Every finding on record at Lawrence Hall Health & Rehabilitation

Number of residents sampled: Number of residents cited: Based on record review, observations, interviews, facility policy review, it was determined the facility failed to maintain an accepted professional standard of practice and maintain medical records with accurate documentation for two (Resident #59 and Resident #10) of two residents reviewed. Specifically, Registered Nurse (RN) #1 logged into the Electronic Health Record (EHR) and allowed Medication Assistant-Certified (MAC) #2 to review, pull, sign out and administer medication to Resident #10 and Resident #59 under RN #1's name in the Medication Administration Record (MAR) on 07/08/2026 during the morning medication pass. The findings include: Resident #10 A review of the admission Record, indicated the facility admitted Resident #10 on 04/18/2024 with diagnoses that include kidney failure, chronic kidney disease (stage-4), type-2 diabetes mellitus, urogenital implant, depression, colostomy, high cholesterol, dementia, heart failure, and Parkinson's disease. A review of the quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/10/2026, revealed Resident #10 had a Brief Interview for Mental Status (BIMS) score of 9 which indicated the resident had moderate cognitive impairment. The MDS also indicated Resident #10 was taking medications in the high-risk drug class such as antipsychotics, antidepressants, anticoagulants, an antiplatelet, and hypoglycemics. A review of Resident #10's Care Plan, initiated on 07/07/2026, revealed the resident received medications with a black box warning. Interventions included reporting any signs or symptoms observed to the MD [Medical Director]. A review of MAR dated July 2026 revealed during the morning medication pass Resident #10 received medication for heart disease, heart health, depression, anticoagulant, enlarged prostate glands, hypothyroidism, neuromuscular dysfunction of the bladder, bone health, anemia, hypo magnesium, and a medication to treat stage 4 kidney disease. During a medication pass observation made on 07/08/2026, at 8:41AM. MAC #2 was observed passing medications to Resident #10, MAC #2 was in the [EHR charting system ]. Resident #10's medications were verified with the EHR MAR by MAC #2. The medication was removed from the card and placed in a cup and administered to Resident #10 by MAC #2. MAC #2 returned to the cart and turned to RN #1 and stated, I don't know your stuff. As she gestured her hand toward the computer screen. RN #1 stated, Oh. This surveyor then observed RN #1 walk to the medication cart, typed in her login information and step away afterwards. MAC #2 then continued with the medication pass. Resident #59 A review of the admission Record, indicated the facility admitted Resident #59 on 04/05/2022 with diagnoses that include: stroke, kidney failure, insomnia, dementia, cognitive communication deficit, schizophrenia, seizures, anxiety, hypertension, depression. The quarterly MDS, with an ARD of 05/22/2026, revealed Resident #59 had a BIMS score of 7 which indicated the resident had severe cognitive impairment. The MDS indicated Resident #59 displayed symptoms of hallucinations and delusions, was dependent on self-care needs such as upper and lower body dressing, toileting, showers, and personal hygiene. Resident #59 was dependent for mobility functions such as sitting, lying, chair transfers, toileting and showers. The MDS also indicated Resident #59 was taking medications in the high-risk class such as antipsychotics, anti-anxiety medication, antidepressants, an antiplatelet, and an anti-convulsant. A review of Resident #59's Care Plan, initiated on 09/08/2023, revealed the resident received medications with black box warnings. A review of a MAR dated July 2026 revealed during the morning medication pass, Resident #59 received medications for heart health, osteoarthrosis, vitamin deficiency, schizophrenia, anemia, high blood pressure, seizures, hypothyroidism, a liquid supplement and a topical patch for neck pain. During a second medication pass observation on 07/08/2026 at 9:01 AM, MAC #2 was observed working in the [EHR charting system]. MAC#2 verified the medication, pulled the medication from the card and administered the medication to Resident #59. This surveyor asked MAC #2 to point to their login name or username on the EHR. MAC #2 pointed to the top of the computer screen which was logged into [EHR charting system] and RN #1's name was listed. During an interview on 07/08/2026 at 9:15 AM, the Medication Assistant-Certified MAC #2 indicated her orientation was complete and she was capable of working independently. MAC #2 verified that she had her own [ EHR charting system] login information. MAC #2 indicated she was working with RN #1 and that facility staff should only work under their own login and username. During an interview on 07/08/2026 at 9:20 AM, RN#1 indicated it was okay to allow MAC #2 to work under their login username because they were working together. During an interview on 07/08/2026 at 9:20 AM, the Administrator stated, You cannot login and allow someone to work under your name. Not usually in any situation, on any job. During an interview on 07/08/2026 at 2:00 PM the Advance Practical Registered Nurse (APRN), stated. No, you cannot sign in and allow anyone to work under your name. The APRN indicated any documentation or actions completed in error would be blamed on the person logged in. During an interview on 07/09/2026 at 1:35 PM with the Assistant Director of Nursing (ADON) stated, You never access a computer and allow someone to work under your name. That is a legal medical record. During an interview on 07/09/2026 at 2:05 PM the Director of Nursing (DON) indicated RNs and MACs had different roles based on their titles. RNs were allowed to access more information and change or document more than a MAC. The DON stated We do not allow anyone to work under our license on your computer. That is why we have such detailed passwords. It is false documentation. During an interview, the Administrator indicated each staff member was supposed to work under their own login. The Administrator stated, That is not accurate documentation. and That is not a professional standard of nursing. On 07/09/2026 at 11:00 AM, the Administrator stated the facility did not have a policy or instructions for employees to only work under their own login and not allow others to work under their login/name in the Electronic Health Record. A review of an undated facility policy titled, Medication Administration, stated, Facility nursing staff will ensure medications are administered safely, accurately, and in accordance with physician orders and accepted standards of nursing practice. A review of a facility policy titled, Code of Business Conduct and Code of Ethics dated 04/24/2021, stated, Each employee is responsible for the integrity and accuracy of our organizations documents and records. Records must never be altered or contain false information. A review of the document titled, Documentation Guidelines: The Medical Record Maintenance and Access Requirements by the Center for Medicare and Medicaid Services (CMS) specifies that all electronic entries must be authenticated, meaning each note or action is definitively tied to the nurse's unique login ID. A review of the document titled Key CMS Guidelines for Nursing Logins and Electronic Signatures stated, Individual Accountability: Every nurse must use their own unique username and password. and Entries utilizing unauthorized, shared logins render the record incomplete, which can result in severe claim denials during a CMS audit.

Based on interviews, record review, and facility document review, it was determined the facility failed to have a policy and procedure in place for Medication Regimen Review for five (Resident #4, #5, #11, # 21 and #47) of five residents reviewed. The findings include:Resident #4A review of the admission Record revealed the facility admitted Resident #4 on 08/02/2024 with diagnoses that included major depressive disorder, end stage renal disease, chronic congestive heart failure, type-2 diabetes and morbid obesity. A review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/07/2026 revealed Resident #4 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated Resident #4 was cognitively intact.A review of Resident #4's Care Plan Report revealed Resident #4 had a potential risk for falls with an initiated date of 08/01/2024, had an altered cardiovascular status, used an antidepressant and received injectable antihyperglycemic therapy with an initiated date of 08/29/2024. The Care Plan Report also indicated Resident #4 had chronic left lower leg pain and received as needed pain medication therapy and used antianxiety medication with an initiated date of 08/29/2024, Resident #4 also received anticoagulant therapy with an initiation date of 04/20/2026. The Care Plan Report continued that Resident #4 had the potential for a behavior problem with an initiated date of 03/11/2026 and required hemodialysis treatment due to end stage renal.A review of the Order Summary Report revealed Resident #4 had an order with a start date of 04/02/2026 for monthly psychotropic medication charting on the second of every month on the evening shift, an order for anticoagulant therapy 5 mg [milligram] to be given two times a day with a start date of 03/05/2026, an order with a start date of 04/25/2025 for an antihistamine 25 mg to be given at bedtime, and an order with a start date of 04/24/2025 for a semi-synthetic opioid pain medication tablet 10mg to be given every four hours as needed. The Order Summary Report also indicated Resident #4 had two separate orders for insulin that with a start date of 04/25/2025, an insulin pen injectable with 32 units to be given before meals, and an insulin pen injectable to be given per sliding scale before meals and at bedtime, and an order for an insulin pen injectable to be given two times a day with a start date of 01/14/2026. Resident #5A review of the admission Record, for Resident #5 revealed the facility admitted Resident #5 on 02/18/2026with diagnoses that included dementia, altered mental status, type-2 diabetes, depression, and anxiety. A review of the signification change MDS, with an ARD of 05/28/2026, revealed Resident #5 had a BIMS score of 14 which indicated the resident was cognitively intact. A review of Resident #5's Care Plan Report, initiated on 02/18/2026, revealed the resident used antipsychotic medication related to vascular dementia, depression and anxiety. Interventions included to consult with pharmacy, medical doctor to consider dosage reduction when clinically appropriate at least quarterly.Resident #11A review of the Diagnoses Report indicated Resident #11 had diagnoses that included chronic obstructive pulmonary disease (COPD), emphysema, heart failure, atrial fibrillation, anxiety disorder and depression.A review of a significant change MDS with an ARD of 06/26/2026 revealed Resident #11 had a BIMS of 15 which indicated the resident was cognitively intact.A review of the Order Summary Report an order date range from 03/01/2026-7/31/2026 revealed Resident #11 had physician's orders for an antianxiety tablet 0.5 mg to be given every 8 hours as needed, an antidepressant oral capsule delayed release sprinkle 60 mg to be given one time a day, an anticoagulant tablet 5 mg to be given two times a day, an opioid pain medication 5-325 mg to be given every 6 hours as needed for pain and an antihistamine tablet 25 mg to be given every 12 hours as needed for anxiety. Resident #21A review of the admission Record, revealed the facility admitted Resident #21 on 08/19/2024 with diagnoses that included type-2 diabetes, epilepsy, dementia, depression, chronic pain, and anxiety.A review of the quarterly MDS, with an ARD of 05/15/2026, revealed Resident #21 had a BIMS score of 9 which indicated the resident had moderate cognitive impairment. A review of Resident #21's Care Plan, initiated on 09/16/2024, revealed the resident used psychotropic medications related to major depression disorder. Interventions included to consult with pharmacy at least quarterly, the medical doctor is to consider dosage reduction when clinically appropriate.A review of the Pharmacy Record Review with a printed date of 05/31/2026 revealed that a Gradual Dose Reduction (GDR) was completed on 05/31/2026, on an antipsychotic but was not sent to facility by pharmacist until 07/07/2026 and then sent to Physician for review. Per Email sent from DON to Pharmacist on 07/07/2026, DON asked for the reports for May and June due to surveyors in the building.Resident #47A review of the admission Record, indicated the facility admitted Resident #47 on [Date] with diagnoses that included depression, dementia, cognitive communication deficit, and hallucinations.A review of the signification change MDS, with an ARD of 06/16/2026, revealed Resident #47 had a BIMS score of 3 which indicated the resident had severe cognitive impairment. The MDS indicated Resident #47 displayed verbal behavior symptoms directed towards others for at least 1 to 3 days during the last seven days that had worsened since the prior assessment. The MDS also indicated Resident #47 utilized a wheelchair for ambulation and mobility and took the following high-risk medications: an antipsychotic, an antidepressant, an antiplatelet, a hypoglycemic, and an anticonvulsant with antipsychotics being received on a routine basis.A review of the Medication Administration Record, dated for July 2026 revealed Resident #47 received oral antipsychotic medications for dementia with behavioral disturbance, and recurrent depressive disorder, injections for high blood sugars twice daily and monthly psychotropic medication with monitoring twice daily.A review of the document labeled Medication Regimen Review (MRR) with a printed date of 05/31/2026 for Resident #47 revealed the pharmacist's completed medication record review for an antidepressant and insomnia medication but there was not a physician's signature or date. During an interview on 07/09/2026 at 10:33 AM, the Administrator stated the facility did not have a policy for Medication Review or Pharmacy Record Review.During an interview on 07/09/2026 at 12:58 PM, the Assistant Director of Nursing (ADON) stated the facility does not have a process to ensure the Pharmacy Record Reviews are sent to the facility. She indicated the facility sends to the Medical Doctor (MD); and MD reviews and returns back to facility. The ADON stated that her expectation was for the Pharmacist to send the Medication Regimen Reviews to the facility in a timely manner (at least a week) after review was completed.During an interview on 07/09/2026 at 1:31 PM, the Director of Nursing (DON) stated a report request should not be sent to the Pharmacist. The Pharmacist should send the Pharmacy Record Review to the facility within a week so the MD can review and submit medication changes if needed in a timely manner. The DON stated they have not had a process in place for the Pharmacy Record Reviews and the previous ADON took care of the medication reviews.

Based on observation, interview, record review, and facility policy review, it was determined that the facility failed to ensure Enhanced Barrier Precautions (EBP) were utilized for 1 (Resident #5) of 4 residents reviewed for pressure ulcers. The findings include: 1. A review of an admission Record, indicated Resident #5 had diagnoses which included a stage 2 pressure ulcer of the right buttocks. (A stage 2 pressure injury indicates partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough or bruising). a. A review of the admission Minimum Data Set (MDS) with an Assessment Reference Date of 03/07/2025, revealed Resident #5 had a Brief Interview for Mental Status score of 03, which indicated the resident had severe cognitive impairment. The MDS also revealed Resident #5 had one unhealed pressure ulcer. b. A review of Resident #5 ' s Order Summary Report, revealed orders for wound care to the resident ' s buttocks. c. During an observation on 05/27/2025 at 1:15 PM, this surveyor observed the Treatment Nurse performing wound care on Resident #5, without wearing personal protective equipment (PPE), as indicated for EBP. Specifically, a gown was not utilized. The Treatment Nurse stated when a resident was on EBP a gown would be worn if the resident ' s wound had drainage. d. During an interview on 05/29/2025 at 10:00 AM, the Infection Preventionist (IP) revealed residents were placed on EBP for chronic wounds or copious amounts of draining, but for small wounds the facility did not place residents on it. If a resident had a stage 2 pressure ulcer, with no drainage, the facility would not put them on EBP as long as the wound was dry. The IP verified that the importance of ensuring EBP was the prevention and spread of infection. e. A review of a facility policy titled, Enhanced Barrier Precautions PP, dated 04/01/2024, indicated Enhanced barrier precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities .

Based on observation, record review, and interview, the facility failed to ensure medications were not stored on top of the nurse ' s station counter near residents, to prevent misappropriate use of resident owned medications or accidents affecting 1sampled (Resident #72) resident. The facility also failed to ensure the appropriate temperature range was maintained in the 300 Hall medication refrigerator to ensure flu vaccines were stored at the recommended temperatures. The findings include: 1.a. On 12/11/2024 at 09:48 AM, Five (5) medication cards of an anti-viral medication were observed resting on top of the nurse ' s station counter near an empty pharmacy bag. Licensed Practical Nurse (LPN) #3 was observed with her back turned talking on the telephone. Two (2) residents in specialty chairs and Resident #72, an ambulatory resident, was sitting in a nearby chair. LPN #3 was asked the process for receiving medications from the pharmacy. LPN #3 stated medications are counted together with the pharmacy on arrival. LPN #3 also stated she did not know where the anti-viral medications came from. LPN #1 walked up and said this was his fault. He stated, he removed the medication cards from the top of my cart and placed them on the counter of the nurse ' s station and walked off to give medication to a resident and just forgot. The survey asked if this was an appropriate way to store medications. LPN #1 responded, no. LPN #1 stated a resident could have taken the medications and he would not have known and confirmed medications should be locked on the cart or in the medication room. 2.a. On 12/11/2024 at 09:49 AM, Licensed Practical Nurse (LPN) #1 opened the narcotic refrigerator, located in the 300 Hall medication room, and verified the temperature was 30 degrees Fahrenheit. LPN #1 counted a box of flu vaccines with three (3) remaining doses, and an unopened box of flu vaccines with 10 doses. This surveyor asked at what temperature vaccines were to be maintained. Licensed Practical Nurse (LPN) #1 read from the flu vaccine box 35-46 degrees Fahrenheit. This Surveyor asked what process was followed to make sure the narcotic refrigerator is at the right temperature. LPN #1 stated third shift recorded the temperature, and if it was wrong the nurse was supposed to adjust the temperature until it was correct. This surveyor asked why it was important to maintain the appropriate temperature. LPN #1 responded the medication might not be as effective. LPN #1 pointed out the temperature log on front of the refrigerator that indicated the temperature should be between 36-46 degrees Fahrenheit, and if the temperature was incorrect, it should be adjusted until it was in range. b. During an interview, the Director of Nursing DON was asked if it was appropriate to store medications on top of the nurse ' s station counter, what the facility process was, and if any of the three residents at the counter were able to ambulate independently to where the medication was left. The Director of Nursing (DON) identified Resident #72 could ambulate and confirmed that someone could have taken the medications, and they would not have known. This surveyor asked what process the nurses follow to make sure refrigerated medications were stored at the right temperature. The DON stated nurses were to check the thermometer and let the DON know if it was not correct. This surveyor asked if staff notified the DON of the temperature on 12/08/2024. The DON looked at the temperature log and confirmed that no staff let her know the temperature was 32 degrees on 12/08/24. This surveyor asked the DON why it was important to monitor refrigerator temperatures. The DON stated because vaccines and medications could become less effect when not stored at the recommended temperature. This surveyor requested the medication storage policy and in-services. c. On 12/11/2024 at 01:00 PM, the DON provided Medication Administration in-service documentation that showed staff, including LPN #1, received training on 10/3/24 and 03/06/24. The in-service did not cover medication storage, or maintaining temperatures for refrigerated medications. d. On 12/12/2024 at 09:30 AM. DON was asked again for a medication storage policy and the information provided in their Medication Administration in-service addressed medication storage.

