025 at 09:15 PM, LVN K stated she had worked at the facility for 3 years. LVN K stated if a resident got outside the facility that would be considered an elopement. LVN K stated if a resident eloped, after she ensured the resident was safe, she would complete the required incident report, document in the resident's chart, notify the family, physician, and DON. LVN K stated it was important to document and report exit seeking behaviors and elopements to protect the resident and provide the most appropriate person-centered care to keep the residents safe. LVN K defined exit seeking behaviors as going to the door repeatedly, fiddling with the door handles, and window locks and setting off the alarms. LVN K defined elopement as requesting to go home, packing up their items, and getting out of the facility's door. LVN K stated if a resident eloped, the resident could suffer from physical injuries, falls, or being hit by car, or environmental injuries, heat or cold weather exposure. Therefore, reporting the incidents would result in an investigation to figure out how to prevent another occurrence of that nature. LVN K stated all the nurses at the facility regardless of shift, full- time or part time have a group chat for communication also. LVN K stated she could not recall receiving information in the group chat regarding Resident #1 being out of the building lying near the parking lot. LVN K said she worked on 7/27/2024 from 6 PM to 6 AM and was the charge nurse. LVN K said she did remember Resident #1 exited the facility and was found lying near the parking lot. LVN K said she vaguely recalled someone coming into the facility saying a resident was outside. LVN K said she could not recall any more details. During an interview on 01/29/2025 at 09:35 PM, CNA L stated she vaguely remembered someone had reported a resident outside the facility around 5:00 AM or 6:00 AM. CNA L stated she immediately verified that the residents on halls 100 and 400 were accounted for. She stated she had heard it was Resident #1, but she had not seen it for herself. CNA L stated she was not for sure of when it occurred. CNA L stated she could barely remember that incident. CNA L stated it was important to report to the charge nurse any exit seeking behaviors. CNA L stated if an elopement occurred, always ensure resident safety, then notify the nurse for assessments and reports to be completed. CNA L stated it was important to communicate the residents' required care to protect the residents from harm. Attempted telephone interview on 01/30/2025 at 09:50 AM to Kitchen Aide D. A voice message was left requesting a call back. (Kitchen Aide D was no longer employed at the facility.) Attempted telephone interview on 01/30/2025 at 09:53 AM to LVN M. A voice message was left requesting a call back. During an interview 01/30/2025 at 11:45 AM, the ADON stated there had not been any incidents of elopement. The ADON stated if a resident attempted to leave or made the alarm go off those were considered exit seeking behaviors. The ADON stated if a resident opened the door, and stepped outside the facility that was considered elopement. The ADON stated both exit seeking behaviors and elopements should be reported, documented, and the family and doctor should be notified. The ADON said this communication helped ensure the safety and continuity of care. The care plan should be updated to accurately reflect the needs of the residents so the staff can provide appropriate interventions. The ADON stated Resident #1 wandered. The ADON stated she was not aware of any incidents involving exit seeking behaviors or elopements with Resident #1. During a telephone interview on 01/30/2025, the Medical Director stated that he nor his physician assistant had been notified recently of any elopements from the facility or of Resident #1 exhibiting exit seeking behaviors. The Medical Director stated he could not be for sure, but he thought he was notified of a resident that got out of the facility on hall 5 but that had been several months ago. The Medical Director stated he expected the facility staff to notify him of any types of elopements and of exit seeking behaviors. The Medical Director stated he also expected appropriate incident reports and documentation to be completed and investigated so that the residents' care plans could be updated to meet their needs. The Medical Director stated without that vital information, the resident was at risk of injury and harm, and he could not properly assess the residents' needs. During an interview on 01/30/2025 at 03:45 PM, the Administrator defined elopement as a resident that constantly asked and stated they wanted to go home - packing items, cannot be redirected, and she realized she was coming back to the facility. The Administrator stated he need more education and had some regrouping to do and stated the documentation should have been completed and reflected on the reports and in Resident #1's chart. The Administrator stated he was never told that Resident #1 had attempted to elope or exhibited exit seeking behaviors by attempting to leave out of the facility. The Administrator stated he stayed at the facility from 9 AM to 5 PM daily and found it hard to believe the reported incidents only occurred when LVN B was working. The Administrator stated he felt targeted by staff that had been terminated. The Administrator stated LVN B had been terminated. The Administrator stated Resident #1 was in the process of being transferred to a secure unit at this time. The Administrator stated if an elopement occurred or a resident was exhibiting exit seeing behaviors, it was important to properly document it, complete an incident report, start an investigation, and notify the family and the physician to ensure the residents' safety. An undated facility policy titled Nursing Policies and Procedures - Elopement/Missing Resident indicated: .To safely and timely redirect patients/residents to a safe environment. A prompt investigation and search will be conducted if a patient/resident is considered missing . (6) When the patient/resident is located, the charge nurse completes a head-to-toe assessment. The Social Service Designee assess the patient/resident for emotional distress The Administrator was notified on 01/30/2025 at 04:48 PM that an Immediate Jeopardy situation was identified due to the above failure. The Administrator was provided the Immediate Jeopardy template on 01/30/2025 at 04:53 PM. The facility's Plan of Removal was accepted on 01/31/2025 at 08:12 AM. and included: Residents who have suffered or are likely to suffer a serious adverse outcome as a result of noncompliance. The failure to ensure that staff were following our elopement Policy had the potential to adversely affect all residents. Actions the facility will take. Regional Nurse provided in-service training to Administrator in person on the following topics. Inservice completed on 1/30/25 5:50 pm with Administrator, Director of nurses is currently outside of the country. Regional nurse will complete the same training before Director of nurses returns to next scheduled workday. Identifying an Elopement The importance of training staff to Document any elopements, Notifications required when elopements do occur. Importance of facility investigating each elopement and placing intervention to prevent reoccurrence which could result in injury or harm to the resident. The importance of facility elopement screening and assessments being completed accurate to determine wanderguard placement or potential secure unit placement. How to report an Elopement to HHSC. Completed at 5:50 pm In-services to all Staff were iniated1/30/25 @ 6:15 pm. Training will be conducted by administrator, ADONS and Regional nurses. Topics covered include Facility revised elopement policy. Policy addresses required assessments, documentation to complete and Notifications employees should contact. All in servicing will be completed by 1/31/25 @ 10am. No employee will be allowed to work until in servicing is completed. Elopement policy will be included in new hire training packets. All resident's elopement screens, and care plans were updated to ensure accuracy. Facility will follow elopement screen assessment guidelines for identifying level of risk. Facility screening tool provides a risk level numerical value based on key questions. All high-risk residents will be placed on Wander guard System. Audit and updates were completed by unit managers and ADONS Initiated 1/30/25 @7pm to be completed on 1/31/25 @ 8am. All residents that are on wanderguard will be identified in a binder at the nurse's station, with resident demographics (face sheet) to identify each. Completed by Unit managers and ADONS Initiated on 1/30/24 Resident # 1 was assigned a designated sitter until secure unit placement can be arranged.1/30/25 @ 5pm Facility adopted a new Elopement policy on 1/30/25. The Updated policy clearly defines steps for employees to take during an elopement. The new policy directs staff on necessary notifications to make, and all documents to complete. Incident reports and medical record entry are covered as well On 01/31/2025 the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by: During an observation at 01/31/2025 at 11:10 AM, Resident #1 had a 1:1 sitter outside her room door. Record review of in service dated 01/30/2025 provided by the Regional Nurse training to Administrator in person on the following topics. Identifying an Elopement The importance of training staff to Document any elopements, Notifications required when elopements do occur. Importance of facility investigating each elopement and placing intervention to prevent reoccurrence which could result in injury or harm to the resident. The importance of facility elopement screening and assessments being completed accurate to determine wanderguard placement or potential secure unit placement. How to report an Elopement to HHSC. Record review of In-services dated initiated on 1/30/25 provided by administrator, ADONS and Regional nurses. Completed by Topics covered include Facility revised elopement policy. Policy addresses required assessments, documentation to complete and Notifications employees should contact. All in servicing will be completed by 1/31/25 @ 10am. No employee will be allowed to work until in servicing is completed. Elopement policy will be included in new hire training packets. Record Review of all resident's elopement screens and care plans were updated to ensure accuracy. Audit and updates were completed by unit managers and ADONS. Record Review of wanderguard binder located at the nurse's station, with resident demographics (face sheet) to identify each was completed by Unit managers and ADONS. Record Review of new Elopement policy dated 1/30/25. The policy clearly defines steps for employees to take during an elopement which included: directs staff on necessary notifications to make, and all documents to complete. and Incident reports/medical record entry. Record Review of the QAPI Committee Review -committee meeting was completed on 01/30/2025. Interviews of nursing staff: 6 AM - 6 PM - ADON, ADON QQ, MDS Nurse, LVN H, LVN P, LVN Q, LVN R, LVN BB, LVN VV, HA KK, HA LL, HA MM, HA NN, MA S, MA T, CNA U, CNA V, CNA W, CNA X, CNA Y, CNA AA, CNA CC, CNA DD, HA EE, HA FF, HA GG, CNA HHH. Social Worker, Activity Director Assistant, Transport Driver, Maintenance Supervisor, Receptionist, BOM, Medical Records, Laundry Aide SS, Housekeeper UU, Kitchen Aide C, Housekeeper Supervisor, Dietary Aide DDD, Dietary Aide EEE, Dietary FFF, Dietary GGG, Assistant Cook, Dietary Supervisor. 6 PM - 6 AM - LVN K, LVN N, LVN TT, HA PP, HA OO, HA RR, CNA G, CNA L, HA RR, CNA WW, CNA XX, CNA Z, HA HH, CNA A, CNA CCC. During these interviews' staff were able to correctly identify steps to take in the event of an elopement per the facility's policy such as types of exit seeking behaviors, interventions for exit seeking behaviors, required reporting and to whom, documentation of incidents reports and resident chart including care plans, and notifications to the family and physician. On 01/31/2025 at 2:06 PM., the Administrator was informed the IJ was removed; however, the facility remained out of compliance at a potential for more than minimal harm with a scope identified as isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. On 01/31/2025 at 02:06 PM., the Administrator was informed the IJ was removed; however, the facility remained out of compliance at a potential for more than minimal harm with a scope identified as isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems.

Based on interview and record review, the facility failed to ensure basic life support, including cardiopulmonary resuscitation (CPR), was provided to a resident requiring such emergency care prior to the arrival of emergency medical personnel and subject to related physician orders and the resident's advance directives for 1 of 4 (Resident #1) residents reviewed for CPR. 1. The facility failed to ensure staff utilized the AED (automated external defibrillator, is a medical device that analyzes the heart's rhythm and, if necessary, delivers an electrical shock to the heart in attempt to re-establish an effective rhythm) when Resident #1 was found unresponsive and not breathing because the facility staff could not locate the AED pads (Automated External Defibrillator pads are an essential part of the AED machine. The pads are connected via wire to the AED machine and are placed on the bare chest. The AED pads detect the heart rhythm and deliver electric current [shock] through the chest wall when the AED machine detects a shockable rhythm). 2. The facility failed to ensure staff adequately checked the crash cart to ensure the AED was ready for use and the AED pads were with the AED machine. These failures resulted in an identification of an Immediate Jeopardy (IJ) on [DATE] at 4:30 p.m. While the IJ was removed on [DATE], the facility remained out of compliance at no actual harm with potential for more than minimal harm that is not immediate jeopardy with a scope identified as isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. These failures could place residents at risk of not receiving necessary life-saving measures, decline in health, and death. Findings include: Record review of the face sheet dated [DATE] indicated Resident #1 was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses including fracture of the upper end of the left humerus (upper arm bone), subsequent encounter for fracture with routine healing, end stage renal disease (the last stage of long term kidney disease), convulsions, type 2 diabetes, CAD (coronary artery disease-damage or disease in the heart's major blood vessels caused by plaque), venous insufficiency (improper functioning of the vein valves in the leg), and peripheral vascular disease (circulatory condition in which narrowed blood vessels reduce blood flow to the limbs). The face sheet indicated Resident #1 was a full code (if a person's heart stopped beating and/or they stopped breathing, all resuscitation procedures would be provided to keep them alive. This process can include chest compressions, artificial ventilation and defibrillation and is referred to as CPR.). Record review of MDS assessment dated [DATE] indicated Resident #1 had clear speech, understood others and made herself understood. The MDS indicated Resident #1 had moderately impaired cognitive function (BIMS of 10). The MDS did not indicate Resident had a DNR advanced directive in place. Record review of the care plan last revised on [DATE] indicated Resident #1 was a full code. Record review of the physician order summary report dated [DATE] stated Resident #1 was a full code. Record review of MDS dated [DATE] indicated Resident #1 had clear speech, understood others and made herself understood. The MDS indicated Resident #1 had moderately impaired cognitive function (BIMS of 10). The MDS did not indicate Resident had a DNR advanced directive in place. Record review of the care plan last revised on [DATE] indicated Resident #1 was a full code. Record review of the nursing note dated [DATE] at 6:19 a.m. stated nurse aide called for nurses. Upon entering room resident had no rise or fall of chest. Nurse called for code status. Resident being a full code CPR was initiated. This nurse called 911 at 0621 (6:21 a.m.). This nurse along with fell ow coworkers performed CPR taking turns with compressions. This writer was the last nurse to speak to resident at 0510 (5:10 a.m.) while administering morning medication . The nursing note was not signed. Record review of the nursing note dated [DATE] as a late entry at 6:19 a.m. stated, This nurse was called to room by CNA, that resident was not breathing- upon exam there were no resp (respirations) immediately called code status .911 called - all measures taking with CPR administered and continued until EMS arrived at 6:35 a.m. Res (resident) was given 3 rounds of epi (epinephrine) with fluids. Res (resident) was intubated. CPR continued until 6:55 a.m. without success The nursing note was signed by ADON B. During an interview on [DATE] at 1:52 p.m., ADON B said on [DATE] she worked the floor and was assigned Resident #1 on the 6:00 a.m. to 6:00 p.m. shift. ADON B said that morning ([DATE]) she immediately responded when the CNA yelled out that Resident #1 was not breathing. ADON B said Resident #1 was a full code and CPR was started immediately. ADON B said the night shift nurses, LVN A and LVN C were still in the facility and also responded. ADON B said the crash cart was brought in immediately but the AED pads for the AED machine could not be located. ADON B said nurses continued CPR as she attempted to locate the AED pads. ADON B said she could not locate the pads and called the DON for assistance. ADON B said she was told by the DON that extra AED pads were located in one of the cabinets in the medication room. ADON B said she could not find the AED pads in the medication room. ADON B said she never found the AED pads. ADON B said AED pads were not placed on Resident #1 until EMS arrived and placed their AED (the AED brought by EMS) on Resident #1. ADON B said there was no way to know if Resident #1 had a shockable rhythm prior to EMS arrival. ADON B said the AED pads were not located until after the code. The ADON said the DON found the AED pads upon his arrival to the facility. ADON B said she did not know why the AED pads were not on the crash cart on [DATE]. ADON B said the crash cart was checked daily. She said part of those checks were to ensure the AED machine was ready for use and AED pads were attached to the machine. ADON B said a green indicator light flashes on the AED signaling the pads were connected and the AED was ready for use. ADON B said she assumed whoever had performed the daily check on crash cart before the code event had not ensured the green light was flashing /AED pads were connected. While viewing the Crash Cart Checklist from [DATE] to [DATE] ADON B identified all of the signatures on the checklist as herself, LVN C, and LVN E. Record review of the Crash Cart Checklist from [DATE] to [DATE] indicated the crash cart had been checked daily. The checklist contained a check box labeled AED. The crash cart checklist did not specify the crash cart was checked for AED pads or the blinking green indicator light. The Crash Cart Checklist documented the following nurses' signatures on the following specified dates leading up to Resident #1's death; *[DATE]- signed by ADON B; *[DATE]- signed by ADON B; *[DATE]- signed by LVN C; *[DATE]- signed by LVN C; *[DATE]- signed by LVN C; *[DATE]- signed by LVN E; *[DATE]- signed by LVN E; *[DATE]- signed by LVN C; and *[DATE]- signed by LVN C. During an interview on [DATE] at 2:15 p.m., LVN A said she had worked [DATE] from 6:00 p.m. to [DATE] to 6:00 a.m. and was the nurse assigned to Resident #1. LVN