Every finding on record at Jones Co Rest Home

Based on interviews, observation, record review, facility investigation review, and facility policy review, the facility failed to provide adequate supervision to prevent Resident #1 and Resident #2 from eloping from the facility on 5/18/26 at 5:41 PM. The facility staff did not know that Resident #1 and Resident #2 were out of the facility on the facility grounds for 11 minutes. This concern was identified for two (2) of eight (8) residents reviewed for diagnoses of Alzheimer's disease and dementia (Resident #1 and Resident #2). The facility's failure to provide adequate supervision resulted in Resident #1 and Resident #2 leaving the facility unsupervised, placing these residents and other residents with diagnoses of Alzheimer's disease and dementia at risk for elopement and the likelihood of serious injury, harm, impairment, or death. The situation was determined to be Immediate Jeopardy (IJ) that began on 5/18/26 when Resident #1 and Resident #2 exited from the facility unattended and unsupervised. The facility Administrator was notified of the IJ and SQC on 5/26/26 at 3:20 PM and was presented with the IJ template.The facility provided an acceptable Corrective Action Plan on 5/27/26, in which they alleged all corrective actions to remove the IJ were completed on 5/19/26 and the IJ removed on 5/20/26, prior to SA entrance on 5/26/26. Based on the facility's implementation of corrective actions on 5/19/26, the SA determined the IJ and SQC to be Past Non-Compliance (PNC). Findings include: A review of the facility's policy, Elopement/Missing Resident Policy, reviewed date: 5/19/2026, revealed, Purpose: To ensure residents who exhibit unsafe wandering behavior and/or who are at risk for elopement receive preventative measure, adequate supervision.Definition: Elopement occurs when a resident leaves the premises or a safe area without authorization or supervision . A review of the facility's policy, FALLS ACCIDENTS AND INCIDENTS POLICY, reviewed date: 5/8/26, revealed, Purpose: To promote an environment as free as is possible, of accident hazards over which the facility has control. Scope: Staff to provide adequate supervision and assistive devices to help prevent avoidable accidents and injury. Responsibilities: All staff are to be involved in observing and identifying potential hazards in the environment, while taking into consideration the unique characteristics and abilities of each resident . A record review of the facility investigation revealed on 5/18/26 at approximately 5:41 PM, a transportation service employee who was not employed with the facility exited the facility through the front door using his badge for access. Resident #1 and Resident #2 followed him outside prior to the front door entrance closing. At approximately 5:52 PM, according to video surveillance, a dietary aide observed both residents in the parking lot. He immediately returned to the facility and notified a Registered Nurse. At the same time, another resident's family member was driving into the parking lot, observed the residents in the parking lot, and immediately phoned the facility to report the residents outside. The investigation determined Resident #1 and Resident #2 were outside unattended for approximately 11 minutes. Resident #1 Record review of the admission Record revealed the facility admitted Resident #1 on 2/3/24 with diagnoses including unspecified dementia, severe, with agitation and Alzheimer's disease. Record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/21/26 revealed a Brief Interview for Mental Status (BIMS) score of three (3), indicating severe cognitive impairment. Record review of the Elopement Risk Evaluation effective date, 4/22/26, the category was at risk, due to the resident having a history of elopement prior to admission while at home, she did not demonstrate exiting behavior while at the facility. Resident #2 Record review of the admission Record revealed the facility admitted Resident #2 on 12/5/21 with diagnoses including Dementia. Record review of the Quarterly MDS with an ARD of 3/24/26 BIMS score of five (5), indicating severe cognitive impairment. Record review of the Elopement Risk Evaluation effective date, 3/24/26, category was NA (Not Applicable). On 5/26/26 at 11:45 AM, an observation was made of the route the residents were seen ambulating up the driveway. The residents ambulated approximately 90 feet from the front entrance to an open concrete driveway/entrance loop bordered by low curved concrete retaining walls with landscaped grassy areas and trees on each side. The driveway was wide, unobstructed, and led from the covered front entrance toward the outer drive/roadway area. The distance from the facility front door to the area observed was approximately 90 feet. The area was exposed to vehicle traffic; however, the residents remained within the facility parking lot. In a record review of the local weather conditions at the time of the elopement revealed on 5/18/26 at 5:30 PM, there was no rain, with the temperature approximately 80 degrees. On 5/26/26 at 12:30 PM, an interview by phone, with one of the Resident's daughters-in-law, who was driving to the facility as both Residents #1 and #2 were both outside. She confirmed that at 5:55 PM on 5/18/26, she phoned the facility to inform staff of the unattended residents outside while her husband was standing beside the residents speaking with them. She revealed staff were running outside as she was calling the facility. On 5/26/26 at 1:00 PM, during an interview with the Dietary Aide, he revealed that he was outside of the facility moving his automobile to a different location. As he was driving within the facility parking lot, he observed both residents using their walkers in the facility parking lot. He attempted to speak with them, but they informed him they were allowed to be outside alone. He then immediately went into the facility and notified Registered Nurse (RN) #1. On 5/26/26 at 1:20 PM, during an interview with RN #1, she revealed that staff alerted her that both Residents #1 and #2 were outside in the facility parking lot, and staff immediately ran outside to retrieve the residents. They were both redirected and re-entered the facility. Both residents were assessed with no evidence of injuries. She notified the Director of Nursing (DON), attempted to contact both Resident Representatives, and notified the Medical Provider. She revealed both residents had not previously attempted to exit the building. On 5/26/26 at 3:00 PM, during an interview with Licensed Practical Nurse (LPN) #1, she revealed she was informed by a family member of another resident, who phoned the facility informing her that two (2) residents were outside walking in the parking lot. The family member remained with the residents until staff arrived. The residents were located on the facility driveway, not the main road. Upon locating the residents, they were redirected back into the facility. The residents ambulated back with their walkers without aggression. Staff immediately assessed both residents, notified the DON, attempted to notify the Resident Representatives, and notified the Medical Doctor (MD). Upon assessment, staff found no skin tears or injuries. The residents were then placed on one-to-one supervision until the following morning. On 5/26/26 at 3:15 PM, during an interview with the DON, he revealed the interdisciplinary team had previously assessed Resident #1 and Resident #2 and determined they were not at risk for elopement, prior to the incident. He verified both residents had diagnoses of Alzheimer's Disease and Dementia and were able to ambulate with walkers. Following the incident, both residents were reassessed for elopement risk, wander guards were applied, and additional supervision interventions were implemented. He further revealed staff were re-educated regarding monitoring residents near the facility entrance and ensuring residents did not exit the facility unsupervised. On 5/26/26 at 3:30 PM, during an interview with the Administrator, she revealed the facility investigation and video surveillance confirmed Resident #1 and Resident #2 exited the facility through the front entrance behind a transportation service employee and remained outside of the facility without staff knowledge or supervision. She revealed staff were unaware the residents had exited the facility until notified by staff and a family member. The Administrator confirmed both residents were outside unattended for approximately 11 minutes on facility grounds and were not under staff supervision during that time. Following the incident, the facility reassessed both residents for elopement risk and implemented additional supervision interventions. The facility submitted the following acceptable Corrective Removal Plan on 5/27/26: This letter serves as a formal report of resident elopement that occurred on May 18, 2026, at Proper name of the facility. The facility acknowledges an Immediate Jeopardy was cited on May 26, 2026, at 3:20 PM. Resident #1 is an [AGE] year-old female with a diagnosis of Alzheimer's disease, unspecified dementia with agitation and a Brief Interview for Mental Status (BIMS) of 3. Resident #2 is a [AGE] year-old female with a diagnosis of unspecified dementia without behavioral disturbance, sequelae of cerebral infarction, and a BIMS of 5. The residents are roommates and are both ambulatory with the assistance of their walker. On 5/18/2026 at approximately 5:41 PM, a transportation service employee (Transportation Service Employee #1) exited the facility through the front door using his badge for access. At that time, Resident #1 and Resident #2 followed behind the employee. Review of security camera footage indicates that prior to the Transportation Service Employee #1's exit, Resident #1 and Resident #2 were seated in the front foyer. When Transportation Service Employee #1 opened the door to exit, Resident #1 and Resident #2 stood up and proceeded toward the exit just before the door closed. Upon exit, Resident #1 and Resident #2 sat in rocking chairs immediately to the right of the entrance until approximately 5:51 PM. At that time, Resident #1 and Resident #2 stood up and began walking toward the driveway area. A dietary employee (Dietary Employee #1), who was in his vehicle at the time, observed Resident #1 and Resident #2 in the driveway. At approximately 5:52 PM, Dietary Employee #1 approached Resident #1 and Resident #2, and asked whether they were supposed to be outside alone. Resident #1 and Resident #2 both responded yes. Dietary Employee #1 immediately returned inside the facility and notified Registered Nurse (RN #1). At this time, the facility received an incoming call from a resident's family member (Resident Representative #1). Resident Representative #1 stated that she and her husband were coming to the facility to visit their loved one and observed two residents standing in the driveway with their walkers. Resident Representative states they stopped to ask the residents where they were going and called in to the facility to notify staff of the residents in the driveway. At approximately 5:53 PM, RN #1 along with a Licensed Practical Nurse (LPN #1) and a Certified Nursing Assistant (CNA #1), responded promptly, located Resident #1 and Resident #2, and assisted them back into the facility. Resident #1 and Resident #2 were immediately assessed by RN #1, and LPN #1 upon re-entry into the facility and were found to be unharmed, uninjured, and free of any signs or symptoms of distress. Resident #1 and Resident #2 were placed on one-on-one monitoring until 7:00 AM on 5/19/26, at which time a Wander Guard was placed on Resident #1 and Resident #2. On 5/18/26 at 6:00 PM, RN #1 completed a head count of each resident in the facility and found all to be accounted for. On 5/18/26 at 6:45 PM, staff in-servicing began by RN #1, on elopement prevention procedures, including monitoring of exit areas, proper response to potential elopement situations, and expectations for supervision and accountability as well as staying with the resident once found. This education is intended to reinforce staff awareness and ensure consistent compliance with facility policies related to resident safety. These in-services continued on 5/19/26 by the Director of Nurses (DON) and were completed by 100% of staff on 5/19/26. No staff were allowed to work until in-serviced. On 5/19/26 at 7:00 AM, Minimum Data Set (MDS) staff completed an updated Elopement Evaluation on Resident #1 and Resident #2. Both residents were fitted with a Wander Guard device to alert staff if they are in close proximity to any exit doors. Care Plans for Resident #1 and Resident #2 was updated on 5/19/26 to reflect Wander Guard devices and increased elopement risk. The Nursing Home Administrator (NHA) notified the Mississippi State Department of Health of the incident on 5/19/26. The Interdisciplinary Team (IDT) held an emergency Quality Assurance Performance Improvement (QAPI) meeting on 5/19/26. During the QAPI meeting, the facility Elopement/Missing Resident Policy was reviewed. Revisions were made to include the following: Once located, the staff member will stay with resident and notify charge nurse. Additionally, on 5/19/26, the following revisions were made to the exit and entrance procedures as a result of the QAPI meeting. The NHA contacted organizational security to remove remote entry from nurse's stations. Nursing home staff are no longer able to remotely allow visitors from the nurse station and must physically go to the door to allow entry and exit, ensuring better visibility and supervision of traffic in and out of the building. At this time, all contract employee badges were disabled. Going forward, all contract employees will be required to ring the doorbell and wait for staff assistance to allow entry and exit. Additionally, facial recognition access for family members during non-business office hours was disabled to reduce the risk of unmonitored entry and exit. A revised memorandum was posted on the inside and outside of the facility entrance to remind family members and visitors not to assist residents outside of the facility. A comprehensive facility-wide Elopement Risk Assessment was conducted and completed for all residents on 5/19/26 by the MDS team. All names and photos of residents identified as being at high risk for elopement have been updated on a designated list in the Elopement Book by the DON on 5/19/26. An Elopement Book is maintained at each Nurse Station and in the Front Office. An Elopement Drill was completed with staff by the DON on 5/19/26 at 10:45 AM. A second Elopement Drill was completed with staff by the DON on 5/19/26 at 4:00 PM. A third Elopement Drill was completed with staff by the Assistant Director of Nurses (ADON) 5/19/26 at 11:15 PM. Quality monitoring will include the DON conducting Elopement Drills weekly times four (4) weeks, then monthly times two (2) months, The IDT will have a QAPI meeting on 5/28/26 and 6/11/26 to review the monitoring process to ensure compliance is met and substantiated. The facility alleges all corrective actions were completed on 5/19/26 and the Immediate Jeopardy was removed on 5/20/2026. Validation: The SA validated the removal plan through observations, interviews, and record reviews on 5/27/26 and the immediacy was removed on 5/20/26 prior to exit.

Based on observation, interview, and record review, the facility failed to ensure the ongoing provision of behavioral health services for a cognitively impaired resident with severe, escalating behaviors following discharge from a behavioral health unit and despite continued aggression, delusions, and medication refusal, the facility discontinued behavioral health services without a documented rationale, contributing to ongoing physical aggression toward staff and others for one (1) of 23 sampled residents. Resident #10 Findings include: On 03/17/25 at 1:16 PM, during an observation and interview, Resident #10 pleasantly confused, verbalizing that she needed to go home. A record review of the Admission Record revealed the facility admitted Resident #10 on 10/01/21 with diagnoses including Bipolar Disorder, Unspecified, Psychotic Disorder with Hallucinations Due to Known Physiological Conditions, Psychotic Disorder with Delusions, and Other Symptoms and Sign Involving Cognitive Function and Awareness. A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/09/25 revealed Resident #10 required a Staff Assessment for Mental Status, which indicated a memory problem for short term memory, memory okay for long term memory, and moderately impaired for cognitive skills for daily decision making. A review of Section E revealed Resident #10 delusions, physical, verbal, and other behavior symptoms directed towards others during the (7) day look back. The behavior of Rejection of Care occurred daily. A record review of the Behavior Monitoring and Interventions documentation, completed by Certified Nursing Assistants (CNAs), for March 2025 revealed Resident #10 exhibited frequent behavioral symptoms, including physical aggression, verbal outbursts, and refusal of care. Behavioral episodes were documented on multiple dates across all shifts, including 03/01, 03/04, 03/09, 03/10, 03/11, 03/12, 03/13, 03/14, 03/15, 03/16, 03/17, 03/18, 03/19, and 03/20, often involving grabbing, hitting, screaming, cursing, and threatening staff. The interventions included redirecting the resident, providing food/drink, re-approach, and offering comfort measures such as massage or repositioning. However, the documented outcomes were consistently noted as either same (unchanged) or worsened. There was no documentation the CNA notified the nurse of the resident's behaviors or that the behaviors were unchanged or had worsened after attempting the documented interventions. A record review of the Medication Administration Record (MAR) for March 2025 revealed that Resident #10 refused medications except for Morphine and Lorazepam. Resident #10 received Lorazepam 03/01, 03/02, 03/03, 03/05, 03/06, 03/09 (twice), 03/10, 03/11, and 03/13 (three times), 03/14, 03/15, 03/16 (twice), 03/17, 03/18 (twice), and 03/19 (twice). Resident #10 received Morphine on 03/01, 03/02, 03/05, 03/06, 03/09, 03/10, 03/13 (three times), 03/14, 03/15, 03/16 (twice), 03/18 (twice), and 03/19 (twice). There is no documentation on the MAR indicating resident-specific behaviors, interventions, and effectiveness of interventions. A record review of the Social Services Quarterly Note dated 01/09/25 revealed Resident #10 had was irritable, agitated, refused meds, and resistant of care during brief changes and bath. It was noted that every day the resident exhibited restlessness and annoyance/short temper and had refused to eat. The note indicated Resident #10 has had a Change in status in her cognitive status, social interaction, mood status, behavioral status, and rejection of care/resident choices. The document also indicated that psychological/psychiatric services were currently indicated for the resident with documentation including Resident is seen by Psychiatric Nurse Practitioner (NP) (10/11 and 12/13/2024) for follow-up/medication review/support. A record review of the Physician's Order Sheet revealed Resident #10 had a Physician's Order, dated 08/29/2024 to send the resident to an emergency room for evaluation of increased behaviors, and another physician's order, dated 11/14/2024, to send the resident to a Behavioral Health Unit (BHU) for further evaluation. A record review of the BHU documentation Discharge Instructions, dated 9/10/24, and 11/23/24, revealed Resident #10 received treatment from an inpatient BHU. A record review of the Psychiatric NP visit documentation, dated 12/13/24, for Resident #10 revealed . Anxiety not controlled, Psychosis not controlled . often refuses medications due to paranoid ideations, believing meds have been poisoned . On 03/17/25 at 1:25 PM, during an interview with CNA #3, she stated that Resident #10 is consistently confused and exhibits daily behavioral symptoms. She explained that the resident is often noncompliant with care and becomes physically aggressive during care. CNA #3 added that these behaviors have been ongoing for several months. On 03/18/2025 at 11:15 AM, during an interview with CNA #3, she stated that Resident #10's behaviors include kicking, spitting, hitting, and smearing anything she can get her hands on, including food and feces. On the morning of 3/18/2025, Resident #10 threw a full tray on her during breakfast. On 03/18/2025 at 1:00 PM, during an interview with the Director of Nursing (DON), he stated the facility offers psychiatric services, but once the resident was on palliative or comfort care, those services were discontinued. He reported that Resident #10 had previously seen psych services but was removed from the caseload after transitioning to Comfort Measures Only. He stated that Resident #10 continues to experience behavioral outbursts, hallucinations, and delusions, and was sent to the BHU twice. He explained that after one of the BHU visits, medications including Depakote were discontinued due to high lab levels. Since that time, the resident experienced a significant decline, refusing medications and eating very little. On 03/18/2025 at 3:00 PM, during an interview with Licensed Practical Nurse (LPN) #3, she explained that Resident #10 had exhibited ongoing behavioral symptoms for several months and had remained in a prolonged state of psychosis following the discontinuation of Depakote. She reported that the resident had not consistently taken any oral medications for months; however, earlier that day, she was able to administer oral Morphine and Ativan. LPN #3 stated that while attempting to provide wound care to a skin tear on the resident's right forearm, Resident #10 became physically aggressive, striking her on the arm and using profane language. She reported that this type of behavior occurs regularly, and that facility management is aware. According to LPN #3, the Resident #10 often refuses oral medications, believing them to be poisoned and had knocked the medications out of her hand earlier that day. The physician had considered discontinuing all oral medications, but the resident's daughter requested that they be continued in case the resident became willing to take them in the future. LPN #3 further explained that Resident #10 routinely throws items at staff, including food, trash, and bodily fluids. That morning, the resident reportedly threw an entire breakfast tray at a CNA. LPN #3 stated that the family had requested the resident remain at the facility under Comfort Measures Only. On 03/18/2025 at 4:10 PM, during an interview with CNA #5, she explained that Resident #10 had consistently exhibited behavioral concerns, with some evenings being more challenging than others. She stated that providing care always requires at least two staff members due to the resident's behaviors. Even with the assistance of two CNAs, the resident often remains combative, frequently kicking, scratching, and pinching during care. CNA #5 added that while the resident can occasionally be distracted, these moments are brief, and the resident is generally not easily redirected. On 03/19/2025 at 10:05 AM, during an interview with LPN #4, she explained that Resident #10 exhibited ongoing behavioral symptoms, including scratching herself and staff, hitting, cursing, and throwing food and bodily waste at staff on a daily basis. She stated that earlier that morning, the resident refused all oral medications and became physically aggressive toward the CNA during breakfast assistance. LPN #4 reported that she was able to administer the resident's anxiety and pain medications using an oral syringe, which resulted in the resident calming somewhat afterward. On 03/19/25 at 12:15 PM, during an interview and observation of incontinence care for Resident #10, CNA #4 and CNA #6 reported that the resident has behaviors that occur on a near daily basis. Resident #10 was observed to be resisting care and fighting the CNAs. On 03/19/25 at 2:25 PM, during a follow up interview with the DON, he confirmed that Resident #10 had been transferred to a BHU on two occasions-once in September 2024 and again in November 2024-due to escalating behavioral concerns, refusal to take medications, and decreased oral intake. Following the last BHU admission, the resident's family elected to initiate comfort measures only, and the facility honored that decision. The DON stated that despite the transition to comfort-focused care, Resident #10 continued to exhibit frequent behavioral disturbances and remained noncompliant with oral medications and nutrition. He acknowledged that there had been no improvement in the resident's behaviors since returning from the BHU. The DON could not recall the specific recommendations provided at the time of discharge from the BHU but noted the facility opted to manage her symptoms through its Comfort Measures protocol using anxiety and pain medications. On 03/20/25 at 9:00 AM, during an interview with the DON and the Assistant Director of Nursing (ADON), the DON explained Resident #10 had become increasingly combative with all aspects of care. The DON also clarified that the facility does not contract with an external hospice agency; instead, they provide in-house palliative care under a comfort measures protocol, which includes the use of Ativan as needed. On 03/20/25 at 10:40 AM, during a phone interview with Resident #10's granddaughter, she stated that both she and her mother are nurses and have been actively involved in the resident's care. She explained that over the past six (6) months to a year, there had been a noticeable decline in her grandmother's mental status. The resident had a longstanding history of mental health issues, including behavioral disturbances and dementia. She confirmed that Resident #10 had recently been admitted to a geriatric psychiatric facility on two (2) occasions. Following the most recent discharge, the resident initially showed slight improvement but quickly returned to her prior state. Based on the resident's continued decline and stated wishes, the family collectively agreed to place her on comfort measures only. The granddaughter shared that the resident continues to exhibit significant behavioral symptoms, including delusions, hallucinations, and verbal aggression. Due to the severity of these behaviors, family visits are often brief. She acknowledged that her grandmother consistently refuses medications and has poor nutritional intake but believes alternative behavioral medications or formulations could be explored. She confirmed awareness of the resident's significant weight loss but stated that the family made the decision not to pursue feeding tube placement. On 03/20/25 at 12:25 PM, during an interview with Social Services #1, she stated that she is part of the interdisciplinary team responsible for referring residents to behavioral health services. She acknowledged that Resident #10 had ongoing behavioral issues but reported that behavioral services were discontinued when the resident was placed on comfort measures. On 03/20/25 at 01:40 PM, during a phone interview with the Psychiatric NP, she explained that her services for Resident #10 were discontinued once the resident was placed on comfort measures. She stated that during her visits, Resident #10 often became upset and agitated by her presence, frequently refusing to participate in care. The NP shared that Resident #10 would regularly display aggressive behavior, including calling her derogatory names and exhibiting paranoid ideations. She noted that Resident #10 had been noncompliant with both care and medications for several months prior to the initiation of comfort measures and had experienced a noticeable decline in behavior. The NP consulted with colleagues due to the resident's worsening symptoms and it was eventually determined that her ammonia levels were elevated, prompting the discontinuation of Depakote. Although alternative medications were trialed, the resident continued to exhibit paranoid delusions and hallucinations. The NP confirmed that she was aware the resident was not taking prescribed medications, which contributed to the decision to begin comfort care. She stated that during her final visit in December 2024, Resident #10 was still experiencing uncontrolled anxiety and psychosis. She clarified that under the facility's palliative care approach, comfort measures are limited to managing symptoms without further psychiatric intervention.