Through observations, interviews, and policy/procedure reviews, it was determined the facility failed to ensure that essential equipment and appliances were kept clean and free of debris and food items were properly stored and labeled. The findings are: On [DATE] at 10:10 AM, one bag of sliced white bread was not closed after being used for breakfast. The Certified Dietary Manager (CDM) confirmed the bag was left open after the breakfast meal. There was a possibility to cross-contaminate the bread in the bag. On [DATE] at 10:15AM, the drink cooler contained the following drinks without a received date nor an open date: 15 half pint whole milk containers, four half pint - one percent low-fat buttermilk, 16 half pint - two percent milk, three half pint - fat free milk, four - eight fluid ounce advanced therapeutic milk chocolate nutrition, two - eight fluid ounce vanilla almond milk, 28 - four fluid ounce thickened lemon water, three - four fluid ounce thickened orange juice, seven - four fluid ounce thickened apple juice, eight - four fluid ounce apple juice, three - four ounce fluid ounce cranberry juice cocktail, ten - for fluid ounce grape juice, six - four fluid ounce prune juice. The Certified Dietary Manager confirmed there were not any received nor open dates for the drinks in the drink cooler. On [DATE] at 10:22AM, the drink cooler tray that held the four-ounce prune juice containers had unknown brownish syrupy, sticky substance under the juice containers and on one - four-ounce prune juice container. The Certified Dietary Manager stated the tray was on the rotation clean list to be done at least once a week and stated the tray shouldn't be like this; the tray should have been changed; the prune juice container should be disposed of for safety reasons and was unable to identify what the unknown brownish syrupy sticky substance was. On [DATE] at 10:28AM, the food serving area contained two wheeled silver carts. The first wheeled cart's first sheet pan appeared to have five unknown white dried, crusty type spills with unknown white particles along the sides and bottom of the sheet pan. The sheet pan contained the following snacks for residents: four - 50-gram honey buns, three individual, packaged wheat peanut butter and strawberry jam sandwiches, four individual blueberry breakfast bars, three individual, packaged chocolate chip cookies, two individual, packaged peanut butter cookies, two individual, packaged oatmeal raisin cookies, two individual, packaged vanilla sandwich cookies, and one individual, packaged graham crackers. The second shelf contained 15 disposable food domes, not properly covered to keep foreign objects from being on the food covering surface and unknown brown and white particles near the disposable food domes. The second sheet pan contained one package puffy cheese snacks, two package baked barbeque chips and one package salted baked chips. The third sheet pan held the toaster, used at breakfast. The toaster contained numerous unknown brown and white specks on top of the toaster surrounding the four slots to put bread into. The bottom of the sheet pan had numerous unknown brown and white specks surrounding the toaster. The Certified Dietary Manager stated the sheet pans were scheduled to be cleaned at least one-time weekly or as needed and confirmed that the food domes should be inverted to keep unknown particles from landing inside and cross-contaminating when flipped over the food and confirmed the toaster should had been cleaned after breakfast to not attract various pests. On [DATE] at 10:29AM, the second wheeled cart's first sheet pan appeared to have the appearance of broken flake cereal towards the front edge of the pan and the back third section of the pan. This pan contained the following cereals without a received date or an opened date for residents to consume: six factory individualized, pre-portioned sugar covered flakes, seven factory individualized, pre-portioned grain O rings, and four kitchen portion plain flakes. On [DATE] at 10:31AM, the second wheeled cart's second sheet pan contained the following cereals without a received date or an opened date for residents to consume: nine factory individualized, pre-portioned sweetened cereal with marshmallows, three factory individualized, pre-portioned unsweetened crisped rice, five factory individualized, pre-portioned bran flakes with raisins, and two factory individualized, pre-portioned grain circles of various colors. On [DATE] at 10:32AM the Certified Dietary Manager confirmed the cereals on both shelves of the second wheeled cart did not have neither the received date nor the open date. On [DATE] at 10:34AM, above the tray line serving area a container of adapted forks and spoons looked to had been tossed in into an uncovered silver steam table container where the eating part of one utensil crossed the handle of a different eating utensil. The regular forks, spoons and knives were placed in an uncovered divided container. The Certified Dietary Manager confirmed neither set of utensils for resident's use were covered. The Certified Dietary Manager stated the utensils were used for the meals. On [DATE] at 10:39AM, five open coffee carafes were in an upright position, without a cover on the bottom shelf, underneath the drink preparation table. The Certified Dietary Manager confirmed the open carafes should had been inverted or covered to keep out debris and other cross-contaminations that could cause the residents to become sick. On [DATE] at 10:43AM, the kitchen condiment area contained the following condiments in containers without a received date or open date: three full containers of individual ketchup cups, one container of individual sized white creamy dressing, two containers of individual sized salsa, two containers of barbeque sauce, one container of individual sized sugar-free pancake syrup, one container of individual sized pancake syrup, one container of individual sized relish, one container of individual sized raspberry vinegar dressing, one container of individual sized creamy red dressing, one container of individual sized herb flavored dressing. The Certified Dietary Manager confirmed there was neither a received date nor an expiration date for any of the condiments. On [DATE] at 10:43AM, the bulk sugar container was approximately three-quarters of the way full held various sized white and brown crumbly debris on the top with unknown black ground-in debris in various areas, to include the handle used to open the lid. The outside walls of the bulk sugar container also had the same unknown black ground-in debris in various areas. The carrying handle had an unknown yellowish-brown substance built up. Along the top inside edges of the container were gouges and scratches with dark brown and black unknown substance. The indents from the carrying handles has a black ground in looking unknown substance. The Certified Dietary Manager stated the bulk sugar container was not considered clean and there was too much build up around the edges of the container. The Certified Dietary Manager stated areas of concern were how long the substance build up had been there and not knowing what the built-up substance was due to the possibility for the substance to get into the sugar used for various foods provided to the residents for consumption. On [DATE] at 10:53AM, the dish warmer's lid closure was prevented by 42 plates on the left side and 28 plates on the right side above the maximum limit. The dish warmer's lid ' s inability to close properly resulted in the plates not having the serving side properly covered. The Certified Dietary Manager confirmed that the plates should be inside the plate warmer with the lid closed. The lid not closed could cause cross-contamination of all the plates in the plate warmer. On [DATE] at 11:05AM, on the inside door around the clasp to hold the door shut of the walk-in refrigerator was an unknown brown substance built up around and in the seam of the clasp bracket. The unknown brown substance built up was also in the indentations around the door clasp on the inside of the refrigerator door and the crevasse of the inside door that meets the refrigerator frame ' s edge. The latch secured to the outside wall of the refrigerator contained a scaley brown and white unknown substance built in the seams of the latch plate around the bolts to secure the latch plate and on the wall surrounding the latch plate. Approximately 40 inches above the latch towards the ceiling the unknown brown substance was encrusted in the wall. The left inside door frame had a piece of plastic missing that exposed the wood beneath. The outside panel above the door contained an unknown dark greyish substance the spread the length of the panel and about half the height. The right side of the walk-in refrigerator outside wall contained a dark brown unknown substance that ran the entire height of the door. The door hinges and plates were encrusted with an unknown reddish-brown substance. The seal around the entire walk-in refrigerator door held a black grimy sludge like unknown substance. This black grimy sludge like unknown substance was embedded into to grooves of the seal. There was a gap between the floor edging under the walk-in refrigerator door and the wall. The gap was filled with various unknown debris, with a thick brown and white unknown substance attached to the wall and floor edging. The Certified Dietary Manager confirmed the unknown substances were in the crevasses, hinges, plates, grooves, gaps. The Certified Dietary Manager stated there were concerns of the unknown substance growth in the walk-in refrigerator area due to possible cross contamination of food stored in the walk-in refrigerator. On [DATE] at 11:11AM, in the three-door pastry refrigerator on the left side of the kitchen a five-pound container of egg salad expired on [DATE]. The Certified Dietary Manager confirmed the egg salad was expired. The Certified Dietary Manager sent a staff member to collect all egg salad sandwiches that had been sent to the facility's halls for residents' snacks. The Certified Dietary Manager confirmed that expired food should not be served due to concern of bacterial growth. On [DATE] at 11:26AM the dry good storage shelving contained the following food items without a received date or an open date: 54 individual four fluid ounce cranberry juice, 45 individual four fluid ounce thicken sweet tea, 32 individual four fluid ounce thickened apple juice, 65 individual four ounce prune juice, 80 individual eight fluid ounce of various flavors, 18 individual four fluid ounce thickened orange juice, 70 individual four ounce thickened lemon water, 90 individual four fluid ounce grape juice, 57 individual eight fluid ounce high protein nutritional drink, 60 individual four fluid ounce apple juice, 42 individual four fluid ounce orange juice. The Certified Dietary Manager confirmed there were not received dates nor open dates for the drinks stored on the dry good shelves. On [DATE] at 11:32AM the storage container with chocolate cake mix was not completely sealed. The back right corner was not completely sealed. The outside cover of the storage container was covered with an unknown powdery white substance with some small white clumps scattered within the powdery unknown substance. The Certified Dietary Manager confirmed the unknown white powdery substance, and clumps were able to cross-contaminate the cake mix inside the storage container. With the seal not properly closed it could allow other contaminants to enter the storage container with the cake mix that was used for residents' meals. On [DATE] at 12:09PM the dishwasher machine had an unknown white crusty substance over the entire outside housing unit. The unknown white crusty substance had water drip marks that ran down the machine sides. The dirty side entrance had a white and blue unknown substance build up in the crevasses. The front right third edge of the dishwashing machine had an unknown brownish substance in the crevasse. The long side of the dishwashing machine crevasse had a white and blue unknown substance in the crevasse. The left edge side of the top of the dishwashing machine held a buildup of an unknown crusty white substance. The right edge middle side of the top of the dishwashing machine held approximately three inches by four-inch gooey bluish unknown substance. The clean side of the dishwashing machine had a thick unknown white build up substance on the cloth strips the clean dishes pass through to exit the machine. The dishwashing machine clean side top back wall had unknown thick white build up in the crevasses and a quarter of the way up the wall. The back wall had brownish unknown substance that gathered in various sections on top of the thick white build up and along the right side back wall. The left side crevasse held the unknown white substance that ran the entire length of the crevasse. The Certified Dietary Manager confirmed the dishwasher needed to be deep cleaned weekly and wiped down daily. On [DATE] at 12:06PM three baking sheets of sausage sitting on a wheeled cart preparation cart were stacked on top of each other without a barrier placed between the frozen sausage patties and the bottom of the baking sheet on top. The Certified Dietary Manager confirmed the sausage patties should have something to cover the sausage patties before the baking sheet was placed on top. The CDM stated cross contamination could occur due to not knowing what the bottom of the baking sheet had touched. A review of the cleaning schedules dated [DATE] through [DATE] showed that: [DATE] the dishwasher was not cleaned by kitchen staff [DATE], [DATE], and [DATE] the dishwasher was cleaned by kitchen staff [DATE] and [DATE] 3 dietary roll carts were cleaned by staff A review of the facility approved policy or procedure Infection Prevention in Dietary for Infection Prevention Dietary Services Policy Number 1C#VII A effective date of [DATE]; Last revision date [DATE]; Last review date [DATE] showed B1. Cleaning schedules will be followed, department director is responsible to see that cleaning schedules are followed. B2. Equipment will be checked often to ensure proper working condition. B3. Employees are to report equipment defects immediately to the department director, who makes sure defects are repaired quickly.

Based on interviews, record review, and facility policy review, it was determined the facility failed to ensure a written discharge summary and information form was completed for 1 (Resident #90) of 1 resident reviewed for discharge. The findings included: Review of updated facility policy titled Resident Discharge Process dated 06/28/2024, indicated when a resident was discharged home, the Director of Nursing/Designee will ensure a discharge note was completed. A review of resident medical diagnoses indicated the facility admitted Resident #90 with diagnoses of dementia and diabetes. The quarterly Minimum Data Set with an Assessment Reference Date of 08/14/2024 revealed Resident #90 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident was cognitively intact. A review of Resident #90's medical records revealed no completed discharge summary was present. During an interview with the Director of Nursing (DON) on 12/11/2024 at 11:00AM, the DON stated that the discharge summary was not completed for Resident #90.

Based on observations, interviews, record review, and facility document review, it was determined that the facility failed to ensure a resident was in the proper position for consuming a meal while in bed for 1 (Resident #13) of 1 resident reviewed for proper positioning during meal consumption. The findings include: On 12/12/2024 at 11:55 AM, the Director of Nursing (DON) stated the facility did not have a policy for positioning during meal consumption. A review of the Medical Diagnosis, indicated the facility admitted Resident #13 with diagnoses that included dementia, dysphagia (difficulty swallowing), gastrointestinal hemorrhage (bleeding of the digestive tract), and gastro-esophageal reflux disease with esophagitis (a condition in which stomach acid repeatedly flows back up into the tube connecting the mouth and stomach). The quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 09/03/2024, revealed Resident #13 had a Staff Interview for Mental Status (SAMS) score of 3 which indicated the resident was severely impaired for daily decision making. Resident #13 was dependent with bed mobility. A review of Resident #13's Care Plan, revised on 12/18/2023, revealed Resident #13 had potential risk for complications related to deficits in self-care activities of daily living and preferred to stay in bed most days. Interventions included substantial assistance with all bed mobility which included lying to sitting and dependent assistance of one staff member with eating. During an observation on 12/09/2024 at 12:53 PM, Resident #13 was lying in bed with the over-the-bed table across the bed. Resident #13 was down in the bed, unable to see what was on the table. A plate of pureed food was sitting in front of Resident #13 and had not been eaten. Resident #13 stated I'm not too hungry right now. During an observation on 12/10/2024 at 8:16 AM, Resident #13 was lying in bed with the head of the bed elevated approximately 30 degrees, a breakfast tray was on the over-the-bed table which was across the resident. Resident #13 was not upright in the bed with the resident's head barely above the over-the-bed table and the resident could not see what was on the table. During an interview on 12/10/2024 at 8:25 AM, the Certified Nursing Assistant (CNA) #5 confirmed that Resident #13 should not be down in the bed when asked if Resident #13 was in the correct position to eat. During an interview on 12/10/2024 at 2:22 PM, the Director of Nursing (DON) confirmed that Resident #13 should have been pulled up in the bed and someone should have assisted the resident with eating. The DON stated that being down in the bed could lead to choking.

Based on observations, interviews, record review, and facility document review, it was determined that the facility failed to ensure resident received the correct physician ordered diet for 1 (Resident #13) of 1 resident reviewed for therapeutic diet. The findings include: On 12/12/2024 at 11:31 AM, the Director of Nursing (DON) stated the facility did not have a policy regarding checking meal trays prior to serving. A review of the Medical Diagnosis, indicated the facility admitted Resident #13 with diagnoses that included dementia, dysphagia, gastrointestinal hemorrhage, and gastro-esophageal reflux disease with esophagitis. The quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 09/03/2024, revealed Resident #13 had a Staff Interview for Mental Status (SAMS) score of 3 which indicated the resident was severely impaired mental cognition and indicated Resident #13 was on a therapeutic and mechanically altered diet. A review of Resident #13's Care Plan, revised on 11/16/2023, revealed Resident #13 was at risk for potential nutritional problem inadequate protein/caloric intake related to disease progression and decreased nutrient intake. Interventions included providing and serving a low concentrated sweets (LCS) diet with pureed texture. A review of the Order Summary Report, revealed Resident #13 had an order for LCS diet with pureed texture, and regular consistency liquids. During an observation, on 12/10/2024 at 8:19 AM, Resident #13 was observed with a plate of food on the over-the-bed table, in front of the resident. The eggs appeared lumpy, the meat was grainy in appearance, and the cereal was glazed over. There was a spoon in the eggs and a spoon in the meat. No one was assisting Resident #13 with eating. Resident #13's tray ticket for the meal called for LCS Pureed. During an interview on 12/10/2024 at 8:25, Certified Nursing Assistant (CNA)#5 stated Resident #13's food was pureed. CNA #5 confirmed the meat was grainy in appearance and the eggs were regular scrambled eggs when CNA #5 turned the food over with the spoon. CNA #5 stated Resident #13's roommate had gotten a tray early that morning due to an appointment and that dietary had sent a tray for Resident #13 as well. CNA #5 stated, we are about to go get another tray. During an interview on 12/10/2024 at 10:47 AM, the Certified Dietary Manager/Kitchen Director (CDM/KD) confirmed that the meat appeared to be minced, and the eggs were regular scrambled eggs. During an interview on 12/10/2024 at 2:22 PM, the Director of Nursing (DON) stated the meat appeared to be minced and the eggs from the meal tray of Resident #13 appeared to be regular scrambled eggs. The DON stated the nurses, CNAs or resident assistants (RAs) were responsible for making sure the right diet and consistency were served to the residents when passing out meal trays.