A said she was still in the facility completing her charting when Resident #1 was found not breathing by the day shift CNA. LVN A said ADON B was her relief that morning and ran to check Resident #1. LVN A said ADON B yelled out for the Resident #1's code status. LVN A said she checked Resident #1's code status and found she was full code and immediately yelled out to ADON B that Resident #1 was a full code. LVN A said LVN C and LVN D immediately grabbed the crash cart and went to Resident #1's room. LVN #1 said she immediately called 911 and went to the room. LVN A said the AED pads could not immediately be located on the crash cart and there was a delay applying the AED pads to Resident #1 because the pads were not on the crash cart as they should have been. LVN A said she believed the AED pads were located and applied to Resident #1 before the arrival of EMS. Resident #1 said the delay in applying the AED pads was more than one minute but could not have been longer than 5 minutes. LVN A said she was not in the room the entire time the code was in process before the arrival of EMS because she stepped out of the room while on the phone with 911 in order to provide more detailed information regarding Resident #1. During an interview on [DATE] at 2:20 p.m., LVN C said he immediately responded when Resident #1 was found not breathing. LVN C said he initiated chest compressions and was the primary nurse that delivered compressions until EMS arrival. LVN C said he was in the room the entire time the code was in process prior to the arrival of EMS. LVN C said the AED was not used prior to the arrival of EMS because the AED pads could not be located. LVN C said there was no way to know if Resident #1 had a shockable rhythm until EMS arrived because the AED pads could not be found. LVN C said on [DATE]-[DATE] and [DATE]-[DATE], he had just signed the crash cart check list because he trusted the nurses that had signed before him but did not verify the AED had pads connected/green indicator light was flashing. During an interview on [DATE] at 2:40 p.m., LVN D said she was working the morning of [DATE] when Resident #1 was found unresponsive. LVN D said she ran and got the crash cart and by the time she arrived in Resident #1's room with the crash cart, CPR had already been started. LVN D said she remained in Resident #1's room the entire time the code was underway until the arrival of EMS. LVN D said the AED pads could not be found and so the AED was not utilized. LVN D said she heard someone say Resident #1 had an ICD (implantable cardioverter-defibrillator a small battery-powered device placed in the chest. It detects and stops irregular heartbeats, also called arrhythmias. An ICD continuously checks the heartbeat. It delivers electric shocks, when needed, to restore a regular heart rhythm. ICDs require regular checks to ensure they are operational.) LVN D said when EMS arrived, they used their AED machine on Resident #1. LVN D said she was not sure a shock was delivered because she left the room shortly after EMS arrived. LVN D said the facility AED pads were not found until after the code. During an interview on [DATE] at 3:05 p.m., the Medical Director said Resident #1 had a history of cardiac arrest. The Medical Director said if an ICD is functioning properly an AED would not be needed. The Medical Director said he believed Resident #1 had an ICD but could not say when she (Resident #1) last saw her cardiologist or had the device checked. During an interview at [DATE] at 3:10 p.m., the DON said the AED pads were to be with the AED at all times. The DON said the AED was supposed to checked daily as part of the crash cart daily checks. He explained, there was green indicator light that flashed on the AED indicating the AED was ready for use. The DON said the indicator light would not flash if the AED pads were not connected. The DON said he expected nurses to ensure the AED pads were connected and the AED was ready for use when daily crash cart checks were performed. The DON said ADON B had called him when the AED pads were not with the AED and could not be located on [DATE]. The DON said he tried to instruct ADON B on where to find the replacement AED pads. The DON said he found the AED pads when he arrived to the facility in one of the medication room cabinets. The DON said Resident #1 had an ICD but could not say when the device was last checked. The DON said there was no way to know for sure if Resident #1 had a shockable rhythm before the arrival of EMS as an AED was not utilized prior to their (EMS) arrival. The DON said he ensured after the incident that AED pads were connected to the AED and an extra set of AED pads were placed within the back zipper pocket of the AED case. The DON said other than word of mouth there had been no in-services for staff related to the incident. The DON said he was not sure he had notified the Administrator regarding the incident. During an interview at [DATE] at 3:39 p.m., the Administrator said he had not been notified by anyone that staff could not locate AED pads on the morning of [DATE] when Resident #1 coded. The Administrator said he had not been notified that there had been no use of an AED until the arrival of EMS as a result of staff not having been unable to locate the AED pads. The Administrator said the AED pads should be with the AED at all times and nurses should be checking that the pads are there during daily crash cart checks. Record review of the EMS report dated [DATE] reflected Resident #1's ECG (electrocardiogram, a recording of the heart's electrical activity) displayed a rhythm of asystole (the heart's electrical system fails entirely, which causes the heart to stop pumping. It is also known as flat-line. Asystole is a non-shockable rhythm). The EMS record indicated EMS arrived at approximately 6:30 a.m. and continued resuscitation efforts until 6:52 a.m., at which time efforts were discontinued and Resident #1 was pronounced dead. Record review of the facility policy and procedure titled Automatic External Defibrillator, Use and Care of, revised March of 2015 found the policy and procedure stated, Personnel have completed training on the initiation of cardiopulmonary resuscitation (CPR) and basic life support, including defibrillation, for victims of sudden cardiac arrest. Policy Interpretation and Implementation (1) During a sudden cardiac arrest event, follow guidelines outlined in the procedure for Cardiopulmonary Resuscitation and Basic life Support . (3) The automatic external defibrillator (AED) will be used to try to restore normal cardiac rhythm when arrhythmia is strongly suspected. Recognizing the signs and symptoms of arrhythmia (and when to use the AED) is part of the CPR/BLS training. (4) In general, SCA [sudden cardia arrest] should be suspected if: (a)The victim's symptoms appeared very suddenly; (b) He or she is unresponsive; and (c)His or her breathing has stopped. (5) If an individual is found unconscious and SCA is suspected, begin the AED Protocol below. Initial Assessment and Safety Precautions . (3) Assess the victim: (a)Responsiveness - if unresponsive, retrieve (or direct someone to retrieve) the AED from its location and bring it to the victim .Applying Pads to the Victim .(6) Attach two AED pads to the victim's bare chest (one on the upper right , one on the left) .Defibrillation. (1) After applying pads .The AED will analyze the heart rhythm and indicate whether a shock is needed . (5) Follow the AED prompts until the emergency medical service arrives . The facility policy and procedure titled Emergency procedure- Cardiopulmonary Resuscitation, revised [DATE] found the policy and procedure stated, Policy Statement-Personnel have completed training on the initiation of cardiopulmonary resuscitation (CPR) and basic life support (BLS), including defibrillation, for victims of sudden cardiac arrest. General Guidelines . (4) The chances of surviving SCA may be increased if CPR is initiated immediately upon collapse. (5) Early delivery of a shock with a defibrillator plus CPR within ,d+[DATE] minutes of collapse can further increase chances of survival . Preparation for Cardiopulmonary Resuscitation . (6) Maintain equipment and supplies necessary for CPR/BLS in the facility at all times. Emergency Procedures- Cardiopulmonary Resuscitation- . (7) When the AED arrives, assess for need and follow AED protocol as indicated. (8) Continue with CPR/BLS until emergency medical personnel arrive. The Administrator was notified on [DATE] at 4:42 p.m. that an Immediate Jeopardy situation was identified due to the above failures. The Administrator was provided the Immediate Jeopardy template on [DATE] at 4:57 p.m. The facility's plan of removal was requested on [DATE] at 4:57 p.m. The facility's Plan of Removal was accepted on [DATE] at 12:58 p.m. and included: Regional nurse provided in-service to the director of nursing and administrator on regulations of CPR and AED. Topics of in-service included, AED must be checked daily to ensure it is functioning properly and ready to go. Education also provided that the facility must identify a storage area for emergency supplies and ensure staff know the location. Initiated: [DATE] completed: [DATE] 5:25 p.m. In-services on the CPR policy including the use of AED, daily checks verifying pads are connected and ready to use. Location of replacement pads in the facility and importance of replacing immediately if used. daily check sheet updated with checks to include battery connected and replacement pads, in-services were started on [DATE] at 5:45pm by DON for all licensed nursing staff. All licensed nurses will be in-serviced prior to their next shift. No nurse will be allowed to work until in-service is completed. Initiated [DATE] to be completed on [DATE] 1:00 p.m. Administrator and DON verified that the AED is functioning as manufacturer intended, with pads connected. replacement pads added to AED storage compartment. completed on [DATE] 5:30 p.m. An audit of all employees for CPR certification and training was completed by the administrator on [DATE] for CPR compliance. facility audited the last 90days of resident discharges to ensure no other full code residents were affected. no other residents required CPR inside the facility. Initiated: [DATE] completed: [DATE] 7:00 p.m. Facility scheduled a QA with medical director to be held on [DATE] at 8:00 a.m. Initiated: [DATE] completed: [DATE] at 8:30 a.m. Facilities policy and procedure titled Emergency Procedure- Cardiopulmonary Resuscitation was reviewed and updated by administrator and regional nurse on [DATE] to ensure that current policy meets the standards of practice and regulatory requirements on properly trained staff are in the building ,d+[DATE]. Initiated: [DATE] completed: [DATE] 5:00 p.m. Ongoing systematic change to ensure CPR trained staff are knowledgeable on AED and location of all emergency supplies and equipment on all shifts is that all licensed personnel will receive training at the time of hire. Storage area for AED pads has been identified with a large red sign AED pads here- initiated: [DATE] completed [DATE] 7:30 p.m. The QAPI team, led by the administrator, will meet weekly for 3 weeks to discuss coordination of completion of all in-services, assessments, and interventions are utilized and completed. The medical director was notified on [DATE] of the immediate jeopardy called on facility. Initiated: [DATE] completed: [DATE] 8:00 p.m. On [DATE] the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by: Record review of the signed statement dated [DATE] at 5:30 p.m., verified the crash cart was checked by both the Administrator and DON for AED pads were connected to the AED, the green indicator light was observed flashing, an extra set of AED pads were in place. The expiration dates of the pads were checked and the AED powered on and prompts began without error codes. Record review of the undated facility document titled Future QAPI Dates QAPI plan to meet weekly for 3 weeks ([DATE] at 10:00 a.m., [DATE] at 10:00 a.m., and [DATE] at 10:00 a.m.). Record review of the undated new Crash Cart Checklist displayed the following added check off items: *AED pads connected; *Extra AED pads in bag; and *Expiration date on AED pads checked. The new Crash Cart Checklist had been completed with the new items checked off and signed. Record review of the CPR Certification Audit document reflected AUDIT OF all nurses for CPR certification and training was completed by the administrator on [DATE] for CPR compliance. Record review of the in-service training report dated [DATE], Topic: Potential for Clause reflected the DON and Administrator had received in-service over the importance of actual failures or potential for failures must be reported, investigated, staff in-serviced as necessary to ensure no other residents would be affected, all corrective actions taken and monitored. Record review of the in-service training report dated [DATE], Topic: Importance of Regulation 678 reflected the DON and Administrator and received in-service/instruction that the AED must be checked daily to ensure it is functioning properly and ready to go and that the facility must identify a storage area for emergency supplies /ensure staff know the location. Record review of the in-service training report and accompanied sign in sheet dated [DATE], Topic: Checking the AED and AED pads reflected nurse in-services over; the updated Emergency Procedure -CPR policy; on the use of AED; on daily checks- verifying pads were connected and ready to use; on the location of replacement pads in the facility; and importance of replacing the pads immediately after use; and the updated crash cart check off list had been initiated. Record review of the audit document of deceased residents since [DATE] verified in the last 90 days no additional discharged /deceased residents had required full code interventions. Record review of the facility QA agenda and sign in sheet dated [DATE] reflected a QA meeting with the Medical Director was held on [DATE] at 8:00 a.m. and agenda outline included Medical Director notification of identified system failure and identification of Immediate Jeopardy on [DATE] and corrective actions taken as of [DATE] at 8:00 a.m. The document was signed by the Medical Director. Record review of the updated policy and procedure titled Emergency Procedure- Cardiopulmonary Resuscitation found the policy and procedure had been reviewed and revised and ensured maintain equipment and supplies necessary for CPR/BLS in the facility at all times remained in the policy and procedure. Record review of the undated, AED acknowledgment form found that the new applicants would sign acknowledgement form which stated, The AED must be checked every day. Nurses must ensure the green light is flashing verifying the pads and batteries are connected. Nurses must check to ensure replacement pads are in the storage compartment. Replacement pads are also located in the Med Room in a cabinet with a red sign alerting to the location. If at any time the AED is not functioning properly, the DON and Administrator must be notified immediately. During an observation on [DATE] at 12:40 p.m., a large red sign taped to a cabinet door in medication room alerted the viewer of the location of extra AED pads. Three additional boxes of AED pads were labeled and in place. During an observation on [DATE] at 12:45 p.m., the facility crash cart was found with the AED in place, the green indicator light was flashing on the AED, AED pads were connected to the AED, an additional set of AED pads were found in the attached zipper compartment, and the expiration date checked on both set of pads. The placement and use of the new Crash Cart Checklist was also observed. Staff interviewed on [DATE] between 1:00 p.m. and 3:00 p.m. (LVN F, LVN, G, LVN H, LVN C, RN I, RN J, LVN K, LVN L, LVN M, ADON N, ADON B, ADON, O, LVN P and LVN Q [ these nurses comprise 6 of 7 of the facilities staff day shift nurses, 3 of 7 staff night nurses plus 4 nurses with other primary roles- 3 of which regularly work the floor]), said crash cart checks were to be performed daily and those checks must include ensuring AED pads were connected to the AED machine, the flashing green indicator light was observed, extra pads were in the attached zipper pocket of the AED case and the expiration dates on both sets of the AED pads were checked. The nurses also said in addition to the extra set of AED pads a spare battery was located in the attached zipper pocket. The nurses said that after a code the AED pads were to be replaced immediately after the code. The nurses said the replacement pads could be found in the medication room behind the cabinet labeled with a red sign indicating the location of the AED pads. The nurses said if they went to replace the pads and they were not in those locations they would immediately notify the DON. The nurses correctly identified the changes made to the crash cart checklist as, AED pads connected; Extra AED pads in bag; and Expiration date on AED pads checked. The nurses also said that checking the box marked AED meant the AED was on the crash cart and the AED's blinking green indicator light was observed. The nurses said the flashing green indicator light indicated pads were connected and the AED was ready for use. The nurses also stated if any issues or obstacles were encountered during the course of care for residents that resulted in a bad outcome or potentially could result in a bad outcome, they would notify the DON and Administrator in order for administration and QAPI team to review the situation take any corrective actions and ensure no additional residents were affected. During an interview on [DATE] at 3:06 p.m., the DON said he should have notified the Administrator of the failure to have the AED pads readily available on [DATE] (which resulted in Resident #1 not receiving AED intervention until arrival of EMS). The DON said he should have ensured the notification so that the situation could have been reviewed, all failures identified and all corrective actions put in place, including staff in-services. The DON said going forward the facility would implement a system to ensure DON was notified any time the crash cart was pulled for use, even if after pulling the cart it was discovered/determined the resident was a DNR and the cart was not used. The DON said perhaps this was the situation that resulted in the AED pads not being in place when Resident #1 coded on [DATE] as the facility audit for the past 90 days discovered no other resident that been administered a full code. The DON said anytime the cart is pulled the entire crash cart would be audited to ensure all essential equipment (including AED pads) were replaced. He said in addition spots checks would be initiated to ensure nurses completed crash cart checks appropriately. The DON said all new staff hired would read and sign the AED acknowledgement form and in addition, all staff would have to sign the acknowledgement annually. The DON said there had also been discussion of mounting the AED machine, making it visible from the nursing station to ensure the green indicator light could be easily and readily viewed. The DON said all nurses that have worked since the identification of the IJ had received in-services and that no nurse would be allowed to return to work until in-services were completed. During an interview on [DATE] at 3:13 p.m., the Administrator said all nurses that have worked since the identification of the IJ had received in-services and that no nurse would be allowed to work until in-services were completed. While the IJ was removed on [DATE] at 3:22 p.m., the facility remained out of compliance at no actual harm with potential for more than minimal harm that is not immediate jeopardy with a scope identified as isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems.