Based on interview, record review, and facility policy review the facility failed to develop and implement a comprehensive, person-centered care plan and individualized interventions, as evidenced by not addressing ongoing behavioral symptoms and providing individualized comfort care interventions, despite a known history of psychotic and aggressive behaviors, which resulted in Resident #10 having frequent behavioral episodes, refusal of medications and food, and frequent combative interactions with staff.for one (1) of twenty-three (23) residents reviewed for care planning. Resident #10 Findings include: A review of the facility's policy titled, MDS (Minimum Data Set), CAA (Care Area Assessments), and Care Plan Documentation Policy, with a reviewed date of 01/24/24, revealed, . It is the purpose of this facility to provide documentation in the medical record for MDS, CAA, and care plan purposes . Discussion: . 6. The care plan will be updated on an ongoing basis with significant changes in interventions . A record review of Resident #10's Comprehensive Care Plan revealed Resident #10 had a MOOD care plan with interventions in place. The interventions, however were not all inclusive and aligned with all the Certified Nursing Assistant (CNA) documentation interventions indicated in the Behavior Monitoring Interventions for Resident #10. A record review of Resident #10's Admission Record revealed the facility admitted the resident on 10/01/21 with diagnoses that included Bipolar Disorder, Psychotic Disorder with Hallucinations Due to Known Physiological Conditions, Psychotic Disorder with Delusions, and other cognitive disorders. A record review of the Behavior Monitoring and Interventions documentation for March 2025 revealed Resident #10 exhibited frequent and escalating behavioral symptoms, including physical aggression, verbal outbursts, and refusal of care. Behavioral episodes were documented on multiple dates across all shifts, including but not limited to 03/11, 03/13, 03/14, 03/15, 03/16, 03/17, 03/21, and 03/22, often involving grabbing, hitting, pushing, scratching, screaming, cursing, and threatening staff. The most frequently used interventions included redirecting the resident, providing food/drink, re-approach, and offering comfort measures such as massage or repositioning. However, the documented outcomes were consistently noted as either same (unchanged) or worsened. In addition, the intervention choices for the CNA documentation were not specific to Resident #10 and did not align with comprehensive care plan interventions. During an interview, on 03/17/25 at 1:25 PM, CNA #3 stated that Resident #10 is always confused and has daily behaviors. She explained that the resident is noncompliant with care and becomes aggressive during care. She confirmed the behaviors have been ongoing for many months. During an interview with the Director of Nursing (DON) on 03/18/25 at 1:00 PM, he explained that the facility provides psychiatric services. However, once a resident is placed on palliative or comfort care, psychiatric services are no longer offered. During an interview on 03/18/25 at 3:00 PM, Licensed Practical Nurse (LPN) #3 explained that Resident #10 had been in a prolonged state of psychosis since her Depakote was discontinued. The family requested the resident be kept on comfort measures only. She stated the only behavioral intervention in place is administration of anxiety medication. On 03/19/25 at 3:20 PM, during an interview with LPN #2, she explained that care plans are updated daily and used by staff to guide resident care. She reported that staff are expected to follow the care plan to meet residents' needs. On 03/20/25 at 9:00 AM, during an interview with the DON and Assistant DON, the DON acknowledged facility does not have a contract hospice agency and instead provides comfort measures following their own internal palliative care protocol, which includes administration of Ativan as needed. On 03/20/25 at 12:20 PM, during an interview with LPN #5, she reviewed Resident #10's care plan and confirmed it lacked detailed comfort care interventions. She noted the care plan did not outline specific interventions related to behavioral management or psychotropic medications. On 03/20/25 at 1:00 PM, during an interview with the Administrator, she acknowledged Resident #10's clinical decline and stated that she expects staff to complete care plans accurately and in a timely manner. She reported that all regulations regarding care planning should be followed.

Based on interviews, record review, and facility policy review, the facility failed to complete a Significant Change in Status Minimum Data Set (MDS) assessment after a resident experienced two (2) or more declines in activities of daily living and an increase in behavioral symptoms for one (1) of twenty-three (23) sampled residents. Resident #10. Findings included: A review of the facility's MDS (Minimum Data Set), CAA (Care Area Assessments), and Care Plan Documentation Policy, revised 11/14/2023, . It is the purpose of this facility to provide documentation in the medical record for MDS, CAA, and care plan purposes . Discussion: 1. The staff completing each portion of the MDS is responsible for ensuring that documentation is found in the medical record to support the coding they perform . A review of the Long Term Care Resident Assessment Instrument (RAI) User's Manual Version 1.19.1 dated October 2024 revealed, . A 'significant change' is a major decline or improvement in a resident's status that: 1. Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions, the decline is not considered 'self-limiting'; 2. Impacts more than one area of the resident's health status; and 3. Requires interdisciplinary review and/or revision of the care plan . A record review of Resident #10's Admission Record revealed the facility admitted the resident on 10/01/2021 with diagnoses including Bipolar Disorder, Unspecified, Psychotic Disorder with Hallucinations Due to Known Physiological Conditions, Psychotic Disorder with Delusions, and Other Symptoms and Sign Involving Cognitive Function and Awareness. A record review of Resident #10's MDS Care Profile revealed no Significant Change MDS had been completed since admission. The most recent Quarterly MDS was completed on 01/09/2025. A record review of the Order Summary Report with active orders as of 03/19/2025, revealed Resident #10 had a physician's order, dated 11/26/2024, Do Not Resuscitate (DNR), Do Not Transfer, Comfort Measures Only, dated 11/26/2024, with no diagnosis or clinical rational for comfort measures indicated. A record review of the Physician's Order Sheet revealed Resident #10 had a Physician's Order, dated 08/29/2024 to send the resident to an emergency room for evaluation of increased behaviors, and another Physician's Order, dated 11/14/2024, to send the resident to a Behavioral Health Unit (BHU) for further evaluation. A record review of the Social Services Quarterly Note dated 01/09/25 revealed Resident #10 has had a Change in status in her cognitive status, social interaction, mood status, behavioral status, and rejection of care/resident choices. On 03/19/2025 at 2:25 PM, during an interview, the Director of Nursing (DON) confirmed Resident #10 had been sent to a BHU twice. Resident #10 was sent out once on 08/2024 and again on 11/14/2024. The resident had demonstrated increased behaviors, ceased taking oral medications, and was eating very little. Following the last BHU visit (11/14/24), the resident's family elected to place her on comfort measures only. The DON acknowledged that Resident #10 continued to refuse medications and food. On 03/19/2025 at 3:20 PM, during an interview, Licensed Practical Nurse (LPN) #2/MDS Nurse, she explained that a Significant Change MDS should be completed when a resident experiences two (2) or more significant changes in health status. LPN #2 confirmed that Resident #10 had not had a Significant Change MDS in the past year despite having been to the BHU twice, refusing oral medications, eating inconsistently, experiencing significant weight loss, and being placed on comfort measures. She stated that a Significant Change Assessment should have been completed. On 03/20/2025 at 12:45 PM, during an interview, Registered Nurse (RN) #3, who serves as the Reimbursement Coordinator and completes Pre-Admission Screening and Resident Review (PASRR), stated that she was aware of Resident #10's recent health status changes. She confirmed the resident had been to a BHU twice, placed on comfort measures, refused oral medications, and lost significant weight-all of which met criteria for a Significant Change in Status Assessment. She acknowledged that the assessment had not been completed and stated, It was just missed. On 03/20/2025 at 1:00 PM, during an interview, the Administrator stated that she was aware of the decline in Resident #10's condition and expects all staff to perform their job duties correctly, including ensuring assessments are completed accurately and on time.

Based on interviews, record review, and facility policy review, the facility failed to notify the state mental health authority following a significant change in status for one (1) of two (2) residents reviewed for Preadmission Screening and Resident Review (PASRR) Level II. Resident #10 Findings included: A review of the facility's policy titled PASRR Screening with a review date of 11/19/2023 revealed, . This facility coordinates assessments with the preadmission screening and resident review (PASRR) program under Medicaid to ensure that individuals with a mental disorder, intellectual disability, or a related condition receives care and services in the most integrated setting appropriate to their needs . Policy Explanation and Compliance Guidelines: . 7. Any Level II resident who experiences a significant change in status will be referred promptly to the state mental health or intellectual disability authority for additional review. 8. Any resident who exhibits a newly evident or possible serious mental disorder, intellectual disability, or a related condition will be referred promptly to the state mental health or intellectual disability authority for a level II resident review. Examples include: . c. A resident transferred, admitted , or readmitted to the facility following an inpatient psychiatric stay or equally intensive treatment . A record review of Resident #10's Admission Record revealed the facility admitted the resident on 10/01/2021 with diagnoses including Bipolar Disorder, Unspecified, Psychotic Disorder with Hallucinations Due to Known Physiological Conditions, Psychotic Disorder with Delusions, and Other Symptoms and Sign Involving Cognitive Function and Awareness. A record review of Resident #10's Preadmission Screening and Resident Review (PASRR) dated 08/24/2020 revealed no diagnosis of Alzheimer's Disease but noted that the resident had a recent history of mental illness and takes or has a history of taking psychotropic medications. A record review of Resident #10's PASRR Level II dated 09/08/2020 revealed the resident was exempt from PASRR at that time. The documentation also stated, If there is a change in symptoms, behaviors, or a new diagnosis, the nursing facility should submit a status change. A record review of the Physician's Order Sheet revealed Resident #10 had a Physician's Order, dated 08/29/2024 to send the resident to an emergency room for evaluation of increased behaviors, and another physician's order, dated 11/14/2024, to send the resident to a Behavioral Health Unit (BHU) for further evaluation. On 03/18/2025 at 1:00 PM, during an interview with the Director of Nursing (DON), he explained that the facility does offer psychiatric services, but once a resident is on palliative or comfort care, those services are discontinued. The DON stated that Resident #10 had previously received psych services, but since being placed on comfort measures only, she is no longer followed. The DON acknowledged that Resident #10 continues to experience good and bad days with behaviors, hallucinations, and delusions. The resident had been sent to the hospital and subsequently admitted to a Behavioral Health Unit (BHU) twice. The family later elected comfort measures only. The DON confirmed that the facility did not submit a change in status referral for a PASRR Level II after either BHU admission. He stated that the PAS (Pre-admission Screening) and PASRR on file were the only screenings completed and acknowledged he was not aware that being sent to a BHU or an increase in behaviors required a new referral. On 03/20/2025 at 12:45 PM, during an interview with Registered Nurse (RN) #3, she explained that she is the Reimbursement Coordinator and Minimum Data Set (MDS) Coordinator and completes the PASRR process. She confirmed that she was aware Resident #10 had been to the BHU twice recently. She stated she was not aware that a resident with a Level II, or a resident transferred and admitted to an inpatient psychiatric stay, required a status change referral to the state mental health authority. On 03/20/2025 at 1:00 PM, during an interview with the Administrator, she explained that she was aware of the decline in Resident #10's health status, increased behaviors, and that the resident had been admitted to an inpatient BHU twice. She stated that she expects all staff to perform their duties correctly and for assessments to be completed accurately and on time. The Administrator acknowledged she was not aware that an inpatient psychiatric stay triggered a requirement for a PASRR status change referral. She believed that if the resident's behaviors were ongoing, a new referral was not required.

Based on interview and record review the facility failed to provide a reason for a resident transfer for one (1) of 23 residents sampled. Resident #5 Findings Include: A review of the facility's Notice of Transfer or Discharge dated 09/02/24 revealed there was no explanation for the resident's discharge to the hospital. A review of the facility's Notice of Transfer or Discharge dated 12/14/24 revealed there was no explanation for the resident's discharge to the hospital. A record review of the facility's admission Record revealed the facility admitted the resident on 5/20/16 with diagnoses including Heart Failure. On 3/20/25 at 8:05 AM, an interview with the Social Services Director revealed the Charge Nurse is responsible for filling in the Notice of Resident Transfer or Discharge form and the Business Office Coordinator mails the form to the Resident Representative (RR). On 03/20/25 at 9:50 AM, an interview with Registered Nurse (RN) #1 Charge Nurse revealed she has never filled in the Notice of Resident Transfer or Discharge at the time a resident is sent to the hospital. RN #1 stated she fills out the Functional Abilities and Goals: Discharge form on the computer. RN #1 stated there is no place on the form for a reason for the hospitalization. RN #1 stated she notates the reason for the hospitalization in the progress note. On 03/20/25 at 10:13 AM, an interview with RN #2 Charge Nurse revealed she does not fill in the Notice of Resident Transfer or Discharge at the time of a resident being sent from the facility to the hospital. RN #2 stated she fills out the Functional Abilities and Goals: Discharge form on the computer. RN#2 stated she will then write a progress not regarding the hospitalization. On 03/20/25 at 10:30 AM, an interview with the Business Office Coordinator (BOC), acknowledged that it is her responsibility to mail the Notification of Resident Transfer or Discharge to the Resident Representative. The BOC stated she receives a notification from the Electronic Medical Record that lets her know that the Notification of Resident Transfer or Discharge has been saved to the system. The BOC stated she will print the form and mail it to the Resident Representative. On 03/20/25 at 11:12 AM, an interview with the Assistant Director of Nursing (ADON) revealed it is the responsibility of the Charge Nurse to fill in the Notification of Resident Transfer or Discharge at the time a resident is being sent to the hospital. The ADON acknowledged that Notification of Resident Transfer or Discharge forms dated 9/2/24 and 12/14/2024 did not list information detailing the reason for the hospitalization. The ADON stated going forward she expects the facility's staff to adequately inform the resident and the RR in writing of the reason for hospitalization. On 03/20/25 at 11:20 AM, during an interview the Director of Nursing (DON) acknowledged the Notification of Resident Transfer or Discharge forms dated 9/2/24 and 12/14/24 did not list information detailing the reason for the hospitalization. The DON stated it is the responsibility of the Charge Nurse to fill in the form. The DON acknowledged that the RR would benefit from having clear written communication regarding the residents' hospitalizations. The DON stated that going forward they will make the forms instructions clearer to provide more information.

Based on observation, interviews, record reviews, and facility policy review, the facility failed to honor resident food dislikes by placing food items on meal trays that were identified as dislikes for one (1) of four (4) days of observation. Resident #58. Findings included: A review of the facility's Resident Rights Policy, revised 12/4/2016, revealed, . Responsibilities .The facility must support the resident in the exercise of his or her rights . Procedure . 6. Resident Rights. The resident has the right to a dignified existence, self-determination . A review of the facility's booklet titled A Matter of Rights: A Guide to Your Rights and Responsibilities as a Resident with a copyright date of 2017 revealed, . Freedom of Choice - You are entitled to make decisions, whenever possible, for yourself based on your interests and preferences . On 03/17/2025 at 12:27 PM, during an interview and observation, Resident #58 was observed eating lunch independently. The lunch tray included lasagna and mashed potatoes with gravy. Resident #58 stated that she has told kitchen staff repeatedly not to serve certain items, yet they continue to send her food she requested not to receive. She explained the staff ask her multiple times what she wants but still brings her the wrong meal. An observation of the resident's tray card revealed lasagna was listed as a dislike. Resident #58 stated she now relies on her own food because she is tired of telling staff to bring something else. On 03/17/2025 at 12:40 PM, during an interview, Certified Nurse Aide (CNA) #1 confirmed that lasagna was listed as a dislike on Resident #58's meal ticket, yet she received it for lunch. On 03/19/2025 at 8:25 AM, during an interview, the Dietary Manager (DM) stated she could not recall whether she completed Resident #58's likes and dislikes documentation. She explained that likes and dislikes documentation should be completed for all new admissions and updated as needed. She stated that CNAs or nurses should notify the kitchen when residents are not eating or when changes to the meal ticket are required. She confirmed the [NAME] is responsible for reading meal tray tickets and honoring preferences during tray line setup. The DM was not aware Resident #58 received lasagna on 03/17/2025 and stated that this was an error by the cook. She confirmed her expectation that all residents' likes and dislikes are honored. On 03/20/2025 at 1:00 PM, during an interview, the Administrator stated that all staff are expected to honor residents' rights and choices at all times to ensure high-quality care. A record review of Resident #58's Admission Record revealed the facility admitted the resident on 01/13/2025 with diagnoses including Limb-Girdle Muscular Dystrophy. A record review of Resident #58's Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/21/2025 revealed she had a Brief Interview for Mental Status (BIMS) score of 15, which indicated she was cognitively intact. A record review of Resident #58's meal tickets dated 03/17/2025 and 03/18/2025 revealed lasagna listed as a dislike.

Based on observation, staff interviews and facility policy review, the facility failed to store food in accordance with professional standards for food service safety related to food items not dated with a use-by date, food items not discarded by the use-by date, spoiled foods not discarded, food items without an identifying label, food items improperly stored, and food items opened and not sealed for one (1) of three (3) kitchen observations and had the potential to affect all residents who receive food items from the kitchen. Findings Include: A review of the facility's policy, Food and Supply Storage, revised ,d+[DATE], revealed, . All food .shall be stored in such a manner as to prevent contamination .Procedures .Cover, label and date unused portions and open packages .Discard food past the use-by or expiration date .Dry Storage .Foods that must be opened must be store in .approved containers that have tight-fitting lids .Hang scoop. Scoops may be stored in bins on a scoop holder .Refrigerated Stored .sort produce daily to remove spoiled pieces . On [DATE] at 11:45 AM, during an observation and interview of the kitchen with the Chef revealed the following: 1. An observation of the dry storage bins revealed a scoop that was not stored in the designated holder and was lying on top of the sugar. 2. An observation of the contents of Refrigerator #1 revealed one (1) opened carton of prune juice that had a date opened label of [DATE] and indicated the juice was good through [DATE]. There were two (2) opened cartons of thickened orange juice and one (1) opened carton of thickened dairy beverage with no label indicating the use-by date. 3. An observation of Refrigerator #2 revealed one (1) unopened ham with no label indicating the use-by date or a manufacturer's expiration date. There were two (2) containers of strawberries covered with white biological growth. There were three (3) 10-pound packages of meat with no identifying label and no use-by date. The Chef stated the meat was ground beef. There was one (1) sheet pan of rolls with no use-by date. 4. An observation of the Freezer revealed one (1) opened bag of French fries with no use-by date on the package. 5. An observation of the dry food storage area revealed one (1) opened bottle of lemon juice with a manufacturer's label that indicated refrigerate after opening. There was one (1) opened plastic bag of corn starch, which was unsealed, and the product was visible. There was one (1) box of quick creamy wheat, the top flap of the box was opened, unsealed, and the product was visible. The Chef stated in an interview during the tour that he would discard the expired, opened, undated, unlabeled items and any expired foods. On [DATE], at 10:12 AM, an interview with the Dietary Manager (DM), revealed her expectation is that expired foods be discarded, the dry food storage items be securely sealed and properly stored. The DM acknowledged that the food items could cause the residents to get sick. The DM stated the scoop being left on top of the sugar and the strawberries covered in white biological growth were unacceptable. On [DATE] at 09:34 AM, in an interview with the Administrator, she confirmed that her expectation was that food should be labeled and monitored daily for expiration dates.