Based on observation, record review, interview, and facility policy review, the facility failed to ensure the 200 Hall Soiled Utility door was locked to prevent resident access to dirty linens and trash, failed to ensure the 200 Hall Linen Closet door was locked to prevent resident access to linens, and failed to prevent clean laundry items from resting against the floor to prevent cross contamination. The facility also failed to ensure appropriate hand hygiene was performed during perineal care for 1 (Resident #20) of 1 sampled resident, and during meal service to prevent cross contamination and the risk for infection. The findings include: 1.a. On 12/09/2024 at 11:35 AM, the Soiled Utility door on 200 hall was found to be open despite a push button lock, and sign stating Soiled Utility please keep door closed. b. On 12/09/2024 at 01:38 PM, Registered Nurse (RN) #2 revealed the Soiled Utility door should be locked to prevent residents from going inside because it contained dirty linens and trash that they would not want the residents to have access to. It is an infection control issue, stated RN #2. 2.a. On 12/09/2024 at 01:33 PM, the Linen Closet door on 200 hall was found to be open despite a push button lock. There was a folded towel, wash cloth, pillow care, and lift pads resting on the floor. b. On 12/09/2024 at 01:34 PM, RN #2 identified lift pads, folded blanket, washcloth and pillowcase resting on the floor. Rn #2 stated, It is unsanitary. The surveyor asked RN #2 who was responsible for the linen closet. RN #2 stated, Laundry stocks it, but aides are in and out getting supplies. Anyone that gets something from this closet is responsible for making sure nothing is on the floor. It is an infection control issue. c. On 12/10/2024 at 02:10 PM, during an interview the Director of Nursing (DON) was asked what the procedure was for maintaining the Soiled Utility room and Linen Closet on 200 Hall outside the closed unit. The DON confirmed that the linen and supply closets should remain locked to prevent residents ' access to the dirty linens and trash in the Soiled Utility room. The surveyor asked if it was appropriate for linens and clean lift pads to touch the floor or be on the floor of the Linen closet. The DON confirmed that linens and lift pads should not rest on the floor and resident access to dirty linens and trash were infection control issues. The DON confirmed that lift pads were sent to the linen closet in a bag and the bag should be hung on the hook in the linen room to prevent pads from touching the floor because it is an infection control issue. The surveyor requested any in-services and policies and procedures on storing linen and resident access to dirty linens or trash. d. 12/11/24 09:25 AM, The DON provided education titled July 2024 Education, revealing when linens are taken off the cart, they should be placed in a bag to keep them from being soiled. If any linens touch the floor without a barrier, they are considered dirty and should be sent to the laundry. Nothing should be placed on the floor even if it is in a bag. Education, dated 09/2024, revealed if any linens, including resident clothing, touch the floor, they were to be sent to the laundry. The DON did not have a policy addressing linen and trash storage, and stated she provided the education piece. 3. A review of Medical Diagnosis revealed Resident #20 had diagnoses of psychosis, anxiety, and arthritis. The quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 09/10/2024, revealed a Staff Assessment for Mental Status (SAMs) indicating Resident #20 had memory problems. Section H0300, and H0400 suggest Resident #20 was always incontinent of bowel and bladder. a. On 12/09/24 01:50 PM, Certified Nursing Assistant (CNA) #4 was observed picking up a package of wipes and pulling out one wipe at a time, using both hands, while providing peri care to Resident #20's perineal area and buttocks. CNA #4 did not perform hand hygiene between holding the package of wipes and pulling out clean wipes. b. On 12/09/24 01:55 PM, CNA #4 was asked the process for removing gloves and maintaining good hand hygiene when removing wipes. CNA #4 stated that the wipes get stuck, and she must grab onto the bag with one hand and use the other to pull them out with a shake, and confirmed the wipes are not clean if hand hygiene is not performed before pulling wipes from the package during peri care. c. During an interview on 12/11/24 at 11:15 AM, the DON was asked what process staff were expected to use during perineal care to ensure wipes were used in a manner that promotes good hand hygiene. The DON stated that staff are trained to pull out multiple wipes before peri care, when their gloves are clean, and to place wipes on a clean barrier so staff are not grabbing clean wipes with a dirty hand during peri care, because that is an infection control issue. The surveyor asked for in-services and policies and procedures for perineal care. d. On 12/11/24 at 01:00 PM, the DON provided an in-service titled Hand Hygiene, date range 01/01/2024-12/11/2024 which revealed gloves help reduce the spread of organisms and must be worn properly when there is a risk of contact with infectious material. Change gloves when visibly soiled with body fluids, or changing from a contaminated to a clean body site. e. On 12/11/24 at 03:47 PM, the Infection Preventionist (IP) provided a policy titled Hand Washing Technique, revealing handwashing was the most important way to prevent the spread of disease, and staff should perform hand hygiene when going from a contaminated body site to a clean body site. Policy titled Infection Prevention and Control Plan, revealed healthcare workers, visitors, and others in a healthcare environment can be protected when education emphasizes hand washing. 4. A review of a facility policy titled, Hand Washing Technique, revised in April 2009, indicated that handwashing was important in preventing the spread of infections and that hand washing facilities were conveniently located throughout the facility and that approved antimicrobial soaps and alcohol-based hand rubs were also available in all the appropriate areas. During an observation on 12/10/2024 at 8:00 AM, Licensed Practical Nurse (LPN)/Staffing Coordinator (SC) started serving the breakfast meal in the dining room on 400 hall. The LPN/SC did not sanitize hands prior to serving the first tray from the meal cart. At 8:03 AM, the LPN/SC went to the meal cart and got another tray and did not sanitize hands prior to serving the tray to the resident, unwrapped the silverware and set the tray up. Then LPN/SC left the dining room, went across the hall, and returned to the dining room holding two milk cartons. At 8:06 AM, the LPN/SC went back across the hall for more milk and returned to the dining room holding a disposable cup and gave the cup to a resident. After delivering the cup, the LPN/SC went to the meal cart, did not sanitize hands, and got another tray to deliver. During an interview on 12/10/2024 at 9:30 AM, the LPN/SC confirmed that hands were not sanitized prior to serving trays and in between residents. The LPN/SC stated, I couldn't find any, then I finally saw it on top of the cart after I had already served the trays. During an interview on 12/11/2024 at 10:32 AM, the Director of Nursing (DON) confirmed that hands should be washed, or hand sanitizer used between residents/trays. When asked what the importance of hand sanitation was, the DON stated, for infection control.

49071 Based on interview and record review, the facility failed to ensure a request for Level ll Preadmission Screening and Resident Review (PASRR) was completed and referred to the appropriate state agency for 2 Residents (Resident's #33 and #67), of 45 residents who had a negative Level 1 pre-screen who was later identified with a newly evident serious mental disorder. The findings are: 1. Resident #33 had an admitted [DATE] to facility with no mental health diagnosis and an Arkansas Pre-Admission Screening Mental Illness/Mental Retardation-Level 1 Identification Screen (DMS-787) completed by the facility Admission Coordinator. a. On 11/28/23 at 2:39 AM, the Administrator provided documentation of Pre-Admission Screening form 787 dated 3/9/2016 which documented, No on all sections of identification questions. b. Resident #33 received a diagnosis of Post Traumatic Stress Disorder (PTSD) on 6/21/2018 documented in the electronic medical record with a note created on 10/12/21. c. A Diagnosis/History form dated 4/18/16 showed a diagnosis of mood disorder due to known physiological condition with depressive features with an onset date of 3/9/2016. d. A Minimum Data Set (MDS) with an Assessment Review Date (ARD) of 9/25/2023 documented Yes under section I Psychiatric/Mood Disorder for Anxiety Disorder, Depressive Disorder, and PTSD. Section N0410 documented Resident #33 had received an antidepressant for the past 7 days since admission. 2. Resident #67 admitted on [DATE] with no mental health diagnosis and an Arkansas Pre-Admission Screening Mental Illness/Mental Retardation-Level 1 Identification (DMS-787) completed by the facilities Admission Coordinator dated 10/30/23. a. Resident #67 received a new bipolar disorder diagnosis documented in the electronic records dated 11/10/23. b. On 11/29/23 at 2:45 PM, the Surveyor asked the Admission Nurse, when is a PASSR completed? The Admissions Nurse stated, Upon Admission and if they have a new mental health diagnosis, we do a Level 1. The Surveyor asked if Resident #67 received a new mental health diagnosis after admission, and was a new application submitted to State Designated Professional Associates . The Admissions Nurse stated, No, I wasn't aware that I was supposed to send one in for a Level II after they received a new diagnosis after they were admitted . c. On 11/29/23 at 3:15 PM, the Administrator informed the Surveyor that the facility did not have a PASSR policy.

Based on observation, interview and record review, the facility failed to ensure nail care, and personal hygiene was provided on a regular basis to prevent injury, infection, or cross contamination for 2 Residents (R #17 and R #64). Findings follow: 1. On 11/29/23 at 8:59 AM, the Surveyor observed R #17 fingernails to be approximately 1/4 - 1/2 inch past the fingertips with brown colored substance visible underneath nails on both hands. The Surveyor asked R #17 if he liked his nails, the way they were. R #17 answered, No, they are long and need to be cut. I need a bath. The Surveyor asked R #17 when his last bath was. R #17 answered, I'm not sure but it was a week ago this past Monday (11/27/23). The Surveyor asked if it had been 10 days or more since the last bath. R #17 answered, Yes, I think so. The Surveyor asked R #17 if he told anyone his nails needed to be trimmed and he needed a bath. R #17 stated, Yes, I'm supposed to get a bath today. Maybe they will do them when I get my bath. a. On 11/29/23 at 11:10 AM, the Surveyor observed R #17 had not had a shave. Nails remained the same length with brown substance visible under fingernails. b. On 11/29/23 at 2:48 PM, the Surveyor asked R#17 if he had gotten his bath yet, or his nails cleaned and trimmed. R #17 answered, no. c. On 11/29/23 at 2:50 PM, the Surveyor asked Certified Nursing Assistant (CNA) #1 if Resident # 17 had gotten a shower, and what his shower schedule was. CNA #1 stated, No, I addressed that this morning with the shower aide. The Surveyor asked CNA #1 if R #17 had set days that he was supposed to get showers, shaves, and nail care. CNA answered, I don't know. He wasn't on the list. I [the shower aide] have to find out when they are going to do it. The Surveyor asked CNA #1 who was responsible for finding out when resident showers were and who made the shower schedule. CNA #1 stated, I don't know who makes the shower schedule. d. On 11/29/23 at 2:52 PM, the Surveyor asked CNA #1 to describe R #17's fingernails. CNA #1 stated, answered, They are dirty, and they need clipped. The Surveyor asked CNA #1 who was responsible for nailcare. CNA #1 answered, We are, the aides. e. On 11/29/23 at 03:02 PM, the Surveyor asked Licensed Practical Nurse (LPN) #2 what R #17 shower schedule was. LPN #2 answered, They are supposed to be offered a shower within the first 24 hours of admission. It looks like he had one on the 20th, and he refused on the 28th at 1:42 PM. The Surveyor asked what days R #17 was scheduled to have a shower. LPN #2 answered, Tuesday and Saturday. LPN #2 stated, All residents have the right to a shower all they have to do is ask for it on a prn [as needed] basis. The Surveyor asked LPN #2 if R #17 had asked for a shower. LPN #2 answered, I don't know but he refused it yesterday. The Surveyor asked if R #17 was told he could ask for a shower, and who is responsible for telling the residents that they have a right to a shower. LPN #2 answered, I don't know who or when. f. On 11/29/23 at 3:07 PM, the Surveyor asked the Director of Nursing (DON) to describe R #17's nails. The DON answered, They need some attention. They need cleaned, and they need cut. The Surveyor asked who was responsible for nail care for residents. The DON answered, The Certified Nurse Assistants (CNA's) do nail care. If Diabetic the nurses and the wound care nurse, does it. 2. On 11/27/2023 at 11:15 AM, the Surveyor observed R #64 in room with 1/2-inch nails on both hands with dark brown substance under nails. a. On 11/27/2023 at 3:10 PM, the Surveyor observed R #64 with 1/2 inch nails on both hands with brown substance under nails on both hands. b. On 11/28/2023 at 8:15 AM, the Surveyor asked R #64 with long 1/2 inch nails on both hands and brown substance under the nails. Surveyor asked the resident, does the facility staff clean and cut your nails and resident stated, not very often. c. On 11/29/2023 at 2:25 PM, the Surveyor interviewed LPN #1, how often do the residents receive nail care? LPN #1 stated Monthly or some have orders for every 2 weeks. The Surveyor asked who is responsible for making sure nail care is done? LPN #1 stated, The CNA's do the non-diabetic residents, and the nurses do the diabetics. The Surveyor asked should brown substance be under the resident's nails for several days? LPN #1 replied, no it should not. d. On 11/29/23 at 2:37 PM, the Surveyor interviewed Director of Nursing (DON) and asked how often nail care is provided to the residents? The DON stated, Every 14 days or as needed. The Surveyor asked who is responsible for making sure that nail care is done/ The DON stated, The CNA's are for the residents who are not diabetic and the nurses do the diabetic residents. The Surveyor asked should there be brown substance under resident nails for several days DON stated, No it should not. e. On 11/29/23 at 3:15 PM, the Administrator informed the surveyor that the facility did not have a nail care policy.