46062 Based on observation, interview, and record review, the facility failed to ensure residents maintained acceptable parameters of nutritional status for 2 of 24 residents (Resident #55 and Resident #90) reviewed for nutrition/weight loss. 1.The facility failed to provide Resident #55 with physician prescribed dietary supplements. Subsequently, Resident #55 developed a pressure wound and low albumin levels. 2.The facility failed to implement dietician recommendations for Resident #90, resulting in significant weight loss. An Immediate Jeopardy (IJ) situation was identified on 03/01/2023 at 4:30 p.m. Th Administrator was notified, and a POR (plan of removal) was requested. These failures could place residents at risk for decreased nutritional status, decline in health, serious illness, or hospitalization . Findings included: 1. Record review of an undated face sheet revealed Resident #55 was a 64- year-old- female, admitted on [DATE] with the diagnoses of dementia (a general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), COPD (a group of lung diseases that make it hard to breathe and get worse over time), and malnutrition (a nutritional status in which reduced availability of nutrients leads to changes in body composition and function). Record review of an MDS assessment dated [DATE] for Resident #55 revealed a BIMS of 08, which indicated a moderate memory impairment. The MDS also revealed Resident #55 required supervision for bed mobility, transfers, and toileting. Resident #55 was independent with eating. The MDS revealed Resident #55's weight as 75 pounds with no significant weight loss or gain. The MDS revealed no skin impairment. Record review of the care plan dated 12/06/2022 for Resident #55 revealed no skin impairment care plan. Record review of the pressure ulcer risk assessment dated [DATE] revealed Resident #55 was at risk for developing pressure ulcers. Record review of the MD telephone orders dated 12/14/2022 revealed an order for the daily administration of a multivitamin with minerals for protein calorie malnutrition for Resident #55. Record review of the MAR for December 2022 revealed no order for daily multivitamin with minerals administered to Resident #55. The order was not transcribed to the MAR. 18 doses of multivitamin with minearls were missed in December 2022 for Resident #55. Record review of the MAR for January 2023 revealed no order for daily multivitamin with minerals administered to Resident #55. The order was not transcribed to the MAR. 31 doses of multivitamin with minerals were missed in January 2023 for Resident #55. Record review of the MD telephone orders dated 02/14/2023 revealed an order for Med Pass 2.0 (dietary supplement) 2 ounces four times daily for protein calorie malnutrition. Record review of the MAR for February 2023 revealed an order for Med Pass 2.0-2oz four times daily with times of 5:00 p.m. and 9:00 p.m. marked for administration times. The MAR revealed Med Pass 2.0-2 oz was administered twice daily beginning on 02/14/2023 at 5:00 p.m. and 9:00p.m. 26 doses of Med Pass 2.0-2 oz. were missed in February 2023. Record review of the MD telephone orders dated 02/14/2023 revealed an order for Prostat (protein supplement) 30 ml three times daily for protein calorie malnutrition. Record review of the MAR for February 2023 revealed an order for Prostat 30 ml three times daily. The MAR revealed Prostat 30ml was administered once daily at 8:00 p.m. marked for administration times. 26 doses of Prostat were missed in February 2023. During an interview on 02/27/2023 at 9:15 a.m., Resident #55 stated the treatment nurse found a pressure ulcer to her right hip while doing a skin assessment on the morning of 02/27/2023. Resident #55 stated she did not refuse any supplements or medications from the nurses. Record review of wound care notes dated 03/01/2023 indicated Resident #55 developed a new pressure ulcer classified as a deep tissue injury to the right hip measuring 5.0 cm x 5.5 cm x undetermined depth on 02/27/2023. Record review of Resident #55's laboratory results dated [DATE] revealed a prealbumin (helps clinicians detect the effectiveness of nutritional support efforts) level of 5. Normal ranges for a prealbumin level are 20-40. 2. Record review of Resident #90's undated face sheet, indicated Resident #90 was a [AGE] year-old male admitted to the facility on [DATE] with the diagnoses of dementia (a general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), malnutrition (a nutritional status in which reduced availability of nutrients leads to changes in body composition and function) and depression (is a common and serious medical illness that negatively affects how you feel, the way you think and how you act). Record review of Resident #90's MDS dated [DATE] revealed Resident #90 had a BIMS of 05 which indicated a severe memory impairment. Resident #90 required extensive assistance for bed mobility, transfers, and toileting, and limited assistance for eating. The MDS revealed Resident #90 had a weight of 151 pounds and was 75 inches tall. The MDS revealed Resident #90 was not on a therapeutic diet and had no significant weight loss or gain. Record review of Resident #90s care plan dated 02/22/2022 revealed Resident #90 was at risk for alteration in nutritional status related to a therapeutic diet. Interventions for Resident #90s care plan included providing supplements as ordered with the goal of preventing weight loss. Record review of the facility's monthly weight sheet dated March 2023 revealed Resident #90 weighted 148 pounds as of 03/01/2023. The weight sheet revealed Resident #90 weighed 151 in February 2023, 165 in December, and 169 in November 2022. 151-148= 3 pounds/ 2% in 30 days 165-148=17 pounds/ 11.5% in 90 days 169-148=21 pounds/ 14.2% in less than 180 days. Record review of the Nutritional Recommendations by RD Consultant form dated 01/03/2023 revealed a dietary recommendation for Resident #90 related to inadequate calcium and protein intake and constipation. The recommendations were as follows: Med Pass 2.0- 90 cc three times daily Prostat 30 ml three times daily Supercereal (cereal with added protein/fat) at breakfast Prune juice with evening meal Record review of MARS dated January 2023 and February 2023 revealed no orders for Med Pass 2.0- 90 cc three times daily and no order for Prostat 30 ml three times daily. During an interview on 03/01/2023 at 3 p.m., ADON I revealed she did not write the orders for Med Pass 2.0 -90 cc three times daily or for Prostat 30 ml three times daily. ADON I stated she was miseducated on how to read the recommendation sheet from the dietician. ADON I stated she thought she was supposed to choose one intervention that the RD recommended. ADON I stated she was not aware that all the listed recommendations were to be transcribed. ADON I stated she chose the supercereal for Resident #90 because he was already on it. ADON I stated not receiving prescribed dietary supplements could lead to weight loss, skin impairment and overall decline in the elderly. During an interview on 03/01/2023 at 3:00p.m., ADON I stated she was the nurse responsible for the weight/nutrition system in the building. ADON I explained the residents were all weighted by the 7th of the month for monthly weights. The weights were then given to her, and she calculated gain and loss percentages. ADON I stated she then notified the MD and RD of the weight loss/gain. ADON I stated when the recommendations were made by the RD or MD, she wrote a telephone order and transcribed the order to the MAR. ADON I stated she alerted the nurses by writing the new order on the 24-hour sheet and called the family of the resident and let them know of the new orders. ADON I stated she must have missed the Multivitamin with Minerals order for Resident #55. ADON I stated she did not write the time the medications were due on the MAR for Med Pass 2.0-2oz. four times daily or Prostat 30ml three times daily resulting in missed doses of both orders. ADON I stated missing a multivitamin, a dietary supplement and a protein supplement could result in weight loss, skin impairment, and overall decline in the resident's condition. ADON I stated there was no one designated to check behind her to ensure nothing was missed During an interview on 03/01/2023 at 3:15 p.m., the Nurse Consultant stated that all recommendations listed on the Nutritional Recommendations by RD Consultant report were to be followed unless an allergy was noted. The Nurse Consultant stated ADON I failed to write the times on the MARS for Resident #55 to indicate when the dietary supplements should have been administered and the nurses failed to read the orders on the MAR and carry them out. The Nurse Consultant stated ADON# I failed to transcribe the RD recommendations for Resident #90 and Resident #90 had lost significant weight at the 90 day and less than 180-day marks. The Nurse Consultant stated weight loss greater than 7.5% in 90 days and greater than 10% in 180 days indicated a significant weight loss. During an interview on 03/01/2023 at 3:30 p.m., the interim DON stated ADON #I oversaw the weight/nutrition system and had been doing it for over a year. The DON stated the weight discrepancies were discussed in morning meetings but prior to the DON's arrival a few months ago, she was unsure if the weights were discussed in the morning meetings. The DON stated she knew for certain the weights were discussed for the last 4-6 weeks in morning meetings. The DON stated dietary recommendations were not discussed. The DON stated she expected ADON #I to transcribe the order, call the family, ensure the medication was on the MAR, ensure diet changes were communicated to the kitchen, and note the entire process in the resident's clinical record. The DON stated there was no system to follow up behind the ADON to ensure nothing was missed. The DON stated nutrition in the elderly was important to prevent weight loss, muscle loss, skin integrity impairment, and overall decline. During an interview on 03/01/2023 at 3:34 p.m., the Administrator stated the ADON I oversaw the weight/nutrition system. The Administrator stated that nutrition in the elderly was highly important to prevent a decline in their health status. The Administrator named weight loss and skin impairment as side effects of poor nutrition in the elderly. During an interview on 03/02/2023 at 10:00 a.m., the RD revealed she was informed of weight loss and gain each month by the 7th. She then calculated weight loss and gain for each resident. The RD stated she often asked for reweighs if the weight fell in the category of significant loss or gain. The RD stated once the significant losses and gains were identified, she reviewed the charts for recent labs, looked at ADL sheets to see how each resident was eating, and looked at mediations added and taken away from each resident. The RD stated once all aspects of nutrition had been considered, she made dietary recommendations and gave a copy of the recommendations to the DON and ADON# I. The RD stated all recommendations were expected to be followed. The RD stated not following the dietary recommendations made could result in further weight loss and skin impairment. The RD stated Resident #55 had a less than ideal nutritional status upon admission weighing less than 80 pounds, and that was why she made the recommendations for the supplements to prevent to weight loss and loss of skin integrity. The RD stated if supplements had been administered as they were ordered for Resident #55, she would have had a better chance not to develop pressure ulcers. The RD stated Resident #90 needed added calories because of fluctuating food intake between 25-75%. The RD stated she recommended the supplements two months prior to prevent further weight loss by adding calories and protein to Resident #90's diet daily. During an interview on 03/02/2023 at 11:50 a.m., MD #3 stated he left all nutrition and nutritional support recommendations to the RD. MD #3 stated it was not his area of expertise and the facility had a dietician to make nutritional recommendations to meet the resident's needs. MD#3 stated weight loss and skin impairment could occur when a resident did not have optimal nutrition. MD#3 stated he was uncertain if the supplements ordered for Resident #55 and Resident #90 would have prevented skin breakdown or weight loss. Record review of an undated Weight Monitoring policy indicated based on the resident's comprehensive assessment, the facility will ensure that all residents maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance A significant change in weight is defined as: a. 5% change in one month, b. 7.5% change in 3 months, c. 10% change in 6 months. Documentation: a. The physician should be informed of a significant change in weight and may order nutritional interventions. No policy was provided related to nutritional status. The Administrator was notified on 03/01/2023 at 5:30 p.m. that an Immediate Jeopardy (IJ) with actual harm was identified due to the above failures. The Administrator was provided with the IJ template on 03/01/2023 at 5:45 p.m. and a POR (plan of removal) was requested. The following Plan of Removal submitted by the facility. The plan of removal was accepted on 03/02/2023 at 1:16 p.m. and included the following: THE ADMINISTRATOR AND DON WERE IN-SERVICED ON 3/01/23 AT 6:50 PM BY THE REGIONAL NURSE ON THE POLICY AND PROCEDURE OF ACCURATELY TRANSCRIBING PHYSICIAN ORDERS AND THE IMPORTANCE OF NUTRITION, HYDRATION, AND WEIGHT MANAGEMENT IN LONG-TERM CARE.?INTIATED: 03/01/23 COMPLETED: 3/01/23 6:55 P.M.?? IN-SERVICES DONE BY THE DON, ADMIN, OR DESIGNEE ON THE IMPORTANCE OF HYDRATION AND NUTRITION NEEDS IN THE ELDERLY AND ACCURATELY WEIGHING RESIDENTS. THE ADVERSE OUTCOMES TO A RESIDENT WITH POOR NUTRITION COULD LEAD TO WEIGHT LOSS, WOUNDS, AVOIDABLE hospitalization S, AND POSSIBLY DEATH. IN-SERVICE PROVIDED TO ALL DIRECT CARE STAFF.?ALL STAFF WILL BE IN-SERVICED PRIOR TO NEXT SCHEDULED SHIFT. INITIATED: 3/01/23 COMPLETED: 3/02/23 11:55 PM. IN-SERVICES DONE BY DON, ADMIN, OR DESIGNEE TO ALL LICENSED NURSES ON THE IMPORTANCE OF ACCURATE PHYSICIAN ORDER TRANSCRIPTION, INCLUDING ACCURANCY OF TIMES, LENGTH OF DURATION, AND VERIFYING THE CORRECT SCHEDULED TIME IS ASSIGNED ACCORDING TO FREQUENCY OF ADMINISTRATION ON MEDICATION ADMINISTRATION RECORD. THE IMPORTANCE OF TIMELY NOTIFICATION TO THE PHYSICIAN WITH DIETARY RECOMMENDATIONS.?ALL NURSES WILL BE IN-SERVICED PRIOR TO NEXT SCHEDULED SHIFT. INITIATED: 3/01/23 COMPLETED: 3/02/23 11:55 P.M. ADMINISTRATOR VERIFIED THAT A REGISTERED DIETICIAN WOULD COME to the facility on [DATE] AT APPROXIMATELY 9 AM TO RECONCILE ALL DIETARY INTERVENTIONS AND RECOMMENDATIONS.?INITIATED: 3/02/23 COMPLETED: 3/02/23 11:55 P.M. PHYSICIAN OF RESIDENTS #55 AND #90, WILL BE AT THE FACILITY ON 03/02/2023 AT 9:00 AM TO RE-ASSESS BOTH RESIDENTS IDENTIFIED.?INITIATED: 3/02/23 COMPLETED: 3/02/23 11:55 P.M THE DON OR ADONS WILL WEIGH 100% OF RESIDENTS STARTING ON 03/01/2023. ALL RESIDENTS WITH WEIGHT VARIANCES WILL BE ADDRESSED BY A DIETICIAN IN-HOUSE.?INITIATED: 3/02/23 COMPLETED: 3/02/23 11:55 P.M. WOUND CARE NURSE, WILL COMPLETE