Based on interviews, record review, and facility policy review the facility failed to ensure grievances related to dietary services were resolved for ten (10) of 24 sampled residents. (Resident #1, #18, #22, #42, #58, #61, #67, #94, #96 and #104) Findings include: Review of the facility's, Grievance Policy revised 06/23/23 revealed, .To ensure the resident, our resident representatives right, to voice grievances to the facility or other agency or entity that hears grievances without discrimination or reprisal and without the fear of discrimination or reprisal .Responsibilities .The facility will review grievances in a timely manner and must make prompt efforts to resolve grievances .Procedure .4. Grievances may be voiced orally to the department manager, to the Grievance Official, during resident council .8. Any immediate action needed to prevent further violations of any residents' rights will be taken .10. The grievance official will take steps to resolve the grievance and record information about the grievance and those actions on the grievance form. 11. Steps to resolve the grievance may involve discussion with the appropriate department manager for follow up . A record review of the Resident Council Meeting, dated 4/25/23 revealed a representative of the food service company was in attendance and food seasoning was discussed. A record review of the Resident Council Meeting, dated 5/30/23 revealed a resident concern regarding green beans tastes as if they are out of the can. A record review of the Resident Council Meeting, dated 6/27/23 revealed that the DM was not in attendance, but residents verbalized a food concern that peanuts were not cooked long enough. Record review of the Resident Council Meeting, dated 7/25/23, 8/29/23, and 9/26/23, revealed the Dietary Manager (DM) was in attendance. Residents voiced multiple food concerns. During a meeting with the Resident council members on 10/24/23 at 03:00 PM, the residents complained the food was cold and had not tasted good since the new dietary company had taken over for the facility. The residents said they had invited the Dietary Manager (DM) to attend their meetings each month to discuss their dietary concerns, but nothing had changed regarding the taste of the food, because the food was bland and had no flavor. During an interview on 10/25/23 at 12:50 PM, with the DM, she explained that the dietary staff could not add seasonings to the food recipe. She confirmed she had been invited to attend resident council meetings every month and tried to assist with the resident's requests, but the Registered Dietician (RD) made the decisions regarding seasoning changes for the recipes and would not allow the DM to alter the recipes. She stated that the facility had residents that had orders for bland diets and that the residents could add salt or pepper from the packets on their meal trays. During an interview on 10/25/23 at 1:00 PM, with the Social Worker (SW), she reported that she records the minutes of the Resident Council meetings. She confirmed that the residents had complained about the taste and temperature of the food. The SW confirmed she failed to document the food complaints on the council meeting minutes if the DM was present for the meeting and discussed the concerns with the residents. The SW also stated that the residents' food concerns had been discussed in daily stand-up (communication) meetings during the past several months. During an interview on 10/25/23 at 1:20 PM, with the Director of Nursing (DON), he confirmed the residents have complained for several months of the food being cold and not having a good taste. The DON confirmed that the DM was attending monthly resident council meetings and he thought she was working to correct the residents' concerns. The DON confirmed that the food concerns had been discussed in stand-up meetings. During an interview on 10/26/23 at 09:00 AM, with the Administrator, she confirmed the residents had complained about the food being served cold and did not taste good, since the new company had began at the facility. The Administrator explained that the new company had been at the facility for one year and she was giving them time to correct the residents' concerns. She confirmed the concerns had been discussed in stand-up meetings and with the DM, RD and corporate team. During an interview on 10/26/23 at 10:10 AM, with the RD, he confirmed that the resident had complained about the taste of the food and that the food was served cold. He explained that he was allowing the dietary service to work out the residents' concerns and he had encouraged the DM to use salt or other spices to make the food savory. The RD reported that there was only one (1) resident who received a bland diet. Resident #1 A record Review of the Transfer/Discharge Report revealed the facility admitted Resident #1 on 03/07/23 with a diagnosis of Cerebral Palsy. A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 9/1/23 revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated she was cognitively Intact. Resident #18 A record Review of the Transfer/Discharge Report revealed the facility admitted Resident #18 on 09/03/23 with a diagnosis of Cerebral Infarction. A record review of the Quarterly MDS with an ARD of 9/6/23 revealed Resident #18 had a BIMS score of 15, which indicated she was cognitively intact. Resident #22 A record Review of the Transfer/Discharge Report revealed the facility admitted Resident #22 on 08/6/23 with a diagnosis of Chronic Obstructive Pulmonary Disease (COPD). A record review of the Quarterly MDS with an ARD of 8/24/23 revealed Resident #22 had a BIMS score of 15, which indicated Resident #22 was cognitively intact. Resident #42 A record Review of the Transfer/Discharge Report revealed the facility admitted Resident #42 on 01/11/22 with a diagnosis of Hypertension. A record review of the Quarterly MDS with an ARD of 9/4/23 revealed Resident #42 had a BIMS score of 15, which indicated she was cognitively intact. Resident #58 A record Review of the Transfer/Discharge Report revealed the facility admitted Resident #58 on 04/14/23 with a diagnosis of Bipolar Disorder. A record review of the Minimum Data Set (MDS) with an ARD of 10/17/23 revealed Resident #58 had a BIMS score of 15, which indicated she was cognitively Intact. Resident #61 A record Review of the Transfer/Discharge Report revealed the facility admitted Resident #61 on 02/10/23 with a diagnosis of COPD. A record review of the Quarterly MDS with an ARD of 8/3/23 revealed Resident #61 had BIMS score of 15, which indicated she was cognitively intact. Resident #67 A record Review of the Transfer/Discharge Report revealed the facility admitted Resident #67 on 09/05/23 with a diagnosis of Diabetes Mellitus. A record review of the Quarterly MDS with an ARD of 9/20/2023 revealed Resident #67 had a BIMS score of 14, which indicated she was cognitively Intact. Resident #94 A record Review of the Transfer/Discharge Report revealed the facility admitted Resident #94 on 03/18/23 with a diagnosis of COPD. A record review of the MDS with an ARD of 10/10/23 revealed Resident #94 had BIMS score of 12, which indicated her cognition was moderately impaired. Resident #96 A record Review of the Transfer/Discharge Report revealed the facility admitted Resident #96 on 05/29/23 with a diagnosis of Aneurysm. A record review of the Quarterly Minimum Data Set (MDS) with Assessment Reference Date (ARD) 9/26/23 revealed Resident #96 had a BIMS score of 15, which indicates resident is cognitively Intact. Resident #104 A record Review of the Transfer/Discharge Report revealed the facility admitted Resident #104 on 05/08/23 with a diagnosis of Chronic Kidney Disease. A record review of the Quarterly MDS with an ARD of 9/21/23 revealed Resident #104 had a BIMS score of 13, which indicated she was cognitively intact.

Based on observation, staff interviews, record review, and facility policy review, the facility failed to ensure staff washed or sanitized hands during Percutaneous Endoscopic Gastrostomy (PEG) site care for one (1) of two (2) residents reviewed with PEG tubes. Resident # 38 Findings Include: Review of the facility's policy, Infection Prevention and Control Program Policy, revised 8/22/2019, revealed, Purpose: To establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections . During PEG site care, on 10/24/23 at 10:20 AM, for Resident # 38, Licensed Practical Nurse (LPN) #1 did not wash or sanitize her hands or change her gloves after removing the soiled dressing from the PEG site. She used the same gloves to clean the site. LPN #1 also did not wash or sanitize her hands before she donned a clean pair of gloves and applied the treatment to the PEG site. On 10/25/23 at 02:38 PM, in an interview with LPN #1, she confirmed that she should have discarded her gloves after she had removed the soiled dressing from the PEG site. She stated she should have washed or sanitized her hands before and applied clean gloves prior to cleaning the PEG site and before she applied a clean dressing. She explained that her actions could have led to the resident acquiring an infection. Record review of the Transfer and Discharge Report revealed the facility admitted Resident #38 on 6/15/23 with diagnosis of Adult Failure to Thrive and Dysphagia. Record review of the Order Listing Report revealed Resident #38 had a Physician's Order with an order date of 01/23/2023 to Clean peg site with normal saline, pat dry, apply hydrophilic foam under peg bumper daily . On 10/26/23 at 09:45 AM, in an interview with the Director of Nursing (DON), he stated that LPN #1 should have performed hand hygiene after removing the soiled dressing, applied clean gloves, and then cleaned the PEG site. She should have performed hand hygiene after touching the dressing and between gloves changes. She should have changed gloves after touching the bed remote. The DON stated there is a good possibility that her actions could cause the resident to get an infection. On 10/26/23 at 10:07 AM, in an interview with Registered Nurse #1 (RN)/Infection Preventionist, she confirmed LPN #1 should have performed hand hygiene between glove changes and should have discarded her gloves after removing and discarding the soiled dressing because of infection control issues.

Based on interviews, record review and facility policy review, the facility failed to provide the Resident and the Resident Representative (RR) with written notification of the bed hold policy at the time of transfer to the hospital for one (1) of two (2) residents reviewed for hospitalization s. Resident #65 Findings include: Record Review of the facility's policy, Notice of Bed Hold and Return Policy, with a revision date of 1/9/20, revealed, It is the policy of this facility to provide written information to the resident and/or the resident representative regarding bed hold policies prior to and upon transferring a resident to the hospital . On 10/23/23 at 12:35 PM, in an interview with Resident #65, she revealed she had been admitted to the local hospital several times due to tremors and pneumonia. She stated at the time of her hospitalization s, she had not received anything in writing from the facility regarding their bed hold policy. A record review of the Physician Order Sheet, for Resident #65, revealed there an order dated 9/18/23, to send the resident to the ER (emergency room ) related to respiratory distress. On 9/28/23, there was another physician order to send the resident to the ER for SOB (shortness of breath). On 10/23/23 at 3:29 PM, in an interview the License Social Worker (LSW) revealed when a resident is sent to the hospital, the nurse fills out the bed hold letter and gives it to her. She then calls the family and gives the letters to the Administrator Assistant (AA) or Business Office Coordinator (BOC) to mail. She stated the original letters are kept in a binder in the front office. She further commented, this is done every time a resident transferred to an acute care hospital. On 10/24/23 at 11:39 AM, in an interview with the LSW, she revealed she had looked for the bed hold letters for September and could not find them. She stated she usually keeps a copy, with a notation of who she had given the letters to mail. However, she could not find letters for the month of September, and she could not recall if she did that for the month of September. On 10/24/23 at 11:40 AM in an interview with BOC, she revealed if she had been given the bed hold letters for the month of September, she would have mailed the original to the Resident Representative (RR) and kept a copy to place in the binder in the front office. The BOC confirmed there were no bed hold letters in the binder for the month of September. On 10/24/23 at 12:05 PM, in an interview with the AA, she revealed after bed hold letters are mailed, they put a copy of the original in the binder. She confirmed there are no bed hold letters in the binder for the month of September. She stated no one gave her the letters. On 10/25/23 at 2:35 PM, in an interview with the Administrator, she acknowledged she was made aware of the letters not being done. She stated she expects staff to follow the facility's policy related to transfers and discharges regarding bed holds. Record review of Transfer/Discharge Report for Resident #65 revealed a readmitted [DATE] with diagnoses of Chronic Obstructive Pulmonary Disease, Acute and Chronic Respiratory Failure, and Essential Tremors. Record review of Resident #65's Discharge Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 9/13/2023, as well as the Discharge MDS, with an ARD date of 9/28/23, revealed the resident was discharged to an acute care hospital. Record review of Annual MDS with ARD 6/19/23 revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated resident was cognitively intact. Record review of the facility's Progress Notes revealed Resident #65 was transferred to an acute care hospital on 9/13/23, related to low O2 Sats (oxygen saturation) levels ranging from 56%-84%. Progress Notes dated 9/28/23, revealed Resident #65 was again transferred to an acute hospital, related to cyanosis (bluish discoloration) and inability to respond to commands.

Based on interviews, record review, and facility policy review, the facility failed to provide written notification of transfer to the resident and the Resident's Representative (RR), for a resident transferred to the hospital for one (1) of two (2) resident records reviewed for hospitalization s. Resident #65 Findings include: Record Review of the facility's policy, Resident Transfer and Discharge Policy, with a revision date of 3/11/22, revealed, . 7. Emergency Transfers/Discharges initiated by the facility for medical reasons e. Complete and send the following forms at the time of transfer: i. Notice of Bed Hold for the resident representative ii. Notice of transfer for the resident representative . At 12:35 PM on 10/23/23, in an interview with Resident #65, she revealed she had been admitted to the hospital several times due to tremors and pneumonia. She stated she was not given anything in writing from the facility at the time of her transfers to the hospital. A record review of the Physician Order Sheet, for Resident #65, revealed there was an order dated 9/18/23, to send the resident to the ER (emergency room ) related to respiratory distress. There was another physician order dated 9/28/23, to send the resident to the ER for SOB (shortness of breath). The Licensed Social Worker (LSW) revealed on 10/23/23 at 3:29 PM, in an interview, when a resident is sent to the hospital, the nurse fills out the transfer letter. She stated once the nurse fills out the letter, it is given to her, she calls the family, and gives the letter to the Administrator Assistant (AA) or Business Office Coordinator (BOC) to mail. The LSW added that they mail the original letters and keep a copy for their records. The LSW stated this is done every time a resident is sent out to a hospital. The LSW reported on 10/24/23 at 11:39 AM, in an interview, that she looked for hospital transfer letters for September. However, she stated she could not find them. She stated once she forwards the letters to the AA or BOC, she usually makes a copy and documents to whom she gave the letters to mail. She revealed that without a copy of the letters and a notation regarding their disposition, she could not remember who or when she gave them to and cannot recall if she did that for the September letters at all. In an interview on 10/24/23 at 11:40 AM, with the BOC, she revealed if she was given the original copies, she would have mailed the original to the RR and placed a copy in a binder. However, she stated she could not recall the letters being given to her to be mailed. She stated the LSW is supposed to give the letters to her or the AA to be mailed to the RR, however, she confirmed there were no copies of letters for September in the binder. During an interview on 10/24/23 at 12:05 PM, in an interview with the AA, she revealed the facility keeps a copy of the original letters in a binder. She stated there are no letters in the binder for September, she does not have the letters, and no one gave her letters for September. In an interview on 10/25/23 at 2:35 PM, the Administrator revealed she was made aware of the letters not being done. She stated she expects staff to follow the facility's policy related to resident transfers. Record review of Resident #65's Transfer/Discharge Report, revealed a readmitted [DATE], with diagnoses of Chronic Obstructive Pulmonary Disease, Acute and Chronic Respiratory Failure, and Essential Tremors. Record review of Resident #65's Discharge Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 9/13/2023, as well as the Discharge MDS with an ARD of 9/28/23, revealed the resident was discharged to an acute care hospital. Record review of Annual MDS with ARD 6/19/23 revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. Record review of Progress Notes revealed Resident #65 was transferred to an acute care hospital on 9/13/23, related to low O2 Sats (oxygen saturation) levels ranging from 56%-84%. Progress Notes, dated 9/28/23, revealed Resident #65 was again transferred to an acute care hospital related to cyanosis (bluish discoloration) and inability to respond to commands.

Based on staff interview, record review, and facility policy review, the facility failed to transmit a discharge Minimum Data Set (MDS) Assessment for one (1) of 24 residents reviewed for MDS assessments. (Resident #78) Findings Include: Review of facility's, MDS (Minimum Data Set), CAA (Care Area Assessment), and Care Plan Documentation Policy, revised 10/18/2019, revealed, .It is the policy of this facility to provide documentation in the medical record for MDS, CAA, and care plan purposes . Record review of the Transfer/Discharge Report revealed the facility admitted Resident #78 on 6/5/23 with a diagnosis of Alzheimer's Disease. Record review of the Progress Notes revealed a Discharge Summary note, dated 7/2/23 at 12:30 (PM), for Resident #78 for .1230 (12:30 PM) Coroner called to pronounce death . Review of the medical record revealed Resident #78 had a Death in Facility MDS with an ARD of 7/2/23 completed and signed on 7/3/23. Review of the MDS submission report revealed the Submission Date/Time was 10/25/23 at 16:24 (4:24 PM) and the Discharge MDS for Resident #78 that was completed on 7/3/23 was not transmitted until 10/25/23, which was more than 14 days. During an interview on 10/25/23 at 03:11 PM, with Licensed Practical Nurse (LPN) #2, she acknowledged that she failed to submit the MDS for the death in the facility for Resident #78 in a timely manner. LPN #2 stated that she checked the wrong box when completing the MDS and chose do not submit in error. She confirmed that the MDS was completed but was not transmitted. During an interview on 10/25/23 at 03:54 PM, with the Director of Nursing (DON), he stated that he had not reviewed the MDS, but he expected the nurses to submit the MDS in a timely manner.

Based on observations, record review, interviews, and facility policy review, the facility failed to ensure implementation of additional precautions intended to mitigate the transmission and spread of COVID-19 for all staff who are not fully vaccinated for COVID-19 for one (1) of four (4) kitchen observations. Findings include: Record review of the facility policy titled Novel Coronavirus Prevention and Response, with revision date 10/12/22, revealed, Purpose: To provide facility guidelines to identify, treat, respond to, and prevent the spread of SARS-CoV-2 infections .Source Control: Masks are required where the facility is experiencing an outbreak of COVID-19. Staff who are Unvaccinated or Not Fully Vaccinated will wear a surgical mask at all times Record review of the CDC document, included with the facility infection control policies, titled SEQUENCE FOR PUTTING ON PERSONAL PROTECTIVE EQUIPMENT (PPE), undated, revealed, .2. MASK . Fit flexible band to nose bridge. Fit snug to face and below chin . On 5/11/23 at 9:30 AM, an observation revealed the facility had a printed notice posted on the front entrance door which stated that the facility was in a COVID-19 Outbreak. On 5/11/23 at 9:47 AM, an observation through a window in the hallway into the kitchen revealed the Cook was wearing her face mask inappropriately, pulled down below her nose. On 5/11/23 at 9:50 AM, in an interview with the Infection Preventionist (IP), she confirmed that the facility was in a COVID-19 outbreak and that the Cook should have her face mask secured over the bridge of her nose and was not wearing her face mask correctly. On 5/11/23 at 11:40 AM an interview with the 'interim' Certified Dietary Manager (CDM) revealed all dietary staff working in the facility were required to follow the infection control and Novel Coronavirus Prevention and Response policies and procedures in place at the facility. She confirmed the policies included unvaccinated workers wearing face masks at all times, while in the facility. She confirmed that wearing a face mask pulled down below the nose was not acceptable and did not follow infection control guidelines. On 5/11/23 at 2:10 PM in an interview with the Cook she stated, I had just got finished serving and was going to wash dishes. I was still in the kitchen and my mask should have been over my nose. She confirmed that she was aware that the facility was currently in an outbreak of COVID-19 and that all staff were required to wear face masks correctly. She also confirmed that she was not vaccinated against COVID-19 and when the facility accepted her non-medical exemption, she was instructed that she would need to wear a face mask at all times while in the facility. She confirmed that she knew the correct way to wear a face mask was to have it fitted on (or over) the bridge of the nose. On 5/11/23 at 3:52 PM, in an interview the IP, she confirmed that the Cook had requested and received a non-medical exemption from COVID-19 vaccination and was required to always wear a face mask appropriately when in the facility as a mitigation technique.