Based on observation, interview and record review, the facility failed to date and contain oxygen tubing, nebulizer tubing, and date and contain Continuous Positive Airway Pressure (CPAP) tubing, mask, and connectors for 4 Residents (Resident #17, #33, #60, and #239) receiving oxygen/respiratory therapy to prevent cross contamination and infection. The findings are: 1. On 11/27/23 at 10:39 AM, the Surveyor observed Resident #17 with a CPAP machine on the night stand next to the Resident's bed. The Bilevel Positive Airway Pressure (BIPAP) mask was not contained and sitting on nightstand. There was oxygen tubing connected to the wall unit which was undated. The Surveyor asked Resident #17 how often he used the CPAP machine. Resident #17 stated, I use it every night. a. On 11/28/23 8:27 AM, Resident #17's oxygen tubing was bagged, but not dated. There was a green sticker lying on nightstand beside machine dated 11/27/23 that was not attached to any tubing or oxygen equipment. b. On 11/29/23 at 8:59 AM, Resident #17's masks are bagged, but the oxygen tubing was not dated. The Green sticker remained on the nightstand next to the CPAP machine. The CPAP Tubing was not bagged and on the floor. c. On 11/29/23 at 11:10 AM, Resident #17's CPAP tubing was unbagged, the connector tube was lying on the floor and the green sticker with the date of 11/27/23 remained lying on the nightstand next to the CPAP machine. d. On 11/29/23 at 3:10 PM, the Surveyor accompanied the DON to R#17 asked the DON if Resident #17's oxygen tubing, CPAP mask, and tubing should be contained and dated. The DON answered, That mask is hanging on the flow meter, and it should be in a bag. Yes, it gets changed weekly so it should be dated. The Surveyor asked the DON to look at both sets of tubing and read the date. The DON answered, I don't see a sticker. e. 11/29/23 3:12 AM, The Surveyor asked the Certified Respiratory Therapist (CRT) if the oxygen and CPAP tubing should be bagged and dated. The CRT answered, No, it's all contained and doesn't come into contact with his face or nose like a cannula. The Surveyor asked if the connector tubing that attached to the resident's mask and CPAP machine that was on the floor should be contained. The DON stated, The end of the tubing was on the floor. The CRT answered, Oh, I'm so sorry, I'm going to change that now and I'll get shorter tubing. The Surveyor asked the CRT which tubing the green sticker lying on the nightstand that was dated 11/27/23 was pertaining to since it wasn't attached to anything. The CRT stated, He doesn't need that because he's not on a cannula. f. 11/29/23 3:53 PM, the Surveyor asked how the green sticker got on the nightstand in Resident #17's room. The CRT answered, I put that there because I thought he had a cannula, but he didn't. The Surveyor asked the CRT if the green stickers were put on all of the oxygen tubing on Tuesday (11/28) that were dated 11/23/23. The CRT answered, Yes, but I'm going to change that tomorrow. The Surveyor clarified that the tubing and stickers were not changed last week. The CRT answered, No, I wasn't here last week. I had already predated the stickers and just put them on Tuesday (11/28/23). 2. Resident #33 had MD orders dated 10/31/23 documenting, Oxygen: change oxygen tubing, supplies and oxygen interface and attach green sticker with date weekly and as needed, every day shift every Thursday, and as needed soiled, damaged. and .make sure oxygen accessories in bag: make sure cannulas, updraft, BIPAP, CPAP, and Trilogy items are in the Respiratory bag when not in use. a. On 11/28/23 at 8:41 AM, the Surveyor observed Resident #33 O2 tubing with nasal cannula hanging over bedpost, and not contained. The Surveyor asked Resident #33 when the oxygen tubing was changed on the concentrator. Resident #33 stated, They changed the oxygen tubing today. The Surveyor observed a green sticker on the tubing dated 11/23/23. b. On 11/28/23 at 9:00 AM, A green sticker was on the tubing connected to Resident #33 ' s concentrator dated 11/23/23. c. On 11/28/23 at 10:59 AM, the Surveyor observed Resident 33's O2 tubing and nasal cannula laying over the top of bedpost with the nasal prongs in contact with the outside of the right wheel of Resident #33's wheelchair. There was no bag for tubing observed in the room. d. On 11/29/23 at 3:00 PM, the Surveyor observed the oxygen tubing in a bag hanging on the flow meter of the concentrator. The green sticker on the tubing was dated 11/23/23. 3. On 11/27/23 at 10:28 AM, the Surveyor observed oxygen and nebulizer tubing dated 11/16/23 for Resident #60. a. On 11/27/23 at 2:28 PM, the Surveyor observed oxygen and nebulizer tubing dated 11/16/23 for Resident #60. 4. On 11/27/23 at 10:36 AM, the Surveyor observed oxygen and nebulizer tubing was not dated for Resident #230. a. On 11/27/23 at 2:26 PM, the Surveyor observed that oxygen and nebulizer tubing was not dated for Resident #230. b. On 11/29/23 at 2:30 PM, the Surveyor interviewed Licensed Practical Nurse (LPN) #1, who is responsible for dating and changing the oxygen and nebulizer tubing. LPN #1 stated, The Respiratory Therapist or if she isn't there the nurses do it. The Surveyor asked according to your policy how often should the tubing be changed and dated? LPN #1 stated, Weekly or more often if needed. The Surveyor asked what could the outcome be if the oxygen tubing isn't changed weekly? LPN #1 stated, respiratory infection. c. On 11/29/23 at 2:36 PM, the Surveyor interviewed the DON, who is responsible for making sure oxygen and nebulizer tubing is changed and dated? The DON stated, Respiratory Therapist or nurses. d. On 11/29/23 at 3:15 PM, the Administrator informed the Surveyor that the facility did not have a respiratory or oxygen policy.

Based on record review, and interview, the facility failed to ensure that transfers were conducted according to manufacturer's guidelines to decrease the potential for injury for 1 (Resident #1) of 3 (#1, #2, #3) sampled residents who were dependent on mechanical lifts for transfers. This had the potential to cause more than minimal harm to 38 residents who required a lift for transfers, according to a list provided by the Administrator [DATE] at 10:50am. This failed practice resulted in past non-compliance Immediate Jeopardy for Resident #1, who was transferred with a mechanical lift which overturned during the transfer resulting in a fall. The Administrator was notified of the past non-compliance Immediate Jeopardy on [DATE] at 3:52pm. The findings are: 1. Resident #1 had diagnoses of Spastic Hemiplegic Cerebral Palsy and Morbid Obesity. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE] documented the resident scored 15 (,d+[DATE] indicates cognitively intact) on a Brief Interview for Mental Status (BIMS) and required extensive assistance with bed mobility, transfers, dressing, and toileting, and total assistance with bathing. a. The Comprehensive Care Plan with an initiation date of [DATE] indicated Resident #1 required the use of a mechanical lift for all transfers. b. An Office of Long-Term Care (OLTC) Witness Statement form dated [DATE] written by Certified Nursing Assistant (CNA) #2 at 1:00 pm documented, . CNA #1 and I were getting Resident #1 for her shower, when we got her in the lift it died , and we were transferring back to the bed when the lift started tipping and we gently as possible lowered her to the floor to avoid injury. The legs on the lift were closed as to fit it under the bed . c. An OLTC Witness Statement form dated [DATE] written by CNA #3 at 1:00pm documented, .I was about to go in a resident's room and [CNA #1] yelled saying they need me in Resident #1's room. I go in there and she's in the floor and the lift is on its side. I run and grab LPN #1 [Licensed Practical Nurse] (my nurse on the hall) they tell us the battery was dead and the lift tipped over. They said the legs on the lift were closed under the bed. LPN #1 calls LPN #2 and me and LPN #1 get the lift pad unhooked because it's squashing and hurting her . d. An OLTC Witness Statement form dated [DATE] written by LPN #1 at 1:15pm documented, .This nurse was called to resident room by CNA who yelled Hurry, help we need you now! This nurse took off with CNA to the resident's room. Upon entering the resident's room, I found the resident in the lift in the floor with the lift flipped on its side. This nurse noticed the lift legs were together (closed) and asked the CNAs why the legs were closed, and they stated, Because we were moving her out from under the bed. This nurse stated, It does not matter the legs have to be open and the CNAs stated, It was under the bed. This nurse began removing the lift pad from the hooks to release the resident and the CNAs began to help. This nurse called the other LPN to the room STAT [Urgent] who also called the DON (Director of Nursing) and the Administrator. All staff in the room got the resident back in lift properly with a new charged battery and got resident back in bed. Resident denies any pain at this time and refuses to go to ER [emergency room ]. APN #1 [Advance Practice Nurse] contacted by this nurse who stated to start neuros [neurological checks] and if resident starts c/o [complaining of] pain send her to ER or X-Ray . e. An OLTC Witness Statement form dated [DATE] written by CNA #1 at 1:35pm documented, .We were transferring Resident #1 back to her bed cause the lift died on us in the middle of the transfer the lift fell over but me and CNA#2 were lowering her to the floor along with the lift she did not hit the floor we got her to floor safely and we yelled for help . (Checked) f. On [DATE] at 13:48 [1:48]pm, An I and A [Incident and Accident] report documented, .This nurse was standing at medication cart at 400 Hall nurses' station when CNA began yelling Hurry, help we need you, NOW! this nurse took off to resident room with the CNA. Upon entering resident room this nurse found resident in floor, in the lift pad connected to lift, lift completely over on its side, two they got this nurse. This nurse asked what happened and why the lift legs were closed. CNAs stated, Because we were moving her out from under the bed. this nurse stated, It does not matter the legs have to be open. The CNA replied It was under the bed. This nurse began removing lift pad from lift hooks with help of CNAs to release resident. This nurse called the other LPN who came down to assist. Other LPN notified DON and the Administrator. All staff mentioned came to room and assisted to get resident back in lift properly with charged battery. Resident was assisted correctly in lift from floor to bed. Resident denies any pain at this time and refuses to go to ER to be evaluated. This nurse contacted [APN #1] who ordered to start neuro checks and stated if resident later c/o [complained of] pain send to ER or get order for X-Ray. Resident is stable at this time, redness noted to left inner breast. BP [Blood Pressure] ,d+[DATE] temp [temperature] 97.9 pulse 88 02 [oxygen] @ [at] 90% [percent] Resident Description: Resident stated, 'The lift tipped over and then I was on the floor. Intervention: One on one education on proper use of mechanical lift with specific CNAs involved, facility wide written education provided regarding proper use of lifts, one on one competency check offs completed with involved CNAs and all direct care staff . g. An OLTC Witness Statement form dated [DATE] written by LPN # 2 at 1400 (2:00pm) documented, . Resident #1 incident statement: Resident stated CNAs lifted her up in lift. The lift started to tilt. CNAs attempted to stop the lift from fall over. Resident stated assistants discussed calling for help but didn't because they didn't want to get in trouble. Resident then stated the lift went to the ground and the CNAs assisted her decent. Then the assistants called for help . h. An Incident and Accident Next Day Reporting form 7734 with a fax date and time of [DATE] at 4:50pm documented, .Resident #1 was being transferred from the bed to the shower stretcher via mechanical lift by two CNAs and the battery quit working and the lift started to overturn. The resident was assisted to the floor, still in the sling and sling was intact on the lift. No injury noted . i. Form DMS-762, page 4, signed by the Administrator on [DATE] (no time) documented, .Upon notification of incident the resident was assisted back to the bed using the mechanical lift and several staff members. The two assistants, [CNA#1] and [CNA#2] were pulled to the DON office for interview and the assistants reenacted the transfer. During reenactment it was identified that the assistants did not have the legs of the lift completely open. The assistants were immediately in-serviced, and observation made by Clinical Educator using another LPN to ensure the assistants properly completed a mechanical lift transfer. Upon investigation, it was identified the bar under the bed potentially prevented the legs of the lift to open completely. The Clinical Educator did an audit on the beds to ensure no bars are obstructing under the bed for a mechanical lift to be inserted properly. A Work Order was completed by the DON for the Maintenance staff to check all batteries to ensure each one will charge. Staff in-service sent out to ensure batteries are charged prior to using the mechanical lift. The Clinical Educator and Clinical staff ensured all staff completed mechanical lift competency check offs . j. On [DATE] at 10:12am., Resident #1 was lying in her bed. The Surveyor introduced herself and requested an interview. She agreed. The Surveyor asked her how long she has resided in the facility. She replied, I've been here about 4 ,d+[DATE] years. The Surveyor asked if she could explain the incident involving the mechanical lift. She replied, The two little girls didn't know what they were doing. They almost had me on the stretcher and the battery went out. They were going to put me back in the bed. That girl said, This thing is hard to roll. They didn't have the legs open on it and it tipped over. I fell half-way on this bed (while pointing to the mattress) and half-way on the floor. I slid off the bed and landed in the floor. They didn't get help until I was on the floor. They never opened the legs on the lift. The Surveyor asked, Did anyone assist you to the floor? She replied, No, they never touched me. They claim I hit my head, but I didn't. I saw that bar and I moved my head when I was going down. She was pointing to the underside of the bed and the Surveyor asked, Are you talking about the bed frame that the mattress is lying on? Resident #1 replied, Yes. The Surveyor asked, What happened next? She replied, They left me lying there naked and went and got help. The Surveyor asked, They both left you? She replied, No. One of them stayed with me. Then, a bunch of them showed up. They got me unhooked, went and got another battery for the lift and used the lift and got me back in bed. The Surveyor asked, Were you hurt? She replied, No, I wasn't hurt. She became tearful and stated, I heard one of them say, Good thing she had plenty of cushion. They weighed me later and I weighed 348 pounds. They are using a different lift on me now. k. On [DATE] at 8:15am., the Administrator provided documents titled, . [named lift] .Operating Manual . which documented on page 25, Base Adjustment: The base of the [named lift] should be open to its widest position for all transfers . l. On [DATE] at 8:39am., the Surveyor requested to see the lift that was used during the transfer. The DON brought the lift and on it were laminated instructions titled, Full Mechanical Lift Information and Sling Sizing Information which documented on the last page, .The base of the [named lift] should be open to its widest position for all transfers . m. On [DATE] at 2:09pm., the Surveyor asked LPN #1 to describe the events which occurred regarding the lift turning over with Resident #1 during a transfer. She explained, CNA #3 called me to the room. The lift was on its side, and Resident #1 was still in the lift pad on the floor. The lift pad was still connected to the lift. I noticed the legs were closed on the lift and I said, Why are the legs closed, the legs are supposed to be open. They [CNA #1 and CNA #2] said the battery went dead when they were transferring to the shower stretcher, so they were moving her back to bed. They said they closed the legs so they could get the lift to go under the bed. I told them The legs are always supposed to be open when you have someone in the lift. The Surveyor asked, Was the resident injured during the incident? LPN #1 replied, She had a discoloration on her left breast toward the inside where the lift was on her. The Surveyor asked, Do you use the lift much? She replied, I help the CNAs sometimes. The Surveyor asked, How did you know the legs on the lift should be open during transfers? She replied, Because I was a CNA for five years before I became a nurse. The legs have to be open. n. On [DATE] at 2:34pm., the Surveyor asked CNA #3 to describe the events that occurred regarding the lift turning over with Resident #1 during a transfer. She explained, I was walking down the hall when [CNA #1] said, We need help. When I went into the room, the resident was in the floor and the lift was turned over. I went and got [LPN #1]. We pulled the lift off of the resident, it was pressing into her skin where the lift pad was connected. Her body was under the edge of the bed a little bit. The Surveyor asked, What did you hear being said when the nurse entered the room? She replied, The CNAs were arguing with the nurse about the legs being closed on the lift, like they were supposed to be closed to get the lift to go under the bed. The Surveyor asked, How should the legs on a lift be positioned when transferring a resident? She replied, Open at all times. The Surveyor asked, What should you do if there is limited space to accommodate the lift legs being open? She stated, Move objects to create room for the transfer. o. On [DATE] at 9:40am., the Surveyor asked LPN #3 2 if he witnessed any of the events that occurred when the lift tipped over with Resident #1. He explained, No, but I went to talk to her [Resident #1] afterward. She wouldn't talk with anyone else about it. The Surveyor asked, What did she say happened? He asked if he could look at his witness statement to recall the conversation. He read his witness statement and replied, She told me that she was in the lift and that it tipped over. She said she hit the bed and the floor. She said that the assistants talked about how were afraid they were going to get into trouble. The Surveyor asked, What position should the legs on the lift be in when transferring a resident? He replied, The instructions are right on the lift. You leave them open. p. On [DATE] at 10:08am., the Surveyor asked CNA #1 how long she had been a CNA. She stated, Seven years. The Surveyor asked her to describe the incident that occurred when the lift tipped over with Resident #1. She explained, We were going moving her from the bed to the shower stretcher when the battery died on the lift. She wasn't up high enough to get her on the shower stretcher, so we were having to put her back in bed. She was about halfway over the bed when the lift started tipping over. I have always been taught the legs had to be closed to get the lift under the bed, so the legs were closed. The Surveyor asked, Have you had any training on the proper use of the lift during a transfer? She replied, Yes, we had to come to the DON office immediately after and were checked off on the lift. The Surveyor asked, Did you have any training during the hiring process? Were you checked off on using the lift? She replied, No. q. On [DATE] at 10:25am., the Surveyor asked CNA #2 to describe the incident involving Resident #1 when the lift tipped over. She explained, We were transferring her [Resident #1] from bed to bath stretcher when the lift died . She wasn't up high enough to get her on the stretcher and the lift wouldn't go up any higher because the battery was drained. I had a hold of the lift pad and [CNA #1] was operating the lift. She closed the lift legs and the weight shifted and the lift tipped. I was on the other side of the bed holding on to the lift pad guiding the resident when it tipped and started going to the floor. That's how I assisted the resident to the floor. She was halfway over the bed and when the lift tipped, I still had a hold of her, and she slowly slid off the bed onto the floor. The Surveyor asked, Have you received any training on using the lift? She replied, Yes, immediately after this occurred, we were checked off on using the lift. The Surveyor asked, In what position should the legs of the lift be when transferring the resident? She replied, Always open. r. On [DATE] at 11:22am., the Surveyor asked the DON to describe her experience during the incident involving the lift tipping over with [Resident #1]. She explained, When I made it to the room, the resident was lying in the floor by the bed still in the sling. There was a sheet over her. We assessed her and she denied injury. We unhooked her and repositioned the lift upright. We used the lift to transfer her back to bed. She refused to go to the ER. The staff was saying that the lift battery went dead, and they were trying to get her back in bed when the lift overturned. The Surveyor asked, What position are the legs on the lift supposed to be in when transferring a resident? She stated, Open. The Surveyor asked, Why? She replied, To increase your center of gravity and decrease the likelihood to tip. s. On [DATE] at 12:41pm., the Surveyor asked the Administrator for a policy on transferring the residents and was told that she does not have a policy for that.