A SKIN ASSESSMENT ON RESIDENTS #55 AND #90 TO ENSURE RESIDENTS HAVE APPROPRIATE TREATMENTS IN PLACE.?INITIATED: 3/01/23 COMPLETED: 3/01/23 8:30 P.M. ADON WAS IN-SERVICED BY DON ON THE IMPORTANCE OF PROMPTLY NOTIFYING THE PHYSICIAN WITH ALL RECOMMENDATIONS AND REQUEST, SUCH AS DIETARY OR PHARMACY. THE IMPORTANCE OF ACCURATELY COMMUNICATING ALL SUGGESTED RECOMMENDATIONS TO THE TO THE PHYSICIAN. ACCURATELY RECEIVING THE PHYSICIANS ORDER AND TRANSCRIBING ACCURATELY TO THE MAR INCLUDING ASSIGNING DESIGNATED ADMINISTRATION TIMES ON THE MAR. INIATED 03/01/23 COMPLETED 03/01/23 8PM THE DON WILL BE RESPONSIBLE FOR ENSURING ALL RESIDENTS ARE IDENTIFIED AND REFERRED TO REGISTERED DIETICIAN, ALL RECOMMENDATIONS ARE DISCUSSED WITH PHYSICIAN PROMPTLY AND THAT THE RESIDENT RECEIVES THE APPROPRIATE TREATMENT AND VERIFICATION THAT RESIDENT IS RECEIVING BY VERIFICATION OF ACCURATE ADMINISTRATION ON MAR. INITIATED: 3/01/23 COMPLETED: 3/01/23 11:55 P.M. QAPI ON WEIGHTS, NUTRITION AND HYDRATION SCHEDULED 03/02/23. THE REGINAL NURSE NOTIFIED THE MEDICAL DIRECTOR ON 03/01/2023 AT 5:59 P.M. OF IMMEDIATE JEOPARDY SITUATION. INITIATED: 3/01/23 COMPLETED: 3/02/23 1:00 P.M. FACILITIES POLICY AND PROCEDURE TITLED WEIGHT LOSS PROTOCOL ASSESSMENT WAS REVIEWED AND UPDATED BY THE ADMINISTRATOR AND REGIONAL NURSE ON 3/01/2023 TO ENSURE THAT THE CURRENT POLICY MEETS THE STANDARDS OF PRACTICE AND REGULATORY REQUIREMENTS.?FACILITY REPLACED PRIOR POLICY WITH NEW ADDOPTED POLICY TILTED NUTRITION/UNPLANNED WEIGHT LOSS CLINICAL PROTOCOL. INITATED: 3/01/23 COMPLETED: 3/01/23 12:00 P.M. NEW ADOPTED POLICY IDENTIFIES THE THRESHOLD FOR SIGNIFICANT AND UNPLANNED WEIGHT LOSS WITH MORE CURRENT PARAMATERS. NEW POLICY ALSO NOW REFLECTS CAUSE IDENTIFICATION OF WEIGHT LOSS. NEW POLICY UPDATED TO INCLUDE TREAMTMENT AND MANAGEMENT GUIDEANCE. NEW POLICY NOW IDENTIFIES MONITORING. Monitoring for the implementation of the POR initiated on 03/02/2023 Record review of the Monthly Weight Sheet dated 03/02/2023 indicated 100% of residents were weighed for March 2023 by ADON I, Staffing Coordinator H, and Director of Transportation S. During an observation on 03/02/2023 at 8:00 a.m., Director of Transporation S and Staffing Coordinator H were observed properly weighing, documenting , and reporting the daily weight of 4 residents. Record review of monthly weight variance record dated 03/01/2023 indicated 12 residents had weight variances identified. Record review of the physician orders indicated the physician had implemented supplements, dietician referrals, and weekly weight monitoring for all 12 residents with weight variances. Record review of the facility's weight variance policy indicated it was revised and updated on 03/02/2023 and was changed to Nutrition/Unplanned Weight Loss Clinical Protocol The new policy included threshold for significant and unplanned weight loss with parameters, included identifcation of weightloss procedures, treatment and management guidance, and identifed monitoring. Record review of progress notes dated 03/02/2023 indicated MD#3 assessed and evaluated Resident #55 and Resident #90. Record review of skin assessments dated 03/02/2023 indcated Resident #55 and Resident #90 were assessed and evaluated. Record review of in-service training report dated 03/01/2023 indicated the DON and Administrator had been in serviced on accurate transcription of an MD order and the importance of nutrition in the elderly. Record review of in-service training report dated 03/02/2023 indicated ADON# I received training on accurate transcription of MD orders and the importance of nutrition and hydration in the elderly. Record review of in-service training report dated 03/02/2023 indicated to implement all orders in a timely manner. 1. Receiving and noting MD orders about nutrition, and any other orders must be implemented in a timely manner. 2. Importance of nutrition and hydration in the elderly with risk factors of poor nutrition. Interviews on 03/03/2023 from 10:00 a.m. until 1:48 p.m. the surveyor confirmed the facility implemented their plan of removal. Interviews with 5 (6am-6pm) nurses LVN J, LVN W and LVN Q, LVN D, and RN E and interviews with 2 (6pm-6am) nurses RN Y and RN C said they were in-serviced on obtaining weights, reporting weight changes to the physician, transcription of MD orders, and communicated adverse effects of poor nutrition. The nurses were educated separately and demonstrated understanding of transcription of MD orders and nutrition and hydration in the elderly. Interviews with 4 (6am-2pm) CNAs- CNA A, CNA F, CNA N, and CNA O and interviews with 3 (2pm-10am) CNAs -CNA T, CNA V, CNA W and 1(10p.m. to 6 a.m.) CNA- HA B indicated they were in-serviced on obtaining weights on admission, to record them and to report them to the nurses and all CNAs identified adverse effects of poor nutrition. The CNAs were educated separately and demonstrated understanding of nutrition and hydration in the elderly. The education included how to weigh residents, who to report the weight to, offering supplements with meal refusals, and signs of malnutrition and dehydration in the elderly. Interviews with the Director of Transportation S, Staffing Coordinator H, therapy PTA K and COTA L indicated they were in-serviced on the proper way to obtain weights, recording, and reporting the weights. All identified adverse effects of poor nutrition in the elderly. The staff were educated separately and demonstrated understanding of nutrition and hydration in the elderly The education included how to weigh residents, who to report the weight to, offering supplements with meal refusals, and signs of malnutrition and dehydration in the elderly. Interviews with the interim DON and the Administrator indicated they were in-serviced on the proper way to obtain weights, recording, and reporting the weights. All identified adverse effects of poor nutrition in the elderly. The DON and Administrator were in serviced separately and demonstrated understanding of nutrition and hydration in the elderly The education included how to weigh residents, who to report the weight to, offering supplements with meal refusals, and signs of malnutrition and dehydration in the elderly. The interim DON and Administrator were informed the Immediate Jeopardy was removed on 03/03/2023 at 12:00 p.m. The facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy and a scope of pattern due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

Based on interview, observation, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 of 7 residents (Resident #98) and 2 of 4 medication storage location (medication storage #1 and #2) reviewed for pharmacy services. 1. The facility failed to clarify the open-ended order for Lovenox (an anticoagulant medication used to prevent blood clots) therapy when Resident #98 returned from his hospital admissions on 1/25/23 and again on 2/7/23. 2. The facility failed to have system in place to ensure appropriate medication reconciliation was performed for Resident #98. 3. The facility failed to have a system in place to ensure accurate duration of anticoagulant therapy for Resident #98. 4. The facility failed ensure Resident #98 was assessed (and those assessments documented) for signs and symptoms of complications from anticoagulant therapy. 5. The facility failed ensure Glucosamine Chondroitin (a dietary supplement indicated to reduce symptoms of osteoarthritis) was not expired in medication storage location #1. 6. The facility failed to ensure One Daily Vitamin, Folic Acid (important in red blood cell formation and for healthy cell growth and function) 400 mcg, Famotidine (used to prevent and treat heartburn due to acid indigestion and sour stomach caused by eating or drinking certain foods or drinks) 10mg, Geri-Kot (used to treat constipation) 8.6mg were not expired in medication storage #2. These failures resulted in an identification of an Immediate Jeopardy (IJ) on 3/2/23. While the IJ was removed on 3/4/23, the facility remained out of compliance at actual harm that is not immediate with a scope identified as isolated, due to the facilities need to complete in-services and evaluate the effectiveness of the corrective systems. These failures could place residents requiring anticoagulant therapy at risk of severe anemia, hemorrhage, or death and adverse effects and reduced therapeutic effects of medication and supplies. Findings included: Record review of Resident #98's physician orders indicated he was [AGE] years old and admitted to the facility on [DATE] with diagnoses including displaced spiral fracture of shaft of the right femur (fracture of the right thigh bone), dependance on renal dialysis, Hypertensive urgency (marked elevation in blood pressure without evidence of target organ damage), anemia, type II diabetes, chronic respiratory failure (slow developing respiratory failure that happens when the airways that carry air to your lungs become narrow and damaged), chronic obstructive pulmonary disease (group of lung diseases that block airflow and make it difficult to breathe) and end stage renal disease ( final, permanent stage of chronic kidney disease, where kidney function has declined to the point that the kidneys can no longer function on their own. A patient with end-stage renal failure must receive dialysis or kidney transplantation). Record review of the MDS assessment dated [DATE] indicated Resident #98 was understood and made himself understood. The MDS indicated he was cognitively intact as evidence by a BIMS score of 14. The MDS indicated he had no behavior of rejecting care. The MDS indicated he required extensive assistance with transfers, walking, dressing, personal hygiene and bathing. The MDS indicated he was always continent of bowel and bladder. The MDS indicated he had active diagnoses of renal insufficiency, renal failure, or end stage renal disease, as well as anemia, diabetes and hip fracture. The MDS indicated Resident #98 had a major surgical procedure during the prior inpatient hospital stay that required active care. The MDS indicated he underwent orthopedic surgery for repair of fracture(s) of the pelvis, hip, leg, knee or ankle. The MDS indicated Resident # 98 had received anticoagulant therapy 3 days during the seven days look back period. Record review of Resident #98's care plan dated 1/27/23 indicated Resident #98 was on anticoagulant therapy. The care plan interventions included adjust medications per facility protocol, and observe for signs of active bleeding (nosebleeds, bleeding gums, petechiae [ small red or purple spot caused by bleeding into the skin], purpura [ rash of purple spots on the skin caused by internal bleeding from small blood vessels], ecchymotic areas [bruising], hematoma [solid swelling of clotted blood within the tissues], blood in urine, blood in stools, hemoptysis [coughing up blood], elevated temp, pain in joints, abdominal pain). Record review of the Operative Report from the hospital dated 1/20/23 dictated by the Orthopedic Surgeon indicated Resident #98 underwent Open reduction (open reduction involves open incision to access the bone and realign it, so it heals properly) internal fixation (internal fixation involves piecing the bone fragments together with hardware such as pins, plates, rods, screws, or a combination of these) of a right subtrochanteric femur (area just below [within 5cm] where the thigh bone connects to the pelvis) fracture. Record review of the Orthopedic Follow Up Note written on 1/23/23 from the hospital by the Orthopedic Surgeon indicated Resident #98 was to be discharged to SNF (skilled nursing facility) and administered anticoagulation therapy for 1 month. Record review of the Discharge Home Medication List dated 1/24/23 at 5:06 p.m., from the hospital indicated Resident #98 was to be administered Lovenox 30 mg injection subcutaneously (means beneath, or under, all the layers of the skin) once a day. Record review of the active physician order with a start date of 1/25/23 indicated Resident #98 was to be administered Lovenox 30 mg injection subcutaneously once a day at 6:00 a.m. due to diagnosis of displaced spiral fracture of the right femur. The physician order had no stop date. Record review of Resident #98's medication administration record from 1/25/23 to 1/28/23 indicated he was administered Lovenox daily at 6:00 a.m. on the following dates: 1/26/23 to 1/28/23. Record review of the nursing notes from 1/25/23 to 1/28/23 for Resident #98 did not indicate he had been monitored for complications of anticoagulant therapy. Record review of the MAR and TAR for Resident #98 from 1/25/23 to 1/28/23 did not indicate he had been monitored for complications of anticoagulant therapy. Record review of the nursing note dated 1/28/23 at 12:00 p.m., indicated Resident #98 was sent to the ER for uncontrolled pain. Record review of the nursing note dated 1/28/23 at 2:30 p.m., indicated Resident #98 had returned to facility from the emergency room . Record review of the physician order dated 1/28/23 from the hospital indicated Resident #98 was to resume previous physician orders. Record review of Resident #98's medication administration record from 1/28/23 to 1/31/23 indicated he was administered Lovenox daily at 6:00 a.m. on the following dates: 1/28/23 to 1/31/23. Record review of the nursing notes from 1/28/23 to 1/31/23 for Resident #98 did not indicate he had been monitored for complications of anticoagulant therapy. Record review of the MAR and TAR for Resident #98 from 1/28/23 to 1/31/23 did not indicate he had been monitored for complications of anticoagulant therapy. Record review of the nursing note dated 1/31/23 indicated Resident #98 had been sent to the hospital for decreased level of consciousness, decreased oxygen saturation and decreased blood pressure. Record review of the nursing note dated 2/7/23 at 3:40 p.m. by RN C indicated Resident #98 had been readmitted to the facility from the hospital. Record review of the discharge home medication list dated 2/7/23 from the hospital indicated Resident #98 was to continue taking Lovenox 30 mg injections daily at 6:00 a.m. There was no stop dated listed on the discharge home medication list. Record review of Resident #98's medication administration record from 2/7/23 to 2/28/23 indicated he was administered Lovenox daily at 6:00 a.m. on the following dates: 2/9/23 to 2/27/23. Record review of the nursing notes from 2/7/23 to 2/10/23 for Resident #98 did not indicate he had been monitored for complications of anticoagulant therapy. Record review of the nursing note dated 2/11/23 at 3:30 p.m. written by RN C indicated Resident #98 had blood coming from his dialysis shunt after he (Resident #98) removed the dressing from the site. The note indicated the nurse (RN C) cleaned the site and applied a new dressing and would continue to monitor for bleeding. There were no additional nursing notes for 2/11/23. Record review of the nursing notes from 2/12/23 to 2/28/23 for Resident #98 did not indicate he had been monitored for complications of anticoagulant therapy. Record review of the MAR and TAR for Resident #98 from 2/7/23 to 2/28/23 did not indicate he had been monitored for complications of