Based on record review, interviews, and facility policy review, the facility failed to reconcile a resident's pre-discharge medications with the post-discharge medications for one (1) of three (3) discharged residents reviewed. Resident #2. Findings include: A record review of a statement dated 12/28/22 and signed by the Administrator revealed the facility does not currently have a policy related to medication reconciliation during the discharge process. A record review of the Face Sheet revealed Resident #2 was admitted by the facility on 09/09/2022 and discharged on [DATE] with a diagnosis of Hypertensive urgency. A record review of the Receipt for Resident's Medications for Resident #2 dated 10/14/22 revealed, .Amount: 30 .Medication and Strength: Celexa 20 mg (milligrams) . The form was signed by Registered Nurse (RN) #1, and specified that .All medication must be picked up at (Proper Name of Facility) upon discharge . A record review of the Discharge Summary for Resident #2, revealed Celexa was not listed in the Medication Orders. A record review of the Departmental Notes dated 10/14/22 at 1:49 PM, revealed a MDS Note/ADL Documentation signed by RN #1 for .All med (medications) left from stay were given and signed for . On 12/19/22 at 3:15 PM, during an interview with the Director of Nursing (DON), he stated that when Resident #2 was discharged from the facility, RN #1 received the resident's medications from the nurse and completed the Receipt for Resident's Medications form using the actual medication cards. She did not compare the medication cards with the resident's discharge orders to perform a medication reconciliation. She also did not realize the medication nurse had given her another resident's medication card for Celexa 20 mg, which she added to the form and gave to the Resident Representative (RR). On 12/19/22 at 3:50 PM, in an interview with RN #1, she stated that she received Resident #2's medication cards from the medication nurse and completed the Receipt for Resident's Medication using the medication cards. RN #1 confirmed that she did not review the resident's name on the medication card and added another resident's medication, Celexa, with Resident #2's medication. RN #1 confirmed that she did not reconcile the medications for Resident #2 with the Physician's Discharge Orders.

Based on observation, staff interviews, and facility policy reviews, the facility failed to properly sanitize the food processors for pureed diets which could affect 11 of 11 residents receiving puree diets for one (1)of three (3) days survey. Findings include: Review of the facility policy titled Dietary Employee Hygiene and Personal Cleanliness, revealed, Purpose: To maintain a high level of sanitation during all activities in the food service area .Test solutions with test strips regularly to ensure that they are maintaining the proper strength of sanitizer for food contact surfaces .Concentration - not using enough sanitizing agent will result in an inadequate reduction of microorganisms. On 03/03/21, 11:02 AM, during an Observation of the kitchen three compartment sink revealed a dietary staff member #1 was washing a food processor. Dietary staff member #1 washed the food processor in the soapy water, rinsed it in the second sink and placed the food processor in the third sink of clear water. The dietary member took the food processor out of the water and was walking away when the State Agency (SA) ask the Dietary Staff Member #1 if she knew how to sanitize the equipment. Dietary Staff Member #1 placed the sanitizer strip in the water. The strip did not change color to indicate the recommended level of sanitizer necessary to sanitize items washed. The staff member placed the strip in the water again. The strip did not change colors. The dietary staff member turned on the sanitation machine and nothing came out. The dietary staff member looked under the sink and noticed the sanitation jug was empty. On 03/03/21, 11:10 AM, an interview with Dietary Staff Member #1 revealed she did not know there was no sanitization solution in the sink. The Dietary Staff Member said the Cooks are responsible for making sure the sanitization solution was changed. The Dietary Staff Member confirmed by not sanitizing the equipment could cause food borne illness. During an interview on 03/05/21, at 10:17 AM, with Dietary #2 revealed she was responsible for checking the sanitation of the three compartment sink on 3/3/21. Dietary #2 said she was busy and had not checked the sanitation at that time. Dietary #2 said she had not washed any pots and pans at that time. Dietary #2 said it is the responsibility of everybody in the kitchen to check the sanitation prior to washing equipment. The sanitation is checked every day along with temperatures and placed on the log. During an interview on 03/05/21, at 10:40 AM, the Dietary Manager confirmed Dietary #1 should have checked the sanitation prior to cleaning the food processor. Dietary #1 did not know to check the sanitation. The manager said the logs are done daily by the cook. The logs are checked daily by the assistant dietary manager. The dietary manager confirmed by not sanitizing the food processor could cause the residents to get sick. The dietary manager also said the facility has eleven residents with pureed diets. During an interview on 03/05/21, at 11:19 AM, the Administrator confirmed Dietary #1 should have checked the sanitation prior to washing the food processor. The Administrator said this could cause the residents to get sick. Record review of a Dietary Inservice conducted 11/24/20, which included the three compartment sink sanitization, revealed Dietary #1 and #2 signed as attended. Record review of a Dietary Inservice conducted 3/2/21, which included the three compartment sink, revealed Dietary #1 and #2 signed as attended.

Based on observation, staff interviews, record reviews, and facility policy review, the facility failed to maintain a medication error rate of less than five percent (5%) for one of six (6) medication administration observations. The medication error rate was seven (7) percent. Resident #66. Findings include: Review of the facility's policy titled, Administration and Charting of Medications Policy, dated April 2019, revealed: It is the policy of this facility to administer medications per physician's orders [REDACTED]. Administer the medications and ensure that the resident swallows medications administered via oral route. On 03/03/21, at 08:45 AM, upon entrance into Resident # 66's room, with LPN #2, a medication cup was observed on the bedside table with two (2) pills in the cup. On 03/03/21, at 8:50 AM, interview with LPN #2 revealed the medication looks like her evening medication was not given on 3/2/21 by the medication nurse. LPN #2 compared the medication in the cup to Resident #66's medication and stated the medication is a [MEDICATION NAME] 20 Milligrams (MG) and a [MEDICATION NAME] 25 MG. LPN #2 revealed the nurse should have given her medication as ordered and it was not to be left on the bedside table unsupervised. LPN #2 revealed leaving medication unsupervised could cause problems for Resident #66 if she did not receive her medication, such as swelling or hypertension. On 03/02/21, at 11:00 AM, interview with the Director of Nurses (DON) revealed if a medication is prescribed the nurse should give it and should never leave medication at the bedside. This is not the standards of practice we perform at the facility. On 03/04/21, at 1:47 PM, an interview with LPN #3 revealed, I was in the process of giving medication to Resident #66 but when I heard my name in the hall, I thought there was in emergency left the room and forgot to go back and give (Resident #66) her medication. LPN #3 stated that If Resident #66 did not receive her medication she could have an increase in swelling and hypertension. Record review of the Face Sheet revealed the facility admitted Resident #66 on 09/28/20, with the [DIAGNOSES REDACTED]. A review of physician orders [REDACTED]. A record review of a Nurses' Note dated 03/03/21 at 10:36 AM revealed no [MEDICAL CONDITION] in upper or lower extremities and Blood Pressure (B/P) 111/56. A review of the Comprehensive Minimum Data Set (MDS) for Resident #66, with an Assessment Reference Date (ARD) of 12/28/20, revealed the MDS was coded in Section C0500, Brief Interview Mental for Mental Status (BIMS), Section C0600- revealed a score of 08, indicating moderately impaired cognition.

Based on observation, staff interviews, record reviews, and facility policy reviews the facility failed to prevent the possible spread of infection as evidenced by the wound care nurse touching multiple surfaces with contaminated gloves for one (1) of four (4) wound care observations. Resident #74. Findings Include: The facility's policy, Clean Dressing Change, reviewed date 3/11/2020 revealed, To provide wound care in a manner to decrease potential for infection and/or cross-contamination. On 03/04/21, at 08:54 AM, an observation of wound care being done by Licensed Practical Nurse (LPN) #1/Wound Care Nurse. LPN #1/Wound Care Nurse applied clean gloves and closed the privacy curtain with right gloved hands. She picked up the bed control, adjusted the bed, and removed Resident #74's wound dressing without changing gloves. A record review of Resident #74's Face Sheet revealed resident was admitted on [DATE], with a primary [DIAGNOSES REDACTED]. A record review of the Physician order, dated 9/16/2020 revealed pressure ulcer of right buttock stage 4. A record review of the Physician order [REDACTED]. Pat dry. Skin prep peri wound. Loosely pack wound with [MEDICATION NAME] AG et (and) cover with foam dressing. Change daily and prn (as needed) till healed. (Stage 4 Pressure Ulcer) A review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/17/20, revealed a Brief Interview for Mental Status (BIMS) was not done due to resident is rarely/ never understood. On 03/05/21, at 10:10 AM, in an interview with LPN#1/Wound Care Nurse stated I should have washed my hands and change gloves after I closed the curtain and let the bed up. She stated I could have caused cross contamination and could have contaminated the wound. She stated that she has completed computer training on Infection Control. On 3/5/21, at 10:33 AM, in an interview with the Director of Nurses (DON), stated LPN #1/Wound Care Nurse should have not used gloves to close the curtain and raise the bed or she should have removed her gloves, washed her hands, and put clean gloves on. She stated that the LPN #1/Wound Care Nurse's actions could have caused cross contamination. A record review of LPN #1/Wound Care Nurse's competency check off list revealed she passed check off's on 12/16/2020. A record review revealed LPN #1/Wound Care Nurse's certificate of computer completion was dated 12/16/20.

Based on record review, interview, and facility policy review, the facility failed to ensure a resident was free from verbal abuse, for one (1) of four (4) residents reviewed, Resident #1. Findings include: A review of the facility's, Abuse, Neglect, and Exploitation Policy, dated 01/23/2020, revealed, verbal abuse means the use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within the hearing distance regardless of their age, ability to comprehend, or disability. A review of the facility's statement, dated 03/20/2020 and signed by the Director of Nurses (DON), revealed, on 03/02/2020 at approximately 12:10 PM, Certified Nursing Assistant (CNA) #2 observed CNA #1 slap Resident #1 on the arm. CNA #2 reported, she and CNA #1 were providing care to Resident #1. CNA #2 revealed CNA #1 turned Resident #1 over, and the resident yelled for her to stop for fear of falling off the bed. CNA #2 stated Resident #1 slapped CNA #1, and then CNA #1 slapped Resident #1 on her right arm. CNA #2 revealed CNA #1 stated to Resident #1, Fine, sit in your[***] I don ' t care and walked out of the room. Review of the facility's Historical Employee Clocking and Schedule for 03/02/2020 revealed, CNA #1 was in the facility on 03/02/2020 from 7:22 AM to 12:39 PM. A review of the facility's document titled, Report of Termination/Hour Reduction dated 03/03/2020, revealed, CNA #1 was suspended following an allegation of abuse towards a resident. The document indicated CNA #1's last day worked was on 03/02/2020, and date terminated as of 03/03/2020. A review of a typed statement given by CNA #1, attached to the Report of Termination/Hour Reduction document, revealed, she acknowledged she stated Well, sit in your own[***]out loud but to herself. CNA #1 revealed in the statement, that she pushed Resident #1's arm down to place it in the opposite direction, so that she could roll her over. CNA #1 revealed she was frustrated, but did not hurt her resident. During an interview, on 03/09/2020 at 8:45 AM, the Administrator revealed when she spoke to CNA #1, she admitted that she cursed Resident #1, but did not hit her. The Administrator stated CNA #1 admitted to saying that Resident #1 could sit in her own[***]but stated she mumbled it, and did not say it directly to Resident #1. During an interview, on 03/09/2020 at 10:08 AM, CNA #2 stated she walked into Resident #1's room to see if CNA #1 needed anything. CNA #2 stated she saw Resident #1 slap CNA #1, and then CNA #1 slapped Resident #1 on her right forearm. CNA #2 revealed CNA #1 stated to Resident #1, Whatever, you can sit in your[***] I don't care, and walked out of the room to go get a nurse. During an interview, on 03/09/2020 at 11:37 AM, CNA #1 revealed on the day of the incident (03/02/2020), she was in the room changing Resident #1. CNA #1 stated she rolled Resident #1 to one side, and the Resident #1 rolled back towards her, hitting her in the eye. CNA #1 stated she took Resident #1 by the arm, and placed it on the opposite side of the bed so that she could change her. She stated that she did not hit Resident #1. CNA #1 stated CNA #2 may not have understood what was going on with Resident #1. CNA #1 confirmed she did make the statement that Resident #1 could lie in her[***] but she mumbled it to herself, as she was going out the door to get the nurse. A review of the facility's document titled, Abuse, Neglect and Exploitation of Vulnerable Person Acknowledgement, revealed CNA #1 was educated on Abuse and Neglect on 10/30/2019. During an interview, on 03/10/2020 at 9:05 AM, the Administrator stated the abuse did occur and it should have never occurred. The Administrator stated, This is never acceptable. On 03/10/2020 at 9:08 AM, during an interview with the DON, she stated verbal abuse did happen, and it never should have happened. She stated they have in-serviced on abuse and neglect. The DON stated they are looking at getting an outside counselor to come in and talk to staff about stress and burnout.

Based on review of the facility's policy, observations, and interviews, the facility failed to ensure proper cleaning of the ice machine in accordance with professional standards for service safety and prevention of infection. The deficient practice effected all of the residents on the east wing, who were served ice and water that was being dispensed from an unsanitary machine. Findings include: Review of the manufacturer's recommendations titled, Maintenance and Cleaning Instruction-GEMD270A, undated, revealed the ice machine should have maintenance completed at least two (2) times per year which included taking the ice spout off the machine, washing and sanitizing it. Continued review revealed the water system should be thoroughly cleaned during the regular maintenance by running a manufacture recommended cleaning solution through the water system. Further review of the recommendations revealed the times and the procedures for maintenance and cleaning were given as guidelines but were not to be construed as absolute or invariable. Review of the facility's policy titled, Infection Control Policy for Food Services Department, dated 06/14/18, revealed all iced used would be free from visible trash and sediment. The policy further specified the ice storage bin would be cleaned on a regular basis following the manufacturer's recommendation. Observation on the east wing, near the nurses' station, on 02/25/19 at 11:40 AM, revealed an ice and water dispenser used by the facility staff to deliver ice and water to the residents of the 100, 200, and 300 halls. Continued observation revealed a white and gray, crusty substance on and around the dispensing mechanism (where the ice and water come out of). Observation and interview, on 02/25/19 at 2:02 PM, with the facility's Registered Dietitian, confirmed there was white and gray, crusty sediment on and around the dispensing mechanism. The dietitian stated the ice machine was dirty, and the area where the water and ice were actually dispensed was gray, white, and slimy. Observation and interview, on 02/25/19 at 2:12 PM, with the facility's Maintenance Employee revealed he was responsible for cleaning the ice and water machine. Continued observation revealed the Maintenance Employee took a white wash cloth and wiped the inside of the dispensing mechanism where the ice and water come out; when he removed the wash cloth, there was a black substance on the wash cloth. The maintenance employee stated he had never cleaned that part of the machine and did not realize it was dirty. Observation and interview on 02/25/19 at 2:22 PM, with the Infection Control Nurse, revealed the nurse stated the ice machine needed to be cleaned. She stated it was important the ice/water machine was cleaned due to infection control concerns such as mold. She further stated maintenance was to schedule cleaning and maintenance of the ice machine. Interview, on 02/28/19 at 4:25 PM, with the Administrator revealed it was her expectation maintenance would have cleaned the ice machine per manufacturers recommendations. The Administrator confirmed the importance of cleaning the ice machine to reduce infection control and food borne illness concerns.