Based on observation, record review, and interview, the facility failed to ensure 1 of 3 ice scoop holders and 1 of 3 ice machines were maintained in a clean and sanitary condition to prevent potential contamination of residents' beverages for residents who received meals from 1 of 1 kitchen; failed to ensure foods stored in the freezer, refrigerator and dry storage area were covered, sealed, and dated to minimize the potential for food borne illness for residents who received meals from 1 of 1 kitchen; failed to ensure 1 of 3 ice scoops and 1 of 3 ice machines were maintained in a clean and sanitary condition to prevent potential contamination of residents' beverages for residents who received meals from 1 of 1 kitchen; expired food items were promptly removed/discarded by the expiration or use by dates, and foods were dated when received to assure first in first out usage to prevent potential for food bone illness, and dietary staff washed their hands before handling clean equipment. These failed practices had the potential to affect 93 residents who received meals from the kitchen (total census: 95) as documented on a list provided by the Registered Dietitian on [DATE]. The findings are: 1. On [DATE] at 10:43 AM, during the initial tour of the kitchen with the Registered Dietitian the following were observed: a. [DATE] 10:45 AM, The ice scoop holder attached on the right-hand side of the ice machine has brown sticky substance at the bottom of it. The Surveyor asked the Registered Dietician to wipe the residue settled at the bottom of scoop holder. She did, and the brown sticky residue easily transferred to the tissue. The Surveyor asked her to describe the contents at the bottom of the ice scoop holder She stated, It look like brown sticky residue. They are supposed to clean it daily. The Surveyor asked, does it look like it has been cleaned daily? She stated, Definitely not. b. On [DATE] at 10:46 AM, The ice machine panel had an accumulation of wet, pink residue on it. The Surveyor asked the Registered Dietician to wipe the residue on the panel of the ice machine with a tissue She did, and the wet, pink residue easily transferred to the tissue. The Surveyor asked the Dietician to describe the contents within the ice machine panel. She stated, It was pink residue. They are supposed to clean it weekly. The Surveyor asked, does it look like it has been cleaned every week? She stated, No, it doesn't look like it has been cleaned weekly. At 4:12 PM, The Surveyor asked Dietary Employee #1 who uses the ice from the ice machine? He stated, We put ice in the tea before we send them down with food at mealtimes c. On [DATE] at 10:49 AM, Dietary Employee #1 was wearing gloves on her hands. She opened the refrigerator door and removed a container of ham and a container of cheese and placed them on the counter by the stove. She untied the bread bag, removed slices of bread, and placed them on the tray. Without changing gloves and washing her hands, she removed slices of ham from the container and placed them on slices of bread to prepare sandwiches to serve to the residents who requested a sandwich with their lunch meal and placed them in dessert refrigerator. 2. On [DATE] at 10:51 AM, An opened container with the following food items were on the counter in the kitchen: a. An opened bag of hot dog buns with expiration date of [DATE]. b. An 8-count bag of hamburger buns c. Two unidentified items wrapped with foil. There was no date or food type written on the foil to indicate what was in the foil or when it was stored. The Surveyor asked the Registered Dietitian what was wrapped in the foil. She unwrapped them and stated, Hamburger buns. d. There were 5 individual open bags of diced bread with no date as of when they were stored. 3. On [DATE] at 10:54 AM, the leftover refrigerator contained the following food items that had no date when opened or received: a. Two containers of potato salad with no received date. b. A container of pimento cheese with no opened date. c. A container of tuna salad with no received date. 4. On [DATE] at 11:03 AM, The following food items in the walk-in freezer were not covered or sealed: a. Two boxes of Crispitos. b. Chicken breast. c. Chicken nuggets. d. One box of Hoagie buns. e. One box of bread sticks. 5. On [DATE] at 11:13 AM, The following were in the walk-in refrigerator: a. A container of leftover diced sausage documented, Stored [DATE] used by [DATE] was on a shelf in the walk-in refrigerator. b. Two boxes of protein and calorie powder had no received date. 6. On [DATE] at 11:35 AM, Dietary Employee #1 plugged the steam table into the wall socket. He pushed a trash can out of the way. Without washing his hands, he removed gloves from the glove box and placed them on his hands contaminating the gloves. He picked up a clean blade and attached it to the base of the blender to be used to puree food items for the residents who required mechanical soft or pureed diets. The Surveyor asked the Dietary Employee- what he should have done before he touched the clean objects and before he handled the clean equipment. He stated, I should have changed gloves and washed my hands. 7. On [DATE] at 3:32 PM Dietary Employee #3 removed individual containers of ranch dressing from a box and placed them on the salad plates for the residents who requested salad with their meal. The Surveyor immediately asked the Dietary Employee if it was okay to place a container of dressing out of a box on top of salad to be served to the residents. She stated, That's how I was trained. 8. The facility's policy for leftover food items documented, Leftovers are not to be more than 5 days old.

Based on interview and record review the facility failed to ensure an antianxiety medication was discontinued or reevaluated for use after 14 days for 2 (residents #58 and #90) of 13 (#3, #5, #6, #10, #22, #35, #50, #53, #57, #65, #72, #84 and #90) final sample residents who had PRN [as needed] antianxiety medications according to a list provided by The Assistant Director of Nursing on 09/14/22 at 10:56 AM. 1. Resident #58 had diagnosis of Anxiety. A Significant Change MDS [Minimum Data Set] with an Assessment Reference Date (ARD) on 7/28/2022 documented a SAMS [staff assessment for mental status of 1/1 [ short- and long-term memory loss]. Residents Care Plan with an initiated date of 10/21/2021, documented, . The resident uses antianxiety medications ([MEDICATION(S)] PRN [as needed]) r/t [related to] Anxiety, comfort care protocol, Date Initiated: 08/03/2022 . a. Physician's Orders for September 14, 2022 documented, .[MEDICATION(S)] Tablet 1 MG (milligrams) Give 1 tablet by mouth every 8 hours as needed for Anxiety, Pharmacy Active 7/22/2022 14:45 . b. Pharmacy recommendations dated 7/26/2022 documented a recommendation to discontinue or document their rational for continuing this medication due to its PRN status. No resolution or recommendation was identified on consultant report. On 9/14/2022 at 2:29 PM the DON stated, .we don't have anything for that . 2. Resident #90 had diagnosis of Generalized Anxiety Disorder. An Annual MDS with an ARD of 6/21/2022 documented a BIMS [Brief interview for Mental Status] of 14 [13-15 indicated cognitively intact]. Physician's September 14, 2022 Orders documented, .[MEDICATION(S)] Tablet 0.5 MG [milligrams] ([MEDICATION(S)]) Give 0.5 tablet by mouth every 24 hours as needed for agitation Pharmacy Active 8/20/2022 11:00 . Residents Care Plan documented, . The resident uses anti-anxiety medications ([MEDICATION(S)]) r/t Anxiety disorder Date Initiated: 12/13/2021 . a. On 09/14/2022 at 10:29 AM, Pharmacy consults reports reviewed, the current report dated 8/26/2022 had no recommendation of changing or discontinuing the antianxiety PRN medication after 14 days.

Based on observation, record review, and interview, the facility failed to ensure meals were prepared and served according to the planned written menu to meet the nutritional needs of the residents for 2 of 2 meals observed. This failed practice had the potential to affect 6 residents who received pureed diets, 7 residents who received mechanical soft diets from 1 of 1 kitchen according to a list provided by the Dietary Supervisor on 9/13/2022. The findings are: 1. On 9/ , the menu for the lunch meal documented residents who received a pureed diet were to receive a # 8 scoop (1/2 cup) of pureed pork roast and a # 8 (1/2 cup) of pureed peas. Mechanical soft diets were to receive 4 oz (ounces) pork roast. 2. On 9/12/2022 at 12:47 PM the following observations were made during the lunch meal service: a. Dietary Employee used #16 scoop to serve a single one serving of pureed green beans to the residents on pureed diets. b. On 09/13/22 at 7:56 AM, the Surveyor asked Dietary Employee what scoop size did you use to serve pureed green beans yesterday? She stated, The blue scoop which was #8 scoop. She immediately was informed by surveyor that blue scoop is #16 scoop and gray scoop is #8. She stated, I thought blue scoop was #8 scoop. That's how I was taught. 3. On 9/12/2022 The menu for the supper meal documented residents on regular diets, mechanical soft diets and pureed diets were to receive 1 cup of Swedish meat balls each, 1/2 cup of penne pasta and 1/2 cup of fried green beans and residents who received pureed diets were to receive 1 cup of pureed Swedish meat balls, 1/2 cup of pureed of pureed penne pasta and 1/2 cup of pureed fried green beans. a. On 9/12/2022 at 5:17 PM, the following observations were made during the supper meal service: i. Dietary Employee #1 used #8 scoop which is equivalent to 1/2 cup to served 3 Swedish meat balls with penne pasta to the residents on regular diets for supper meal. The menu specified 1 cup Swedish meat balls for each and 1/2 cup of penne pasta for each resident on regular diets. ii. Dietary Employee used a #16 (blue scoop) which is 1/4 cup to serve a single portion of pureed fried green beans to the residents on pureed diets. The menu specified 1/2 cup of pureed fried green beans. iii. Dietary Employee #1 used a #16 scoop to serve a single portion of pureed Swedish meat balls with penne pasta to the residents on pureed diets, instead of 1 cup as per the written menu. iv. Dietary Employee #1 used a #16 (blue scoop) equivalent to 1/4 cup to serve single portion of ground penne pasta with Swedish meat balls to the residents on mechanical soft diets. v. Dietary Employee #1 used a #16 scoop which is equivalent to 1/4 cup to serve a single portion of ground fried green beans to the residents who received mechanical soft diets, instead of 1/2 cup of ground fried green beans. vi. On 9/12/22 at 5:44 PM, The Surveyor asked Dietary Employee #1, how many meat balls did you serve to the residents? He stated, I gave them 3 meat balls with noodles.

Based on observation and interview, the facility failed to ensure pureed food items were blended to a smooth, lump-free consistency to minimize the risk of choking or other complications for residents who required pureed diets for 2 of 2 meals observed. This failed practice had the potential to affect 12 residents who received pureed diets, as documented on the Diet List provided by the Food Service Supervisor on 9/13/2022 at 2:40 PM. The findings are: 1. On 9/12/22 at 11:44 AM, A pan of pureed bread was on the steam table. The consistency of the pureed bread was thick, not smooth. 2. On 9/12/22 at 3:35 PM, Dietary Employee #1 used a 4 oz [ounce] spoon to place 12 servings of penne pasta with Swedish meat balls into a blender and ground. He poured half of the ground noodles with Swedish meat balls into a pan and stated, That's for moist soft. I have 5 residents on moist soft. He then, added 1/2 [half] cup of milk to the remaining ground noodles with Swedish meat balls and pureed. 3. On 09/12/22 at 3:40 PM, He poured the pureed noodle pasta into a pan and placed in the oven. The consistency of the pureed noodle with Swedish meat was lumpy, thick, not smooth. The Surveyor asked, how much of noodles with Swedish meat balls did you use? He stated, I put 12 servings. The other half is for puree diets. I am doing 10 pureed diets. 3. On 9/12/22 at 4:19 PM, Dietary Employee #1 used a 4 oz spoon and placed 11 servings fried green beans into a blender, added 1/2 cup of milk and pureed. At 4:22 PM, He scooped pureed fried green beans into a pan and placed it in the oven. The consistency of the pureed fried green beans was thick, not smooth. 4. On 9/12/22 at 4:28 PM, Dietary Employee #1 placed 16 slices of bread into a blender, added milk and pureed. At 4:37 PM, He poured the pureed bread into a pan and placed it on the steam table. The consistency was lumpy and was not smooth. Pieces of bread were still visible in the mixture. 5. On 9/12/22 at 5:30 PM, The Surveyor asked the Registered Dietitian to describe the consistency of the food items served to the residents on pureed diets. She stated, Puree fried green beans was too thick, pureed noodle with Swedish meat balls needed to be smooth. They shouldn't have lumps and pureed bread should have no lumps.

Based on Observation, interview, and record review the facility failed to ensure that during the 8:00 AM medication pass, manufacturers guidelines were consistently followed when administering insulin via a pen insulin device for 1 (Resident #51) resident. This failed practice had the potential to effect 4 (#49, #51, #65 and #91) sample residents who had physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The findings are: Resident #51 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] ., do not mix with other insulins, rotate sites ., Resident had new physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .[MEDICATION(S)] KwikPen Solution Pen-injector 100 UNIT/ML (Insulin [MEDICATION(S)]) Inject 55 unit subcutaneously in the morning ., do not mix with other insulins, rotate site. Prime pen prior to use 1.Resident #51's Care Plan with an initiated date of 10/21/2021, documented, .The resident has Diabetes Mellitus and [CONDITION(S)]. Refused therapeutic diet. Frequently eats sweet snacks, oversized portions, etc. Receives oral and injectable glycemic meds (scheduled and sliding scale insulin) Date Initiated: 10/18/2021 Revision on: 04/29/2022 ., Diabetes medication as ordered by doctor. Monitor/document for side effects and effectiveness. Date Initiated: 12/09/2021 . a. On 9/14/2022 at 8:09 AM during the 8:00 AM medication pass, [MEDICATION(S)] peninsulin administration was observed. RN #1 dialed up 55 units of insulin without priming the pen initially. RN #1 injected the insulin into the left upper arm of the resident, then immediately removed the pen from residents' arm without holding for any count to ensure all of insulin had been injected. b. On 9/14/2022 at 2:29 AM the Surveyor asked the DON [Director of Nurses], if the manufacturer recommendations for [MEDICATION(S)] insulin pens are to prime the pen prior to dialing up the prescribed dose? She stated, .yes, they should all be primed . If the pen isn't primed as per manufacturers recommendations, what is a potential outcome? She stated, .the dose could be wrong, the resident wouldn't get the appropriate dose What is a potential outcome if the pen isn't primed correctly? She stated, .The resident wouldn't get the whole dose . After administering the insulin dose, do manufacturer instruction read to hold for a specific time? She stated, .yes, all pen plungers are to be held for a certain count. Usually 5-10 seconds . What would be a potential outcome if the resident didn't get their prescribed dose? She stated, .it could result in an elevated blood sugar due to not getting the medication . c. On 9/14/2022 at 3:45 PM RN #1 was interviewed and asked, for insulin pens, is it standard practice to prime the pen prior to dialing up the ordered dose? She Stated, .apparently yes, I just found out . You didn't know prior to today that insulin pens had to be primed prior to dialing up the dose? She stated, .no, I didn't. We didn't get training in school for that . Were you in-serviced by the facility? She stated, .yes, just a while ago . The facility had an in-service January 11th and 12th of this year. Did you attend? She stated, .I don't remember . So, until today, you had no knowledge of how to properly draw up and give an insulin pen injection? She stated, .no . Is it the nurse's responsibility giving the medications to know how to properly give medications? She stated, .I guess . When completing an insulin pen injection, is there a specific time to hold the plunger down to ensure all of the medication has been given? She stated, .yes, the plunger should be held down to make sure all of the insulin was given . Did you hold the plunger down after administering the insulin? She stated, .no, I didn't . What could potentially happen if a resident doesn't get the ordered amount of insulin? She stated, .they could have high blood sugar . d. On 09/14/22 at 8:57 A.M. The Package Insert provided by DON for [MEDICATION(S)] (insulin [MEDICATION(S)] injection) with a revision date of 09/2018 showed, Prime before each injection . Priming means removing the air from the Needle and Cartridge that may collect during normal use. It is important to prime your Pen before each injection so that it will work correctly ., If you do not prime before each injection, you may get too much or too little insulin , To prime your pen, turn the Dose Knob to select 2 units ., Hold your pen with the needle pointing up. Tap the Cartridge Holder gently to collect air bubbles at the top ., Continue holding your pen with needle pointing up. Push the Dose Knob in until it stops, and 0 is seen in the dose window. Hold the dose knob in and count to 5 slowly ., You should see insulin at the tip of the Needle ., If you do not see insulin, repeat the priming steps, but no more than 4 times ., If you still do not see insulin, change the needle and repeat the priming .Small air bubbles are normal and will not affect your dose .

Based on observation, interview, and record review the facility failed to consistently store prescription, Narcotic and over the counter medications in the 300 Hall locked medication cart, to prevent the potential for self-mobile residents to have access to these medications. This failed practice had the potential to effect 3 (#25, #51 and #94) final sample residents who resided on 300 Hall and were self-mobile according to a list provided by the ADON [Assistant Director of Nursing] on 9/14/2022 at 12:07 PM. a. On 09/14/22 at 08:01 AM, the medication cart on 300 Hall was in the hall, unlocked, outside of room [ROOM NUMBER] with the door to residents' room closed completely. No staff was present. b. On 09/14/22 at 08:03 AM, RN# 1 exited room [ROOM NUMBER] and pushed the medication cart to the side and pushed the latch to lock it. The Surveyor asked if she just locked the cart. She stated, .yes, I did . The Surveyor asked, should the medication cart be locked when no staff are present? She stated, .yes, it should be locked, but the door wouldn't stay open . The Surveyor asked, what is a potential outcome if a resident was confused and was able to get medications out of the cart and take them. She stated, .it could hurt them . c. On 9/14/2022 at 2:29 PM the DON [Director of Nursing] was interviewed, the Surveyor asked what the policy was for securing medications in the medication cart. She stated, .the medication cart should be locked at all times that it is out of sight of the nurse passing medications .What is a potential complication with having the medication cart unlocked and unsupervised? She stated, .anyone, resident or staff, could get into the cart . What type of medications are kept in the medication cart? She stated, .over the counter meds, prescription meds and narcotics . The Surveyor asked, If the medication cart is unlocked and uncovered, does that ensure that the narcotics are double locked? She stated, .No, it doesn't . d. On 09/14/22 at 9:39 AM, The DON provided A Policy and Procedure for Medication Storage with effective date: 5/17/16, Date of Revision 05/20/2019 showed, .Policy: All medications shall be properly stored throughout the nursing home according to State and Federal Regulations ., All legend drugs will be kept in a locked location, medication room doors, medication cabinets, and medication carts shall be locked at all times.

Based on observation, record review and interview, the facility failed to ensure food was not overcooked and meals were served at temperatures that were acceptable to the residents to improve palatability and encourage good nutritional intake during 2 of 2 meals observed. The failed practices had the potential to affect 95 residents who received meals from the kitchen (total census: 100), as documented on a list provided by the Dietary Supervisor on 11/8/2021. 1. On 11/7/21 at 12:33 PM, an unheated food cart that contained 17 lunch trays was delivered to the 400 Hall by Certified Nursing Assistant (CNA) #1. At 12:48 PM immediately after the last resident received a tray, the temperatures of the food items on a test tray from the cart were checked and read by Dietary Employee #1 with the following results: a. Corn 106 degrees Fahrenheit. b. Green beans 103 degrees Fahrenheit. c. Baked chicken 90 degrees Fahrenheit. 2. On 11/7/21 at 12:45 PM, an unheated food cart that contained 14 lunch trays was delivered to the 300 Hall by CNA #1. At 1:04 PM immediately after the last resident received a tray, the temperatures of the food items on a test tray from the cart were checked and read by Dietary Employee #1 with the following results: a. Ground meat 105 degrees Fahrenheit. b. Corn 109 degrees Fahrenheit. c. Mashed potatoes 107 degrees Fahrenheit. d. Green beans 104 degrees Fahrenheit. e. Baked chicken 101 degrees Fahrenheit. 3. On 11/7/21 at 1:02 PM, an unheated food cart that contained 15 lunch trays was delivered to the 200 Hall by CNA #1. At 1:23 PM, immediately after the last resident received a tray, the temperatures of the food items on a test tray from the cart were checked and read by Dietary Employee #1 with the following results: a. Ground baked chicken 103 degrees Fahrenheit. b. Pureed bread 97 degrees Fahrenheit. c. Mashed potatoes 104 degrees Fahrenheit. d. Green beans 102 degrees Fahrenheit. e. Corn 107 degrees Fahrenheit. f. Baked chicken 109 degrees Fahrenheit. 4. On 11/7/21 at 1:12 PM, an unheated food cart that contained 18 lunch trays was delivered to the 100 Hall by CNA #1. At 1:31 PM immediately after the last resident received a tray, the temperatures of the food items on a test tray from the cart were checked and read by Dietary Employee #1 with the following results: a. Ground baked chicken 105 degrees Fahrenheit. b. Corn 109 degrees Fahrenheit. 5. On 11/8/21 at 8:41 AM, an unheated food cart that contained 14 breakfast trays was delivered to the 300 Hall. At 09:06 AM, immediately after the last resident received a tray, the temperatures of the food items on a test tray from the cart were checked and read by the CNA #2 with the following results: a. Milk 46 degrees Fahrenheit. b. Pureed oatmeal 91 degrees Fahrenheit. c. Pureed eggs 90 degrees Fahrenheit. d. Sausage link 90 degrees Fahrenheit. e. Scrambled eggs 90 degrees Fahrenheit. On 11/8/21 at 9:06 AM, Certified Nursing Assistant #2 felt the food items on the test tray with her fingers and stated they were cold. She was asked to describe the appearance of the scrambled eggs. She stated, Scrambled eggs are overcooked and scorched. 6. On 11/8/2021 at 11:04 AM, 7 cognitively intact residents participated in a group interview and were asked, Is your hot food served hot? and Is your cold food served cold? Their responses included the following: No, we are served on Styrofoam and it is cold. Milk is always warm; they put it on the tray and not in the tub they used to use, so it gets warm. 8. On 11/8/2021 at 3:44 PM, the Dietary Supervisor was asked to describe the appearance of the scrambled eggs, cheese omelet and cream of wheat served to the residents for breakfast. He stated, Scrambled eggs have a brown color and water at the bottom of it. Cream of wheat was thick. I was trying to thin it out. Cheese omelet was burnt.

Complaint # (AR 587) was substantiated, all or in part, in these findings: Based on record review and interview, the facility failed to ensure appropriate treatment and services were provided in accordance with professional standards of practice, to prevent potential injury or complications related to enteral feeding, as evidenced by a licensed facility nurse's use of a wire coat hanger to unclog a percutaneous endoscopic gastrostomy (PEG) tube for 1 (Resident #1) of 2 (Residents #1 and #5) case mix residents who had PEG tubes. The failed practice resulted in immediate jeopardy, which caused or could have caused serious harm, injury, or death to Resident #1, and had the potential to cause more than minimal harm to 4 residents who had PEG tubes, as documented on a list provided by the Business Office Manager on 11/7/16. The facility removed the immediate jeopardy situation prior to initiation of the survey; however, the facility failed to fully correct the underlying deficient practices. The Administrator was informed of the removed immediate jeopardy on 11/9/16 at 1:15 p.m. The findings are: Resident #1 had [DIAGNOSES REDACTED]. The Significant Change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/30/16 documented the resident scored 8 (8-12 indicates moderately impaired) on a Brief Interview for Mental Status (BIMS), was totally dependent on one staff member for eating, required extensive assistance from two plus people for bed mobility and had a feeding tube, through which the resident received 26 to 50% of the total daily caloric intake and 501 cubic centimeters (cc) of fluid per day. a. An Office of Long Term Care Incident and Accident Report, Division of Medical Services (DMS) form 7734 dated 10/25/16 documented, .Date of I & A (Incident and Accident) 10/01/16 (at) 9:30-10:00 p.m. (Licensed Practical Nurse (LPN) #1) used a metal coat hanger to attempt to unclog the resident's feeding tube . Complete Description of Incident .On October 1, 2016 at approximately between the hour of 9 p.m. and 10:30 p.m., (LPN #1) used a metal coat hanger to attempt to unclog above stated resident's feeding tube. (LPN #1) was told by (LPN #2) that she could not use the clothes hanger to unclog the feeding tube. (LPN #1) continued to use the clothes hanger to attempt to unclog the tube. This method was not successful and no harm came to the resident. (Facility) is attached to (Hospital) which gave (LPN #1) direct access to an emergency room . An OLTC Witness Statement Form dated 10/17/16 documented, .Witness Full Name: (LPN #1) .Tried to flush peg tube with water, warm water, soda pop and worked PEG tube with my fingers carefully but all intervention which I tried had no impact on unplugging his tube, no matter what I did nothing seemed to help . then I remembered back in nursing school what our instructor told us which was more than [AGE] years ago. If you try anything to unplug a PEG tube and nothing absolutely nothing does work take a part of a wire clothes hanger, bend it straight and even with no nicks or sharp edges just totally smooth and insert the hanger into tubing .I remembered it from nursing school which we were also told don't ever get caught doing it . b. On 11/8/16 at 2:53 p.m., the former Administrator was asked why the facility's investigation and corrective actions were not initiated immediately after being informed of the alleged incident and stated, Well I didn't (initiate it immediately) because myself, the Director of Nursing, the Assistant Director of Nursing, and the Social Worker saw it as an out of date practice. We just started an internal invesigation. That is why I didn't report it to the Office of Long Term Care. c. On 11/8/16 at 2:58 p.m., the former Director of Nursing (DON) was asked about the incident and stated, It was Friday, October 7th, and it wasn't reported to me; it was mentioned by a nurse. I went to tell the Administrator, and she said, 'I heard about it, and the CNA (Certifed Nursing Assistant) doesn't like the LPN', and again, she said there was nothing to it. That was on Friday, and I thought it didn't happen. On Saturday night (October 8th), she called me and said apparently it did happen. I started the paperwork and Human Resources began an internal investigation. This was a period of 7 days after the incident occurred. Staff schedules provided by Employee Services Staff #1 on 11/8/16 at 9:38 a.m. documented LPN #1 continued to work in the facility on the 3:00 p.m. to 11:00 p.m. shift, potentially providing care to Resident #1 and / or the three other residents in the facility who had PEG tubes, on 10/2/16, 10/3/16 and 10/5/16 through 10/8/16 during that 7-day period. d. On 11/9/16 at 11:15 a.m., LPN #2 was asked, Were you a witness to the PEG tube incident? What happened? She stated, .I was walking down the hall, and I saw (LPN #1) with a coat hanger, and I asked her what she was doing. She said his (Resident #1's) PEG tube was clogged, and she was unclogging it. I followed her to the room and I told her she couldn't do that, but she did it anyway. The CNA reported it to (LPN #3), and when I got back to my station, I talked to (LPN #3) about it. She said that she had to report it to the Administrator. I was told by another nurse six days later that they needed a statement. e. On 11/9/16 at 1:21 p.m., LPN #3 was asked, When was the PEG tube incident with (Resident #1) reported to you? Who reported it to you, and what action did you take? She stated, The incident was reported to me on the night of 10/01/16, and I tried to call the Administrator, DON, and ADON. They did not answer their phones, so I reported it to the Administrator on 10/2/16. She was asked, When you reported it to the Administrator, what happened? She stated, I came back up to the facility on [DATE]. I reported it to the Administrator and the Assistant Director of Nursing at the time. She (Administrator) told me that she would work on it the next morning, and I didn't hear anything else until Friday the 7th. She called me and said it needed to be written down, because one of the CNAs had called State, and now she had to fix this mess. f. The facility removed the immediate jeopardy and reduced the scope / severity to E on 10/9/16 by implementing the following corrective actions: 1.) An in-service sheet titled, PEG Tube Education for Nurses documented the in-service was provided to 9 licensed facility nurses on 10/9/16. The in-service content documented, In the event a PEG Tube becomes stopped up and unable to be flushed, the resident will go to the ER (emergency room ) for evaluation and treatment. Do not insert any item to clear the tube. 2.) A typed statement signed by LPN #1 and the ADON documented LPN #1 was educated on, proper handling of PEG tubes. When a PEG tube is stopped up and will not flush she will send the resident to the ER for evaluation and treatment. She will not use any item in the tube to unstop it . There was no date on this document. 3.) The Facility Investigation Report for Resident Abuse, Neglect, Misappropriation of Property & Exploitation of Residents in Long Term Care Facilities, DMS form 762 dated 10/25/16 documented, .Findings and Actions Taken . The above stated incident was reported to Administrator on October 2, 2016. On October 10, 2016, the incident was reported by a witness to Human Resources and on October 12, 2016, (LPN #1) was suspended until her termination of employment on October 25, 2016 for committing an action that could have affected the safety of a patient and for [MEDICATION NAME] outside her scope of practice. Resident was assessed by RN (Registered Nurse) and was reported to have no known injuries or declination of health that resulted from this incident. Primary physician was contacted . 4.) An Arkansas State Board of Nursing Complaint Report form, not dated, documented the facility reported LPN #1's actions to the State Board. The attached certified mail receipt indicated the report was mailed to the State Board on 10/26/16. g. On 11/9/16 at 12:54 p.m., the Director of Nursing was asked, What monitoring system is in place to ensure proper care and services are provided to residents with PEG tubes? She stated, I wasn't the DON (at the time of the incident), and he (former DON) didn't have anything in place when he left. She was asked, So as of right now, is there any monitoring in place? She stated, No. h. The Practical [MEDICATION NAME] article titled, Clogged Feeding Tubes: A Clinician's Thorn, March 2014, documented there are only three currently approved mechanical devices for clearing feeding tubes: 1.) Described as a flexible nylon stem with soft bristles on the end that, .are intended to minimize mucosal injury . 2.) Described as a flexible plastic stem with a, .screw and thread design for use only by trained professionals. 3.) Described as single-use stems paired with a control box that plugs into AC power and is for use only in hospital settings.

Based on observation, record review and interview, the facility failed to ensure necessary care and services were provided for management of [MEDICAL CONDITION] and Ascites, as evidenced by failure to ensure physician orders [REDACTED].#3) of 1 case mix resident with physician orders [REDACTED]. The failed practice resulted in a pattern of actual harm for Resident #3, who required repeated large volume paracentesis procedures which resulted in [MEDICAL CONDITION] and other electrolyte imbalances, and had the potential to cause more than minimal harm for 2 residents with physician orders [REDACTED]. The facility also failed to ensure necessary routine monitoring of blood pressure readings was provided for management of medications ordered on an as-needed (PRN) basis, in order to determine if PRN antihypertensive medication should be administered, to prevent potential complications for 1 (Resident #5) of 2 (Residents #1 and #5) case mix residents who had physician orders [REDACTED]. This failed practice had the potential to affect 15 residents with physician orders [REDACTED]. 1. Resident #3 had [DIAGNOSES REDACTED]. The Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) date of 9/10/16 documented the resident scored 15 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status (BIMS) required limited assistance of one person for bed mobility and transfers, supervision with set up only for eating and had unspecified [MEDICAL CONDITION]. b. The November 2016 Physician order [REDACTED]. c. The physician progress notes [REDACTED].Subjective: .Her sodium is 124 . Physical Examination: General: .She has a large amount of ascites with some tight abdominal tissue. She is complaining of frequent cramping and abdominal discomfort. Impression: 1. [MEDICAL CONDITION]. 2. [MEDICAL CONDITION]. 3. Ascites. Plan: Limit fluid intake to 1000 ml (milliliters) daily . I discussed this with the patient and she understood . d. The (hospital) Post Procedure Report dated 10/12/16 documented, .Pre-Procedure Diagnosis: [REDACTED]. Findings: Clear yellow fluid drained RUQ (right upper quadrant). Specimen Removed: 12,000 ml . One gallon equals 3785.41 milliliters; therefore, 12,000 milliliters equals 3.17 gallons of fluid removed from the resident's abdomen on this encounter. e. The physician progress notes [REDACTED].Physical Assessment: .She is lying in bed. Her abdomen is very large and distended and tight. There is ascites present with a fluid wave . Her extremities have 1 (plus) [MEDICAL CONDITION] from knee down . Impression: 1. [MEDICAL CONDITION] bilateral lower extremities. 2. Increased bruising. 3. [MEDICAL CONDITION]. 4. [MEDICAL CONDITION] of the liver. 5. [MEDICAL CONDITION]. Plan: I spoke with the patient at length about the effects of the frequent paracentesis causing her sodium to drop as well as other electrolytes. She is receiving paracentesis every two weeks because of increased [MEDICAL CONDITION]. She insists that she has decreased her fluid intake and her last sodium has improved by 2 points. She has chronic [MEDICAL CONDITION] and the diuretics cannot safely be increased, and I made her aware of that. I also reported to her that she has multiple medical problems, all of which will intensify some of these problems. Patient seems to understand . I continue to encourage the patient to reduce her fluid intake to 1000 cc (cubic centimeters) a day and restrict salt. f. The Hospital Nursing Progress Record dated 10/26/16 documented, Procedure: Paracentesis . 1140 (11:40 a.m.) 2000 ml yellow fluid drained . 1225 (12:25 p.m.) 1800 ml yellow fluid emptied . 1250 (12:50 p.m.) 2250 ml yellow fluid emptied . 1315 (1:15 p.m.) 1950 ml yellow fluid drained . 1350 (1:50 p.m.) 800 ml yellow urine drained . g. On 11/8/16 at 8:50 a.m., the resident was lying in bed with a distended abdomen and the following fluids on the over-bed table within her reach: Three 7.5-ounce (oz) cans of Diet Dr. Pepper; one 24-oz Styrofoam cup of water; one 32-oz jug of brown liquid; one 20-oz (2302.5 ml) pitcher of water. i. As of 11/8/16 at 1:00 p.m., the Resident Plan of Care updated 9/24/16 did not address the physician-ordered fluid restriction or provide staff with any indication of how much fluid the resident could be offered each shift. j. On 11/8/16 at 1:55 p.m., after being asked how the facility was monitoring and following this resident's fluid restriction order, the Risk Management Registered Nurse (RN) brought an approximate accounting of the fluids each department had been offering the resident since 10/7/16, which documented as follows: Dietary 1560 ml; Certified Nursing Assistants (CNAs) 300 ml; Nurses 180 ml, for a total of 2040 ml per day. At 2:00 p.m., the Risk Management RN was asked if, prior to this day, anyone had calculated how much fluid the resident should receive from each discipline on each shift, as per the order received on 10/7/16. She stated, We did not have it documented anywhere how much she was to receive from any discipline until now, nor were any of her fluid intakes being monitored. We should have; this was a complete system failure. We were offering her too much; we need to fix it. Her family also brings in sodas and other fluids on top of what we have been offering her. But in our defense, she does not comply with this fluid restriction order. We should have contacted the doctor that ordered this before now and let him know about her non-compliance. k. The hospital Gastrointestinal (GI) Laboratory Procedure Note dated 11/9/16 documented, .Large Volume Paracentesis History: .diuretic resistant ascites. She has [MEDICAL CONDITION] of the liver. It has been two weeks since her last paracentesis, and now she has a massively large abdomen and she is short of breath. A large volume paracentesis is undertaken. Impression: 1. Large volume paracentesis-therapeutic paracentesis of 13 liters (13,000 milliliters). Plan: Continue salt restriction. Increased diuretics but watch creatinine. I discussed with her a [MEDICATION NAME] (drainage system) and will schedule this in radiology . l. On 11/9/16 at 3:30 p.m., Resident #3 was lying in her bed on her left side, slightly holding her head over the side just above the trash can. There was a large 32-oz jug with soda (1/4 left), two 20-oz water pitchers (one 1/4 full and one 1/2 full) on top of her over bed table next to her bed. She was asked if she wasn't feeling well. She stated, No, I'm sick to my stomach. She was then asked if she thought lunch made her sick. She stated, No, I was sick before that; I had fluid drawn off of me this morning. That usually helps, but it didn't today. She was then asked if she knew she was on a fluid restriction for this problem. She stated, Yes. She was then asked if she ever refused to comply with the fluid restriction order. She stated, No, because I've been a nurse for [AGE] years and I know how important it is to limit my fluid intake because of my disease process. She was then asked if the facility ever monitored her fluid intake. She stated, No, I try to do it myself, because I know how important it is. 2. Resident #5 had a [DIAGNOSES REDACTED]. The Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 9/19/16 documented the resident scored 15 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status (BIMS), required extensive assistance of two plus people for transfers and was totally dependent on the assistant of one person for dressing, hygiene and bathing. a. The November 2016 Physician order [REDACTED].> (greater than) 180 or DBP (diastolic blood pressure) > (greater than) 110 . b. The Vital Sign Record and Nurses Notes dated 10/27/16 through the current date did not document routine monitoring of the resident's blood pressure to determine if the PRN [MEDICATION NAME] should be administered. Since 10/27/16, the resident's blood pressure was taken on 10 occasions. If checked every 4 hours, a total of 60 opportunities for blood pressure checks occurred during this period; if checked every shift, a total of 42 opportunities for blood pressure checks occurred. The 10 documented blood pressures ranged from 98/50 to 126/75. c. On 11/8/16 at 2:25 p.m., the Risk Management RN and the Director of Nursing (DON) were shown the physician order [REDACTED].

Based on observation, record review and interview, the facility failed to ensure Resident #1 received the necessary care and services to manage pain. The facility failed to ensure the resident was frequently assessed for pain; pain medication was administered as ordered prior to treatment and whenever indicated by pain assessment; the resident was monitored for effectiveness of pain medication; and the physician was notified promptly whenever the pain medication was ineffective for 1 of 1 (Resident #1) case mix residents who had physician orders [REDACTED]. This failed practice resulted in a pattern of actual harm for Resident #1, who had little to no pain relief during wound care, and did not have the potential to affect any other resident at the time of the survey as documented on a list provided by the Business Office Manager on 4/16/15 at 1:10 p.m. The findings are: Resident #1 had [DIAGNOSES REDACTED]. A significant change Minimum Data Set with an Assessment Reference Date of 4/7/15 documented the resident had severely impaired cognitive skills for decision-making per a staff assessment for mental status, required extensive assistance of one person for bed mobility, was totally dependent on two plus persons for transfers, totally dependent on one person for locomotion, dressing, eating, personal hygiene and bathing, was incontinent of bowel and bladder, was non-ambulatory, had functional limitation in range of motion to bilateral lower extremities and was at risk for pressure ulcers. a. The Resident ' s care plan documented, " ...Problem Onset: 3/29/12 Potential for pain r/t (related to) disease process ... (Goal & Target Date) Strive to keep as comfortable as possible. 7/07/15 ... (Approaches) Assess pain and chart pain level. Give pain meds as ordered. Assess effectiveness of pain medication. Monitor for s/s or c/o pain and report ... " The Hospice Plan of Care/Comprehensive Assessment - Initial dated 3/31/15 documented, " Tylenol ([MEDICATION NAME]) - 325 mg (milligrams) x 2 = 650 mg, PO (by mouth), q (every) 4 hrs (hours) prn (as needed) [MEDICATION NAME] (Opioid [MEDICATION NAME]) (marketed as [MEDICATION NAME]) - 50 mg 1-2 tabs, PO, q 6 hrs ...Summary of Assessment and Needs ...Grimaces and guards bilateral lower extremities when moved ...Pain Location ...Had recent procedure to take right hallux toenail off, pressure sores noted to top of foot, inner portion by hallux and outer portion of foot ...Pain intensity: ...Moderate ...What makes pain worse: On movement ... " b. The Hospice Progress Notes - Nursing dated 4/8/15 at 9:50 a.m. documented, "Met up with (Treatment Nurse) RN (Registered Nurse) to watch her do a dressing change on Pt. (patient). Upon touching foot pt was very anxious. During the removal of dressing patient was pulling leg up away from Treatment nurse, moaning. When asked if pain med (medication) had been given was stated that [MEDICATION NAME] has been given. During assessment, (Treatment Nurse) measured areas on right foot to be documented as Right inner 2 x(by) 3 x 1, to right outer 1.8x2x1. (Treatment Nurse) states, ' I just don't know what else to do, I am trying everything I know to do. ' Pt foot redressed using [MEDICATION NAME] dressing applied daily and cleaned with normal saline. Requested for patient to have patient to have pain medication ..." 1) The Narcotic Record for the resident ' s [MEDICATION NAME] was reviewed on 4/15/15. The record documented the resident received [MEDICATION NAME] 50 mg at 6:00 a.m. and 9:15 a.m. on 4/8/15. The Departmental Notes dated 4/8/15 at 8:25 a.m. did not document an assessment of pain. The 8:31 p.m. note documented, " ...No acute distress or pain noted at this time ... " The back of the April 2015 MAR indicated [REDACTED]. c. The Hospice Progress Notes - Nursing dated 4/9/15 at 5:30 p.m. documented, " ...c/o (complains of) severe pain to lower extremity. Grimaces and guards bilateral lower extremities when moved ...During Assessment Daughter (name) was present and requested stronger pain medications for her mother ...Talked with Daughter about pain medication and that pt would continue to be assessed for pain control. Daughter expressed concerns about pt being assessed for pain and that didn ' t feel that her mother was getting her medication throughout the day. The Narcotic Record for the resident ' s [MEDICATION NAME] was reviewed on 4/15/15. The record documented the resident received [MEDICATION NAME] 50 mg at 6:15 a.m. and 5:30 p.m. on 4/9/15. The Departmental Notes dated 4/9/15 did not document an assessment of pain. The back of the April 2015 MAR indicated [REDACTED]. d. A physician's orders [REDACTED]." A physician's orders [REDACTED]." e. A Departmental note dated 4/10/15 at 7:28 a.m. documented, "Role: Charge Nurse, Category: Nurse's Note, new orders received: ...3) [MEDICATION NAME] 2mg (milligrams) by mouth/sublingual every 4 hours as needed for pain 4) [MEDICATION NAME] 2mg by mouth/sublingual 1 hour before dressing change, 5) assess for pain every 4 hours, 6) [MEDICATION NAME] 0.25 mg one by mouth three times a day as needed for increased anxiety, ..." The Hospice Progress Notes - Nursing dated 4/10/15 at 3:40 p.m. documented, " Talked with (name) Assistant Director of Nursing (ADON)), she was concerned as to why patient had not received [MEDICATION NAME]. Fixed problem and medication was delivered. Also, addressed the fact that (name) pts daughter had called earlier and stated that pt still was not being assessed for pain and given her prn pain med, [MEDICATION NAME]. (ADON) informed that she would talk with nurses about assessing more often and giving prn pain med and that she would check to make sure it was done ... " The Narcotic Record for the resident ' s [MEDICATION NAME] was reviewed on 4/15/15. The record documented the resident received [MEDICATION NAME] 50 mg at 6:00 a.m. on 4/10/15. The Narcotic Record for the resident ' s [MEDICATION NAME] ([MEDICATION NAME]) was reviewed on 4/15/15. The record documented the resident received [MEDICATION NAME] 2 mg/.1 ml (milliliters) at 4:00 p.m. on 4/10/15. The Departmental Notes dated 4/10/15 did not document an assessment of pain. The back of the April 2015 MAR indicated [REDACTED]. f. The Hospice Progress Notes - Nursing dated 4/14/15 at 4:30 p.m. documented, " ...Pain Intensity ...9 unable to define intensity ...What makes pain better: unable to determine ... Patients daughter verbalized concern that her mother was still not be assessed for pain. Orders were written for pain to be assessed every 4 hrs and to give pain meds when needed and pain med was to be given 1 hr before dressing change ... " The Narcotic Record for the resident ' s [MEDICATION NAME] and the [MEDICATION NAME] ([MEDICATION NAME]) was reviewed on 4/15/15. The record documented the resident received: 4/11/15- [MEDICATION NAME] 50 mg at 2:00 p.m.; [MEDICATION NAME] 2 mg/.1 ml (milliliters) at 5:30 a.m., 9:30 a.m.; and 6:15 p.m. 4/12/15 - [MEDICATION NAME] 50 mg at 9:00 a.m. and (unable to determine time) p.m.; [MEDICATION NAME] 2 mg/.1 ml (milliliters) at 4:35 a.m. 4/13/15 - [MEDICATION NAME] 50 mg at 6:00 a.m.; [MEDICATION NAME] 2 mg/.1 ml (milliliters) at 1:45 a.m., 9:30 a.m., and 5:40 p.m. 4/14/15 - No [MEDICATION NAME] was signed out; [MEDICATION NAME] 2 mg/.1 ml (milliliters) at 4:00 a.m., 12:15 noon, and 5:30 p.m. There were no Departmental Notes documenting pain assessments from 4/11/15 - 4/14/15. The back of the April 2015 MAR indicated [REDACTED]. The back of the April 2015 MAR indicated [REDACTED]. g. On 4/15/15 at 8:55 a.m. the Treatment Nurse stated, "She (indicating Licensed Practical Nurse (LPN #1)) is fixing to medicate her (Resident #1) so there will be minimal pain for her, so it will be just a little bit before we change her dressing." The Narcotic Record dated 4/15/15 received from Licensed Practical Nurse (LPN) #1 on 4/15/15 at 10:24 a.m. documented the resident received Roxinol at 2:15 a.m., [MEDICATION NAME] at 6:00 a.m., and Roxinal at 8:55 a.m. At 9:37 a.m., the Treatment Nurse began the dressing change for the resident. The Treatment Nurse removed the outer dressing. Upon removing the foam dressings from the resident's outer and inner right foot the resident was moaning and jerking her leg back. The resident was asked, "Is your foot hurting when she changes the dressing?" The resident stated, "Yes, she hurts me." As the Treatment Nurse continued to remove the dressing the resident stated, "Oh don't touch me like that, I can't hardly stand it." The treatment nurse stated to the resident, "I know it's not always easy for you, I will give you a minute." After approximately 30 seconds the treatment nurse applied the normal saline and patted it dry with gauze. The resident was holding her bent leg at her knee, jerking her leg back as the Treatment Nurse patted the area. The Treatment Nurse stated, "Honey, I'm so sorry, I don't want to hurt you" as she continued to pat the areas. The resident stated, "Oh, get off that please." While applying the foam dressing to the pressure ulcer on the outside and inner foot, the resident continued jerking her foot back as the Treatment Nurse continued care. The Treatment Nurse asked the resident, "Is that hurting you?" The resident stated, "Yes, oh Lord Jesus help us" as she continued jerking her foot back and holding her bent leg at the knee. The treatment nurse was asked, "Does she react this way every time the dressing is changed?" The Treatment Nurse stated, "Yes, she has a lot of pain with her foot." The Treatment Nurse was asked, "Have you notified the doctor of the amount of pain she has with the dressing change?" The Treatment Nurse stated, "Hospice has, that's the reason we got the extra pain med (medicine), the Roxinal." The Treatment Nurse was asked, "What is the order for?" The Treatment Nurse stated, "One hour before the dressing change." The Treatment Nurse was asked, "What time was it given?" The Treatment Nurse stated, "8:55." The treatment nurse was asked, "The dressing change started at 9:37 a.m. was that an hour?" The Treatment Nurse stated, "I was anxious for you to see it." The Treatment Nurse was asked, "Did I not say whenever it was time and you're ready to come and get me?" The Treatment Nurse stated, "Yes." The treatment nurse was asked, "The Roxinal was ordered on April 10th and you said she still reacts like this every time?" The Treatment Nurse stated, "Well yes, sometimes not as much, sometimes like this." The Treatment Nurse was asked, "Have you notified the doctor that the Roxinal was not holding her and she still has a lot of pain with the dressing change?" The Treatment Nurse stated, "I am today." On 4/15/15 at 10:45 a.m., LPN #1 was asked, "Did you give (Resident #1) any pain medicine today?" The LPN stated, "I gave her Roxinal." The LPN was asked, "What time did you give it?" The LPN stated, "At 8:55." The LPN was asked, "What is her orders?" The LPN stated, "Roxinal 2 milligrams po (by mouth) or sublingual one hour prior to the dressing change." h. On 4/15/15 at 11:10 a.m. via telephone the Hospice Registered Nurse (RN) was asked, "Are you (Resident #1's) nurse?" The RN stated, "Yes." The RN was asked, "Has the facility nurse contacted you about (Resident #1's) pain medication not controlling her pain during the dressing change?" The RN stated, "She just called this morning." The RN was asked, "Had she notified you before this morning?" The RN stated, "No. The nurse on the second shift, I can't remember (LPN #2), had told me that the [MEDICATION NAME] it wasn't helping her so I told her to give it right before the dressing change and not wait. I also wrote and order for them to assess her pain every 4 hours. She already had [MEDICATION NAME] before I wrote the order for Roxinol. It was not being given, to my knowledge, as ordered that's the reason I wrote the order for the Roxinol. It was being given in the morning and not again until later in the afternoon, the [MEDICATION NAME]. I also gave then an order for [REDACTED].#1's) pain medicine?" The RN stated, "Yes ma'am, then I would call the doctor." i. On 4/16/15 at 1 p.m., LPN #2was asked, "Did you contact hospice regarding (Resident #1's) pain?" The LPN stated, "She was up here one night and I told her about the [MEDICATION NAME] wasn't enough for the pain I figured she was having with her foot." The LPN was asked, "Were there indications she was in pain?" The LPN stated, "She always rubs her foot on the bed and sometimes you could see it in her face and to me it showed she was hurting and the constant moving of the legs." The LPN was asked, "Were there other signs and symptoms of pain other than the dressing changes?" The LPN stated, "Yes, throughout the night she would rub her foot and you could just see it on her face, sometimes when she was sleeping she would just look tense." The LPN was asked, "Do you feel like the [MEDICATION NAME] was effective in relieving her pain?" The LPN stated, "I didn't feel like it helped much, it might have helped temporarily but I'd go back and just a few hours later and she would be right back at it." The LPN was asked, "Did you give her more pain medicine then?" The LPN stated, "I would give it to her about 5 or 6 so my shift would be over, so I would just pass it on and say just go back and check on her."

Complaint # (AR 102) was substantiated (all or in part) with these findings: Based on observation, record review and interview the facility failed to ensure thorough assessments of pressure sores to include location, staging, color of the wound, depth, presence or absence of exudate, odor, undermining/tunneling and the condition of the surrounding tissue were completed and documented to facilitate the ability to promptly identify deterioration or track healing progress for 1 (Resident #1) of 3 (Residents #1, #2, and #5) case-mix residents with pressure sores. The facility failed to ensure treatment orders were initiated promptly to promote healing and prevent further decline for 1 (Resident #1) of 3 (Residents #1, #2, and #5) case-mix residents with pressure sores. The facility failed to ensure treatments were performed daily as prescribed to promote healing and prevent declines in skin condition for 1 (Residents #1) of 2 (Resident #1and #2) case mix residents who required daily dressing changes to pressure ulcers. The failed practice resulted in a pattern of actual harm for Resident #1 whose pressure ulcers deteriorated and had the potential to cause more than minimal harm to 3 residents who required daily dressing to pressure ulcers as documented on a list provided by the Business Office Manager on 4/16/15 at 1:10 p.m. The findings are: Resident #1 had [DIAGNOSES REDACTED]. A significant change Minimum Data Set (MDS) with an Assessment Reference Date of 4/7/15 documented the resident severely impaired cognitive skills for decision-making per a staff assessment for mental status; required extensive assistance of one person for bed mobility; was totally dependent on two plus persons for transfers; totally dependent on one person for locomotion, dressing, eating, personal hygiene and bathing; was incontinent of bowel and bladder; was non-ambulatory; had functional limitation in range of motion to bilateral lower extremities, was at risk for pressure ulcers and had two stage 2 pressure ulcers. a. The Hospice Plan of Care/Comprehensive Assessment - Initial dated 3/31/15 documented, " ...Summary of Assessment and Needs ...On assessment patient was lying in hospital bed with feet propped on pillows and protection bar over bilateral feet r/t toenail removal and pressure sore on right foot ...Pt Daughter at bedside states that patient (pt) had toenail removed but then pt guarded foot by lying left foot on top of the right causing pressure sores ... " b. The Hospice Progress Notes - Nursing dated 4/8/15 at 9:50 a.m. documented, "Met up with (Treatment Nurse) RN (Registered Nurse) to watch her do a dressing change on Pt. (patient). Upon touching foot pt was very anxious. During the removal of dressing patient was pulling leg up away from Treatment nurse, moaning. When asked if pain med (medication) had been given was stated that [MEDICATION NAME] has been given. During assessment, (Treatment Nurse) measured areas on right foot to be documented as Right inner 2 x (by) 3 x 1, to right outer 1.8 x 2 x 1. (Treatment Nurse) states, ' I just don't know what else to do, I am trying everything I know to do. ' Pt foot redressed using [MEDICATION NAME] dressing applied daily and cleaned with normal saline. Requested for patient to have patient to have pain medication ... Consulted (name) RN (registered nurse) for wound consult with info (information) that was taken from assessment. (RN) suggestion was to use silver gel and foam pad and wrap ..." The Hospice Progress Notes - Nursing dated 4/9/15 at 7:38 a.m. documented, " Progress Note Summary (facility RN name) contacted me to give the measurement for top of right foot was 2 x 6 cm (centimeters) ... " c. Forms that contained wound measurements received from the Treatment Nurse on 4/14/15 at 12:39 p.m. documented the following: 1) The form with Week Date 3/16/15 - 3/20/15 documented: 1) " ...Wound Description: Deep red area non-blanch Stg (stage) I ...Current MM (measurements) m (millimeters) (HxWxD) (Height by Width by Depth): 2 x .4 x 0 ... Acq (acquire)Date/Where: 3-19-15 facility (no location documented). " 2) " ...Wound Descripton: Deep red area non-blanch Stg (stage) I ...Current MM (measurements) m (millimeters) (HxWxD) (Height times Width times Depth): 2 x .9 x 0 ... Acq (acquire)Date/Where: 3-19-15 facility (no location documented). " 2) The form with Week Date 3/28/15 - 4/3/15 documented: 1) " ...Wound Description: R (right) inner foot (no description documented). Stg: blank Current MM 1.5 X 1.2 X .1 Acq Date/Where: 3-26-15 facility. " 2) " ...Wound Description: R outer foot (no description documented). Stg: blank Current MM 1 x 2 x 0 Acq Date/Where: 3-26-15 facility. " 3) The form with Week Date 4/3/15 - 4/10/15 documented: 1) " ...Wound Description: R (right) inner foot (no description documented). Stg: blank Current MM 2.0 X 3 X 0 Acq Date/Where: 3-26-15 facility. " 2) " ...Wound Description: R outer foot (no description documented). Stg: blank Current MM 1.8 x 2.5 x 0 Acq Date/Where: 3-26-15 facility. " Note: Hospice Notes 4/8/15 documented depth as 1 not 0. d. A physician's orders [REDACTED]." The April 2015 Treatment Administration Record (TAR) documented, "Clean areas to R inner (and) R outer foot (with) NS pat dry apply [MEDICATION NAME] cream to wound cover (with) foam dressing secure (with) silicone tape if needed change daily (and) prn til closed." An the treatment was documented as initiated until 4/13/15. The April 2015 TAR contained no documentation to indicate the wound care was provided from date of last order on 4/9/15 (Thursday) through 4/12/15 (Sunday). e. Interviews with staff concerning wound dressing were as follows: 1) On 4/15/15 at 12:40 p.m., the Assistant Director of Nursing (ADON) was asked, "Should they (staff) initial that treatments have been done (on the TAR)?" The ADON stated, "Yes." The ADON was asked, "Who is responsible for changing your dressings on the weekends?" The ADON stated, "The way it is set-up the charge nurses do the creams and the smaller dressings, the RN supervisor does the bigger dressings like the pressure ulcers." The ADON was asked, "Do the weekend RN supervisors have access to your TAR's (Treatment Administration Records)?" The ADON stated, "Yes." 2) On 4/16/15 at 9:37 a.m., The Treatment Nurse was asked, "When you come in on Monday mornings, have you ever found your dressings when they have not been changed as ordered from the weekends?" The Treatment Nurse stated, "Yes ma ' am." The Treatment Nurse was asked, "Was it the same dressing you had put on Friday?" The Treatment Nurse stated, "Monday?" The surveyor stated, "Yes." The Treatment Nurse stated, "Yes." The Treatment Nurse was asked, "Who is supposed to change the dressings on the weekends?" The Treatment Nurse stated, "On the weekend the weekend RN (Registered Nurse) is supposed to change the larger areas, pressure ulcers, anything that is staged. The LPNs (Licensed Practical Nurses) put on the creams and lotions." 3) On 4/15/15 at 2:00 p.m., Certified Nurse Assistant (CNA) #6 was asked, "When do you work weekends or weekdays?" The CNA stated, "Weekends and Weekdays." The CNA was asked, "Have you ever seen dressings that weren't dated as changed for the weekend on Monday?" The CNA stated, "Yes." The CNA was asked, "Do you work with (Resident #1)?" The CNA stated, "Yes." The CNA was asked, "Have you ever seen her with a dressing that was not changed on the weekend on Monday?" The CNA stated, "Yes." 4) On 4/15/15 at 2:15 p.m., CNA #7 was asked, "When do you work, weekends or weekdays?" The CNA stated, "Weekdays and weekends." The CNA was asked, "Do you see the RN (Registered Nurse) on the weekends changing dressings?" The CNA stated, "No, (treatment nurse) or wound nurse works Monday thru Friday and they don't get changed unless they are bleeding through or something." The CNA was asked, have you ever seen dressings that weren't dated as changed for the weekend on Monday?" The CNA stated, "Yes." The CNA was asked, "Do you work with (Resident #1)?" The CNA stated, "Yes." The CNA was asked, "Have you ever seen her with a dressing that has not been changed on the weekend on Monday?" The CNA stated, "Yes, probably every weekend." 5) On 4/15/15 at 2:20 p.m., CNA #8 was asked, "When do you work, weekends or weekdays?" The CNA stated, "Both." The CNA was asked, "Do you see the RN on the weekends changing dressings?" The CNA stated, "No, not unless it absolutely has to be." The CNA was asked, "Have you ever seen dressings that weren't dated as changed for the weekend on Monday?" The CNA stated, "Yeah, I've seen it before." The CNA was asked, "Do you work with (Resident #1)?" The CNA stated, "Yes." The CNA was asked, "Have you ever seen her with a dressing that has not been changed on the weekend on Monday?" The CNA stated, "I don't know about the weekend Friday. But I come in and say it's the 15th it would be like the 13th, you know the day before the day before." f. The Hospice Wound Care *Skin Integrity* Evaluation dated 4/14/15 documented, 1) " Wound 1 top of foot ...Exudate Min (minimal) ...full thickness ...Pressure Ulcer - Unstageable LxWcm (length by width in centimeters) 2.00 x 6.00 ...Depth utd (unable to determine) ...Wound Bed: 90% necrosis 10% granulation tissue ...Periwound: fragile reddened ... " 2) " Wound 2 R foot (below greater toe) ...Exudate Min (minimal) ...full thickness ...Pressure Ulcer - Unstageable LxWcm (length by width in centimeters) 2.00 x 3.00 ...Depth utd (unable to determine) ...Wound Bed: 80% black eschar 10% granulation tissue with 10% yellow slough ...Periwound: fragile reddened 5 x 5 ... " g. On 4/15/16 at 9:37 a.m., the wound measurements received from the Treatment Nurse were as follows: The outer right foot with eschar measured 1.3 x 2.4 x 0 and was identified as unstageable, the right inner foot 3.8x2.4x0 with eschar was unstageable. The inner right foot pressure ulcer wound width had increased by 1.8 centimeters (cm). There was an area on top of the right foot identified as unstageable measuring 2.8x1.4x0. There was no documentation of the area on the top of the right foot found until 4/9/15 and again 4/14/15 both times the area was noted in the Hospice Notes. On 4/16/15 at 9:37 a.m., the Treatment Nurse was asked, "Can you tell me when the area on top of (Resident #1's) right foot developed?" The treatment nurse stated, "It was last week. It was red and blanched, then Monday it was looking like it was trying to change into a blood blister then yesterday I knew it had to be considered unstageable." The treatment nurse was asked, "Did you change the dressing on Tuesday?" The Treatment Nurse stated, "I change it every day I'm here." The Treatment Nurse was asked, "On Tuesday what did it look like?" The Treatment Nurse stated, "It still looked like it did on Monday." The Treatment Nurse was asked,"It was blanchable last week, then it looked like a blood blister on Monday and Tuseday, then yesterday it was unstageable?" The Treatment Nurse stated, "Yes ma ' am." The Treatment Nurse was asked, "On the documentation you gave me Monday (4/14/15 (actually received on Tuesday) and the last date on the forms was 4/10/15) can you show me where you had documented about the wound on the top of her foot?" The Treatment Nurse stated, "This is for last week, I haven't started the new sheet for this week." The Treatment Nurse was asked, "Did you notify the doctor about the new area on her foot?" The Treatment Nurse stated, "I called him yesterday (4/15/15) when I knew I had to up stage it." The Treatment Nurse was asked, "Did you notify the doctor of the new area?" The Treatment Nurse stated. "I did when I up staged it. I know what an unstageable area looks like and I know what a blood blister looks like the area around it was blanchable." The Treatment Nurse was asked, "Why didn't you notify the doctor?" The Treatment Nurse stated, "Well it wasn't an area that needed treatment." The Treatment Nurse was asked, "What did you do for it?" The Treatment Nurse stated, "I watched and observed it." Note: The call to the physician was 6 days after the 4/9/15 Hospice notation regarding pressure sore to the top of the right foot.

Based on record review and interview, the facility failed to ensure licensed staff continued to provide cardiopulmonary resuscitation (CPR) when the resident was found without vital signs for 1 (Resident #23) of 7 (Residents #3, #5, #9, #11, #17, #21, and #23) case mix residents who had documented full code status in their clinical record. This failed practice resulted in Immediate Jeopardy, which caused or could have caused death to Resident #23, who had documented full code status in the clinical record and staff failed to provide cardiopulmonary resuscitation (CPR) upon identification of a lack of vital signs, and had the potential to cause more than minimal harm to 56 residents who had documented full code status in their clinical records, according to a list provided by the Administrator on [DATE] at 8:30 a.m. The facility was informed of the Immediate Jeopardy condition on [DATE] at 11:35 a.m. The findings are: 1. Resident #23 had [DIAGNOSES REDACTED]. The 14 day Minimum Data Set with an assessment reference date of [DATE] documented the resident had moderately impaired cognitive skills for daily decision making, and was totally dependent on staff for all activities of daily living. a. The Face Sheet with an admitted [DATE] and a discharge date of [DATE] documented, " ... Discharge Status: Death in facility ...Nursing Alerts Full Code ..." A Physician order [REDACTED]." On [DATE] at ,[DATE] a.m., the Director of Nursing (DON)was asked if would the orders for January (2015) be the same as the closed one I printed, indicated the order above. The DON stated, " ... There is no way really to go back in and print (orders) once they are discharged and we don't print them for the chart now that we are electronic. The resident's code status did not change during her admission here and she was still a full code in [DATE]." c. A Nurse's Note dated [DATE] at 6:55 p.m. and signed by Licensed Practical Nurse (LPN) #1 documented, "CNA (Certified Nursing Assistant) was in room at 5:30 p.m. to check in on resident and turn resident, which at this time, resident was fine. CNA went into room at 6:30 p.m. to get resident's vital signs when she noticed resident was not breathing. Charge Nurse was notified, who started CPR at that time. At this time it was evident that resident had expired. Responsible party...coroner...MD (Medical Doctor) notified." 1) On [DATE] at 10:30 a.m., LPN #1 was asked about the incident that occurred on [DATE] at approximately 6:55 p.m. and she stated, "I was the nurse who initiated CPR and I would say I did it about 10 minutes or so. She had passed away but I wasn't 100% sure so I initiated CPR. No one took over. She had no pulse, her facial color had changed and pupils were fixed. The coroner came after I stopped CPR and called him. No ambulance was called. I was busy in the room. I called for another nurse who came in the room. I don't know why an ambulance wasn't called. She was having no signs of life when I entered the room. I originally jumped up to start CPR and she had already defecated on herself. She was dead. The protocol for CPR, I was told by the other nurse, if they were already passed not to initiate CPR. She had stuff out of her mouth and was bleeding from her nose on initiation. If it had been a witnessed arrest she would have gone to the ER. We have a back board and ambu bag but no chemical crash cart here. I am certified but didn't have the chemicals. To best of my knowledge we don't have an Automated Emergency Defibrillator or full crash cart. " 2) On [DATE] at 1:06 p.m., LPN #2 was asked about the incident on [DATE] with (Resident #23) and she stated, "I was on the front end by the front door when a man came in looking for the resident and I learned later it was the coroner. If I know a resident is a full code I initiate CPR and have someone call for help." 3) On [DATE] at 2:28 p.m., LPN #4 was asked about the incident on [DATE] with (#23) and she stated, "I called the family and doctor and notified them of the residents passing for her nurse. I was not in the room. Unless I saw the resident take their last breath I won't start CPR because you can't know how long they have been there without vital signs." c. On [DATE] at 10:37 a.m., the DON was asked if a resident is a full code and absent of vital signs what are you supposed to do. The DON stated, "CPR should be started if someone is full code and has no vital signs. CPR should only be stopped when you reach emergency people to take over. In a code situation our staff calls the emergency room to alert them that they are in a code and on the way over. There is no policy currently saying that. The criteria to withhold CPR include blood pooled, levity, rigor, absent vitals, eyes fixed. You don't stop CPR once started until someone else takes over. I ordered two crash carts for the facility and they came in last week and we are in the process of setting them up and educating the nurses on the use. There is no policy on CPR at present." d. On [DATE] at 11:23 a.m., Registered Nurse (RN) #1 was asked if a resident is a full code and absent of vital signs what are you supposed to do. The RN stated, "If a resident is absent of vital signs and is a full code you should start CPR and continue it until relieved by another person or the Medical Doctor (MD) tells you to stop. We roll them over to the ER (emergency room ). " e. On [DATE] at 11:25 a.m., RN #2 was asked if a resident is a full code and absent of vital signs what are you supposed to do. The RN stated, "If a resident is absent of vital signs and is a full code you should start CPR and continue it until we get them over to the ER. " f. On [DATE] at 11:37 a.m., RN #3 was asked if a resident is a full code and absent of vital signs what are you supposed to do. The RN stated, "If a resident is absent of vital signs and is a full code you should start CPR unless rigor and blood pooling is present then just call the MD and tell him what you found. Only stop CPR when the MD tells us to stop. CPR should continue until we get them over to the ER." 2. The Immediate Jeopardy was removed and the scope/severity reduced to G on [DATE] at 1:30 p.m., when the facility implemented the following Plan of Removal: a. On [DATE] DON/designee immediately began in-service with all staff on when to start CPR on a patient and when to stop CPR on a patient who is full code as well as criteria for withholding CPR and need for contacting emergency medical services. Any staff not in attendance will be inserviced prior to next shift. b. On [DATE] DON/designee immediately identified all residents who are full code who had the potential to be affected with no negative findings. c. On [DATE] at 12:05 p.m., DON and Administrator called LPN #1 and inserviced her on CPR and when to start and when to stop and LPN verbalized understanding. All new staff will be inserviced during orientation prior to working the floor on the protocol for CPR. d. DON/Designee will monitor all new admits and change of code status and CPR protocol to ensure all staff is aware of status daily for 30 days and will review any death in the facility on an ongoing basis to ensure proper procedures are followed and emergency medical services were requested. e. DON/designee will present all findings to the monthly Quality Assurance (QA) committee for further review and recommendation.