anticoagulant therapy. During an observation on 2/27/23 at 11:45 a.m., Resident #98 was sitting in his wheelchair. Resident #98 had no visible bruising and indicated he had no problems with the care he received at the facility. Record review of the nursing note dated 2/28/23 at 5:08 p.m. written by LVN D, indicated Resident #98 was sent to the emergency room due to dark red .bloody stool coming from his rectum non-stop. Record review of Gastroenterology Consultation note from the hospital dated 3/1/23 indicated Resident #98 was brought to the hospital with an acute GI bleed and low blood pressure. The consolation note indicated he had been on Lovenox therapy and was having [NAME] (clinically evident) red blood from his rectum. The note indicated he underwent imaging studies that showed active bleeding in his stomach. The note indicated the Gastroenterologist ordered for Resident #98 to be intubated and administered agents to reverse anticoagulation. The note indicated the GI team was called for emergent endoscopic (endoscopy procedure uses an endoscope to examine the interior of a hollow organ or cavity of the body) evaluation. Record review of Gastroenterology Procedure note from the hospital dated 3/1/23 indicated Resident #98 had endoscopic intervention to treat his upper GI bleed. The procedure note indicated Resident #98 had suffered hemorrhagic shock and would continue blood transfusion. The procedure note indicated he would remain intubated in case repeat endoscopic evaluation was needed during the night. During an interview on 3/2/23 at 9:05 a.m., LVN J said CMA GG was responsible to ensure orders were entered for residents who have returned from or admitted from the hospital. During an interview on 3/2/23 at 9:08 a.m., CMA GG said she reconciled resident orders when they returned from the hospital. CMA GG said she entered orders for residents who admitted from the hospital. CMA GG said she puts the orders in as they come from (as they are) from the hospital unless the admitting nurse directed otherwise. CMA GG said if a resident had an open ended (an order with no stop date) order for Lovenox she would have clarified with the nurse that admitted the resident because Lovenox was not a long-term use medication. CMA GG said a resident on anticoagulant therapy would also have orders for anticoagulant monitoring to ensure nurses assessed and documented whether or not a resident had signs of complications for anticoagulant therapy such as bleeding and bruising. CMA GG said she could not say for sure if she questioned or clarified with the admitting nurse regarding Resident #98's Lovenox order. During an interview on 3/2/23 at 9:20 a.m., the DON indicated there was no process in place to double check orders/reconcile orders that had come from the hospital when a resident admitted from or returned from the hospital. The DON said Resident #98's Lovenox should have had a stop date and said she would ensure that going forward there was a process in place to clarify open ended anticoagulant therapy. The DON said she expected nurses to assess and document anticoagulant monitoring for every resident on anticoagulant therapy. The DON said the documentation should have been on the MAR/TAR or in the nurses' notes. During an interview on 3/2/23 at 9:30 a.m., the Corporate Nurse said there was a system in place to double check orders/reconcile orders that had come from the hospital when a resident admitted from the hospital. The Corporate Nurse indicated CMA GG was to use the admission checklist as a double check to ensure admission orders were appropriately reconciled. Record review of the undated, untitled internal communication form (the checklist provided by the Corporate Nurse) did not address orders for anticoagulant therapy or include any process/ verification for open ended orders of anticoagulant therapy. During an interview on 3/2/23 at 9:35 a.m., RN C said she regularly took care of Resident # 98 on 6:00 a.m. to 6:00 p.m. shift. RN C said she knew Resident #98 was on Lovenox but said the medication was administered on the 6:00 p.m., to 6:00 a.m. shift. RN C said she did monitor Resident #98 for complications of anticoagulant therapy and indicated he (Resident #98) had some bruising to his stomach from the injections. RN C said she could not say if she documented the monitoring. RN C said some residents have a check off on their MAR/TAR to document anticoagulant monitoring but could not say if that was the case for Resident #98. RN C said she had questioned open ended Lovenox therapy in the past with other residents and sought clarification but did not do so on Resident #98 because the Lovenox was administered on the 6:00 p.m. to 6:00 a.m. shift. During an interview on 3/2/23 at 9:41 a.m., MD 4's nurse said there was nothing in communication notes related to the facility seeking clarification regarding Resident #98's Lovenox therapy. During an interview on 3/2/23 at 11:00 a.m., MD 3 said the normal duration for Lovenox therapy was 15- 35 days but said he would defer to the expertise of Orthopedic Surgeon regarding the intended duration of therapy for Resident #98. During an interview on 3/2/23 at 11:10 a.m., LVN D said she regularly took care of Resident # 98 on 6:00 a.m. to 6:00 p.m. shift. LVN D indicated she had monitored Resident #98 for complications regarding anticoagulant therapy and said it should have been documented on the TAR/MAR. LVN D said she thought she had documented Resident #98's monitoring for anticoagulant therapy. LVN D said the usual length of anticoagulant therapy was 30 days. LVN D said she believed Resident #98 was getting close to that length of administration (30 Days) but could not say for sure because night shift administered the medication. LVN D said she took care of Resident #98 on 2/28/23 and was called to his room when he was found to have blood steadily coming out of his rectum upon his return from dialysis. LVN D said he was promptly sent to the emergency room . LVN D said earlier that day Resident #98 was fine and had no symptoms of complications of anticoagulant therapy. During an interview on 3/2/23 at 11:27 a.m., LVN U said she worked the 6:00 p.m. to 6:00 a.m. shift and regularly took care of Resident #98. LVN U said Resident #98 received Lovenox therapy but could not say why he was on the medication. LVN U said the usual duration for Lovenox therapy was 30 days but would administer the medication for whatever duration the physician order directed. LVN U said she was not sure how long Resident #98 had been on Loveonx therapy. LVN U said she could not say that she had questioned or sought clarification regarding Resident #98's Lovenox therapy. LVN U said she had only given Resident #98 his Lovenox a few times. LVN U said she monitored Resident #98 for complications of anticoagulant therapy and documented the monitoring in the nursing notes. During an interview on 3/2/23 at 12:00 p.m., RN FF said she worked the 6:00 p.m. to 6:00 a.m. shift and regularly took care of Resident #98. RN FF indicated she usually worked opposite of LVN U. RN FF said she was not sure how long Resident #98 had been on Lovenox therapy. RN FF said the usual duration for Lovenox therapy was 28 days. RN FF said there was usually a stop date on an order for Lovenox therapy. RN FF said Resident #98 was on Lovenox therapy for DVT (deep venous thrombosis, blood clots) prevention after having hip surgery. RN FF said she did not question Resident #98's open ended order for Lovenox because she assumed he was perhaps on a longer duration of therapy related to his dialysis. During an interview on 3/6/23 at 10:19 a.m., the Orthopedic Surgeon indicated Resident # 98 was to have received Lovenox therapy for 1 month as written in his progress note on 1/23/23. The Orthopedic Surgeon said the additional days of Lovenox therapy Resident #98 received, would not have caused his GI bleed but would have certainly contributed to the amount of blood loss he suffered. During an observation with the interim DON on 02/27/23 at 10:20 a.m., in medication storage location #1, revealed one unopened bottle of Glucosamine Chondroitin with expiration date of 12/22. During an observation with the interim DON on 02/27/23 at 10:28 a.m., in medication storage location #2, revealed one bottles of One Daily, Folic Acid 400mcg, Famotidine 10mg, and Geri-Kot 8.6mg with expiration date of 01/23 was found. During an interview on 03/01/23 at 4:17 p.m., RN C said nurses, MA, and the pharmacy consultant checked the carts and medication room for expired medications. She said the facility checked the medication cart and storeroom once a month; first of the month. RN C said staff members do not sign a checklist proving it was done but the expired medication was placed in the sink of the storeroom and staff notified the DON of meds that needed to be destroyed. She said expired medication was not as good and could lose potency. She said administering expired medications could cause residents to not get what the needed from the medication such as vitamins for vitamin deficiency. RN C said she did not know who would be responsible for ensuring staff did not administer or store expired medication but assumed it was the DON. During an interview on 03/03/23 at 9:51 a.m., MA DD said everyone check for expired medications during med pass before administration. She said the MAs and nurses should check the medication storeroom at least once a month for expired medications but would also check when you grabbed a new bottle.MA DD said expired medication should not be given because they were out of date and could make the resident sick. During an interview on 03/03/23 at 10:05 a.m., MA EE said she was not sure who would be responsible for checking the med carts and storeroom for expired medications, but she did know the pharmacy consultant came once a month and completed cart audits. She said she tried to check her medication cart once a week for expired meds. MA EE said medications were less effective when expired and would not get the desired results the medication was given for. During an interview on 03/03/23 at 12:50 p.m., the interim DON said she expected staff to check medication carts and the storeroom monthly for expired medications. She said the nurses and MAs was responsible for checking for expiration dates, but she would be taking it over. The interim DON said she thought the Pharmacy consultant was also checking for expiration dates when she came once a month. She said expired medication could be ineffective and the resident risked mot getting the desired affect for why the med was prescribed. The interim DON said there was not a formal process in place for checking for expired medication which she was already putting one in place. She said she was responsible for ensuring the staff were not administering or storing expired medications. During an interview on 03/03/23 at 1:32 p.m., the Pharmacy Consultant said she came to the facility mid-month and stayed for 2-3 days. She said she completed monthly audits of the storeroom and medication carts. The PC said during her visit completed gradual dose reduction for certain medication, watched med pass, checked for expired medications, medication destruction, and provided a recommendation of findings. She said she checked for expiration dates of medications, but it was not a complete check and if her report stated she found expired medications then they should do a thorough check. The PC said her report was emailed after her visit to the ADM and DON for review and to make corrections she found or observed. During an interview on 03/03/23 at 2:19 p.m., the ADM said he expected the nursing staff not to administer expired medications. He said LVNs and MAs should check for expired medication weekly and the DON monthly. The ADM said he also expected staff to properly discard expired medication. Record review of the in-service with Topic: Expectation, dated 12/22/22, revealed .nursing check offs .insulin administration checks off .insulin Pen administration check off .flushing PICC line .G-tube med administration check off . Medication storage check off was not noted. Record review of a facility Storage of Medications policy dated 04/07 revealed .the nursing staff shall be responsible for maintaining medication storage .the facility shall not use discounted, outdated .drugs or biologicals . The Administrator was notified on 3/2/23 at 4:40 p.m. that an Immediate Jeopardy situation was identified due to the above failures. The Administrator was provided the Immediate Jeopardy template on 3/2/23 at 4:48 p.m. The facility's Plan of Removal was accepted on 3/3/23 at 1:42 p.m., and included: THE ADMINISTRATOR AND DON WERE IN-SERVICED ON 3/02/23 AT 8:00 PM BY THE REGIONAL NURSE ON THE POLICY AND PROCEDURE OF ACCURATELY TRANSCRIBING PHYSICIAN ORDERS AND THE IMPORTANCE OF ORDER VERIFICATION. IN-SERVICE ON MONITORING OF RESIDENT FOR SIGNS AND SYMPTOMS OF ANTICOAGULANT THERAPY, WHICH INCLUDES BRUISING AND BLEEDING. IN-SERVICED ON HAVING A SYSTEM IN PLACE THAT CHECKS FOR ACCURACY AND TIMELINESS. NURSING UNIT MANAGERS WILL NOW ENTER ALL INFORMATION INTO MATRIX. CLINICAL MEETING WILL BE HELD EACH MORNING TO DISCUSS ALL ADMISSIONS, DISCHARGES, hospitalization S AND NEW ORDERS. EACH ORDER RECEIVED WILL BE VERIFIED THAT MONITORING AND ASSESSMENTS ARE COMPLETES AS WELL. INTIATED: 03/02/23 COMPLETED: 3/02/23 8:00 P.M. IN-SERVICES DONE BY THE DON, ADMIN, OR DESIGNEE ON THE IMPORTANCE OF MONITORING RESIDENTS ON ANTICOAGULANTS. IDENTIFYING SIGNS AND SYMPTOMS OF ADVERSE OUTCOMES RELATED TO ANTICOAGULANT THERAPY. STAFF TRAINED ON MEDICATION FOLLOW-UP AND COMMUNICATION WITH A PHYSICIAN TO ESTABLISH THE LENGTH OF TREATMENT WHEN NECESSARY. IN-SERVICE PROVIDED TO ALL LICENSED NURSING STAFF. ALL LICENSED NURSES WILL BE IN-SERVICED BEFORE THE NEXT SCHEDULED SHIFT. INITIATED: 3/02/23 COMPLETED: 3/03/23 11:55 P.M. REGIONAL NURSES PROVIDED IN-SERVICE TO LICENSED NURSES IN MANAGEMENT POSITIONS ON THE IMPORTANCE OF CHECKING EVERY PHYSICIAN ORDER FOR ACCURACY; WILL INCLUDE ALL REQUIRED INFORMATION. ENSURING ALL RESIDENTS HAVE THE APPROPRIATE DIAGNOSIS FOR PRESCRIBED TREATMENT. MEDICATION AIDE WILL NO LONGER WORK IN DATA ENTRY. ASSIGNED UNIT MANAGERS WILL ENTER PHYSICIAN'S ORDERS INTO MATRIX GOING FORWARD. ALL UNIT MANAGERS ARE LICENSED NURSES AND TRAINED IN MATRIX. ALL 6 NURSE MANGERS WILL BE INSERVICED ON 03/03/23 OR BEFORE THEIR NEXT SHIFT. INITIATED ON 03/02/23 PHARMACY CONSULTANT AWARE AND WILL REVIEW CHARTS AS WELL ON NEXT VISIT. INITIATED PHARMACIST WILL BE AVAILABLE BY PHONE. AND WILL BE IN THE FACILITY ON MARCH 14TH AND 15TH. INITIATED 03/03/23 COMPLETED 03/03/23 11:55 PM QAPI TO ADDRESS FINDINGS ON 03/03/23 INITIATED 03/02/23 COMPLETED 03/03/23. POLICY UPDATED TO INCLUDE VERIFYING THE LENGTH OF TREATMENT AND FREQUENCY WHEN RECEIVING PHYSICIAN'S ORDERS. ALL LICENSED NURSES WILL BE IN SERVICED PRIOR TO WORKING NEXT SHIFT. INITIATED: 3/02/23 COMPLETED: 3/03/23 1:00 p.m. During interviews with staff nurses on 3/4/23 from 10:00 a.m. to 11:45 a.m., (5 of 10 day shift staff nurses [LVN Q, LVN J, LVN D, RN R, LVN II]; 3 of 5 night shift staff nurses [LVN JJ, RN HH, RN Y] ) were performed. During these