Based on observation, interview, record review and facility policy review, the facility failed to provide qualified sufficient nursing staff, a Registered Nurse (RN), or a Respiratory Therapist (RT), with appropriate competencies and skills, to provide respiratory services on a 24 hour basis for residents with a [MEDICAL CONDITION] (Trach) Tube. There were five (5) residents [MEDICAL CONDITION] from the time frame of 5/5/17 until 10/10/18, with only one (1) resident presently in the facility with a Trach, Resident #5. During the time frame of 5/5/17 until 10/10/18, the facility had 412 of 517 days on the 11:00 PM to the 7:00 AM shift and 138 of 517 days on the 3:00 PM to 11:00 PM shifts that did not have any RN/RT coverage. This currently affects one (1) of five (5) residents reviewed who [MEDICAL CONDITION]. The facility's failure to have a RT or RN on the premesis 24 hours per day to provide respiratory care and deep suctioning and other [MEDICAL CONDITION] if needed, placed Resident #5 and other residents with Trachs, in a situation that was likely to cause serious injury, harm, impairment, or death. The situation was determined to be an Immediate Jeopardy (IJ), which began on 5/5/17, when the facility failed to ensure 24 hour coverage of a RN/RT. The facility's Administrator was notified of the IJ on 10/4/18. An acceptable credible Allegation of Compliance (A[NAME]) was received on 10/11/18, in which the facility alleged all corrective actions were completed on 10/10/18, and the IJ removed on 10/11/18. The State Agency (SA) validated the A[NAME] on 10/12/18, and determined the IJ was removed on 10/11/18, prior to exit. Therefore the scope and severity for IJ at 42 CFR 483.35 (a) (1)-(2) was lowered to a D, while the facility develops and implements a plan of correction and monitors the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: Review of the facility staffing policy, entitled, Nurse Staffing Information, dated 10/4/18, revealed the facility will be staffed with Registered Nurse coverage 24 hours each day. There was no staffing policy provided prior to this date. Review of the (local state) Board of Nursing Laws and Rules Administrative Code Part 2830 Practice of Nursing Title 30: Professions and Occupations Chapter 2, Functions of the Licensed Practical Nurse (LPN), revealed: Rule 2. 1-LPN Supervision. The LPN gives nursing care which does not require the specialized skill, judgement, and knowledge required of an RN, under the direction of the RN, Advanced Practice Registered Nurse (APRN), Licensed Physician, or Licensed Dentist. Review of the State Board of Nursing (BON) web site revealed a section on frequently asked questions (FAQ's). The BON's statement regarding the LPN's scope of practice with [MEDICAL CONDITION] care revealed: It is in the scope of practice of the LPN to [MEDICAL CONDITION] and to suction secretions from [MEDICAL CONDITION], however, it is not within the scope of practice for the LPN to perform deep right main stem suctioning. If suctioning is required for the patient, a Registered Nurse (RN) must perform the procedure. Review of the facility's Facility Assessment, with a review date of 6/22/18, revealed the Policy and Procedures (P&P) for provision of care 3.5, included: Policies and Procedures are developed or revised based on changing resident population and acuity, change in service provision, change in regulatory requirements, or change in practice guidelines or standards of practice. Resources used in P&P development to ensure current standards of practice include: State law, State and Federal Regulations Requirements of Participation .State Board of Nursing policies and practices . Review of the Time clock records and staffing schedule revealed no RN coverage for a total of 412 of 517 shifts on 11:00 PM to 7:00 AM and 138 of 517 shifts from 3:00 PM to 11:00 PM shifts from 5/5/17 through 10/10/18. In an interview with the Director of Nursing (DON) on 10/10/18 at 2:30 PM, she confirmed from 5/5/17, the date of the last annual survey, the facility had 412 of 517 days on the 11:00 PM to the 7:00 AM shift and 138 of 517 days on the 3:00 PM to 11:00 PM shifts that did not have any RN/RT coverage. The DON confirmed there was no qualified staff on duty on these shifts who could have provided deep suctioning or emergency procedures of a resident with a Trach, if needed. Interview with LPN #2 on 10/12/18 at 1:05 PM, and LPN #3 on 10/12/18 at 1:12 PM, confirmed there had not always been RNs around the clock to deep suction residents with a Trach, if needed. In an interview on 10/12/18 at 1:50 PM, with, the Medical Director confirmed was involved in the Quality Assurance (QA) meeting regarding the need for 24 hour coverage of RNs and the policy changes on staffing. The Medical Director confirmed there had to be a RN on duty 24 hours per day to provide care for residents with a Trach. The facility submitted an acceptable Allegation of Compliance (AoC) on 10/11/18, for the IJ. Review of the facility's AoC revealed the facility took the following corrective actions to remove the IJ, Prior to exit: Brief summary: An IJ was called due to lack of Registered Nurse (RN) coverage 24 hours per day, seven days per week, for residents with a [MEDICAL CONDITION]; specifically for (412) of (517) of the 11:00 PM to 7:00 AM shifts, and (138) of (517) of the 3:00 PM to 11:00 PM shifts from (MONTH) 5, (YEAR), to (MONTH) 4, (YEAR). [MEDICAL CONDITION] supplies were not readily available at the bedside for emergency care for two (2) residents with a [MEDICAL CONDITION], current resident, Resident #5, nor for Resident #7. Resident #7, who had a [MEDICAL CONDITION] which had become dislodged and resulted in transfer of the resident to the emergency room (ER) for treatment. The care plan did not include having emergency equipment at bedside to provide [MEDICAL CONDITION] care per professional standards of care. [MEDICAL CONDITION] care treatment was not provided per professional standards of care nor was sterile procedure to ensure the proper technique maintained during [MEDICAL CONDITION] care for Resident #5. Facility Actions: 1. On 10/4/18 at approximately 1:45 PM, Medical Director #1 was notified by the Director of Nurses (DON) by phone of the incident of IJ. 2. On 10/4/18 at 3:00 PM, available members of the Quality Assurance (QA) Team; DON, Administrator, Infection Preventionist (IP), Staff Education Nurse, and Regulatory Compliance Coordinator (RCC), met to review findings and to discuss policy and other changes related to an insufficient number of RNs for 24-hour RN coverage for Resident #5, the only resident with a [MEDICAL CONDITION]. 3. On 10/4/18 at 3:15 PM, the DON began notifying nursing staff present in the facility at that time of the requirements to have a RN on duty 24 hours daily to provide [MEDICAL CONDITION] care services that meet professional standards of quality provided by qualified persons in accordance with the resident's plan of care. The in-services regarding required RN staffing, to be provided to all nursing staff by the DON, Assistant Director of Nurses (ADON), IP, or Staff Education Nurse, will continue until all nursing staff have received the in-service. The nurses will not be allowed to work until they have received this in-service. 4. On 10/4/18 at 3:30 PM, the DON made adjustments to the staffing schedule to ensure RN coverage at the facility 24 hours daily. 5. On 10/4/18 at 3:40 PM, the DON determined that Resident #5 was the only resident with a [MEDICAL CONDITION] residing in the facility at this time. Four (4) other residents were in the facility from (MONTH) 5, (YEAR), through (MONTH) 4, (YEAR), with [MEDICAL CONDITION]. No issues were identified related to lack of RN coverage, however it was discovered Resident #7's [MEDICAL CONDITION] came out on (MONTH) 28, (YEAR), and there were no emergency supplies at the bedside to reinsert the [MEDICAL CONDITION]. The resident was transferred to the ER in no distress. The decision was made by the physician to leave the [MEDICAL CONDITION] out. Resident #7 currently resides in the facility with no issues. 6. On 10/4/18 at 5:00 PM, Medical Director #1, Administrator, DON, IP, Staff Education Nurse, and RCC reviewed and made changes to the [MEDICAL CONDITION] Care and Suctioning policy to include guidance on scope of practice for RN's and Licensed Practical Nurses (LPN's) including the RN being the only one that can perform deep right main stem suctioning. Therefore, the RN must be available to perform this procedure. Changes were made to the Nurse Staffing Information policy to include procedures to follow to ensure RN coverage each day, utilization of the RN call pool, and notification of the Administrator-on-call if issues occur. 7. On 10/5/18 at 9:00 AM, the QA and Interdisciplinary Team (IDT): Medical Director #1, Administrator, DON, ADON, IP, Staff Education Nurse, and the RCC, met to discuss and approve the [MEDICAL CONDITION] Care and Suctioning policy changes which included scope of practice for RNs and LPNs and the Nurse Staffing Information policy and procedure changes to require 24 hour RN coverage daily. No additional changes were recommended by QA at that time. 8. On 10/5/18 at 10:00 AM, the IP initiated in-services for the nursing staff regarding the following policy and procedure changes: [MEDICAL CONDITION] Care and Suctioning which includes scope of practice for RNs and LPNs stating the RN being the only one that can perform deep right main stem suctioning. Therefore, the RN must be available to perform this procedure. Nurse Staffing Information policy and procedure changes to require 24 hour RN coverage daily. The nurses will not be allowed to work until they have received this in-service. 9. On 10/05/18 at 3:30 PM, emergency equipment to care for a [MEDICAL CONDITION] was found by the surveyor to be missing from the room of Resident #5. Emergency equipment was placed at the bedside of Resident #5 by the Staff Education Nurse at that time to include resuscitator bag, suction machine, suction catheter kit,[MEDICAL CONDITION] kit in appropriate size and a replacement kit in a smaller size, oxygen, and appropriate personal protective equipment (PPE). The presence of the emergency [MEDICAL CONDITION] care supplies at bedside of residents with a [MEDICAL CONDITION] will be checked by the RN Supervisor every shift and documented on the Medication Administration Record (MAR). . 10. On 10/5/18 at 3:40 PM, the care plan for Resident #5 was updated by Minimum Data Set (MDS)/Care Plan Nurse #1 to include keeping emergency equipment and appropriate PPE at the bedside. 11. On 10/5/18 at 4:45 PM, the Administrator consulted the Director of Respiratory Therapy at a local hospital who provided an in-service regarding proper [MEDICAL CONDITION] care procedures and a policy for review. The RCC and Medical Director #2 updated the policy for [MEDICAL CONDITION] care and suctioning to align with clinical practice guidelines and standards of practice. The policy changes include keeping emergency equipment at the bedside of residents with a [MEDICAL CONDITION] and performing [MEDICAL CONDITION] care with sterile procedures. 12. On 10/5/18 at 5:00 PM, other available members of the (QA) Team; DON, ADON, Administrator, IP, Staff Education Nurse, and RCC met to discuss the policy changes and the new process. QA had no additional policy change recommendations. 13. On 10/5/18 at 5:10 PM, the ADON initiated in-service to the LPNs and RNs regarding the following policy and procedure changes: *24 hour RN coverage *Emergency equipment at bedside to care for a [MEDICAL CONDITION] (resuscitator bag, suction machine, suction catheter kit,[MEDICAL CONDITION] kit in appropriate size and a replacement kit in a smaller size, oxygen, and appropriate PPE) *LPN and RN scope of practice related to [MEDICAL CONDITION] care *[MEDICAL CONDITION] care and suctioning procedures *The care plan policy and procedure was reviewed and no changes were made. The in-services continued until 10/10/18, when (32) of (32) LPNs and (11) of (11) RNs were in-serviced. No nurses will be allowed to work until they receive the in-service. 14. On 10/5/18 at 5:15 PM, the DON arranged [MEDICAL CONDITION] care training for all LPN's and RN's to be provided by the local hospital respiratory therapists. In-services were initiated on 10/5/18 at 5:40 PM by Respiratory Therapist #1 and continued until 10/10/18, when (32) of (32) LPNs and (11) of (11) RNs were in-serviced. The nurses will not be allowed to work until they have received the in-service. 15. On 10/8/18 at 11:00 AM, the DON reviewed the IJ event and all policy and procedure changes with Medical Director #2 who gave approval with no additional changes recommended. 16. On 10/9/18 at 3:30 PM, a QA meeting was called with the Administrator, DON, ADON, IP, RCC, Staff Education Nurse, and Medical Director #2 per phone, to discuss additional policy changes to the [MEDICAL CONDITION] Care and Suctioning policy. Additional changes include if deep right main stem suctioning is required for the patient, a registered nurse must perform this procedure. RN to perform [MEDICAL CONDITION] care and suctioning per resident plan of care. LPN may perform [MEDICAL CONDITION] care per scope of practice guidelines in an emergent situation until RN arrives to perform care. No additional changes were recommended by QA at that time. 17. On 10/9/18 at 5:00 PM, the DON notified RN #1, RN #2, and RN #3 of the new policy requiring the RN to perform [MEDICAL CONDITION] care and deep suctioning to begin immediately. 18. On 10/9/18 at 3:40 PM, MDS/Care Plan Nurse # 1 updated the care plan of Resident #5 to designate the RN to provide [MEDICAL CONDITION] care and deep suctioning. 19. On 10/10/18 at 3:00 PM, MDS/Care Plan Nurse #1, MDS/Care Plan Nurse #2, and MDS/Care Plan Nurse #3 were in-serviced on the MDS, Care Area Assessment (CAA), and Care Plan policy as well as the regulatory requirement that services provided or arranged by the facility, as outlined by the comprehensive care plan to meet professional standards of quality of care. The policy and the regulations (F658 and F659) were reviewed. 20. On 10/10/18 at 7:15 PM, the Administrator revised the facility assessment to include the provision of RN services 24 hours daily by the facility. The facility alleges that all corrective action to remove the IJ was completed on 10/10/18, and the IJ removed as of 10/11/18. The State Agency (SA) validated the facility's AoC and determined the facility took the following actions to correct the IJ, prior to exit: 1. The SA validated through interview that the Medical Director #1 was notified by the Director of Nurses (DON) by phone of the incident of IJ on 10/4/18 2. The SA validated by QA sign in sheet and interview that members of the Quality Assurance (QA) Team; DON, Administrator, Infection Preventionist (IP), Staff Education Nurse, and Regulatory Compliance Coordinator (RCC), met on 10/4/18, to review findings and to discuss policy and other changes related to an insufficient number of RNs for 24-hour RN coverage for Resident #5. The SA validated that Resident #5 is the only resident with a [MEDICAL CONDITION]. 3. The SA validated by interview and record review that on 10/4/18 at 3:15 PM, the DON began notifying nursing staff present in the facility at that time of the requirements to have a RN on duty 24 hours daily to provide [MEDICAL CONDITION] care services that meet professional standards of quality provided by qualified persons in accordance with the resident's plan of care. The in-services included the requirement of RN staffing if a Resident with a [MEDICAL CONDITION] was in the building. The SA validated that no nurses were allowed to work until they had received this in-service. 4. The SA validated by interview and staffing sheets that on 10/4/18, the DON made adjustments to the staffing schedule to ensure RN coverage at the facility 24 hours daily. 5. The SA validated by interview and record review that on 10/4/18, the DON determined that Resident #5 was the only resident with a [MEDICAL CONDITION] residing in the facility at this time. Four (4) other residents were in the facility from (MONTH) 5, (YEAR), through (MONTH) 4, (YEAR), with [MEDICAL CONDITION], with no respiratory issues noted. The SA validated through interview that Resident #7's [MEDICAL CONDITION] came out on (MONTH) 28, (YEAR), and there were no emergency supplies at the bedside to reinsert the [MEDICAL CONDITION]. The SA validated that Resident #7 currently resides in the facility without a [MEDICAL CONDITION], with no issues. 6. The SA validated by record review, policy review, and interviews that on 10/4/18 Medical Director #1, Administrator, DON, IP, Staff Education Nurse, and RCC reviewed and made changes to the [MEDICAL CONDITION] Care and Suctioning policy to include guidance on scope of practice for RN's and Licensed Practical Nurses (LPN's) including the RN being the only one that can perform deep right main stem suctioning. Therefore, the RN must be available to perform this procedure. Changes were made to the Nurse Staffing Information policy to include procedures to follow to ensure RN coverage each day, utilization of the RN call pool, and notification of the Administrator-on-call if issues occur. 7. The SA validated by interview, sign in sheets, and record review that on 10/5/18, the QA and Interdisciplinary Team (IDT): Medical Director #1, Administrator, DON, ADON, IP, Staff Education Nurse, and the RCC, met to discuss and approve the [MEDICAL CONDITION] Care and Suctioning policy changes which included scope of practice for RNs and LPNs and the Nurse Staffing Information policy and procedure changes to require 24 hour RN coverage daily. No additional changes were recommended by QA at that time. 8. The SA validated by sign in sheets, record review and interviews on 10/5/18, the IP initiated in-services for the nursing staff regarding the following policy and procedure changes: *[MEDICAL CONDITION] Care and Suctioning which includes scope of practice for RNs and LPNs stating the RN being the only one that can perform deep right main stem suctioning. Therefore, the RN must be available to perform this procedure. *Nurse Staffing Information policy and procedure changes to require 24 hour RN coverage daily. The SA validated that no nurses were allowed to work until they have received this in-service. 9. The SA validated by observation, interviews and record reviews that on 10/05/18, emergency equipment to care for a [MEDICAL CONDITION] was missing from the room of Resident #5. The SA validated that emergency equipment was placed at the bedside of Resident #5 by the Staff Education Nurse at that time to include resuscitator bag, suction machine, suction catheter kit,[MEDICAL CONDITION] kit in appropriate size and a replacement kit in a smaller size, oxygen, and appropriate personal protective equipment (PPE). The SA validated by interview and record review, that the presence of the emergency [MEDICAL CONDITION] care supplies at bedside of residents with a [MEDICAL CONDITION] is checked by the RN Supervisor every shift, and documented on the MAR. 10. The SA validated by record review and interview that on 10/5/18, the care plan for Resident #5 was updated by Minimum Data Set (MDS)/Care Plan Nurse #1 to include keeping emergency equipment and appropriate PPE at the bedside. 11. The SA validated by interviews, policy reviews, and record review that on 10/5/18, the Director of Respiratory Therapy at a local hospital provided an in-service regarding proper [MEDICAL CONDITION] care procedures and a policy for review. The RCC and Medical Director #2 updated the policy for [MEDICAL CONDITION] care and suctioning to align with clinical practice guidelines and standards of practice. The policy changes include keeping emergency equipment at the bedside of residents with a [MEDICAL CONDITION] and performing [MEDICAL CONDITION] care with sterile procedures. 12. The SA validated by record review and sign in sheets that on 10/5/18, members of the (QA) Team; DON, ADON, Administrator, IP, Staff Education Nurse, and RCC met to discuss the policy changes and the new process. QA had no additional policy change recommendations. 13. The SA validated by interviews, sign in sheets, and record review that on 10/5/18 the ADON initiated in-service to the LPNs and RNs regarding the following policy and procedure changes: *24 hour RN coverage *Emergency equipment at bedside to care for a [MEDICAL CONDITION] (resuscitator bag, suction machine, suction catheter kit,[MEDICAL CONDITION] kit in appropriate size and a replacement kit in a smaller size, oxygen, and appropriate PPE) *LPN and RN scope of practice related to [MEDICAL CONDITION] care *[MEDICAL CONDITION] care and suctioning procedures *The care plan policy and procedure was reviewed and no changes were made. The SA validated through sign in sheets, staffing schedule, and interviews, that the in-services continued until 10/10/18, when (32) of (32) LPNs and (11) of (11) RNs were in-serviced. No nurses were allowed to work until they receive the in-service. 14. The SA validated by interviews and record reviews that on 10/5/18 the DON arranged [MEDICAL CONDITION] care training for all LPN's and RN's to be provided by the local hospital respiratory therapists. In-services were initiated on 10/5/18 at 5:40 PM by Respiratory Therapist #1 and continued until 10/10/18, when (32) of (32) LPNs and (11) of (11) RNs were in-serviced. The nurses were not allowed to work until they have received the in-service. 15. The SA validated by interview that on 10/8/18, the DON reviewed the IJ event and all policy and procedure changes with Medical Director #2 who gave approval with no additional changes recommended. 16. The SA validated by interview, sign in sheet, policy review, and record review, that on 10/9/18, a QA meeting was called with the Administrator, DON, ADON, IP, RCC, Staff Education Nurse, and Medical Director #2 per phone, to discuss additional policy changes to the [MEDICAL CONDITION] Care and Suctioning policy. Additional changes include if deep right main stem suctioning is required for the patient, a registered nurse must perform this procedure. RN to perform [MEDICAL CONDITION] care and suctioning per resident plan of care. LPN may perform [MEDICAL CONDITION] care per scope of practice guidelines in an emergent situation until RN arrives to perform care. No additional changes were recommended by QA at that time. 17. The SA validated by interviews and record review that on 10/9/18 the DON notified RN #1, RN #2, and RN #3 of the new policy requiring the RN to perform [MEDICAL CONDITION] care and deep suctioning to begin immediately. 18. The SA validated by record review and interview that on 10/9/18, MDS/Care Plan Nurse # 1 updated the care plan of Resident #5 to designate the RN to provide [MEDICAL CONDITION] care and deep suctioning. 19. The SA validated by interviews, sign in sheets, and record review on 10/10/18, MDS/Care Plan Nurse #1, MDS/Care Plan Nurse #2, and MDS/Care Plan Nurse #3 were in-serviced on the MDS, Care Area Assessment (CAA), and Care Plan policy as well as the regulatory requirement that services provided or arranged by the facility, as outlined by the comprehensive care plan to meet professional standards of quality of care. The policy and the regulations (F658 and F659) were reviewed. 20. The SA validated by record review and interview that on 10/10/18, the Administrator revised the facility assessment to include the provision of RN services 24 hours daily by the facility. The SA validated that all corrective action to remove the IJ was completed on 10/10/18, and the IJ removed as of 10/11/18.