interviews' the nurses verbalized they understood the importance of monitoring residents on anticoagulant therapy and documenting those findings in the medical record. The nurses verbalized that they would notify the physician if a resident on anticoagulant therapy had excessive bleeding, nosebleeds, blood in the urine (which could look pink, red or coffee colored), bleeding gums, dark red spots under the skin, blood in the stool (which could be dark, almost black, and tarry) or blood in vomit (which may appear black or dark brown like coffee grounds) right away. The nurses indicated there will be a place on the MAR/TAR to document anticoagulant therapy monitoring for all residents receiving anticoagulant therapy. The nurses indicated they would follow up with the physician to establish the desired length of anticoagulant therapy if the order for anticoagulant therapy was open ended. During interviews with Nurse Managers (6 of 6 nurse managers [LVN I, LVN KK, ADON P, ADON M, LVN W, DON]) on 3/4/23 from 10:30 a.m. to 12:02 p.m., the Nurse Managers said every physician order would be checked for accuracy as part of their new process. They indicated they would enter orders/ perform medication reconciliation for their assigned hall when a resident was admitted from the hospital or returned from the hospital. They indicated CMA GG would no longer be responsible for entering medication orders. They indicated they would clarify with the physician regarding any open-ended orders for anticoagulant therapy. During these interviews' the Nurse Managers verbalized they understood the importance of monitoring residents on anticoagulant therapy and ensuring staff nurses had documented those findings in the medical record. The Nurse Managers indicated signs and symptoms that required physician notification with regard to anticoagulant monitoring included; excessive bleeding, nosebleeds, blood in the urine (which could look pink, red or coffee colored), bleeding gums, dark red spots under the skin, blood in the stool (which could be dark, almost black, and tarry) or blood in vomit (which may appear black or dark brown like coffee grounds). The Nurse Managers indicated orders for anticoagulant monitoring would be entered for all residents on anticoagulant therapy and doing so would result in a place on the MAR/TAR for staff nurses to document anticoagulant therapy. The DON indicated the pharmacy consultant had been made aware of the IJ situation and would be in the facility on March 14th and March 15th to ensure compliance. The DON said she had reviewed all residents in the facility for appropriate anticoagulant administration. The DON said the facility would now address all orders in the clinical morning meetings which will include all admissions discharges and hospitalization s. The DON said in addition the clinical morning meetings will review nursing documentation to ensure anticoagulant monitoring was taking place. Record review of the facility QAPI notes for 3/2/23 indicated the QAPI committee addressed the findings of the IJ and indicated going forward all resident receiving anticoagulant therapy would be monitored and all orders for anticoagulant therapy for post operative DVT prevention would have an identified stop date. Record review of the facility in-service log titled In-Service dated 3/2/23 indicated all 6 nurse managers (LVN I, LVN KK, ADON P, ADON M, LVN W, and the DON) had been in-serviced regarding checking physician orders for accuracy; appropriate diagnosis; all appropriate information (such as stop dates). The in-service indicated CMA GG would no longer complete data entry and that Nurse Managers would now enter all orders. Record review of the facility in-service log titled In-Service dated 3/2/23 indicated the DON and Administrator had been in-serviced over the policy and procedure of accurately transcribing physician orders and the importance of order verification. It indicated they were in-serviced on monitoring of residents for signs and symptoms of anticoagulant therapy and in-serviced on having a system in place to check for timeliness and accuracy. Record review of the updated facility policy included verifying the length of treatment and frequency when receiving physician orders. On 3/4/22 at 12:31 p.m., the Administrator was informed the IJ was removed; however, the facility remained out of compliance at actual harm that is not immediate jeopardy with a scope identified as isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. 46062

Based on observation, record review, and interview, the facility failed to ensure pain management was provided to residents who required such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences, for 1 of 24 residents (Resident #160) reviewed for pain management. 1. The facility failed to take timely and appropriate intervention when Resident #160 complained of pain on 2/26/23 and 2/27/23. 2. The facility failed to ensure Resident #160's medication orders were accurately entered when she returned to the facility on [DATE] from the hospital. These failures could place residents at risk for unnecessary pain, discomfort and decreased quality of life. Findings Included: Record review of Resident #160's face sheet indicated she was [AGE] years old readmitted to the facility on [DATE] with diagnoses including history of fracture of the left femur, lumbar spina bifida, pain, peripheral neuropathy, and high blood pressure. Record review of the MDS assessment dated [DATE] indicated Resident #160 was understood and understood others. The MDS indicated she had moderately impaired cognition based on her BIMS score of 8. The MDS indicated Resident #160 frequently had pain during the 5 day look back period. The MDS indicated she rated her pain an 8, at its worst, during the 5 day look back period. Record review of the baseline care plan dated 2/20/23 did not address pain management for Resident #160. The written summary on the baseline care plan indicated Resident #160 had returned to the facility after a failed attempt to return to the community. The summary indicated Resident #160 returned to the hospital after a suspected overdose of ambien (sleeping pill) and oxycontin (pain medication). The summary indicated the emergency room physician discontinued the oxycontin and ambien and indicated all other orders were to be resumed. Record review of the comprehensive care plan dated 2/21/23 indicated Resident #160 had pain. The care plan interventions included, Acknowledge .her pain is unique and believable. Encourage her to let staff know when she is in pain, at times she will not say anything because she does not want to bother anyone .administer pain medications as ordered .Clarify misconceptions about addiction to pain medications . Record review of Resident #160's physician orders dated 1/26/23 (prior to her discharge on 2/13/23) indicated she had been receiving Gabapentin 300 mg twice a day for pain; Gabapentin 600 mg at bedtime for pain; oxycodone 5 mg every 4 hours as needed for pain; and ambien 5 mg at bedtime for sleep. Record review of the emergency room visit note dated 2/20/23 indicated Resident #160 was post an orthopedic procedure to her left hip due to a femur fracture and presented to the emergency room with overtaking her medications, wandering outside at night, and chronic pain. The note indicated her vital signs upon arrival were normal with the exception of her systolic blood pressure which was slightly elevated at 149. The note said Resident #160 was to resume her previous orders prior to discharge. Record review of the signed discharge home medication list dated 2/20/23 from the hospital indicated Resident #160 was to continue taking oxycodone 5 mg every four hours as needed; Tramadol 50 mg every 6 hours as needed for pain; and Ambien 5 mg at bedtime. Record review of the physician order dated 2/20/23 indicated Resident #160's oxycodone 5 mg every 4 hours as needed for pain was to be discontinued. The order also indicated Resident #160's Ambien 5 mg at bedtime for sleep was to be discontinued. There was no discontinue order for her Tramadol. Record review of the wound progress note dated 2/21/23 indicated Resident #160 admitted to the facility with an unstageable pressure wound to her left heel. The note indicated Resident #160 wound on 2/21/23 was found to have underlying deep tissue injury at the muscle/fascia level and revealed itself to be a Stage IV pressure injury. Record review of the MAR from 2/20/23 to 2/28/23 indicated Resident #160 was administered Gabapentin 300 mg twice a day for pain on the following dates: 2/20/23 to 2/28/23. The MAR indicated Resident #160 was administered Gabapentin 600 mg at bedtime for pain on the following dates: 2/20/23 to 2/28/23. The MAR indicated there was no other pain medication administered to Resident #160 from 2/20/23 to 2/28/23. Record review of the physician orders from 2/20/23 to 2/26/23 indicated Resident #160 had no new orders for pain medications. Record review of the nursing note dated 2/26/23 written by RN HH indicated Resident #160 was crying when she complained of pain at approximately 3:30 a.m. (on 2/27/23), to her left leg and heel. The nursing note indicated he (RN HH) faxed a notification to MD 4. Record review of the 24 hour report dated 2/26/23 indicated, regarding Resident #160, she was asking for pain pill and Gabapentin is not working faxed PCP (primary care provider) . During an interview and observation on 2/27/23 at 10:15 a.m., Resident #160 laid in her bed. Resident #160 said she her back and left heel were hurting. Resident #160 rated the pain at an 8 on the 0-10 pain scale (0 being no pain at all 10 being severe pain). Resident #160 said she had been hurting for the last 3 days and indicated the pain was manageable at times. Resident #160 said she had asked for pain medication last night but all she had for pain was Gabapentin (Nerve pain medication) and it just didn't help. Resident #160 said she thought the nurse last night contacted the doctor about her pain. Resident #160 said she would call the nurse and ask for something for pain. During an observation and interview on 2/27/23 at 2:35 p.m., Resident #160 laid in her bed. Resident #160 said her pain was not any better. Resident #160 said she had spina bifida and had always had pain but not like it had been for the past 3 days. Resident #160 said she had told her nurse about her pain. Resident #160 could not name the nurse she told about her pain. During an observation and interview on 2/27/23 at 3:41 p.m., Resident #160 laid in her bed. Resident #160 said she still rated the pain at an 8 on the 0-10 pain scale (0 being no pain at all 10 being severe pain) but said it was a little bit better. Resident #160 said she had not had anything for pain besides Gabapentin. She said the Gabapentin just did not help but thought the nurses were trying to get her some Motrin. During an interview 2/27/23 at 4:00 p.m., LVN J said she was taking care of Resident #160 that day (2/27/23). LVN J said she had been told Resident #160 had pain during the night but had not been told she had any complaints today. LVN J said she assessed Resident #160 that morning but could not say exactly what time it was. During an interview on 2/27/23 at 4:04 p.m., ADON I said RN HH should have notified the on-call physician regarding Resident #160's pain on 2/26/23 and 2/27/23. ADON I said Resident #160's pain had to be addressed and she had just called MD 4 's nurse and received an order for Tramadol for her pain. Record review of the active physician order dated 2/27/23 indicated Resident #160 was to be administered Tramadol 50 mg every 6 hours as needed for pain. During an interview on 2/28/23 at 10:15 a.m., RN HH said he had taken care of Resident #160 the night of 2/26/23 into the morning of 2/27/23. RN HH said the first time Resident #160 complained of pain was at approximately 10:00 p.m. on 2/26/23. He said she rated her pain at a 4-5 on the 0-10 pain scale to her left lower leg and heel. RN HH said he did not perform any interventions because she had no symptoms of pain. RN HH said at approximately 2:00 a.m., RN HH said Resident #160 called out again and was crying asking for pain medication. RN HH said his intervention at that time was that he faxed MD 4 regarding her pain. RN HH said he did not contact the on-call provider regarding Resident #160's pain. RN HH said he took no additional intervention because he peaked in on Resident #160 at approximately 4:00 a.m., and said she was asleep. During an interview on 2/28/23 at 9:15 a.m., Resident #160's family member said she never intended for Resident #160 to have untreated pain. Resident #160's family member said she just did not want her on so much pain medication and hoped the medications could be reduced to the point that she (Resident #160) did not need anything for pain. Resident #160's family member said she had attempted to take Resident #160 home from the nursing home. Resident #160's family member said she suspected Resident #160 had taken too much of her medications then wandered outside and drove her car. Resident #160's family member said Resident #160 was not supposed to be driving and took her to the emergency room . During an interview on 2/28/23 at 10:36 a.m., MD 4's nurse said on 2/15/23 (before the Resident #160 was readmitted to the facility he (MD 4) changed her pain medication to Tramadol and said Resident #160 should have had Tramadol on her readmission orders. During an observation and interview on 2/28/23 at 11:21 a.m., Resident #160 said she was doing much better since she started taking the Tramadol on 2/27/23. Resident #160 said she had no pain at the moment. During an interview on 2/28/23 at 11:59 a.m., the DON said RN HH should have notified the on-call provider regarding Resident #160's pain. The DON said there was some confusion regarding the admission orders for Resident #160 that contributed to the delay in the Tramadol orders and this was in part because the family requested she not be administered any more pain medication. During an interview on 3/2/23 at 12:30 p.m., the Administrator said he expected resident's medication to be accurately reconciled and resident's complaints of pain to be addressed and treated as ordered by the physician. The facility policy and procedure titled Pain Assessment and Management, revised March 2015 stated, The Purposes of this procedure are to help the staff identify pain in the resident an develop interventions that are consistent with the resident's goals .(1) The pain management program is based on a facility wide commitment to resident comfort. (2) 'Pain Management' is defined as the process of alleviating the resident's pain to a level that is acceptable to the resident and is based on his or her clinical condition and established treatment goals. (3) Pain management is a multidisciplinary care process that includes the following: .(b) effectively recognizing the presence of pain .(e)Developing and implementing approaches to pain management .(2) .Possible behavioral signs of pain (a) verbal expressions such as groaning, crying, screaming . 46062

Based on observation, interview, and record review, the facility did not ensure treatment was provided, consistent with professional standards of practice, to prevent new pressure injuries from developing for 1 of 3 residents reviewed for pressure injuries (ulcers). (Resident #25) The facility did not prevent the development of pressure injuries on Resident #25's coccyx/sacrum. The facility failed to follow physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility failed to place a pressure relieving cushion in # 25's wheelchair. This failure could place residents at risk for developing avoidable pressure injuries and the worsening of existing pressure injuries. Findings included: Record review of the consolidated physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Fecal matter empties into a bag secured over the opening). The physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Cleanse daily and as needed. The physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Change daily and as needed. Record review of the admission skin assessment for Resident #25 dated 10/23/2021 indicated a reddened area to the sacrum/coccyx area. Record review of the most recent MDS dated [DATE] indicated Resident #25 was understood and understood by others. The MDS indicated a BIMS (Brief Interview for Mental Status) of 12. This score indicated moderate cognitive impairment for Resident #25. The MDS also indicated Resident #25 required limited assistance with ADLs, including bed mobility, transferring, and walking. Record review of the undated baseline care plan revealed Resident #25 was admitted for the skilled service of therapy. The baseline care plan indicated Resident # 25 had problems with falls, ambulation, transfer, balance and locomotion. No skin issues or risk for pressure injury were addressed on the baseline care plan. Record review of a Skin - Acute Care Plan dated 12/13/2021 indicated a newly opened unstageable pressure injury to sacrum. There was an intervention of a pressure relief device including wheelchair cushion. Weekly skin assessments indicated the following: 1. 11/4/2021 indicated redness to sacrum, encouraged to turn and stay off buttocks as much as possible. 2. 11/11/2021 indicated redness to sacrum, barrier cream, encourage reposition. 3. 11/18/2021 indicated redness to sacrum, continue to use barrier cream, continue to encourage repositioning off buttocks. 4. 11/25/2021 indicated, redness to area. Encouraged to change positions, cream applied to area. 5. 12/2/2021 indicated redness to sacrum. 6. 12/9/2021 indicated redness to sacrum, encouraged to turn side to side. There were no measurements listed on any of the above skin assessments. Record review of a nurse's note on Resident #25's chart by RN D revealed new order 11/20/21 at 11:45 a.m., 1. Cleanse wound to coccyx with NS pat dry apply calcium alginate and cover with dry dressing. Change daily and as needed. 2. [MEDICATION(S)] (an oral nutritional supplement that promotes wound healing). 1 packet by mouth twice a day. 3. Prostat (a supplement that increase protein intake) sugar free 30 milliliters by mouth twice a day. 4. Vitamin C 500 mg by mouth twice a day. 5. Multivitamin with minerals 1 by mouth daily. 6. Zinc 220 milligrams by mouth twice a day .per standing orders. Dr. E and DON notified. Record review of a 24-hour report dated 11/20/2021 and 11/21/2021 revealed a wound to Resident #25's coccyx. Record review of skin treatment flowsheet for Resident #25 dated 12/2021 indicated facility barrier cream to sacrum daily and as needed once a day beginning 12/1/2021 and ending 12/13/2021. The skin treatment flowsheet indicated Sacrum unstageable (an ulcer that has full thickness tissue loss but is covered by necrotic (dead) tissue or eschar (scab or dead tissue) pressure injury - clean with wound cleanser, pat dry, apply collagen to wound, and cover with dry dressing. Change daily and as needed, once a day beginning 12/13/2021. During an observation on 12/13/2021 at 11:08 a.m., Resident #25 was sitting up in a wheelchair at bedside. There was no pressure relieving cushion present in the wheelchair. During an interview on 12/14/2021 at 2:58 p.m., Resident #25's wife said Resident #25 did have a bed sore to his bottom. She said when Resident # 25 was admitted it was only a reddened area. She said someone comes every other day and changes the dressing. During an observation on 12/14/2021 at 2:58 p.m., Resident #25 was sitting up in wheelchair at bedside. There was no pressure relieving cushion present in the wheelchair. During an interview on 12/15/2021 at 9:54 a.m., LVN C (wound care nurse) said he was notified on 12/13/2021 of the open wound to the coccyx/sacrum of Resident #25. He said on the same day he reported the open wound to the wound care physician. He said the wound care physician had not seen the wound yet and would on her next visit to the facility. He said there was not a skin treatment flowsheet for 11/20/2021 because they were only applying barrier cream prior to 12/13/2021. During an observation on 12/15/2021 at 9:58 a.m., LVN C (wound care nurse) provided wound care for Resident #25. Wound was approximately dime sized with slough (yellow/white material to wound bed) to wound bed. During an interview on 12/15/2021 at 10:38 a.m., RN D said he was the one that saw the wound on 11/20/2021 and the wound appeared open to him. He said he reported the wound to the wound care nurse and notified Dr E by fax. He said if he kept a copy of the fax it should be in the chart. He said when anyone finds a wound on a resident. they should notify the wound care nurse, the doctor, the ADON, and fill out a skin assessment sheet. During an interview on 12/15/2021 at 11:18 a.m., Resident #25's wife said after the surveyor had left out of the room on 12/14/2021, staff had come in the room and placed a pressure relieving cushion in Resident #25's wheelchair. She said there had not been a cushion in the wheelchair since sometime the previous week. She said physical therapy had taken the chair that had a pressure relieving cushion and had not brought it back. She said someone had come to get Resident #25 for a shower and she wasn't sure where they had gotten the current wheelchair. She said he had used the wheelchair over the weekend without a pressure relieving cushion. During an interview on 12/15/2021 at 11:50 a.m., LVN C (wound care nurse) said he knew Resident # 25 was admitted with a red area to his coccyx on admission. He said he was not notified until 12/13/2021 that the wound had opened. He said the wound had not been listed on the weekly skin sheet because it was only a reddened area and had not opened. He said prior to 12/13/2021 staff was using barrier cream to the area daily and some nurses were placing an occasional dressing. He said he does not remember the order placed by Dr. E on 11/20/2021. He said any time a wound is first noticed; the nurses have standing orders for vitamins and wound care. He said nurses should have followed this protocol beginning 11/20/2021. He said then he would assess the wound and measure the wound and put the standing orders in place. He would also notify the wound care doctor. He said he did not notify the wound care doctor on 11/20/2021. He notified her on 12/13/2021. He said he does not remember RN D reporting the wound to him on 11/20/2021. He said the pressure relieving cushion was not placed until 12/14/2021. He said he thought physical therapy had placed one in the wheelchair. Once he realized they had not placed one in the wheelchair he placed one in the wheelchair. He said he does all the skin care plans. During an interview on 12/16/2021 at 8:35 a.m., LVN F said Resident #25 had redness to his back and had been applying barrier cream. She said on 11/25/2021 she only placed barrier cream to the area. She said she did discuss the area with LVN C . She said she does not remember seeing an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . She said once orders are written a copy is placed inon the chart and then a copy is sent to medical records to be entered into the system. Written doctor's orders are printed at the end of the month and are reconciled by the unit managers. During an interview on 12/16/2021 at 9:22 a.m., the DON said she assessed Resident # 25 on 11/19/2021 or 11/20/2021 and the wound was not open . She said the nurse did call and notify her and preventative orders were started at that time. She said she believes Dr E was notified at that time. She said the orders were discontinued but she did not know the date. She said the nurses were only using barrier cream because the area was only red. She said if a new open wound is found during the week LVN C would assess the wound or she would assess the wound. Then standing orders would be started. She said they would also notify the doctor. She said the wound care doctor was not notified on 11/20/2021 because the wound was not open. She said that since Resident #25 was receiving therapy, they should have been making sure there was a pressure relieving cushion in his wheelchair . She said he could have been placed in a different wheelchair when he went to shower. She said once she realized his current wheelchair did not have a pressure relieving cushion, she made sure one was placed in the wheelchair. During an interview on 12/16/2021 at 9:51 a.m., Dr E said he does not remember being notified of the wound being open on 11/20/2021. He said he does not even remember giving the order. He said he usually orders whatever the nurses recommend for wound care when they call him. He said he may have told the staff to discontinue the order if the wound improved. He said he feels the staff does a very good job at wound care and he has had no problems in the past. He said he sees the resident once a week. He said he would expect staff to follow any orders he had given and has never had a problem with staff following orders. During an interview on 12/16/2021 at 10:05 a.m., COTA G said she was unaware that Resident #25's wheelchair had been changed out. She said she did not take the first wheelchair. She said it may have been swapped out by mistake. During an interview on 12/16/2021 at 10:18 a.m., the DON said when the wound had been reported to her on 11/20/2021, she did assess the wound but she did not write or document an assessment concerning the area . During an interview on 12/16/2021 at 10:25 a.m., CMA H said she has taken care of Resident #25 since his admission to the facility. She said he sits straight up in bed or sits in his wheelchair daily. She said she has never seen him walking. She said she cannot remember if his wheelchair has ever had a pressure relieving cushion . During an interview on 12/16/2021 at 10:28 a.m., the MDS nurse said she was with the DON when she went to assess the red area on Resident #25's sacrum. She said the area was only red and not open. During an interview on 12/16/2021 at 10:35 a.m., CNA J said Resident #25 goes to therapy and he does walk in the hall with therapy. She said on all the days she works he does sit up in his wheelchair. She said she has never noticed if there was a cushion in the chair or not. During an interview on 12/16/2021 at 10:38 a.m., the DON said the order written on 11/20/2021 was written on a Saturday. She said she looked at the area about that time. She said she saw it was not an open area. She said the order that was written on 11/20/2021 should have been initiated and followed for at least 3 days. She said the weekend nurse should have handwritten a TAR (treatment administration record). She said the following Monday, the area should have been assessed by LVN C (the wound care nurse) and an acute care plan should have been started. She said she does not know why it took 10 days for the order to be discontinued. She said the resident is fragile. She said the order was discontinued by LVN C on 11/30/2021 and the order should have been printed and placed in the chart. She said pressure injury risk care plans should be done initially when the resident is admitted . She said the risk of a resident with skin redness not having pressure relieving cushion is skin breakdown. While looking through the chart she said the only place she could find the skin addressed was on the nutritional assessment. She did agree that calcium alginate was not an appropriate treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] During an interview on 12/16/2021 at 10:54 a.m., the MDS nurse said she does the care plans. She said she receives weekly skin sheets from the wound care nurse so she can add skin issues to the care plan. She said she usually looks at the skin assessments for new admits. She said she normally pays close attention to skin, falls, and nutrition. She does not know why a risk for skin breakdown was not care planned since admission. She said she really focused on Resident #25's nutrition because of his diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . She said the wound care nurse would have completed an acute care plan once the wound opened. She said was unaware of an order placed on 11/20/2021 for wound care. She said Resident #25's wife came to her and told her he had a bed sore and she didn't feel it was being addressed by the wound care nurse. She said this was the week of November 21, 2021, but she could not remember the exact date. She said there would not have been an acute care plan for just redness. She said she assessed the wound at that time with the DON and it was only a reddened area. She said there had been a foam dressing in place at this time and the DON had put the dressing back into place. During an interview on 12/16/2021 at 11:25 a.m., the administrator said normally the wound care nurse or the MDS nurse come to her on admission concerning any skin issues. She said she leaves all the documentation concerning skin, up to the DON and the wound care nurse. Record review of an undated skin assessment policy and procedure indicated, .Purpose: To ensure that all resident's skin integrity remains intact and that all adverse skin problems are identified quickly, documented correctly, treated accordingly and monitored for complications .the Treatment Nurse and/or Designee will perform a full body assessment for each resident weekly and upon admission/readmission and change in condition .all nurses are responsible for providing preventative measures such as pressure relieving mattresses and cushions . Record review of an undated Pressure Ulcer/Decubitus Skin Assessment indicated, .assess any new decubitus ulcer as soon as discovered .Include all pertinent information on pressure sore/decubitus record: location of ulcer, stage, measurement in centimeters of width and depth, surrounding skin conditions and any drainage should be described .schedule for care plan conference .Pressure ulcer means an areas where the skin and underlying tissues are eroded as results of a lack of blood flow cause by pressure of friction .a. Stage 1: a persistent are of skin redness (without a break in the skin) that does not disappear when pressure is applied .Nurses notes include: date and time decubitus ulcer found .complete description .verification that notification was made . interventions initiated .