Based on observation, interview, record review, Board of Nursing documentation review, Nurse Practice Act review, and facility policy review, the facility failed to provide 24 hour coverage by a Registered Nurse (RN) and/or Respiratory Therapist (RT) for emergency respiratory care and services and/or deep suctioning of residents with a [MEDICAL CONDITION] (Trach). Review of staffing from 5/5/17, until 10/4/18, revealed the facility had 412 of 517 days on the 11:00 PM to the 7:00 AM shift, and 138 of 517 days on the 3:00 PM to 11:00 PM shifts, that did not have any RN/RT coverage. There were five (5) residents with Trachs during this time period. The facility failed to provide [MEDICAL CONDITION], per professional standards to help prevent infection for one (1) of two (2)[MEDICAL CONDITION] observations, Resident #5; and failed to have [MEDICAL CONDITION] equipment at the bedside for Resident #5 and Resident #7; for two (2) of five (5) residents reviewed [MEDICAL CONDITION]. The facility's failure to provide RN/RT to provide respiratory care and possible deep suctioning and other [MEDICAL CONDITION] around the clock, for residents with [MEDICAL CONDITION]; failure to provide [MEDICAL CONDITION] Care by professional standards of care; and failure to have [MEDICAL CONDITION] at the bedside for Residents with a Trach, placed Resident #5, and other residents with a Trach, in a situation that was likely to cause serious injury, harm, impairment and death. The situation was determined to be an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC), which began on 5/5/17, when the facility failed to have 24 hour RN/RT coverage for residents with a [MEDICAL CONDITION] (Trach), failed to [MEDICAL CONDITION] by professional standards of care, and failed to have [MEDICAL CONDITION] at the bedside. The facility's Administrator was notified of the IJ and SQC on 10/4/18. An acceptable credible Allegation of Compliance (A[NAME]) was received on 10/11/18, in which the facility alleged all corrective actions were completed on 10/10/18, and the IJ was removed on 10/11/18. The SA validated the A[NAME] on 10/12/18, and determined the IJ to be removed on 10/11/18, prior to exit. Therefore, the scope and severity for the IJ at 42 CFR 483.25 (i) (F695) was lowered to a D, while the facility develops and implements a plan of correction and monitors the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: Review of the facility policy, entitled, [MEDICAL CONDITION] Care and Suctioning, dated 3/19/17, noted routine care of an [MEDICAL CONDITION] not considered a sterile procedure. This policy noted to clean with a dampened wash cloth with mild soap and water after applying clean gloves. This policy did not designate who provided deep suctioning. Review of Medical-Dictionary.thefreedictionary.com/[MEDICAL CONDITION] website, [MEDICAL CONDITION] is usually a sterile technique and [MEDICAL CONDITION] is kept at the bedside at all times, including a [MEDICATION NAME], obturator, and [MEDICAL CONDITION] of at least the same size. Review of the State Board of Nursing Laws and Rules Administrative Code Part 2830 Practice of Nursing Title 30: Professions and Occupations Chapter 2, Functions of the Licensed Practical Nurse (LPN), revealed: Rule 2. 1-LPN Supervision. The LPN gives nursing care which does not require the specialized skill, under the direction of the RN, Advanced Practice Registered Nurse (APRN), Licensed Physician, or Licensed Dentist. Review of the State Board of Nursing (BON) web site revealed a section on frequently asked questions (FAQ's). The BON's statement regarding the LPN's scope of practice with [MEDICAL CONDITION] care, revealed: It is in the scope of practice of the LPN to [MEDICAL CONDITION] and to suction secretions from [MEDICAL CONDITION]. However, it is not within the scope of practice for the LPN to perform deep right main stem suctioning. If deep suctioning is required for the patient, a Registered Nurse (RN) must perform the procedure. Review of staffing schedules and the clock sheets from 5/5/17 to 10/11/18, revealed 412 of 517 days on the 11:00 PM to the 7:00 AM shift and 138 of 517 days on the 3:00 PM to 11:00 PM shifts did not have any RN/RT coverage. During an interview with the Director of Nursing (DON) on 10/10/18 at 2:30 PM, she stated from 5/5/17, the date of the last annual survey, the facility had 412 of 517 days on the 11:00 PM to the 7:00 AM shift, and 138 of 517 days on the 3:00 PM to 11:00 PM shifts, that did not have any RN/RT coverage. She confirmed there were four (4) other residents during that time frame who had a Trach, and only one (1) current resident, Resident #5, with a Trach. She confirmed there would be no one qualified to perform deep suctioning, during an emergency situation, of a resident with a Trach, if a RN was not present on the premesis. The DON revealed the Facility Assessment listed eight (8) hours for RN coverage and did not list having an RN for 24 hour coverage. The DON confirmed there was no one in the facility to perform deep suctioning except when an RN was on duty. Resident #5 Review of physician orders, dated 12/05/16, revealed Resident #5 had a [MEDICAL CONDITION], #6 Shiley XLT, in place due to [MEDICAL CONDITION]/Recurrent Pneumonitis. Review of the medical record revealed no documented concerns [MEDICAL CONDITION], only replacement of [MEDICAL CONDITION] the physician approximately every three (3) months, as ordered. In an observation on 10/5/18 at 2:46 PM, Resident #5 was in bed with the head of the bed elevated with [MEDICAL CONDITION] in place with oxygen (O2) at five (5) liters per minute. There was a Yaunker suction catheter for oral suctioning at the bedside. A suction machine, an obturator, and one (1)[MEDICAL CONDITION] cleaning set was in the room with the resident. There were no replacement Trachs, Ambu bag, sterile suction catheters, or any other emergency equipment at the bedside. On 10/5/18 at 3:05 PM, the RN Charge Nurse was present in Resident #5's room and confirmed there was no replacement Trach, no suction catheters, and no Ambu bag at the bedside for emergency replacement or deep suctioning, if needed. On 10/10/18 at 2:30 PM, the DON confirmed there was no emergency equipment at the bedside for Resident #5 on 10/15/18, except an obturator and a Yaunker suction catheter, for suctioning the mouth. In an observation [MEDICAL CONDITION] on 10/9/18 at 3:12 PM, by LPN #1, she used the wire brush in the [MEDICAL CONDITION] Kit to scrub back and forth several times around the outer portion of [MEDICAL CONDITION] dipped into the sterile Normal Saline (NS) several times causing the NS to become contaminated. LPN #1 then used the cotton tipped applicator, moistened with the contaminated NS, to clean between the openings of [MEDICAL CONDITION] holds [MEDICAL CONDITION]. LPN #1 then used the drain sponge to place underneath each side of [MEDICAL CONDITION] scrubbed up and down. In an interview with LPN #1, on 10/9/18 at 4:05 PM, she stated, Anything to do with airway, you have to be sterile. She confirmed the procedure she performed [MEDICAL CONDITION] with Resident #5 was not sterile. When asked, [MEDICAL CONDITION] is not done correctly, would you be following the Resident's plan of care? LPN #1 responded, I guess not. Interview with the DON on 10/9/18 at 1:20 PM revealed the policy [MEDICAL CONDITION] had been to use clean technique for the past [AGE] years. The DON confirmed they would begin using sterile technique per standard of care. Interview with LPN #2 on 10/12/18 at 1:05 PM, revealed they had been doing clean technique in the past [MEDICAL CONDITION] and not sterile technique, but she knew the policy/procedure was for sterile technique. She confirmed the [MEDICAL CONDITION] procedure had been changed to sterile technique, and the orders and care plans were being changed to reflect the same. In an interview on 10/10/18 at 12:25 PM, RN #1 stated if sterile technique is not being done [MEDICAL CONDITION], it could result in an infection. Interview with the Regional RT, (Consultant [MEDICAL CONDITION]), on 10/5/18 at 4:00 PM, revealed sterile technique was taught during in-services [MEDICAL CONDITION]. The Regional RT stated, We do teach sterile technique, sterile gloves are in their kits. Resident #7 Record review revealed Resident #7 was admitted [DATE], with an order for [REDACTED]. In an interview on 10/10/18 at 11:20 AM, Resident #7 stated she coughed [MEDICAL CONDITION] over one (1) year ago. Resident #7 stated no one at the facility or the nearest local hospital attempted to reinsert [MEDICAL CONDITION] was transported to a larger hospital that was an additional 32 miles away. Resident #7 stated she was told at this hospital that she would require surgery to replace [MEDICAL CONDITION] leave it out because it had already closed up. Resident #7 stated she has done OK without it and is now healed. In an interview on 10/10/18 at 12:25 PM, RN #1 stated she was on duty when Resident #7'[MEDICAL CONDITION] out and she attempted to reinsert [MEDICAL CONDITION] success. RN #1 confirmed there were no emergency equipment at the bedside when the extubation occurred, except an obturator, and she had to go to the supply room to get a [MEDICAL CONDITION] was still unsuccessful with insertion. A review of the Nurses Notes on 11/28/17 at 2:30 PM, revealed RN #1 documented,[MEDICAL CONDITION] cause unknown stoma noted with hypergranular tissue and closure unable to reinsert MD request for her to be sent to ER at (local hospital) for reinsertion. A review of the Nurses Notes on 11/28/17 at 2:11 PM, revealed, RN #1 documented, 1:30 PM CNA (Certified Nursing Assistant) [MEDICAL CONDITION] LPN (Licensed Practical Nurse) [MEDICAL CONDITION] of stoma, she attempted to reinsert but unable to due to growth of hypergranular tissue and narrowing/closure of stoma. Placed patient at 90 degree angle,[MEDICAL CONDITION] reattached and RN attempted to reinsert, unable to insert. There was no documentation of Resident #7's respiratory status other than the oxygen saturation was at 98 percent. Review of the hospital emergency room (ER) record revealed Resident #7 presented to theER on [DATE] at 3:30 PM, with an extubated Trach. The resident denied any trouble breathing and [MEDICAL CONDITION] not re-inserted. In an interview on 10/12/18 at 1:50 PM, the Medical Director confirmed he was involved in the Quality Assurance (QA) meeting regarding using sterile technique [MEDICAL CONDITION] and having [MEDICAL CONDITION] at the bedside. The Medical Director confirmed policy and procedure changes for residents with [MEDICAL CONDITION] included RN coverage,[MEDICAL CONDITION] at the bedside, and using sterile technique [MEDICAL CONDITION]. The facility submitted an acceptable Allegation of Compliance (AoC) on 10/11/18, for the IJ. Review of the facility's AoC revealed the facility took the following corrective actions to remove the IJ, Prior to exit: Brief summary: An IJ was called due to lack of Registered Nurse (RN) coverage 24 hours per day, seven days per week, for residents with a [MEDICAL CONDITION]; specifically for (412) of (517) of the 11:00 PM to 7:00 AM shifts, and (138) of (517) of the 3:00 PM to 11:00 PM shifts from (MONTH) 5, (YEAR), to (MONTH) 4, (YEAR). [MEDICAL CONDITION] supplies were not readily available at the bedside for emergency care for two (2) residents with a [MEDICAL CONDITION], current resident, Resident #5, nor for Resident #7. Resident #7, who had a [MEDICAL CONDITION] which had become dislodged and resulted in transfer of the resident to the emergency room (ER) for treatment. The care plan did not include having emergency equipment at bedside to provide [MEDICAL CONDITION] care per professional standards of care. [MEDICAL CONDITION] care treatment was not provided per professional standards of care nor was sterile procedure to ensure the proper technique maintained during [MEDICAL CONDITION] care for Resident #5. Facility Actions: 1. On 10/4/18 at approximately 1:45 PM, Medical Director #1 was notified by the Director of Nurses (DON) by phone of the incident of IJ. 2. On 10/4/18 at 3:00 PM, available members of the Quality Assurance (QA) Team; DON, Administrator, Infection Preventionist (IP), Staff Education Nurse, and Regulatory Compliance Coordinator (RCC), met to review findings and to discuss policy and other changes related to an insufficient number of RNs for 24-hour RN coverage for Resident #5, the only resident with a [MEDICAL CONDITION]. 3. On 10/4/18 at 3:15 PM, the DON began notifying nursing staff present in the facility at that time of the requirements to have a RN on duty 24 hours daily to provide [MEDICAL CONDITION] care services that meet professional standards of quality provided by qualified persons in accordance with the resident's plan of care. The in-services regarding required RN staffing, to be provided to all nursing staff by the DON, Assistant Director of Nurses (ADON), IP, or Staff Education Nurse, will continue until all nursing staff have received the in-service. The nurses will not be allowed to work until they have received this in-service. 4. On 10/4/18 at 3:30 PM, the DON made adjustments to the staffing schedule to ensure RN coverage at the facility 24 hours daily. 5. On 10/4/18 at 3:40 PM, the DON determined that Resident #5 was the only resident with a [MEDICAL CONDITION] residing in the facility at this time. Four (4) other residents were in the facility from (MONTH) 5, (YEAR), through (MONTH) 4, (YEAR), with [MEDICAL CONDITION]. No issues were identified related to lack of RN coverage, however it was discovered Resident #7's [MEDICAL CONDITION] came out on (MONTH) 28, (YEAR), and there were no emergency supplies at the bedside to reinsert the [MEDICAL CONDITION]. The resident was transferred to the ER in no distress. The decision was made by the physician to leave the [MEDICAL CONDITION] out. Resident #7 currently resides in the facility with no issues. 6. On 10/4/18 at 5:00 PM, Medical Director #1, Administrator, DON, IP, Staff Education Nurse, and RCC reviewed and made changes to the [MEDICAL CONDITION] Care and Suctioning policy to include guidance on scope of practice for RN's and Licensed Practical Nurses (LPN's) including the RN being the only one that can perform deep right main stem suctioning. Therefore, the RN must be available to perform this procedure. Changes were made to the Nurse Staffing Information policy to include procedures to follow to ensure RN coverage each day, utilization of the RN call pool, and notification of the Administrator-on-call if issues occur. 7. On 10/5/18 at 9:00 AM, the QA and Interdisciplinary Team (IDT): Medical Director #1, Administrator, DON, ADON, IP, Staff Education Nurse, and the RCC, met to discuss and approve the [MEDICAL CONDITION] Care and Suctioning policy changes which included scope of practice for RNs and LPNs and the Nurse Staffing Information policy and procedure changes to require 24 hour RN coverage daily. No additional changes were recommended by QA at that time. 8. On 10/5/18 at 10:00 AM, the IP initiated in-services for the nursing staff regarding the following policy and procedure changes: [MEDICAL CONDITION] Care and Suctioning which includes scope of practice for RNs and LPNs stating the RN being the only one that can perform deep right main stem suctioning. Therefore, the RN must be available to perform this procedure. Nurse Staffing Information policy and procedure changes to require 24 hour RN coverage daily. The nurses will not be allowed to work until they have received this in-service. 9. On 10/05/18 at 3:30 PM, emergency equipment to care for a [MEDICAL CONDITION] was found by the surveyor to be missing from the room of Resident #5. Emergency equipment was placed at the bedside of Resident #5 by the Staff Education Nurse at that time to include resuscitator bag, suction machine, suction catheter kit,[MEDICAL CONDITION] kit in appropriate size and a replacement kit in a smaller size, oxygen, and appropriate personal protective equipment (PPE). The presence of the emergency [MEDICAL CONDITION] care supplies at bedside of residents with a [MEDICAL CONDITION] will be checked by the RN Supervisor every shift and documented on the Medication Administration Record (MAR). . 10. On 10/5/18 at 3:40 PM, the care plan for Resident #5 was updated by Minimum Data Set (MDS)/Care Plan Nurse #1 to include keeping emergency equipment and appropriate PPE at the bedside. 11. On 10/5/18 at 4:45 PM, the Administrator consulted the Director of Respiratory Therapy at a local hospital who provided an in-service regarding proper [MEDICAL CONDITION] care procedures and a policy for review. The RCC and Medical Director #2 updated the policy for [MEDICAL CONDITION] care and suctioning to align with clinical practice guidelines and standards of practice. The policy changes include keeping emergency equipment at the bedside of residents with a [MEDICAL CONDITION] and performing [MEDICAL CONDITION] care with sterile procedures. 12. On 10/5/18 at 5:00 PM, other available members of the (QA) Team; DON, ADON, Administrator, IP, Staff Education Nurse, and RCC met to discuss the policy changes and the new process. QA had no additional policy change recommendations. 13. On 10/5/18 at 5:10 PM, the ADON initiated in-service to the LPNs and RNs regarding the following policy and procedure changes: *24 hour RN coverage *Emergency equipment at bedside to care for a [MEDICAL CONDITION] (resuscitator bag, suction machine, suction catheter kit,[MEDICAL CONDITION] kit in appropriate size and a replacement kit in a smaller size, oxygen, and appropriate PPE) *LPN and RN scope of practice related to [MEDICAL CONDITION] care *[MEDICAL CONDITION] care and suctioning procedures *The care plan policy and procedure was reviewed and no changes were made. The in-services continued until 10/10/18, when (32) of (32) LPNs and (11) of (11) RNs were in-serviced. No nurses will be allowed to work until they receive the in-service. 14. On 10/5/18 at 5:15 PM, the DON arranged [MEDICAL CONDITION] care training for all LPN's and RN's to be provided by the local hospital respiratory therapists. In-services were initiated on 10/5/18 at 5:40 PM by Respiratory Therapist #1 and continued until 10/10/18, when (32) of (32) LPNs and (11) of (11) RNs were in-serviced. The nurses will not be allowed to work until they have received the in-service. 15. On 10/8/18 at 11:00 AM, the DON reviewed the IJ event and all policy and procedure changes with Medical Director #2 who gave approval with no additional changes recommended. 16. On 10/9/18 at 3:30 PM, a QA meeting was called with the Administrator, DON, ADON, IP, RCC, Staff Education Nurse, and Medical Director #2 per phone, to discuss additional policy changes to the [MEDICAL CONDITION] Care and Suctioning policy. Additional changes include if deep right main stem suctioning is required for the patient, a registered nurse must perform this procedure. RN to perform [MEDICAL CONDITION] care and suctioning per resident plan of care. LPN may perform [MEDICAL CONDITION] care per scope of practice guidelines in an emergent situation until RN arrives to perform care. No additional changes were recommended by QA at that time. 17. On 10/9/18 at 5:00 PM, the DON notified RN #1, RN #2, and RN #3 of the new policy requiring the RN to perform [MEDICAL CONDITION] care and deep suctioning to begin immediately. 18. On 10/9/18 at 3:40 PM, MDS/Care Plan Nurse # 1 updated the care plan of Resident #5 to designate the RN to provide [MEDICAL CONDITION] care and deep suctioning. 19. On 10/10/18 at 3:00 PM, MDS/Care Plan Nurse #1, MDS/Care Plan Nurse #2, and MDS/Care Plan Nurse #3 were in-serviced on the MDS, Care Area Assessment (CAA), and Care Plan policy as well as the regulatory requirement that services provided or arranged by the facility, as outlined by the comprehensive care plan to meet professional standards of quality of care. The policy and the regulations (F658 and F659) were reviewed. 20. On 10/10/18 at 7:15 PM, the Administrator revised the facility assessment to include the provision of RN services 24 hours daily by the facility. The facility alleges that all corrective action to remove the IJ was completed on 10/10/18, and the IJ removed as of 10/11/18. The State Agency (SA) validated the facility's AoC and determined the facility took the following actions to correct the IJ, prior to exit: 1. The SA validated through interview that the Medical Director #1 was notified by the Director of Nurses (DON) by phone of the incident of IJ on 10/4/18 2. The SA validated by QA sign in sheet and interview that members of the Quality Assurance (QA) Team; DON, Administrator, Infection Preventionist (IP), Staff Education Nurse, and Regulatory Compliance Coordinator (RCC), met on 10/4/18, to review findings and to discuss policy and other changes related to an insufficient number of RNs for 24-hour RN coverage for Resident #5. The SA validated that Resident #5 is the only resident with a [MEDICAL CONDITION]. 3. The SA validated by interview and record review that on 10/4/18 at 3:15 PM, the DON began notifying nursing staff present in the facility at that time of the requirements to have a RN on duty 24 hours daily to provide [MEDICAL CONDITION] care services that meet professional standards of quality provided by qualified persons in accordance with the resident's plan of care. The in-services included the requirement of RN staffing if a Resident with a [MEDICAL CONDITION] was in the building. The SA validated that no nurses were allowed to work until they had received this in-service. 4. The SA validated by interview and staffing sheets that on 10/4/18, the DON made adjustments to the staffing schedule to ensure RN coverage at the facility 24 hours daily. 5. The SA validated by interview and record review that on 10/4/18, the DON determined that Resident #5 was the only resident with a [MEDICAL CONDITION] residing in the facility at this time. Four (4) other residents were in the facility from (MONTH) 5, (YEAR), through (MONTH) 4, (YEAR), with [MEDICAL CONDITION], with no respiratory issues noted. The SA validated through interview that Resident #7's [MEDICAL CONDITION] came out on (MONTH) 28, (YEAR), and there were no emergency supplies at the bedside to reinsert the [MEDICAL CONDITION]. The SA validated that Resident #7 currently resides in the facility without a [MEDICAL CONDITION], with no issues. 6. The SA validated by record review, policy review, and interviews that on 10/4/18 Medical Director #1, Administrator, DON, IP, Staff Education Nurse, and RCC reviewed and made changes to the [MEDICAL CONDITION] Care and Suctioning policy to include guidance on scope of practice for RN's and Licensed Practical Nurses (LPN's) including the RN being the only one that can perform deep right main stem suctioning. Therefore, the RN must be available to perform this procedure. Changes were made to the Nurse Staffing Information policy to include procedures to follow to ensure RN coverage each day, utilization of the RN call pool, and notification of the Administrator-on-call if issues occur. 7. The SA validated by interview, sign in sheets, and record review that on 10/5/18, the QA and Interdisciplinary Team (IDT): Medical Director #1, Administrator, DON, ADON, IP, Staff Education Nurse, and the RCC, met to discuss and approve the [MEDICAL CONDITION] Care and Suctioning policy changes which included scope of practice for RNs and LPNs and the Nurse Staffing Information policy and procedure changes to require 24 hour RN coverage daily. No additional changes were recommended by QA at that time. 8. The SA validated by sign in sheets, record review and interviews on 10/5/18, the IP initiated in-services for the nursing staff regarding the following policy and procedure changes: *[MEDICAL CONDITION] Care and Suctioning which includes scope of practice for RNs and LPNs stating the RN being the only one that can perform deep right main stem suctioning. Therefore, the RN must be available to perform this procedure. *Nurse Staffing Information policy and procedure changes to require 24 hour RN coverage daily. The SA validated that no nurses were allowed to work until they have received this in-service. 9. The SA validated by observation, interviews and record reviews that on 10/05/18, emergency equipment to care for a [MEDICAL CONDITION] was missing from the room of Resident #5. The SA validated that emergency equipment was placed at the bedside of Resident #5 by the Staff Education Nurse at that time to include resuscitator bag, suction machine, suction catheter kit,[MEDICAL CONDITION] kit in appropriate size and a replacement kit in a smaller size, oxygen, and appropriate personal protective equipment (PPE). The SA validated by interview and record review, that the presence of the emergency [MEDICAL CONDITION] care supplies at bedside of residents with a [MEDICAL CONDITION] is checked by the RN Supervisor every shift, and documented on the MAR. 10. The SA validated by record review and interview that on 10/5/18, the care plan for Resident #5 was updated by Minimum Data Set (MDS)/Care Plan Nurse #1 to include keeping emergency equipment and appropriate PPE at the bedside. 11. The SA validated by interviews, policy reviews, and record review that on 10/5/18, the Director of Respiratory Therapy at a local hospital provided an in-service regarding proper [MEDICAL CONDITION] care procedures and a policy for review. The RCC and Medical Director #2 updated the policy for [MEDICAL CONDITION] care and suctioning to align with clinical practice guidelines and standards of practice. The policy changes include keeping emergency equipment at the bedside of residents with a [MEDICAL CONDITION] and performing [MEDICAL CONDITION] care with sterile procedures. 12. The SA validated by record review and sign in sheets that on 10/5/18, members of the (QA) Team; DON, ADON, Administrator, IP, Staff Education Nurse, and RCC met to discuss the policy changes and the new process. QA had no additional policy change recommendations. 13. The SA validated by interviews, sign in sheets, and record review that on 10/5/18 the ADON initiated in-service to the LPNs and RNs regarding the following policy and procedure changes: *24 hour RN coverage *Emergency equipment at bedside to care for a [MEDICAL CONDITION] (resuscitator bag, suction machine, suction catheter kit,[MEDICAL CONDITION] kit in appropriate size and a replacement kit in a smaller size, oxygen, and appropriate PPE) *LPN and RN scope of practice related to [MEDICAL CONDITION] care *[MEDICAL CONDITION] care and suctioning procedures *The care plan policy and procedure was reviewed and no changes were made. The SA validated through sign in sheets, staffing schedule, and interviews, that the in-services continued until 10/10/18, when (32) of (32) LPNs and (11) of (11) RNs were in-serviced. No nurses were allowed to work until they receive the in-service. 14. The SA validated by interviews and record reviews that on 10/5/18 the DON arranged [MEDICAL CONDITION] care training for all LPN's and RN's to be provided by the local hospital respiratory therapists. In-services were initiated on 10/5/18 at 5:40 PM by Respiratory Therapist #1 and continued until 10/10/18, when (32) of (32) LPNs and (11) of (11) RNs were in-serviced. The nurses were not allowed to work until they have received the in-service. 15. The SA validated by interview that on 10/8/18, the DON reviewed the IJ event and all policy and procedure changes with Medical Director #2 who gave approval with no additional changes recommended. 16. The SA validated by interview, sign in sheet, policy review, and record review, that on 10/9/18, a QA meeting was called with the Administrator, DON, ADON, IP, RCC, Staff Education Nurse, and Medical Director #2 per phone, to discuss additional policy changes to the [MEDICAL CONDITION] Care and Suctioning policy. Additional changes include if deep right main stem suctioning is required for the patient, a registered nurse must perform this procedure. RN to perform [MEDICAL CONDITION] care and suctioning per resident plan of care. LPN may perform [MEDICAL CONDITION] care per scope of practice guidelines in an emergent situation until RN arrives to perform care. No additional changes were recommended by QA at that time. 17. The SA validated by interviews and record review that on 10/9/18 the DON notified RN #1, RN #2, and RN #3 of the new policy requiring the RN to perform [MEDICAL CONDITION] care and deep suctioning to begin immediately. 18. The SA validated by record review and interview that on 10/9/18, MDS/Care Plan Nurse # 1 updated the care plan of Resident #5 to designate the RN to provide [MEDICAL CONDITION] care and deep suctioning. 19. The SA validated by interviews, sign in sheets, and record review on 10/10/18, MDS/Care Plan Nurse #1, MDS/Care Plan Nurse #2, and MDS/Care Plan Nurse #3 were in-serviced on the MDS, Care Area Assessment (CAA), and Care Plan policy as well as the regulatory requirement that services provided or arranged by the facility, as outlined by the comprehensive care plan to meet professional standards of quality of care. The policy and the regulations (F658 and F659) were reviewed. 20. The SA validated by record review and interview that on 10/10/18, the Administrator revised the facility assessment to include the provision of RN services 24 hours daily by the facility. The SA validated that all corrective action to remove the IJ was completed on 10/10/18, and the IJ removed as of 10/11/18.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure qualified staff were available and designated, on the care plan, that were knowledgeable and/or competent in how to care for a resident with a [MEDICAL CONDITION] (Trach), to provide deep suctioning and/or other emergency procedures. Resident #5 and Resident #7's comprehensive care plan [MEDICAL CONDITION] failed to identify which licensed professional would perform each task [MEDICAL CONDITION]. This affected two (2) of five (5) sampled residents, the current Resident with a Trach, Resident #5, and Resident #7, who had a [MEDICAL CONDITION] three (3) other residents who resided in the facility during the time frame from 5/5/17 to 10/10/18. The facility failed to have RN coverage available, and designated on the plan of care for [MEDICAL CONDITION], for 412 of 517 days on the 11:00 PM to the 7:00 AM shift and 138 of 517 days on the 3:00 PM to 11:00 PM shifts from 5/5/17 until 10/10/18. This currently affects one (1) of five (5) residents reviewed for Trachs. The failure to have a qualified personnel designated on the care plan, and available for deep suctioning and other respiratory services for residents with a Trach, placed Resident #5, and other residents admitted to the facility with a Trach, at risk for serious injury, harm, impairment or death. The situation was determined to be an Immediate Jeopardy (IJ), which began on 5/5/17, when the facility failed to ensure residents with [MEDICAL CONDITION] care planned for the appropriate discipline, and qualified staff, available 24 hours per day, to perform all aspects [MEDICAL CONDITION], including deep suctioning and emergency care if needed. The State Agency (SA) notified the Administrator on 10/4/18, of the IJ. An acceptable Allegation of Compliance (A[NAME]) was received on 10/11/18, in which the facility alleged all corrective actions were completed on 10/10/18, and the IJ was removed on 10/11/18. The SA validated the AoC on 10/12/18, and determined the IJ to be removed on 10/11/18, prior to exit. Therefore the scope and severity for the IJ at 42 CFR(s) 483.21 (b) (3) (ii) Comprehensive Care Plan services provided by qualified persons, was lowered to a D, while the facility develops and implements a plan of correction and monitors the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: Review of the facility policy, entitled, MDS (Minimum Data Set), CAA (Care Area Assessments), and Care Plan Documentation, dated 1/10/18, documented the services provided or arranged by the facility, as outlined by the comprehensive care plan, will be provided by qualified persons in accordance with each resident's written plan of care. Review of the staffing schedules and time sheets, and interview with the Director of Nursing (DON) on 10/10/18 at 2:30 PM, confirmed from 5/5/17 until 10/10/18, the facility had 412 of 517 days on the 11:00 PM to the 7:00 AM shift and 138 of 517 days on the 3:00 PM to 11:00 PM shifts that did not have any RN/RT coverage. The DON stated there was no qualified staff on duty on these shifts who could have provided deep suctioning of a resident with [MEDICAL CONDITION] needed. The DON stated a resident care plan cannot be followed if there is not a Registered Nurse (RN) available to deep suction as needed. Resident #5 The facility admitted Resident #5 on 6/30/11, with the [DIAGNOSES REDACTED]. Review of Resident #5's MDS, with the Assessment Reference Date (ARD) of 9/18/18, revealed the Brief Interview for Mental Status (BIMS) score was not completed. Review of Resident #5's Plan of Care, updated 9/18/18, revealed Resident #5 had a problem of impaired gas exchange related to [MEDICAL CONDITION] chronic copious secretions with a goal to keep the airway clean and open. The Care Plan (CP) listed approaches to suction [MEDICAL CONDITION] needed, and to clean the outer cannula with a dampened cloth, clean the neck plate/skin with mild soap and water, remove any crust by loosening with Peroxide (dilute equal parts of Peroxide with Normal Saline) and to clean the inner cannula with Peroxide solution, reinsert, change collar/mask every shift and as needed (PRN). This CP did not include or specify who is to provide deep suctioning if needed, or what qualified staff were to perform emergency procedures. Resident #7 The facility admitted Resident #7 on 11/16/17, with the [DIAGNOSES REDACTED]. Review of Resident #7's Significant Change MDS, with the ARD of 7/26/18, revealed the BIMS score was 10, which indicated Resident #7 had moderately impaired cognition. Review of Resident #7's Plan of Care, dated 11/16/18, revealed the problem of: Trach: History of chronic [MEDICAL CONDITION] and pneumonia. The goal was to maintain a patent airway and resolve pneumonia and the listed approaches included to suction as needed. The Care Plan did not include who would provide the type of suctioning, or deep suctioning, as needed, [MEDICAL CONDITION]. The Care Plan did not list what qualified staff were to perform emergency procedures. The interview with Resident #7 on 10/10/18 at 11:20 AM, revealed she coughed [MEDICAL CONDITION] over one (1) year ago. Resident #7 stated no one at the facility or the nearest local hospital attempted to reinsert [MEDICAL CONDITION] was she transported to a larger hospital that was an additional 32 miles away. Resident #7 stated she chose not to have surgery to replace [MEDICAL CONDITION] has done fine without it. In a review of the Nurses Notes, dated 11/28/17 at 2:11 PM, RN #1 documented, the Certified Nursing Assistant (CNA) reported Resident #7'[MEDICAL CONDITION] at 1:30 PM. The LPN reported [MEDICAL CONDITION] of stoma and she attempted to reinsert, but unable to due to growth of hypergranular tissue and narrowing/closure of stoma. The note documented the resident was placed at a 90 degree angle,[MEDICAL CONDITION] reattached, and RN attempted to reinsert, but unsuccessful. Interview with RN #1 on 10/10/18 at 12:25 PM, revealed she was on duty when Resident #7'[MEDICAL CONDITION] out and she attempted to reinsert the Trach, but was unable to reinsert it. RN #1 stated there were no emergency equipment at the bedside except an obturator and she had to go to the supply room to get a [MEDICAL CONDITION] was still unsuccessful at insertion of the Trach. RN #1 stated the resident was in no acute distress at the time of transfer. Interview with the MDS LPN #1 on 10/12/18 at 12:03 PM, revealed it was very important to follow the care plan and have the responsibility of the staff documented as to who could do deep suctioning and care. Interview with MDS LPN #2 on 10/12/18 at 12:20 PM, revealed the care plan should address who was responsible for what care that was provided and who can do deep suctioning for the resident with a Trach. She stated only the RN can deep suction. She confirmed this was not addressed on the care plan for Resident #5. In an interview on 10/12/18 at 1:50 PM, the Medical Director confirmed he was involved in the Quality Assurance (QA) meeting regarding the care of the residents with a Trach, the need for RN coverage and following the plan of care for residents with a Trach. He confirmed there had to be 24 hour coverage by the RN. The facility submitted an acceptable Allegation of Compliance (AoC) on 10/11/18, for the IJ. Review of the facility's AoC revealed the facility took the following corrective actions to remove the IJ, Prior to exit: Brief summary: An IJ was called due to lack of Registered Nurse (RN) coverage 24 hours per day, seven days per week, for residents with a [MEDICAL CONDITION]; specifically for (412) of (517) of the 11:00 PM to 7:00 AM shifts, and (138) of (517) of the 3:00 PM to 11:00 PM shifts from (MONTH) 5, (YEAR), to (MONTH) 4, (YEAR). [MEDICAL CONDITION] supplies were not readily available at the bedside for emergency care for two (2) residents with a [MEDICAL CONDITION], current resident, Resident #5, nor for Resident #7. Resident #7, who had a [MEDICAL CONDITION] which had become dislodged and resulted in transfer of the resident to the emergency room (ER) for treatment. The care plan did not include having emergency equipment at bedside to provide [MEDICAL CONDITION] care per professional standards of care. [MEDICAL CONDITION] care treatment was not provided per professional standards of care nor was sterile procedure to ensure the proper technique maintained during [MEDICAL CONDITION] care for Resident #5. Facility Actions: 1. On 10/4/18 at approximately 1:45 PM, Medical Director #1 was notified by the Director of Nurses (DON) by phone of the incident of IJ. 2. On 10/4/18 at 3:00 PM, available members of the Quality Assurance (QA) Team; DON, Administrator, Infection Preventionist (IP), Staff Education Nurse, and Regulatory Compliance Coordinator (RCC), met to review findings and to discuss policy and other changes related to an insufficient number of RNs for 24-hour RN coverage for Resident #5, the only resident with a [MEDICAL CONDITION]. 3. On 10/4/18 at 3:15 PM, the DON began notifying nursing staff present in the facility at that time of the requirements to have a RN on duty 24 hours daily to provide [MEDICAL CONDITION] care services that meet professional standards of quality provided by qualified persons in accordance with the resident's plan of care. The in-services regarding required RN staffing, to be provided to all nursing staff by the DON, Assistant Director of Nurses (ADON), IP, or Staff Education Nurse, will continue until all nursing staff have received the in-service. The nurses will not be allowed to work until they have received this in-service. 4. On 10/4/18 at 3:30 PM, the DON made adjustments to the staffing schedule to ensure RN coverage at the facility 24 hours daily. 5. On 10/4/18 at 3:40 PM, the DON determined that Resident #5 was the only resident with a [MEDICAL CONDITION] residing in the facility at this time. Four (4) other residents were in the facility from (MONTH) 5, (YEAR), through (MONTH) 4, (YEAR), with [MEDICAL CONDITION]. No issues were identified related to lack of RN coverage, however it was discovered Resident #7's [MEDICAL CONDITION] came out on (MONTH) 28, (YEAR), and there were no emergency supplies at the bedside to reinsert the [MEDICAL CONDITION]. The resident was transferred to the ER in no distress. The decision was made by the physician to leave the [MEDICAL CONDITION] out. Resident #7 currently resides in the facility with no issues. 6. On 10/4/18 at 5:00 PM, Medical Director #1, Administrator, DON, IP, Staff Education Nurse, and RCC reviewed and made changes to the [MEDICAL CONDITION] Care and Suctioning policy to include guidance on scope of practice for RN's and Licensed Practical Nurses (LPN's) including the RN being the only one that can perform deep right main stem suctioning. Therefore, the RN must be available to perform this procedure. Changes were made to the Nurse Staffing Information policy to include procedures to follow to ensure RN coverage each day, utilization of the RN call pool, and notification of the Administrator-on-call if issues occur. 7. On 10/5/18 at 9:00 AM, the QA and Interdisciplinary Team (IDT): Medical Director #1, Administrator, DON, ADON, IP, Staff Education Nurse, and the RCC, met to discuss and approve the [MEDICAL CONDITION] Care and Suctioning policy changes which included scope of practice for RNs and LPNs and the Nurse Staffing Information policy and procedure changes to require 24 hour RN coverage daily. No additional changes were recommended by QA at that time. 8. On 10/5/18 at 10:00 AM, the IP initiated in-services for the nursing staff regarding the following policy and procedure changes: [MEDICAL CONDITION] Care and Suctioning which includes scope of practice for RNs and LPNs stating the RN being the only one that can perform deep right main stem suctioning. Therefore, the RN must be available to perform this procedure. Nurse Staffing Information policy and procedure changes to require 24 hour RN coverage daily. The nurses will not be allowed to work until they have received this in-service. 9. On 10/05/18 at 3:30 PM, emergency equipment to care for a [MEDICAL CONDITION] was found by the surveyor to be missing from the room of Resident #5. Emergency equipment was placed at the bedside of Resident #5 by the Staff Education Nurse at that time to include resuscitator bag, suction machine, suction catheter kit,[MEDICAL CONDITION] kit in appropriate size and a replacement kit in a smaller size, oxygen, and appropriate personal protective equipment (PPE). The presence of the emergency [MEDICAL CONDITION] care supplies at bedside of residents with a [MEDICAL CONDITION] will be checked by the RN Supervisor every shift and documented on the Medication Administration Record (MAR). . 10. On 10/5/18 at 3:40 PM, the care plan for Resident #5 was updated by Minimum Data Set (MDS)/Care Plan Nurse #1 to include keeping emergency equipment and appropriate PPE at the bedside. 11. On 10/5/18 at 4:45 PM, the Administrator consulted the Director of Respiratory Therapy at a local hospital who provided an in-service regarding proper [MEDICAL CONDITION] care procedures and a policy for review. The RCC and Medical Director #2 updated the policy for [MEDICAL CONDITION] care and suctioning to align with clinical practice guidelines and standards of practice. The policy changes include keeping emergency equipment at the bedside of residents with a [MEDICAL CONDITION] and performing [MEDICAL CONDITION] care with sterile procedures. 12. On 10/5/18 at 5:00 PM, other available members of the (QA) Team; DON, ADON, Administrator, IP, Staff Education Nurse, and RCC met to discuss the policy changes and the new process. QA had no additional policy change recommendations. 13. On 10/5/18 at 5:10 PM, the ADON initiated in-service to the LPNs and RNs regarding the following policy and procedure changes: *24 hour RN coverage *Emergency equipment at bedside to care for a [MEDICAL CONDITION] (resuscitator bag, suction machine, suction catheter kit,[MEDICAL CONDITION] kit in appropriate size and a replacement kit in a smaller size, oxygen, and appropriate PPE) *LPN and RN scope of practice related to [MEDICAL CONDITION] care *[MEDICAL CONDITION] care and suctioning procedures *The care plan policy and procedure was reviewed and no changes were made. The in-services continued until 10/10/18, when (32) of (32) LPNs and (11) of (11) RNs were in-serviced. No nurses will be allowed to work until they receive the in-service. 14. On 10/5/18 at 5:15 PM, the DON arranged [MEDICAL CONDITION] care training for all LPN's and RN's to be provided by the local hospital respiratory therapists. In-services were initiated on 10/5/18 at 5:40 PM by Respiratory Therapist #1 and continued until 10/10/18, when (32) of (32) LPNs and (11) of (11) RNs were in-serviced. The nurses will not be allowed to work until they have received the in-service. 15. On 10/8/18 at 11:00 AM, the DON reviewed the IJ event and all policy and procedure changes with Medical Director #2 who gave approval with no additional changes recommended. 16. On 10/9/18 at 3:30 PM, a QA meeting was called with the Administrator, DON, ADON, IP, RCC, Staff Education Nurse, and Medical Director #2 per phone, to discuss additional policy changes to the [MEDICAL CONDITION] Care and Suctioning policy. Additional changes include if deep right main stem suctioning is required for the patient, a registered nurse must perform this procedure. RN to perform [MEDICAL CONDITION] care and suctioning per resident plan of care. LPN may perform [MEDICAL CONDITION] care per scope of practice guidelines in an emergent situation until RN arrives to perform care. No additional changes were recommended by QA at that time. 17. On 10/9/18 at 5:00 PM, the DON notified RN #1, RN #2, and RN #3 of the new policy requiring the RN to perform [MEDICAL CONDITION] care and deep suctioning to begin immediately. 18. On 10/9/18 at 3:40 PM, MDS/Care Plan Nurse # 1 updated the care plan of Resident #5 to designate the RN to provide [MEDICAL CONDITION] care and deep suctioning. 19. On 10/10/18 at 3:00 PM, MDS/Care Plan Nurse #1, MDS/Care Plan Nurse #2, and MDS/Care Plan Nurse #3 were in-serviced on the MDS, Care Area Assessment (CAA), and Care Plan policy as well as the regulatory requirement that services provided or arranged by the facility, as outlined by the comprehensive care plan to meet professional standards of quality of care. The policy and the regulations (F658 and F659) were reviewed. 20. On 10/10/18 at 7:15 PM, the Administrator revised the facility assessment to include the provision of RN services 24 hours daily by the facility. The facility alleges that all corrective action to remove the IJ was completed on 10/10/18, and the IJ removed as of 10/11/18. The State Agency (SA) validated the facility's AoC and determined the facility took the following actions to correct the IJ, prior to exit: 1. The SA validated through interview that the Medical Director #1 was notified by the Director of Nurses (DON) by phone of the incident of IJ on 10/4/18 2. The SA validated by QA sign in sheet and interview that members of the Quality Assurance (QA) Team; DON, Administrator, Infection Preventionist (IP), Staff Education Nurse, and Regulatory Compliance Coordinator (RCC), met on 10/4/18, to review findings and to discuss policy and other changes related to an insufficient number of RNs for 24-hour RN coverage for Resident #5. The SA validated that Resident #5 is the only resident with a [MEDICAL CONDITION]. 3. The SA validated by interview and record review that on 10/4/18 at 3:15 PM, the DON began notifying nursing staff present in the facility at that time of the requirements to have a RN on duty 24 hours daily to provide [MEDICAL CONDITION] care services that meet professional standards of quality provided by qualified persons in accordance with the resident's plan of care. The in-services included the requirement of RN staffing if a Resident with a [MEDICAL CONDITION] was in the building. The SA validated that no nurses were allowed to work until they had received this in-service. 4. The SA validated by interview and staffing sheets that on 10/4/18, the DON made adjustments to the staffing schedule to ensure RN coverage at the facility 24 hours daily. 5. The SA validated by interview and record review that on 10/4/18, the DON determined that Resident #5 was the only resident with a [MEDICAL CONDITION] residing in the facility at this time. Four (4) other residents were in the facility from (MONTH) 5, (YEAR), through (MONTH) 4, (YEAR), with [MEDICAL CONDITION], with no respiratory issues noted. The SA validated through interview that Resident #7's [MEDICAL CONDITION] came out on (MONTH) 28, (YEAR), and there were no emergency supplies at the bedside to reinsert the [MEDICAL CONDITION]. The SA validated that Resident #7 currently resides in the facility without a [MEDICAL CONDITION], with no issues. 6. The SA validated by record review, policy review, and interviews that on 10/4/18 Medical Director #1, Administrator, DON, IP, Staff Education Nurse, and RCC reviewed and made changes to the [MEDICAL CONDITION] Care and Suctioning policy to include guidance on scope of practice for RN's and Licensed Practical Nurses (LPN's) including the RN being the only one that can perform deep right main stem suctioning. Therefore, the RN must be available to perform this procedure. Changes were made to the Nurse Staffing Information policy to include procedures to follow to ensure RN coverage each day, utilization of the RN call pool, and notification of the Administrator-on-call if issues occur. 7. The SA validated by interview, sign in sheets, and record review that on 10/5/18, the QA and Interdisciplinary Team (IDT): Medical Director #1, Administrator, DON, ADON, IP, Staff Education Nurse, and the RCC, met to discuss and approve the [MEDICAL CONDITION] Care and Suctioning policy changes which included scope of practice for RNs and LPNs and the Nurse Staffing Information policy and procedure changes to require 24 hour RN coverage daily. No additional changes were recommended by QA at that time. 8. The SA validated by sign in sheets, record review and interviews on 10/5/18, the IP initiated in-services for the nursing staff regarding the following policy and procedure changes: *[MEDICAL CONDITION] Care and Suctioning which includes scope of practice for RNs and LPNs stating the RN being the only one that can perform deep right main stem suctioning. Therefore, the RN must be available to perform this procedure. *Nurse Staffing Information policy and procedure changes to require 24 hour RN coverage daily. The SA validated that no nurses were allowed to work until they have received this in-service. 9. The SA validated by observation, interviews and record reviews that on 10/05/18, emergency equipment to care for a [MEDICAL CONDITION] was missing from the room of Resident #5. The SA validated that emergency equipment was placed at the bedside of Resident #5 by the Staff Education Nurse at that time to include resuscitator bag, suction machine, suction catheter kit,[MEDICAL CONDITION] kit in appropriate size and a replacement kit in a smaller size, oxygen, and appropriate personal protective equipment (PPE). The SA validated by interview and record review, that the presence of the emergency [MEDICAL CONDITION] care supplies at bedside of residents with a [MEDICAL CONDITION] is checked by the RN Supervisor every shift, and documented on the MAR. 10. The SA validated by record review and interview that on 10/5/18, the care plan for Resident #5 was updated by Minimum Data Set (MDS)/Care Plan Nurse #1 to include keeping emergency equipment and appropriate PPE at the bedside. 11. The SA validated by interviews, policy reviews, and record review that on 10/5/18, the Director of Respiratory Therapy at a local hospital provided an in-service regarding proper [MEDICAL CONDITION] care procedures and a policy for review. The RCC and Medical Director #2 updated the policy for [MEDICAL CONDITION] care and suctioning to align with clinical practice guidelines and standards of practice. The policy changes include keeping emergency equipment at the bedside of residents with a [MEDICAL CONDITION] and performing [MEDICAL CONDITION] care with sterile procedures. 12. The SA validated by record review and sign in sheets that on 10/5/18, members of the (QA) Team; DON, ADON, Administrator, IP, Staff Education Nurse, and RCC met to discuss the policy changes and the new process. QA had no additional policy change recommendations. 13. The SA validated by interviews, sign in sheets, and record review that on 10/5/18 the ADON initiated in-service to the LPNs and RNs regarding the following policy and procedure changes: *24 hour RN coverage *Emergency equipment at bedside to care for a [MEDICAL CONDITION] (resuscitator bag, suction machine, suction catheter kit,[MEDICAL CONDITION] kit in appropriate size and a replacement kit in a smaller size, oxygen, and appropriate PPE) *LPN and RN scope of practice related to [MEDICAL CONDITION] care *[MEDICAL CONDITION] care and suctioning procedures *The care plan policy and procedure was reviewed and no changes were made. The SA validated through sign in sheets, staffing schedule, and interviews, that the in-services continued until 10/10/18, when (32) of (32) LPNs and (11) of (11) RNs were in-serviced. No nurses were allowed to work until they receive the in-service. 14. The SA validated by interviews and record reviews that on 10/5/18 the DON arranged [MEDICAL CONDITION] care training for all LPN's and RN's to be provided by the local hospital respiratory therapists. In-services were initiated on 10/5/18 at 5:40 PM by Respiratory Therapist #1 and continued until 10/10/18, when (32) of (32) LPNs and (11) of (11) RNs were in-serviced. The nurses were not allowed to work until they have received the in-service. 15. The SA validated by interview that on 10/8/18, the DON reviewed the IJ event and all policy and procedure changes with Medical Director #2 who gave approval with no additional changes recommended. 16. The SA validated by interview, sign in sheet, policy review, and record review, that on 10/9/18, a QA meeting was called with the Administrator, DON, ADON, IP, RCC, Staff Education Nurse, and Medical Director #2 per phone, to discuss additional policy changes to the [MEDICAL CONDITION] Care and Suctioning policy. Additional changes include if deep right main stem suctioning is required for the patient, a registered nurse must perform this procedure. RN to perform [MEDICAL CONDITION] care and suctioning per resident plan of care. LPN may perform [MEDICAL CONDITION] care per scope of practice guidelines in an emergent situation until RN arrives to perform care. No additional changes were recommended by QA at that time. 17. The SA validated by interviews and record review that on 10/9/18 the DON notified RN #1, RN #2, and RN #3 of the new policy requiring the RN to perform [MEDICAL CONDITION] care and deep suctioning to begin immediately. 18. The SA validated by record review and interview that on 10/9/18, MDS/Care Plan Nurse # 1 updated the care plan of Resident #5 to designate the RN to provide [MEDICAL CONDITION] care and deep suctioning. 19. The SA validated by interviews, sign in sheets, and record review on 10/10/18, MDS/Care Plan Nurse #1, MDS/Care Plan Nurse #2, and MDS/Care Plan Nurse #3 were in-serviced on the MDS, Care Area Assessment (CAA), and Care Plan policy as well as the regulatory requirement that services provided or arranged by the facility, as outlined by the comprehensive care plan to meet professional standards of quality of care. The policy and the regulations (F658 and F659) were reviewed. 20. The SA validated by record review and interview that on 10/10/18, the Administrator revised the facility assessment to include the provision of RN services 24 hours daily by the facility. The SA validated that all corrective action to remove the IJ was completed on 10/10/18, and the IJ removed as of 10/11/18.

Based on observation, interview, record review and policy review, the facility failed to update and revise care plans related to falls for five (5) of 28 residents reviewed (Residents #20, #21, #10, #9 and #14). Findings include: Resident #20 No observation was made of discharged Resident #20. Record review for Resident #20 revealed that she was admitted to the facility on [DATE], and discharged on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/5/12, revealed that she scored 3 (three) on the Brief Interview for Mental Status (BIMS) which indicated that she had severely impaired cognition. Further record review for Resident #20 revealed the following: 1. A Care Plan, with a problem onset date of 7/10/12 for " Risk for falls with injury R/T (related to) impaired balance at times, psy (psychiatric) meds (medications) ". 2. A Care plan, with a problem onset date of 7/17/12 for "Risk for falls with injury R/T Psyc (Psychiatric) meds, pacing hallway, improper sleep" . Falls were documented on "7/30/12" and "9/8/12" . There was documentation for "Lt (Left) ankle fx (fracture)" . There was an approach 9/11/12 implemented as follows: " PT (Physical Therapy) attempt to evaluate" . There were no other approaches added to the fall Care Plan, including specific care related to the ankle fracture. 3. A Care Plan, with a problem onset date of 9/21/12 for " Risk for falls with injury R/T psych meds, confusion, decreased mobility" . There were 12 falls documented between 10/14 (12) and 12/8 (12). Documentation revealed in the "Problem" area of the Care Plan "will take off alarms". Falls documented "10/14 (12), 10/17 (12) and 10/23 (12) without documentation of revised approaches. Approaches added for the aforementioned falls were "10/16 (12) cont (continue) p.o.c. (Plan of Care), 10/23 (12), 11/24 (12), 11/25 (12) cont p.o.c., 11/26 (12) Freq. (frequent) cueing/monitoring, 12/5 (12) - 12-6 (12) cont. current poc" . The Goal for falls was to "Decrease risk for falls with injury" and "will not take off alarms" . There were 12 falls documented, but no documented evidence of revised approaches for 11 of the 12 falls. 4. A Care Plan, with a problem onset date of 12/6/12 for " Risk for falls with injury R/T psyc meds, confusion, decreased mobility " with additional fall 12/15 (12) " . Also in the problem area was "Takes off alarms at times" . The goal was to " Decrease risk for falls with injury " and "Will not take off alarms" . There was an approach, which was undated, for "Full body pad/mech (mechanical) lift x 2 (two)" . The Care Plan had an approach which was undated. Interview on 6/21/13 at 4:15 p.m. with Registered Nurse (RN) #1 about Resident #20's Care Plan revealed "he was on a low bed. I don't know of anything else in addition to the alarms to prevent her from falling". Resident #21 No observation was made of discharged Resident #21. Record review for Resident #21 revealed that she was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #21 was discharged [DATE]. Review of the quarterly MDS, with an ARD of 7/11/12, revealed that she had moderately impaired decision making abilities. The aforementioned MDS also revealed that she required limited assistance of 1 (one) staff for walking in her room and in the corridor. Further review of Resident #21's record revealed the following: 1. A Care Plan, with a problem onset date of 7/12/12 for " Risk for falls with injury R/T (related to) unsteady gait, muscle wasteing (wasting) ". There were 5 (five) falls documented in the facility between 4/18/12 and 9/12/12. The approaches, which were not in chronological order, were documented as follows: " 9/4 (12) - Make sure has proper footwear prior to ambulation, 8/28 (12) with no documented approach, 8/31 (12) - cont. p.o.c. (continue plan of care), 9/8 (12)- use w/c (wheelchair) for locomotion prn (as needed) 9/11/12 - Bed slip alarm while in bed., Asst (Assist) (with) transfers x (times) 1 (one) staff., Asst (with) ambulation x 1 (one) staff., 9/12 (12) - cont. (continue)". 2. Fall 4/8/12 - fell on leave of absence. No additional approaches documented. 3. Fall 8/31/12 - found on floor. No additional approaches documented. 4. Fall 9/8/12 - fell on leave of absence. No additional approaches documented. 5. Fall 9/10/12 - fell and received hematoma to right eye. Approaches were added to Care Plan. 6. Fall 9/21/12 - fell and received [MEDICAL CONDITION] then discharged to the hospital. Interview on 6/21/13 at 6:45 p.m. with the Director of Nursing (DON), confirmed that Resident #21 was ambulating in room unassisted when she fell and fractured her hip. The DON also confirmed that no new approaches had been added to the Care Plan with each fall. Resident #10 Record review revealed Resident #10 was originally admitted to the facility on [DATE] with readmission on 5/15/13. [DIAGNOSES REDACTED]. Record review of the Minimum Data Set (MDS), dated [DATE], revealed a Brief Interview of Mental Status (BIMS) score of three (3), indicating Resident #10 was severely cognitively impaired. Observation on 6/18/13 at 12:00 p.m. revealed Resident #10 seated in bed with head of bed slightly elevated. Resident did not respond to questions. Record review revealed Resident #10 had a fall with no injuries on 5/7/13. Resident #10's care plan dated 5/24/13 did not have any updated interventions for fall risk from previous care plan dated 12/7/12. Interview on 6/20/13 at 2:45 p.m. with RN #2 revealed all falls are care planned and are updated with the date of any resident falls. Resident #9 Resident # 9 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS), dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of eight (8), which indicated she was moderately impaired. Functional status revealed she needed extensive assistance to transfer and total dependence to move in her room. Observation on 6/18/13 at 10:00 a.m. revealed Resident #9 lying in bed in low position with fall mat and bed alarm attached to the bed. Record review revealed a care plan with dates of falls ( 12/16/12, 4/10/13, 5/8/13) but approaches were not revised until 6/11/13. Review of the Nurses' Notes dated 4/10/13 at 1230 a.m. revealed that Resident #9 was found on the floor on the bedside alarm mat, however it does not address if the alarm was sounding. Interview with the DON ( Director of Nursing) on 6/20/13 at 10:30 a.m. regarding the malfunctioning bed alarm and the care plan update revealed, "I can see that and it upsets me. I also see where the care plan was not updated until June to check the alarm. I'm not happy about it, but that's it." Resident #14 Resident #14 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS), dated [DATE], revealed a Brief Mental Status(BIMS) score of 15, which indicated Resident #14 was cognitively intact. Observation of Resident #14 on 6/19/13 at 12:10 p.m. revealed her lying in bed being fed by a Certified Nursing Assistant (CNA). RN #5 stated that the resident was somewhat confused but that she could answer specific questions. RN #5 also stated that the resident was bedfast due to multiple falls including one which resulted in a [MEDICAL CONDITION], however a lift chair (recliner) was noted to be at bedside. Review of the care plan dated 11/29/12 revealed Approaches that included: Dated 1/31/13, "Make sure resident does not raise chair too high. Observe for this." and "2/12 PT/OT (Physical Therapy/Occupational) screen. Also listed was Falls: 1/30/13, 2/11/13, 2/15/13. There was no new approaches added for the 2/15/13 fall which resulted in Right [MEDICAL CONDITION]. Interview with RN #4 on 6/21/13 revealed, "A CT ( Computerized Tomography) of the head also shows she had several/ multiple [MEDICAL CONDITION]'s ( [MEDICAL CONDITION]) prior to the falls." Further review of the care plan revealed no updates concerning the results of the CT. Review of facility policy's entitled "MDS, CAA, and Care Plan Documentation", dated 6/15/11, revealed "The care plan will be updated on an ongoing basis with significant changes and interventions."

Based on observation, staff interview, record review and policy review, the facility failed to decrease the potential for accidents related to falls with injuries for four (4) of seventeen (17) residents out of a total sample of 28 (Residents #20, #21, #9 and #14). These injuries sustained ranged from fractures, hematomas and lacerations which required treatment. Findings include: Resident #20 No observation was made of discharged Resident #20. Record review for Resident #20 revealed that she was admitted to the facility on [DATE], and discharged on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/5/12, revealed that she scored 3 (three) on the Brief Interview for Mental Status (BIMS), which indicated that she had severely impaired cognition. Further review of the MDS revealed that she was independent with walking in room and walking in corridor. Further record review for Resident #20 revealed: 1. Fall on 7/30/12 at 7:00 a.m. when Resident was found sitting on floor. 2. Fall on 9/8/12 at 12:05 a.m., when Resident was found on floor, sent to hospital, and resulted in fractured left ankle. 3. Fall on 10/14/12 at 11:30 a.m., when Resident was found on knees at foot of bed. 4. Fall on 10/17/12 at 1:30 p.m., when Resident was found on floor. Stated "I sat down". 5. Fall on 10/23/12 at 7:15 a.m., when Resident was found on knees in room. 6. Fall on 11/24/12 at 4:45 a.m., when Resident was found on floor by bed. 7. Fall on 11/25/12 at 3:00 p.m., when Resident slid out of wheelchair. 8. Fall on 11/30/12 at 4:45 p.m., when Resident was found sitting on floor. 9. Falls on 12/1/12 at 9:40 a.m. when Resident was found on floor in front of wheelchair, 2:10 p.m. when Resident stood up quickly and fell , and 3:50 p.m. when Resident was found sitting on floor in front of wheelchair. 10. Fall on 12/2/12 at 6:30 p.m., when Resident was found on her knees in the floor. 11. Fall on 12/5/12 at 12:00 a.m., when Resident was found sitting on mat. 12. Fall on 12/7/12 at 2:40 p.m., when Resident attempted to arise from wheelchair and staff caught Resident. 13. Fall on 12/8/12 at 6:55 p.m., when Resident slid out of wheelchair and fell on to her knees. 14. Fall on 12/15/12 at 8:40 p.m., when Resident slid out of wheelchair while she attempted to arise. 15. Fall on 12/16/12 at 4:15 p.m., when Resident was found on her knees beside the bed. Interview on 6/21/13 at 4:15 p.m. with Registered Nurse (RN) #1, regarding Resident #20, revealed "She was on a low bed. I don't know of anything else in addition to the alarms to prevent her from falling." Interview on 6/22/13 at 10:05 a.m. with Licensed Practical Nurse (LPN) #6, regarding Resident #20, revealed that she should not have been coded independent with walking because "she didn't ambulate any more after she fractured her ankle". Resident #21 No observation was made of discharged Resident #21. Record review for Resident #21 revealed that she was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #21 was discharged [DATE]. Review of the quarterly MDS, with an ARD of 7/11/12, revealed that she had moderately impaired decision making abilities. Further review of Resident #21's record revealed the following: 1. Fall on 8/28/12 at 1:45 p.m. when Resident slipped and fell . 2. Fall 8/31/12 at 3:15 p.m. when Resident was found on floor. 3. Fall 9/10/12 at 11:30 p.m., when Resident fell and received hematoma to right eye. 4. Fall 9/12/12 at 6:25 a.m., when Resident fell and received fractured hip then discharged to hospital. Interview on 6/21/13 at 6:45 p.m. with the DON, confirmed that Resident #21 was ambulating in room unassisted when she fell and fractured her hip. The DON also confirmed that no new interventions had been added to the Care Plan with each fall. Resident #9 Resident # sustained an injury consisting of a hematoma and laceration to the head due to a fall on 4/10/13 at 12:30 a.m. Resident #9 had a total of three (3) falls from December 2012 to May 2013. Resident #9 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS), dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of eight (8), which indicated she was moderately impaired. Functional status revealed she needed extensive assistance to transfer and total dependence to move in her room. Observation on 6/18/13 at 10:00 a.m. revealed Resident #9 lying in bed in low position with fall mat and bed alarm attached to the bed. Interview with RN #3 on 6/18/13 at 10:00 a.m. revealed that Resident #9 had fallen several times even though precautions were in place. Record review revealed a care plan with dates of falls ( 12/16/12, 4/10/13, 5/8/13) but approaches were not revised until 6/11/13. Review of the Nurses' Notes dated 4/10/13 at 12:30 a.m. revealed that Resident #9 was found on the floor on the bedside alarm mat, however it does not address if the alarm was sounding. Review of the "Investigation of Incident" form, dated 4/10/13, revealed in the comment area "device not properly attached". Interview with LPN #7 dated 6/2/13 at 4:30 p.m. revealed "Well I was making my rounds and found her ( Resident # 9) on her alarm mat. The alarm, like I say, was not going off so I reconnected it." Interview with the DON ( Director of Nursing) on 6/20/13 at 10:30 a.m. regarding the malfunctioning bed alarm and the care plan update revealed, "I can see that and it upsets me. I also see where the care plan was not updated until June to check the alarm. I'm not happy about it, but that's it." A further interview with the DON on 6/21/13 at 9:20 a.m. revealed, "The cord came out of the one alarm on Resident #9 so we threw it away." Review of the facility's current fall policy, last revised 3/29/12, entitled "Falls and Incidents" revealed "a list of possible interventions to decrease the risk for falls and/or incidents": "All falls and incidents will be reviewed by the DON/ADON ( Assistant Director of Nursing) to evaluate if there were any contributing factors that need to be considered." Resident #14 Resident #14 sustained an injury consisting of a femoral fracture on 2/15/13. Resident #14 had a total of three (3) falls from January 2013 through February 2013. Resident #14 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS), dated [DATE], revealed a Brief Mental Status(BIMS) score of 15, which indicated Resident #14 was cognitively intact. Observation of Resident #14 on 6/19/13 at 12:10 p.m., revealed her lying in bed being fed by a Certified Nursing Assistant(CNA). RN #5 stated that the resident was somewhat confused but that she could answer specific questions. RN #5 also stated that the resident was bedfast due to multiple falls including one which resulted in a fractured hip, however a lift chair (recliner) was noted to be at bedside. Interview with RN #1 on 6/20/13 at 3:45 p.m. revealed "I know when she came in we did her fall assessment and I saw that she was a high fall risk and we talked to the daughter about it and she refused the alarm. So she had a fall from her lift chair with no injury. It was on 1/30/13. On 2/11/13 she was also found in front of her recliner with no injury. Then on 2/15/13 she was found on the floor in front of her recliner laying on her right side. She had gone to the bathroom and was almost back to the recliner. She went to sit down and didn't make it. The staff heard her calling for help and went to the room and found her. The doctor was called and she was sent to the ER (emergency room ) and that's where they discovered the hip fracture. I'm sorry, femoral fracture. We talked to the daughter from the beginning about that chair but she said her mother loved her chair and refused to let us move it out." Interview with RN #4 on 6/21/13 at 10:00 a.m. revealed "It looks as if she had a history of [REDACTED]. A CT (Computerized Tomography) of the head dated 1/4/13 shows she had several/multiple CVA's (Cerebral Vascular Accident) prior to the falls. It does say that the resident and the RP (Responsible Party) refused the alarm." Interview with the DON on 6/21/13 at 11:00 a.m. revealed "I'm concerned about it, too. Which she was transferred here from another facility and I think that contributed to her decline. It acted like to me that she had a stroke after coming here, however I don't know that. I think that move was the beginning. I remember distinctly wanting to put her on a low bed and the family refused and they wanted full bed rails so we bought them. The family didn't want alarms either. I think we just try to compromise with the families." Record review revealed care plan dated 11/29/12 with Problems/Needs that included: 1) Risk for falls with injury R/T (Related to) OA ( Osteoarthritis) 2) Impaired mobility 3) new environment 4)confusion 5) HX ( history) falls 6) Does not call for assistance 7) Family refuses alarms. Also included under Problem was : Falls- 1/30/13, 2/11/13, 2/15/13. RT (Right) hip fx (fracture) was listed with date of 2/15. Further review of the care plan dated 11/29/12 revealed Approaches that included: 1) Make sure resident does not raise chair too high. Observe for this. Date listed was 1/31/13. Review of the Nurses' Notes, Incident Reports, and Interviews revealed that Resident #14 sustained 3 falls between January 2013-February 2013 primarily as she tried to get in or out of her recliner. The fall on 2/15/13 at 9:45 p.m., in which the resident was found on the floor in front of her recliner, resulted in the [DIAGNOSES REDACTED]. During the interview with RN #4 on 6/21/13 at 10:00 a.m. she revealed "The resident ended up having to have two hip surgeries because she had to have a revision of the first one". Review of the facility's current fall policy, last revised on March 29, 2012, entitled "Falls and Incidents" revealed : 1) Purpose- It is the policy of the facility to provide an environment as free of accident hazards as possible 2) The Nursing staff and CNA are to provide the Residents with adequate supervision and the Therapy department are to assess the need for assistive devices to decrease the risks of accidents and injury 3) Possible interventions to decrease the risks for falls and/or incidents: Thorough evaluation to determine if there are underlying factors 4) The Fall Review Committee will meet weekly to follow up and discuss all falls for the previous week, the corrective actions taken and whether they are effective and appropriate 5) Falls and Incident reviews will also be discussed at the QA (Quality Assurance)/Medical Director's meetings.