Based on observation, interview and record review the facility failed to ensure an infection prevention and control program designed to provide a safe and sanitary environment and to help prevent the development and transmission of communicable diseases and infections were maintained for the facility related to COVID-19 (a new respiratory disease which can cause mild to severe illness with most severe illness in adults [AGE] years and older). The facility staff did not wear appropriate PPE and did not wear N-95 mask correctly on the COVID-19 positive unit and throughout the facility. The facility did not ensure Resident #64 was placed on droplet isolation after her roommate tested positive for COVID-19. This failure resulted in an identification of an Immediate Jeopardy (IJ) on 9/15/20. While the IJ was removed on 9/17/20, the facility remained out of compliance at a potential for more than minimal harm with a scope identified as a pattern due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure could place residents at risk for being exposed to COVID-19, health complications, and death. Findings included: The CDC (Centers of Disease Control and Prevention) article titled Proper N95 Respirator Use for Respiratory Protection Preparedness at https://blogs.cdc.gov/niosh-science-blog/2020/03/16/n95-preparedness/ indicated .OSHA requires healthcare workers who are expected to perform patient activities with those suspected or confirmed to be infected with COVID-19 to wear respiratory protection, such as an N95 respirator. N95 respirator refers to an N95 filtering facepiece respirator (FFR) that seals to the face and uses a filter to remove at least 95% of airborne particles from the user's breathing air. It is important to note that surgical masks, sometimes referred to as facemasks, are different than respirators and are not designed nor approved to provide protection against airborne particles. Surgical masks are designed to provide barrier protection against droplets, however they are not regulated for particulate filtration efficiency and they do not form an adequate seal to the wearer's face to be relied upon for respiratory protection. Without an adequate seal, air and small particles leak around the edges of the respirator and into the wearer's breathing zone . .When properly fitted and worn, minimal leakage occurs around the edges of an N95 respirator when the user inhales, ensuring that the user's breathing air is being directed through the filter material. Staff that are required to use respiratory protection must undergo fit testing, medical clearance, and training, which are all required elements of a healthcare facility's written respiratory protection program. These are requirements of the Occupational Safety and Health Administration (OSHA) Respiratory Protection standard (29 CFR 1910.134) . The CDC website at < https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fcoronavirus%2F2019-ncov%2Finfection-control%2Fcontrol-recommendations.html> accessed 9/18/20 indicated, .HCP who enter the room of a patient with suspected or confirmed [DIAGNOSES REDACTED]-CoV-2 infection should adhere to Standard Precautions and use a NIOSH-approved N95 or equivalent or higher-level respirator (or facemask if a respirator is not available), gown, gloves, and eye protection . The PPE recommended when caring for a patient with suspected or confirmed COVID-19 includes the following: Respirator or Facemask (Cloth face coverings are NOT PPE and should not be worn for the care of patients with suspected or confirmed COVID-19 . Eye protection put on eye protection (i.e., goggles or a face shield that covers the front and sides of the face) .Gloves . Gowns . The Texas Health and Human Services COVID-19 RESPONSE FOR NURSING FACILITIES version 3.0 dated 08/12/2020 indicated .Isolation - Once a case of COVID-19 is identified in the facility, immediate action must be taken to isolate the resident who is positive for COVID-19 away from other residents . .Any roommates should be moved and monitored for fever and symptoms twice daily for 14 days . A Coronavirus Disease Prevention and Control Policy dated March 2020 indicated, Facility leadership and clinical staff are implementing all reasonable measures to protect the health and safety of residents and staff during the current outbreak of coronavirus disease .The response to the current outbreak of coronavirus disease is based on the most current recommendations from health policy officials, state agencies, and the federal government. Infection prevention and control measures are based on established guidelines governing all communicable diseases .Personnel education .reinforcement of standard and transmission-based precaution procedures (including .proper use and disposal of personal protective equipment) . An Employee Training on Infection Control Policy updated January 2012 indicated, The facility shall provide staff with appropriate information and instruction about infection control through various means, including initial orientation and ongoing training programs .Infection control training topic will include at least: standard precautions, including hand hygiene; transmission-based precautions (airborne, droplet, contact); use of personal protective measures; prevention, transmission and symptoms of communicable diseases . An - Isolating Transmission-Based Precautions Policy updated January 2012 indicated, Transmission-Based Precautions will be initiated when there is reason to believe that a resident has a communicable infectious disease . 1. An undated resident list provided by administrator indicated there were eighteen residents who were positive for COVID-19 that resided on the COVID-19 unit. The daily schedules dated 9/14/20 and 9/15/20 indicated LVN A worked Hall 300 (negative hall-no residents positive for COVID-19) and the right side of Hall 600 (warm hall-residents with unknown COVID-19 status). The schedules indicated RN B worked Hall 100 (negative hall) and the left side of Hall 600 (warm hall). During an observation on 9/14/20 at 10:40 a.m., LVN A was wearing a surgical mask under her N95 mask. LVN A was providing care for residents with an unknown COVID-19 status. LVN A said there were 9 residents with an unknown COVID-19 status. During an observation on 9/14/20 at 10:45 a.m., RN B was wearing a surgical mask under her N95 mask. RN B was providing care for residents with an unknown COVID-19 status. During an observation on 9/14/20 at 12:55 p.m., LVN A was wearing a surgical mask under her N95 mask. LVN A was providing care for residents with an unknown COVID-19 status. During an observation on 9/14/20 at 12:56 p.m., LVN E was wearing a surgical mask under her N95 mask. During an observation on 9/14/20 at 2:26 p.m., RN B was wearing a surgical mask under her N95 mask. RN B was providing care for residents with an unknown COVID-19 status. During an observation and interview on 9/14/20 at 3:07 p.m., LVN G was working on the COVID positive unit. LVN G was not wearing a N95 mask, gloves, or goggles. LVN G wore a KN95 mask and it was not fitted securely on her face to provide a tight seal. LVN G had gaps between her nose and the N95 mask. LVN G said she had been trained on how to seal check her N95 mask. LVN G confirmed her mask did not have a tight seal. LVN G said she had not been fit tested . During an observation and interview on 9/14/20 at 3:11 p.m., CNA H was working on the COVID positive unit. CNA H was passing ice to the residents. CNA H was wearing a N95 mask, but the mask was pulled down on her nose and did not have a tight seal. CNA H was not wearing gloves or goggles/ face shield. CNA H said she did not know she needed to wear goggles or a face shield when she worked on the COVID positive unit. CNA H said she had a face shield but did not wear the shield. CNA H said she had not been trained on how to seal check her mask. During an observation and interview on 9/14/20 at 3:13 p.m., Housekeeper J was wearing an KN95 mask that did not have a tight seal, and she was wearing eyeglasses with no face shield or goggles. Housekeeper J said she did not know she needed goggle or a face shield. Housekeeper J said she was told she could wear only her glasses. Housekeeper J said she had not been trained on how to seal check her mask. During an observation and interview on 9/14/20 at 3:15 p.m., CNA K was working on the COVID positive unit. CNA K was wearing a KN95 mask that did not have a tight seal, and eyeglasses without goggles or a face shield. CNA K said the infection preventionist told her if she wore eyeglasses she did not need a face shield or goggles. CNA K said she had not been trained on how to seal check her mask. During an observation on 9/14/20 at 3:32 p.m., RN B was wearing a surgical mask under her N95 mask. RN B was providing care for residents with an unknown COVID status. During an observation on 9/14/20 at 3:33 p.m., CNA K closed a biohazardous box on the COVID positive unit without wearing gloves. During an observation and interview on 9/14/20 at 3:50 p.m., RN B was wearing a surgical mask under her N95 mask. RN B said she was working with 9 residents on the warm hall (the hall residents with unknown COVID status were located). RN B said since the first positive resident case of COVID-19 she has worn a surgical mask under her N95 mask. She said during a staff meeting the administrator recommended staff wear a surgical mask under their N95 masks for better protection from COVID-19. RN B said prior to the first positive resident case she wore only the N95 mask. During an observation and interview on 9/14/20 at 3:52 p.m., CNA D was wearing her N95 mask secured with only the top strap, the bottom strap was loose and hung below her chin. CNA D said that was how she always wore her mask. CNA D said she had not been fit tested or trained on user fit tests. During an interview on 9/14/20 at 5:13 p.m., the administrator said staff had come to her and asked if they could wear a hospital mask under their N95 mask. The administrator said she instructed staff they could wear a hospital mask under the N95 mask for better protection and preservation of the N95 mask; as long as they changed the hospital mask frequently. During an interview on 9/15/20 at 9:21 a.m., Epidemiologist F said wearing a hospital mask under a N95 mask was an issue. Epidemiologist F said wearing a hospital mask under an N95 mask would interfere with the fit and seal of the N95 mask. She said the facility had not asked her about wearing hospital masks under N95 masks. The Epidemiologist said there was no issue with wearing a hospital mask over an N95 mask. During an observation on 9/15/20 at 9:51 a.m., LVN A was wearing a surgical mask under her N95 mask. During an observation on 9/15/20 at 10:03 a.m., NA C was wearing her N95 mask with the bottom strap missing. During an interview on 9/15/20 at 1:55 p.m., the administrator said staff who worked on the COVID-19 positive unit also worked with COVID-19 negative residents on different days scheduled. During an observation on 9/16/20 at 4:56 p.m., LVN R and CNA K were working on the COVID-19 positive unit and were wearing eyeglasses. LVN R and CNA K did not wear goggles or a face shield. LVN R said she did not wear goggles or a face shield if she wore eyeglasses. CNA K said she did not wear goggles or a face shield if she wore eyeglasses. LVN R and CNA K said they had a face shield but did not wear the shield. During an observation and interview on 9/17/20 at 9:31 a.m., LVN E was working as the charge nurse with COVID negative residents. LVN E confirmed she worked the COVID positive unit on 9/15/20. During an observation and interview on 9/17/20 at 1:52 p.m., Maintenance Staff M transported six biohazard boxes from the COVID-19 positive unit through the facility on hall 300 to the biohazard room on hall 100. He did not wear PPE including a gown, face shield/goggles, and gloves when he went from the COVID-19 positive unit to the COVID-19 negative hall where the biohazard room was located. Maintenance Staff M said the biohazard boxes were from the COVID-19 positive hall. During an observation on 9/17/20 at 2:03 p.m., Maintenance Staff M transported six additional biohazard boxes from the COVID-19 positive unit through the facility he did not wear PPE including a gown, face shield/goggles, and gloves when he transferred the biohazard from the COVID-19 positive hall to the COVID-19 negative hall. During an interview on 9/17/20 at 2:06 p.m., the DON said Maintenance Staff M should not bring biohazardous waste from the COVID positive unit through the facility to store in the biohazard room. The DON said the COVID positive waste should be stored in an outdoor storage area. The DON said she would in-service Maintenance Staff M immediately. During an observation and interview on 9/17/20 at 2:36 p.m., LVN G was working as the charge nurse with COVID negative residents. LVN G confirmed she worked the COVID positive unit on 9/14/20. An employee warning notice form dated 9/17/20 indicated Maintenance Staff M received a written warning for improper transfer of biohazard waste through the facility and was suspended until further training was completed. 2. Consolidated physician orders [REDACTED].#64 was [AGE] years old, admitted [DATE] and had [DIAGNOSES REDACTED]. The most recent MDS dated [DATE] indicated Resident #64 usually made herself understood, usually understood others, and had no behavior of rejecting care. The MDS indicated Resident #64 required extensive assistance with transferring, toileting, dressing, personal hygiene, and bathing; and set up assistance with eating. The care plan dated 8/26/20 did not indicate any risk for COVID-19. A laboratory report dated 9/9/20 indicated Resident #64 was negative for COVID-19. Consolidated physician orders [REDACTED].#47 was [AGE] years old and admitted on [DATE] with [DIAGNOSES REDACTED]. The most recent MDS dated [DATE] indicated Resident #47 made herself understood, understood others, and had no behavior of rejecting care. The MDS indicated Resident #47 required extensive assistance with transferring, toileting, dressing, personal hygiene, and bathing; and set up assistance with eating. The care plan dated 8/20/20 did not indicated any risk for COVID -19. A laboratory report dated 9/14/20 indicated Resident #47 was positive for COVID -19. During observations on: *9/14/20 at 12:10 p.m., Resident #64 was not quarantined, and staff were not utilizing droplet precautions after she was exposed to COVID-19 from her roommate Resident #47. There was no sign on the door that showed the resident was on droplet precautions or to be directed to see the nurse before entering the room. CNA delivered Resident #64's tray wearing only an N95 mask. *9/14/20 at 3:10 p.m., Resident #64 was not quarantined, and staff were not utilizing droplet precautions after she was exposed to COVID-19 from her roommate. There was no sign on the door that showed that resident was on droplet precautions or to be directed to see the nurse before entering the room. *9/15/20 at 10:27 a.m., Resident #64 was not quarantined, and staff were not utilizing droplet precautions after she was exposed to COVID-19 from her roommate. There was no sign on the door that showed that resident was on droplet precautions or to be directed to see the nurse before entering the room *9/15/20 at 2:10 p.m., Resident #64 was not quarantined, and staff were not utilizing droplet precautions after she was exposed to COVID-19 from her roommate. There was no sign on the door that showed that resident was on droplet precautions or to be directed to see the nurse before entering the room. During an interview on 9/15/20 at 2:50 p.m., CNA P said Resident #64 was not on droplet precautions. During an interview on 9/15/20 at 2:57 p.m., RN B said Resident #47 ran a fever on 9/13/20 and was tested for COVID-19 on the morning of 9/14/20. RN B said the test was positive and Resident #47 was moved to room [ROOM NUMBER] out of the room with Resident #64. She said Resident #64 was not tested and they do not normally test roommates of positive residents. She said Resident #64 had not been placed in isolation. During an observation and interview on 9/15/20 at 3:21 p.m., the DON said Resident #47 tested positive on 9/14/20 and was moved to the positive unit. The DON said that her roommate, Resident #64, should have been placed on droplet precaution isolation and staff were to wear eye protection, N95 masks, gown, and gloves while in the room. She said there should have been an isolation cart outside of Resident #64's room and a sign on the door. The DON followed the surveyor to Resident #64's room and observed Resident #64 was not on droplet precautions. She said she should have been and would get her a set up at that time. During an observation on 9/15/20 at 3:45 p.m., Resident #64's door had a droplet precaution sign on the outside, and there was an isolation cart in the hallway with PPE. During an observation on 9/14/20 at 10:10 a.m., DA AA was in the kitchen washing dishes. She had a surgical mask under her N95 mask. The N95 mask did not have a secured seal and often went below DA AA's nose. During an observation on 9/14/20 at 10:14 a.m., the dietary supervisor was standing in the kitchen area. She had a surgical mask on under her N95 mask. The N95 mask was not secured properly and was very loose on the face. During an observation on 9/14/20 at 10:20 a.m., DA BB was standing in the kitchen area with a surgical mask on beneath her N95 mask. The N95 mask did not have a secured seal and was loose on the face. During an observation on 9/14/20 at 10:24 a.m., DA CC was washing her hands in the kitchen area. She had a surgical mask on beneath her N95 mask. The N95 mask did not have a secured seal and was loose on her face. During an observation and interview on 9/15/20 at 11:10 a.m., DA AA said she was told by someone (she could not remember) that it was fine for her to wear a surgical mask under her N95. She said she had taken the straps off the N95 mask and stapled the N95 mask to her surgical mask to make the mask last longer. She said that on the evening of 9/14/20 she was told she could not wear her mask that way, but she had not had a chance to change it. DA AA continued to have a surgical mask beneath her N95 mask. The mask was not secured and fit loosely. During an interview on 9/14/20 at 5:44 p.m., the corporate nurse said the dietary staff were just instructed on how to properly wear their N95 masks. She said the dietary staff were wearing the masks backwards with the surgical mask under the N95 mask. The administrator was notified on 9/15/20 at 10:51 a.m. that an Immediate Jeopardy situation was identified due to the above failures. The administrator was provided the Immediate Jeopardy template. The facility's Plan of Removal was accepted on 9/15/20 at 7:49 p.m. and included: All staff will be in serviced on proper use of PPE. *This will include the proper use of and fitting of N95 mask. Staff will be fit tested working COVID or unknown status. They will be proficiency checked and tested to ensure understanding. Staff that were identified with poorly sealed mask have been identified and retrained on deficient practice. All staff members working COVID positive unit will wear N95 respirators have been distributed and redistributed for those working the COVID positive unit. *All staff and managers will be trained on the use of Goggles/Face shield use while in the building to ensure they understand that eye protection has to be worn at all times. Training will be performed by corporate staff and the DON by end of day on 9/16/20. All staff (including administration) is included in theses in services. *All staff will be instructed to wear appropriate PPE when handling any hazardous material. Training will be performed by corporate staff and the DON by end of day on 9/16/20. All staff, including administration, is included in theses in services. *All new hires will complete PPE competencies and testing at time of hire. No new hire will be allowed to work on the floor until competencies completed and return demonstration done correctly. *Regional administrators or the regional nurse will follow up weekly to ensure compliance with all mentioned deficient areas. *100 percent audit completed on all positive residents and prior roommates of positive residents are either on droplet precautions or COVID tested negative. Training related to isolation and COVID testing provided to the DON and the infection preventionist. On 9/17/20 the surveyors confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by: Five LVNs (on all shifts - 6 a.m. to 6 p.m.; 6 p.m. to 6 a.m.; 6 a.m. to 2 p.m.; and weekends), two RNs (6 a.m. to 6 p.m. and weekend RN), 14 CNAs (all shifts), 3 MAs (6 a.m. to 2 p.m., 2 p.m. to 10 p.m., and weekends), one laundry staff, two housekeeping staff, two dietary staff, and one hospitality aide said they were in-serviced on the proper use and fitting of their N95 mask; how to seal test their mask; the type of mask they were supposed to wear while working the positive unit. They said they had been trained on the use of goggles or face shield while in the building and when to wear goggles or a face shield; what PPE was required while handling hazardous waste; and when a resident needed to be placed on droplet precautions. All staff were able to answer the questions with correct information to the above in-service training topics. Staff were observed to be wearing the appropriate PPE and wearing it correctly. On 9/16/20 at 9:20 a.m., the corporate nurse was informed the IJ was removed; however, the facility remained out of compliance at a potential for more than minimal harm with a scope identified as pattern due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems.