Every finding on record at Liberty Retirement Community of Lima Inc

Based on employee file review, interview, and review of the employee handbook, the facility failed to ensure performance evaluations were completed as required. This affected four (#146, #166, #300, and #304) of four Certified Nursing Assistants (CNAs) reviewed for performance evaluations. This had the potential to affect all 51 residents residing in the facility. The facility census was 51. Findings include: Review of employee file for CNA #146 revealed a hire date of 05/23/25. No performance evaluations were located in the file. Review of employee file for CNA #166 revealed a hire date of 06/19/24. No performance evaluations were located in the file. Review of employee file for CNA #300 revealed a hire date of 03/05/26. No 90 day performance evaluation was located in the file. Review of employee file for CNA #304 revealed a hire date of 04/15/25. No performance evaluations were located in the file. Interview on 07/14/26 at 4:04 P.M. with Human Resources (HR#374) revealed that she was new to the position. HR #374 stated that she would give evaluations to the Director of Nursing (DON) and had not received any back. HR #374 verified the above personnel did not have performance evaluations in CNA #146, #166, #300 and #304's employee files. Review of employee handbook provided by the facility revealed the facility conducts annual employee performance appraisals. The facility conducts 90-day employee performance appraisals for CNAs. This deficiency represents noncompliance investigated under Complaint Number 3045177.

Based on infection log review, staff interviews, and policy review, the facility failed to ensure an appropriate Antibiotic Stewardship Program was established as required. This had the potential to affect all 51 residents who reside in the facility. The facility census was 51. Findings include: Review of infection control log for May 2026 and June 2026 revealed that the facility did not use McGeers criteria for infections to determine if antibiotics were necessary or justified. Interview on 07/15/26 at 2:39 P.M. with Infection Preventionist (IP #206) revealed that if an infection is not cultured she only goes by what the physician ordered. IP #206 verified they do not use McGeers criteria at this facility. IP #206 verified that she had not used McGeers or any other criteria to determine infections since she has held the position. IP #206 stated she has been in the position since December 2025. IP #206 verified she had no idea if the antibiotics given were needed or just ordered. IP #206 verified they are not doing antibiotic stewardship. Review of policy titled Antibiotic Stewardship updated 08/2024 revealed antibiotics will be prescribed and administered to residents under the guidance of the facility's Antibiotic Stewardship Program including utilization of McGeer's criteria or equivalent infection screening. This deficiency represents noncompliance investigated under Complaint Number 3044077.

Based on observations, staff interviews, and policy review, the facility failed to ensure a homelike environment regarding pervasive odors. This had the potential to affect 17 (#32, #33, #34, #35, #36, #37, #38, #39, #40, #41, #42, #43, #44, #45, #46, #47, and #48) residents residing on the Tuscan [NAME] hallway. The facility census was 51. Findings include: Observation during initial tour on 07/13/26 from 9:12 A.M. to 9:45 A.M. revealed Tuscan [NAME] hallway had a pervasive urine smell throughout the hallway. Observation on 07/13/26 at 1:27 P.M. revealed Tuscan [NAME] hallway had a strong urine smell that permeated the whole hall. Interview on 07/13/26 at 1:35 P.M. with Housekeeper #358 revealed that she was aware of the strong urine smell on Tuscan West. Housekeeper #358 stated that it was coming from a room in the middle of the hallway. Housekeeper #358 stated they clean the room several times a day but the smell just returns. Follow-up observation on 07/14/26 at 7:46 A.M. revealed the strong urine smell remained on Tuscan West. Follow-up observation 07/14/26 at 8:38 A.M. revealed strong urine smell remained on Tuscan West. Interview on 07/14/26 at 8:48 A.M. with Certified Nursing Assistant (CNA #292) verified the strong urine smell on Tuscan [NAME] and the odor permeated the whole hall. CNA #292 stated that it is caused by one resident and the resident refuses to wear briefs therefore she urinates on herself. CNA #292 stated they try and change the linens and chux pads daily and as needed to help with the odor. The facility confirmed there are 17 (#32, #33, #34, #35, #36, #37, #38, #39, #40, #41, #42, #43, #44, #45, #46, #47, and #48) residents residing on the Tuscan [NAME] hallway. Follow-up observation on 07/14/26 at 2:13 P.M. revealed strong urine smell remained on Tuscan West. Interview on 07/15/26 at 6:11 A.M. with CNAs #276 and #300 verified the strong urine smell on Tuscan West. Follow-up observation on 07/15/26 at 7:21 A.M. revealed strong urine smell remained on Tuscan West. Follow-up observation on 07/15/26 at 9:49 A.M. revealed strong urine smell remained on Tuscan West. Follow-up observation on 07/16/26 at 8:33 A.M. revealed very strong urine smell on Tuscan [NAME] that permeated the whole hallway. The urine odor was stronger about halfway down the hall to the end of the hall. Review of policy titled Quality of Life-Homelike Environment revised May 2017 revealed the facility staff and management shall maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include pleasant, neutral scents. This deficiency represents noncompliance investigated under Complaint Numbers 3091145 and 3072649.

Based on review of the state nurse aide registry, review of electronic mail (email) communications, review of the facility working schedules, review of employee time sheets, observations, staff interviews, and policy review, the facility failed to ensure staff were not working in the facility with abuse findings in the stated nurse aide registry. This had the potential to affect 15 (#16, #17, #19, #20, #21, #22, #23, #24, #25, #26, #27, #28, #29, #30 and #31) residents that reside on [NAME] and [NAME] hallways. The facility census was 51. Findings include: Review of state nurse aide registry revealed Licensed Practical Nurse (LPN #130) was not in good standing and had been found to have committed abuse, neglect, or misappropriation and cannot be employed by a long-term care facility in any capacity. Review of email communications between Ohio Department of Health (ODH) and the facility Administrator dated 07/22/26 confirmed the facility received the notification that LPN #130 was ineligible to work in LTC facilities due to a finding on the nurse aide registry. Review of facility working schedules for 07/22/26 revealed LPN #130 worked 2:00 P.M. to 10:00 P.M. Review of facility working schedules for 07/23/26 revealed LPN #130 worked from 6:00 A.M. to 6:00 P.M. on [NAME] and [NAME] hallway. Review of facility working schedules for 07/25/26 revealed LPN #130 worked from 6:00 A.M. to 6:00 P.M. on [NAME] and [NAME] hallway. Review of facility time punches revealed LPN #130 clocked in and out for the above dates listed. Observation and interview on 07/27/26 at 10:20 A.M. with LPN #130 revealed the nurse was working on [NAME] and [NAME] hallway. LPN #130 informed the surveyor of her [NAME] name. LPN #130 stated that she was not aware that she was not supposed to work at any long-term care facilities due to adverse action on the nurse aide registry. LPN #130 denied being talked to by management on or around 07/22/26. Interview on 07/27/26 at 11:00 A.M. with the Director of Nursing (DON) revealed LPN #130 had an active nursing license, so she believed the nurse was able to work in the facility. During the interview, DON seemed to be under the impression that she did not know LPN #130 could not work due to the finding in the nurse aide registry. DON stated she was confused by the last name in the nurse aide registry for LPN #130. DON was informed by the surveyor that the nurse aide registry listed the [NAME] name of LPN #130 and then the DON confirmed LPN #130 was ineligible to work in long term care facilities. The facility confirmed there are 15 (#16, #17, #19, #20, #21, #22, #23, #24, #25, #26, #27, #28, #29, #30 and #31) residents that reside on [NAME] and [NAME] hallways who LPN #130 provide care for. Review of policy titled Abuse, Mistreatment, Neglect, Exploitation and Misappropriation of Resident Property reviewed 10/2024 revealed the facility will do the following prior to hiring a new employee: check the Ohio Nurse Aide Registry (and attempt to check other state registries if the individual is known to have worked in another state) for all potential new employees (licensed and unlicensed) and new volunteers to determine if there is a finding of abuse, neglect or misappropriation of property against the individual prior to the use of that individual. It is the ongoing obligation of all employees to alert facility of any conviction or finding (such as exclusion) that would disqualify them from continued employment with facility under Ohio or Federal law, or the facility's policies. This deficiency represents noncompliance investigated under Complaint Number 3109198.

Based on observations, staff interviews, and policy review, the facility failed to ensure the proper storage of medications. This had the potential to affect 15 (#16, #17, #18, #19, #20, #21, #22, #23, #24, #25, #26, #27, #28, #29 and #30) residents residing on [NAME]/[NAME] hallways and 13 (#1, #2, #3, #4, #5, #6, #7, #8, #9, #49, #50, #51, #52) residents residing on the Tuscan East hallway. The facility census was 51. Findings include: Observation on 07/14/26 at 8:32 A.M. of the medication cart located on [NAME]/[NAME] hallways revealed three bottles of fluticasone sprays undated for a resident that had been discharged . One bottle of artificial tears that was full not in a box with no resident name or date. One box located in the back of the cart for artificial tears empty with a date of 02/12/26. Observation of the medication refrigerator on [NAME]/[NAME] hall revealed a bag containing chicken for a resident, three containers of yogurt, and one can of Dr. Pepper unopened. Interview on 07/14/26 at 8:34 A.M. with Licensed Practical Nurse (LPN #126) revealed that the resident with the fluticasone sprays was no longer at the facility. LPN #126 verified the eye drops were not labeled or dated and assumed the empty box was for those eye drops but could not be sure. LPN #126 verified the food in the medication refrigerator. Observation on 07/15/26 at 6:55 A.M. of the medication cart located on Tuscan East revealed latanoprost ophthalmic solution 0.005 percent (%) with an expiration date of 04/16/26. Interview on 07/15/26 at 7:10 A.M. with Registered Nurse (RN #208) revealed the nurse verified the eye drops were expired and should have been discarded. The facility confirmed there are 15 (#16, #17, #18, #19, #20, #21, #22, #23, #24, #25, #26, #27, #28, #29 and #30) residents residing on [NAME]/[NAME] hallways and 13 (#1, #2, #3, #4, #5, #6, #7, #8, #9, #49, #50, #51, #52) residents residing on the Tuscan East hallway who have medications stored in those medication carts. Review of policy titled Medication Storage not dated revealed expired, discontinued and/or contaminated medications will be removed from the medication storage areas and disposed of in accordance with facility policy. Employee or resident food should not be stored in the medication refrigerator. Exception: food used for administration or medications or specifically ordered for a resident by the physician and/or dietician. This deficiency represents noncompliance investigated under Complaint Number 3045177.

Based on record review, observation, resident and staff interviews, and policy review, the facility failed to ensure a resident's call light was in reach. This affected one (#50) of 10 residents reviewed for call light placement. The facility census was 51. Findings include: Review of medical record for Resident #50 revealed an admission date of 08/31/25 with diagnoses including but not limited to dementia, anxiety, and hypertension. Review of minimum data set (MDS) dated [DATE] revealed the resident had moderate cognitive impairment. The resident required supervision or touching assistance for transfers and ambulation, substantial/maximal assistance for oral hygiene, toileting hygiene, shower/bathing, upper and lower body dressing, putting on/taking off footwear, and personal hygiene. Review of physician orders revealed an order for call light in reach at all times while in room. Review of care plan dated 09/02/25 revealed the resident is at risk for falls or falls with major injury related to weakness, spondylosis, dementia, anxiety, and arthritis. Interventions included keep call light within reach and encourage the resident to use it for assistance as needed. Observation and interview on 07/13/26 at 1:28 P.M. with Resident #50 revealed that the resident stated his call light was hooked to his recliner. Upon observation it was revealed that the call light was not hooked to the recliner and was draped over the call light box on the wall out of reach of the resident. Interview on 07/13/26 at 1:35 P.M. with Housekeeper #158 verified the call light for Resident #50 was draped over the call light box on the wall out of reach of the resident. Review of policy titled Call Lights reviewed 03/20/26 revealed when providing care to the resident, be aware to position the call light conveniently for the resident to use. This deficiency represents noncompliance investigated under Complaint Number 3072649.

Based on record review, staff and physician interviews, and policy review, the facility failed to ensure the physician was notified of laboratory results in a timely manner. This affected one (#54) of three resident reviewed for lab results. The facility census was 51. Findings include: Review of medical record for Resident #54 revealed an admission date of 04/27/26 and discharge date of 05/31/26 with diagnoses including but not limited to chronic respiratory failure, dependence on respirator (ventilator) status, tracheostomy status, pneumonitis due to inhalation of food and vomit, end stage renal disease, dependence on renal dialysis, hypertension, colostomy status, gastrostomy status and osteomyelitis of vertebra sacral and sacrococcygeal region. Further review of medical record for Resident #54 revealed a hospital discharge order on 05/01/26 for vancomycin random level to be drawn on 05/03/26. Hold vancomycin 1-gram intravenous (IV) dose until vancomycin level on 05/03/26. Vancomycin end date will be 05/07/26. Review of nurses note dated 05/01/26 revealed the resident arrived back to the facility via squad. Discharge nurse at facility stated that wound vac was discontinued and per provider at facility it was up to the physician if he would like to continue wound vac or wet to dry dressing daily. Writer spoke with physician and would like to continue wet to dry dressing daily. Residents' vancomycin is also on hold currently due to vancomycin levels are too high. Levels are to be drawn on 05/03/26 and notify Infectious Disease physician of the level. Review of nurses note dated 05/03/26 8:18 A.M. revealed vancomycin level drawn and picked up by the lab. Review of nurses note dated 05/04/26 8:37 A.M. revealed writer contacted the lab regarding the vancomycin level and was informed that the specimen was placed into the wrong-colored tube and would need to be redrawn. Review of nurses note dated 05/04/26 at 12:00 P.M. revealed blood pulled from IV for vancomycin trough. Review of nurses note dated 05/06/26 at 1:58 P.M. revealed writer placed call to Infectious Disease physician to confirm vancomycin trough at 2:00 P.M. with no answer. Message left to call facility back. Review of lab dated 05/04/26 revealed vancomycin trough was 13.7 micrograms (mcg)/milliliter (ml) with a reference range of 10.0-20.0 which indicated the level was in the normal range. Interview of 07/14/26 at 4:30 P.M. with the Director of Nursing (DON) revealed there was no documentation that the vancomycin trough levels were communicated to Infectious Disease (ID) Physician #380. DON verified Resident #54 did not receive vancomycin 1-gram at any time prior to going to the hospital on [DATE] for mucous plug. Interview on 07/15/26 at 1:43 P.M. with ID Physician #380 revealed that Resident #54 was placed on vancomycin for urinary infection. ID Physician #380 verified he did not receive a phone call from the facility until 05/14/26 for him to see the resident regarding his PICC. ID Physician #380 stated that vancomycin was completed at the hospital and was not sure why it was ordered on discharge. ID Physician #380 stated that the vancomycin would not have changed the outcome of the resident and the resident had multiple co-morbities. Review of policy titled Physician Orders Policy and Procedure dated 05/09/24 revealed execution of order and notifications the nurse that takes the physician order will be responsible for executing the order or provide for the safe hand-off to the next nurse. Notify attending or other providers as appropriate and document contacts in the medical record. This deficiency represents an incidental finding investigated under Complaint Number 3044077

Based on record review, observation, and staff interview, the facility failed to ensure medications were administered as ordered resulting in two medication errors out of 31 opportunities or a 6.25 percent (%) medication error rate. This affected one (#25) of three residents observed during medication pass. The facility census was 51. Findings include: Review of medical record for Resident #25 revealed an admission date of 05/08/26 with diagnoses including but not limited to glaucoma and legal blindness. Review of minimum data set (MDS) dated [DATE] revealed the resident had moderate cognitive impairment. Review of physician orders revealed timolol maleate ophthalmic solution 0.5 percent (%) instill one drop in both eyes twice daily (allow for five minutes between drops) and brimonidine tartrate ophthalmic solution 0.2% instill one drop in both eyes twice daily (allow for five minutes between drops). Observation on 07/14/26 at 8:06 A.M. of medication pass for Resident #25 revealed the Licensed Practical Nurse (LPN #126) administered one eye drop in both eyes and was proceeding to administer the second eye drop when the resident informed the nurse that she needed to wait a minute and not do them back-to-back. LPN #126 waited one minute and administered the second eye drop into both eyes. Interview on 07/14/26 at 8:20 A.M. with LPN #126 revealed the nurse verified that she administered the eye drops for Resident #25 without waiting five minutes between the drops per physician order. This deficiency represents noncompliance investigated under Complaint Numbers 3045906 and 3044077.

Based on record review, review of a facility self-reported incident (SRI), staff interviews, and policy review, the facility failed to ensure medications were administered as ordered. This affected two (#37 and #9) of three residents reviewed for medication administration. The facility census was 51. Findings include: 1. Review of medical record for Resident #37 revealed an admission date of 05/23/26 with diagnoses including but not limited to overactive bladder, other seizures, and chronic pain syndrome. Review of hospital discharge date d 05/23/26 revealed start ciprofloxacin 500 milligrams (mg) twice daily for seven days for urinary tract infection (UTI). Review of past physician orders revealed Resident #37's ciprofloxacin 500 mg was not administered and ordered until 05/27/26 for UTI. Interview on 07/14/26 at 4:30 P.M. with Director of Nursing (DON) revealed no documentation located for the reason Resident #37 was not ordered ciprofloxacin 500 mg twice daily on 05/23/26. DON verified Resident #37 did not receive ciprofloxacin 500 mg twice daily until 05/27/26. Review of policy titled Physician Orders Policy and Procedure dated 05/09/24 revealed the nurse that takes the physician order will be responsible for executing the order or provide for the safe hand-off to the next nurse. Contact laboratory services, radiology services, pharmacy services, therapy or other outside vendors as required to execute the medical order. The medication administration record/treatment administration record (MAR/ TAR) should automatically be updated with the new orders if a schedule has been assigned. Notify attending or other providers as appropriate. Document contacts in the medical record. 2. Review of medical record for Resident #9 revealed an admission date of 01/25/22 with diagnoses including but not limited to chronic respiratory failure with hypoxia, type two diabetes, urinary tract infection, major depressive disorder, migraine, delusional disorders, generalized anxiety disorder, and hypertension.Review of physician orders revealed levothyroxine 150 micrograms (mcg) daily. Review of Medication Administration Record (MAR) for June 2026 revealed levothyroxine 150 mcg was signed off as given on 06/05/26. Review of phone interview done on 06/05/26 during SRI investigation with Agency Nurse (AN #381) revealed AN #381 signed off on electronic medication administration record (eMAR) at 4:34 A.M. that Resident #9's levothyroxine as given. When asked where the resident was at that time, AN #381 stated that she realized she did not give Resident #9 the medication but had signed it off and got side-tracked. As a result, the facility placed the nurse on Do Not Return list so she can no longer pick up shifts at the facility. Interview on 07/27/26 at 1:04 P.M. with DON revealed that the statements were obtained by the previous DON involving Resident #9. Current DON verified that the statement interview with AN #381 and security camera review were signed off by the previous DON as being factual. DON verified AN #381 documented she administered Resident #9's levothyroxine but she actually didn't administer the medication on 06/05/26.This deficiency represents noncompliance investigated under Complaint Numbers 3045906 and 3044077.

Based on record review, review of a fall investigation, review of a facility self-reported incident (SRI), and staff interview, the facility failed to ensure that adequate supervision was provided on night shift. This affected one (#9) of three residents reviewed for falls. The facility census was 51. Findings include: Review of medical record for Resident #9 revealed an admission date of 01/25/22 with diagnoses including but not limited to chronic respiratory failure with hypoxia, type two diabetes, urinary tract infection, major depressive disorder, migraine, delusional disorders, generalized anxiety disorder, and hypertension. Review of care plan dated 01/25/22 revealed the resident had activities of daily living (ADL) self-care deficit related to chronic respiratory failure, obesity, anxiety, and depression. Interventions included toileting hygiene require weight bearing assistance by staff for toileting, assist with toileting needs, peri-care, and hygiene as needed. Further review of care plan revealed the resident had potential risk for falls or fall with major injury related to chronic respiratory failure, obesity, hypertension, anxiety, depression, and diabetes. Interventions included blood sugar checks for three days, educate resident to use call light for assistance, education to staff on proper procedure of answering call lights, education provided to resident to always use the call light if she is providing her own activities of daily living (ADL), keep bed in lowest position when not providing care, nonskid strips in front of sink to increase traction/stability during transfers, keep environment free from clutter that could contribute to falls, and keep frequently used items within reach.Further review of care plan revealed the resident has bowel incontinence. Intervention included check frequently and as required for incontinence and check resident frequently and assist with toileting as needed. Further review of care plan revealed the resident has mixed bladder incontinence related to mobility, weakness, and oxygen use. Intervention included check frequently and as required for incontinence, wash, rinse, dry perineum, apply barrier cream, the resident uses disposable briefs, and change when soiled and as needed. Review of progress note dated 06/05/26 at 7:20 A.M. revealed that writer was notified by a Certified Nursing Assistant (CNA) that the resident was on the floor in her bathroom and was stating she was there all night. Upon arrival at the resident's room, writer noted the resident laid across the bathroom floor with only a sports bra on. The resident's skin was dry, cold to touch, with dried urine around the resident's body. Writer took vital signs. Resident #9 denied hitting head. Resident #9 was alert and oriented times three. Resident #9 stated that last night around 7:30 P.M. she went to use the bathroom, started to feel dizzy and attempted to self-transfer to wheelchair without calling for help or assistance. When the resident attempted to sit in the wheelchair, she slid off chair and onto her bottom. The resident stated her bottom hurt and when assessed not redness or bruising was noted. The resident was too far away to use call light at the time of the fall and stated she was yelling out for help, but nobody heard her. Review of nursing note dated 06/05/26 at 11:52 A.M. late entry revealed after interdisciplinary team (IDT) review and root cause analysis, the resident did not call for help getting ready for bed and slipped in the bathroom. Floor strips on the floor in front of the toilet were not long enough so were replaced with longer strips. Resident #9 was educated to call for help. Therapy to see the resident. Review of SRI investigation completed on 06/05/26 revealed interview at 7:40 A.M. with Licensed Practical Nurse (LPN #114) informed the former Director of Nursing (DON) that Resident #9 was found lying on her bathroom floor and the resident stated that she was on the floor all night. LPN #114 stated the resident was naked, cold, and had dried urine on the floor around her. LPN #114 stated the resident was assessed with no injuries. Interview with Resident #9 revealed that she was getting ready for bed last night (06/04/26) and slid onto the floor. Resident #9 stated she lay there all night. Resident #9 denied getting her bedtime medications. Resident #9 stated that she did try yelling for help and banging on the wall. Resident #9 stated that staff found her this morning on the bathroom floor. Interview with CNA #300 revealed that she found Resident #9 lying on the floor in the bathroom, not wearing any clothes, body was cold, clothes she had on the day before (06/04/26) were lying on the bathroom floor. CNA #300 stated that a box was lying on top of Resident #9's bed last night when she left and was still lying on the bed in the same spot this morning and didn't appear that the resident used the bed last night. Phone interview with Agency Nurse (AN #381) revealed that she gave Resident #9 her evening medications when she was sitting at the table in the dining room. AN #381 stated she did not go into Resident #9's room anytime during the night. AN #381 stated that she usually just did her own thing giving medications and did not go into resident rooms unless the aides are on break or if multiple call lights are going off. AN #381 signed of on electronic medication administration record (eMAR) at 4:34 A.M. Resident #9's levothyroxine as given. When asked where the resident was at that time, AN #381 stated that she realized she did not give Resident #9 the medication but had signed it off and got side-tracked. As a result, the facility placed the nurse on Do Not Return list so she can no longer pick up shifts at the facility. Former DON reviewed the security camera from 6:00 P.M. to 6:00 A.M. shift and observed CNA #260 wheeling Resident #9 into her room at 7:59 P.M. then left the room right after. No staff was seen entering her room from 8:00 P.M. to 6:00 A.M. Day shift found the resident on the floor at 7:30 A.M. Interview with CNA #382 revealed she was scheduled to work that night shift. CNA #382 stated the CNA #260 had taken Resident #9 back to her room. CNA #382 stated that Resident #9 puts herself to bed. CNA #382 stated the Resident #9's call light never came on so she never went in her room during her shift. CNA #382 was educated that she needed to check on all residents every two hours to make sure they are okay. CNA #382 has been terminated from employment. Interview on 07/27/26 at 1:04 P.M. with current DON revealed that the statements were obtained by the previous DON involving Resident #9's fall. Current DON verified that the statement interview with AN #381 and security camera review were signed off by the previous DON as being factual. DON verified it is common practice and the facilities expectation that all residents are checked on by staff every two hours. This deficiency represents noncompliance investigated under Complaint Number 3045906.

Based on observation, record review, Emergency Medical Services (EMS) report review, hospital documentation review, death certificate review, resident interview, staff interview, review of facility's policy for Cardio-Pulmonary Resuscitation (CPR), and review of facility's policy and procedure for In Case of Decannulation, the facility failed to ensure the necessary life-sustaining respiratory services were provided to residents who required invasive mechanical ventilation via tracheostomy (a hole in the front of the neck and into the windpipe) cannula. This resulted in Immediate Jeopardy and serious life-threatening harm on [DATE] at 1:40 A.M., when Resident #54 was found unresponsive without a pulse, with the tracheostomy cannula dislodged, and had been without oxygen for an unknown period of time. Staff were not trained in regards to reinserting the cannula or the procedure required to provide life-saving measures. Consequently, lifesaving CPR was not properly performed when Resident #54 was not provided with supplemental oxygen or re-cannulated timely, was transferred to the hospital and subsequently passed away three days later from an anoxic brain injury secondary to hypoxic respiratory failure. This affected one (Resident #54) of four residents reviewed for tracheostomy care. The facility identified two current residents with tracheostomies. The facility census was 47. On [DATE] at 12:13 P.M., the Administrator, the Director of Nursing ( DON) and Chief Compliance Officer (CCO) #300 was notified Immediate Jeopardy began on [DATE] at 1:40 A.M. , when the an agency nurse, Licensed Practical Nurse (LPN) #288, was alerted by Certified Nurse Aide (CNA) #265 that while she was providing care for Resident #54 the tracheostomy (trach) had become de-cannulated and was no longer in place in the resident's trachea. LPN #288 went to assess Resident #54 and found the resident unresponsive with the tracheostomy cannula lying on her chest. LPN #288 attempted to place the tracheostomy cannula back into Resident #54's trachea and was unsuccessful. LPN #288 instructed CNA #265 to call Respiratory Therapist (RT) #236 for instruction and to call for Emergency Services (911). LPN #288 was unable to obtain a pulse on Resident #54 and began chest compression but did not apply any supplemental oxygen to the resident, who required mechanical ventilation to breathe. On [DATE] at 1:51 A.M., 11 minutes after the resident was found to be de-cannulated, unresponsive and without a pulse, RT #236 arrived at the facility along with Emergency Medical Services (EMS) and was able to re-cannulate the resident. After re-cannulating Resident #54's tracheostomy, RT #236 prepared the Ambu-bag (a hand-held, self-inflating device used to provide positive pressure ventilation to patients who are not breathing) with oxygen and began to supply oxygen to Resident #54 via the tracheostomy cannula. EMS assumed CPR chest compressions from LPN #288 and was able to reconnect the ventilator to Resident #54 and transport her to the hospital. While EMS was able to adequately ventilate Resident #54, the resident continued to require CPR measures at the hospital. Once a pulse was obtained, the resident was admitted to the Intensive Care Unit but was found to be non-reactive and in a vegetative state. Resident #54 passed away three days later, on [DATE], with the cause of death determined as anoxic brain injury (brain deprived of oxygen causing rapid cell death within minute), secondary to hypoxic (a dangerous condition where tissue receives insufficient oxygen to maintain homeostasis) respiratory failure. Immediate Jeopardy was removed on [DATE], when the facility implemented the following corrective actions: On [DATE], Resident #54 was transferred to the hospital. On [DATE] at 6:00 A.M., Respiratory Therapist Manager (RTM) #242 verbally in-serviced both agency nurses, LPN #288 and LPN #302. Both nurses returned demonstration and reviewed printed policies and procedures in the agency binder after the incident occurred. This education included suctioning (both open and closed), how to measure the placement of the suction catheter, decannulation, how to use Ambu-bag and the competency checklist for respiratory nursing care for residents on ventilators and residents who have tracheostomy and the location of crash carts and Automated External Defibrillator (AED). On [DATE], CCO #300 and former Human Resource Manager (HRM) #303 in-serviced RNs and LPNs on Respiratory policies, CPR, supplemental oxygen, Trach and Decannulation. Policies and procedures were sent to all nurses via text message for immediate review. There was no documentation of receipt of the text to the staff. On [DATE], CCO #300 and former HRM #303, in-serviced CNAs on personal care for residents with tracheostomies. Policies and procedures were sent to all CNAs via text for immediate review. There was no documentation of receipt of the text to the staff On [DATE] at 10:30 A.M., the Administrator and CCO #300 educated RTM #242 on the facility's requirements for nurses training for ventilator dependent residents, supplemental oxygen, tracheostomy care and emergency procedures. On [DATE] at 10:30 A.M., RTM #242 implemented an education binder to track and audit all facility and agency staff education documents. Beginning on [DATE] at 10:30 A.M., RTM #242 or designated Respiratory Therapist will train agency nursing staff on ventilator dependent residents care plans, protocols for tracheostomy care and emergency procedures for ventilator dependent and/or trach residents prior to providing care to residents. Competency checklist to be completed by Respiratory Therapist. This is a new standard practice going forward without an end date. On [DATE] at 10:45 A.M., RTM #242 re-educated and completed check-off on Competency Checklist for Respiratory Care for Nursing, Decannulation and Emergency Procedures for Registered Nurses (RNs) and LPNs. Education/Training included verbal, return demonstration and printed procedures. This was completed on [DATE]. On [DATE] at 12:30 P.M., a Quality Assurance (QA) meeting was held immediately following notification of Immediate Jeopardy. This included CCO #300, the Administrator, LNHA, DON, Assistant DON, Minimum Data Set (MDS) Nurse, RTM #242, Infection Preventionist/Wound Nurse, Scheduler, Business Office Manager, Social Services, Activity Director, Maintenance Director, Dietary Manager, Therapy Manager, Housekeeping/Laundry Supervisor who met to discuss the [DATE] incident, education needed, policies and procedures to put into place. Beginning on [DATE] at 12:45 P.M., RTM #242 will complete a respiratory assessment for all at risk residents and ensure that residents are provided with respiratory care by trained staff. Completed by [DATE] at 4:00 P.M. Beginning on [DATE] at 1:30 P.M., the Director of Nursing (DON) and RTM #242, uploaded the acknowledgement procedure electronically to the Clipboard staffing agency to notify agency employees that our facility has vent/trach residents that require care outside of normal routine care. Agency staff must be trained by an RT on ventilator dependent resident care plans, protocols for tracheostomy care and emergency procedures for ventilator dependent residents and read and sign the Agency Nurse Binder at the nurse's station before starting their shift. This training will include verbal, return demonstration and printed procedures. Acknowledgement must be signed before the facility job positing applications will allow agency staff to pick up a shift at facility. DON verified posting on [DATE] at 8:05 P.M. On [DATE] at 3:00 P.M., RTM #242 completed Competency checklist and decannulation training for tracheostomy residents with Liberty Dialysis nurses. Training included verbal, return demonstration and printed procedures for respiratory needs of residents with tracheostomies. Completed on [DATE]. Beginning on [DATE], LPN Scheduler #255, DON, and RTM #242 will attempt to schedule at least one facility licensed nurse trained by respiratory therapist per shift. LPN Scheduler #255 will notify DON and RTM #242 of any shifts that do not have a facility nurse trained by RT. In the unplanned event the facility would have two agency nurses working, the facility will have RT coverage or another licensed facility nurse in the facility who has completed training with a Respiratory Therapist for the duration of the shift. This will be ongoing practice, unless there are no residents with vents/traches in the facility. Any resident who has a tracheostomy or ventilator needs to be considered for admission will not be admitted to the facility until an RT is present in facility. No ventilator or tracheostomy residents will be admitted off-hour or on the weekends if RT is not available. Beginning on [DATE], the DON or designated nurse manager and RTM #242 or designated Respiratory Therapist will monitor schedule daily to ensure scheduling compliance with RTs and agency staff. Beginning on [DATE], the RTM #242 or designated Respiratory Therapist will monitor agency education binder daily to ensure all education documents are completed. This will be ongoing. Beginning on [DATE], the DON or designated nurse manager will audit the education binder weekly to ensure that a Respiratory Therapist has trained all facility and agency staff. This will be ongoing. Beginning on [DATE] at 1:45 P.M, during the monthly Quality Assurance and Performance Improvement (QAPI) meeting with the Medical Director, a review of correction plan to ensure the training has been completed for all RNs, LPNs, agency and will be ongoing as needed. This will be reviewed at the quarterly QAPI meeting starting [DATE] and ongoing if the facility has residents that are ventilator dependent or have tracheostomy. Respiratory Department will provide additional training as needed outside of the regularly scheduled trainings. Beginning [DATE] and ongoing monthly, RTM #242 or the designated Respiratory Therapist will attend the monthly nurse and CNA meetings to provide ongoing education, review competency checklist and to ensure that all staff are knowledgeable of policies and procedures related to residents on life sustaining mechanical devices and/or requiring CPR. This training will include verbal, return demonstration and printed procedures. Although the Immediate Jeopardy was removed on [DATE], the deficiency remains at a Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility is in the process of implementing their corrective action plan and monitoring to ensure on-going compliance.Findings include: Record review revealed Resident #54 was admitted on [DATE] and was discharged on [DATE]. Diagnoses included acute and chronic respiratory failure, dependence of a ventilator, obstructive sleep apnea, pulmonary hypertension, and malnutrition. Review of Resident #54's Minimum Data Set (MDS) comprehensive quarterly assessment dated [DATE] revealed the resident had intact cognition, no behaviors, and was receiving invasive ventilation via a tracheostomy cannula. Review of Resident #54's physician orders dated [DATE] revealed she was a Full Code, with a size 16 Shiley cannula with ventilator settings of Assist Control (AC) Respiratory Rate (RR) 12, Positive End-Expiratory Pressure (PEEP) 6, Tidal Volume (Vt) 400, and oxygen titrate to keep saturation at 90 percent. Review of Resident #54's care plans dated [DATE] revealed a focus for tracheostomy related to respiratory failure. Interventions included ensure trach ties are secured at all times, monitor and document restlessness and agitation, monitor respiratory rate, ventilator setting per order with oxygen via the tracheostomy/ventilator. Cannula (tube) out procedure: keep extra trach cannula and obturator (a structure that blocks or closes an opening) at the bedside, if cannula is coughed out, open stoma with hemostat. If cannula cannot be reinserted, monitor/document for signs of respiratory distress, if able to breathe spontaneously elevate head of bed 45 degrees, stay with resident and obtain medical help immediately. Review of the Emergency Medical Service (EMS) care report dated [DATE], revealed a call was reported as received from the facility at 1:44 A.M. EMS was dispatched to the facility, at 1:48 A.M. The EMS arrived at the facility at 1:49 A.M. and arrived at Resident #54's room. At 1:49 A.M., EMS documented the resident's tracheostomy cannula came out, facility staff were able to replace the trach cannula, and Resident #54 was loaded onto a cot and transported to the hospital. Per the EMS care report the staff at the facility were unable to provide any history or information about Resident #54 and no packet containing information was transferred with the patient to the hospital. EMS documented staff reported it was unknown how long the tracheostomy cannula was out of place. Review of the hospital documentation dated [DATE] at 2:09 A.M. revealed Resident #54 arrived at the emergency room by EMS transport. Resident #54 was evaluated for cardiac arrest secondary to hypoxic respiratory failure. Resident #54 had her trach (cannula) pulled out for an undisclosed amount of time. Per the hospital documentation the trach was replace and EMS did Advanced Cardiac Life Support (ACLS) with compression and ventilation prior to arrival. Upon arrival Resident #54 was in asystole (without a heartbeat) and required additional ACLS CPR measures to obtain a cardiac rhythm. Review of the Medical Decision Making section of the report ACLS algorithm was followed to initiate chest compression and medication to stabilize resident. Initial blood gas tests showed the resident had respiratory acidosis (lower than normal blood pH caused by hypoventilation) and it was anticipated that the hypoxic respiratory failure caused cardiac arrest. The hospital physician documented given a clear story of trach dislodgement the focus on respiratory failure as a primary cause for the cardiac arrest. Review of Resident #54's progress notes dated [DATE], entered at 3:36 A.M. for care at 1:15 A.M., revealed LPN #288 documented this nurse was located at the nurse's station at time of incident. LPN #288 was alerted by CNA #265, Resident#54's trach had dislodged from the trachea while giving the resident care. LPN #288 immediately attempted to reinforce the tracheostomy cannula back into the trachea. LPN #288 simultaneously instructed the CNA #265 to call emergency service, and RT #236 for assistance, while attempting replacement of the cannula. RT stated she would come STAT (immediately). LPN #288 immediately began chest compression while awaiting the arrival of assistance. RT #236 arrived in eight to ten minutes along with EMS. RT #236 was able to locate the trach pathway and successfully reinsert the tracheal cannula back into trachea, as EMS was establishing vitals. Resident #54 was transferred out to the hospital. LPN #288 faxed over resident's medication summary and profile to hospital. LPN #288 contacted resident's husband with no answer, left voicemails, and notification of transfer. DON notified, LPN #288 awaiting report from hospital. Review of Resident #54's critical care note dated [DATE] at 6:51 A.M., revealed the Assessment and Plan section included cardiac arrest likely secondary to hypoxic respiratory failure after resident was found unresponsive at the facility for an unknown period of time and found to have dislodged trach. Concern for anoxic brain injury secondary to the cardiac arrest as the resident is not responding at this time with no withdrawal from pain.Review of Respiratory Care Note dated [DATE] at 2:22 P.M., documented by RT #236, called by facility at 1:40 A.M, because the ventilator was alarming and the tracheostomy looked weird. It was noted Resident #54 was completely decannulated. Trach was easily replaced and the resident was back on the ventilator. Resident #54 was very dusky, letting the ventilator carry her with a faint pulse. EMS was unable to get a blood pressure. EMS transferred the resident to gurney and to hospital. Review of Resident #54's death certificate dated [DATE] revealed the primary cause of death was anoxic brain injury secondary to cardiac arrest and hypoxic respiratory failure. During an interview on [DATE] at 9:37 A.M., Resident #24 stated he knew of a resident on a ventilator who had passed away due to the staff working not being trained on how to take care of residents on ventilators. Resident #24 said he heard a commotion one night and it was the EMS and staff talking about how the nurse who assigned to residents on ventilators did not know how to care for them properly. Resident #24 stated he knew there were no respiratory therapists in the building at night. During an interview on [DATE] at 1:25 P.M., RT #236 stated she worked in the facility on [DATE] from 6:00 P.M. to 12:00 A.M. On [DATE] around 11:00 P.M. she provided nighttime respiratory care for Resident #54 which included trach care, ventilator checks, and oxygen checks. RT #236 stated at the time she provided the care Resident #54 was in no distress, the trach was in place, the resident had no secretions, and her oxygen level was around 98 percent. RT #236 stated prior to her clocking out at 12:00 A.M. She asked LPN #288 if she was comfortable caring for Resident #54, as she was an agency nurse who had not worked on the unit before. RT #236 stated LPN #288 had told her, I am good and RT#236 left the facility. RT #236 stated on [DATE] early in the morning she was called by agency nurse LPN #288 and was told Resident #54's trach looked weird. RT #236 stated she asked the nurse simple questions about Resident #54's respiratory status and the only answers LPN #288 gave was saying I don't know. RT #236 stated she told the nurse to call 911 and she would be coming into the facility immediately. RT #236 stated on the phone she asked LPN #288 if the resident had a pulse, was breathing, and what happened to the trach, the only answer LPN #288 gave her was, I don't know. RT #236 stated when she arrived at the facility the EMS were coming into the building. RT #236 stated she led the EMS to the resident's room and reached the resident at 1:51 A.M. RT #236 stated LPN #288 was doing chest compression but was not providing any oxygen via the Ambu-bag or by any other means. RT #236 stated she was able to reinsert the trach cannula and she herself got the Ambu-bag out of the basket located on the vent, in the room. RT #236 stated she hooked it up to the oxygen tank, attached it to Resident #54 and started to supplement the oxygen via the Ambu-bag through the trach. RT #236 stated while she was preparing the Ambu-bag, EMS took over chest compressions and was asking LPN #288 questions about the resident in which LPN #288 kept answering, I don't know where anything is for this resident. RT #236 stated she assisted the EMS with transferring the resident to a gurney and she hooked up the ventilator and assisted EMS to transfer the resident out of the facility on the ventilator. RT #236 stated she then went back to talk to the LPN #288 about the incident, but LPN #288 continued to tell her she did not know where anything was and how to care for the resident's trach when they become dislodged. During an interview on [DATE] at 10:00 A.M., CCO #300 revealed after the [DATE] incident with Resident #54 the CCO #300 did send education to the former Human Resource Manager #303 to have all facility nurses review the policies and procedures for tracheostomy care. CCO #300 stated she did not require signatures for the education, so she was unsure who received the education. During an interview on [DATE] at 9:33 A.M., agency nurse LPN #288 stated she had not worked in the facility with the ventilator residents prior to [DATE]. LPN #288 stated upon her arrival at the facility, on [DATE], from 6:00 P.M. to 6:00 A.M. shift, she was not oriented to the unit, received no resident orientation regarding care plans, and did not receive education or orientation on location of emergency equipment including the crash cart and emergency supplies in Resident #54's room. LPN #288 stated she had no experience in re-cannulating tracheostomy cannulas after they became dislodged and received no education from the facility on what to do if decannulation happens. LPN #288 stated she was led to believe by staff there would be a respiratory therapist in the building for the whole shift. LPN #288 stated on [DATE], she administered nighttime medications, sometime around 11:00 P.M. to Resident #54 and the resident was in no distress. LPN #288 stated she could not recall having any conversation with RT #236 prior to RT #236 leaving for her shift. LPN #288 stated she could not recall the ventilator alarming but stated in the early morning CNA #265 came to her at the nurse's station and said, Resident #54's trach came out. LPN #288 stated she immediately ran to the resident's room and found her trach laying on her chest. LPN #288 stated she tried to reinsert the trach into the resident's trachea but could not get the cannula back in. LPN #288 stated she then told the CNA #236 to call RT #236 and put her on speaker phone. LPN #288 stated she also told the CNA #236 to call for the other agency LPN #302 and 911, when she noticed Resident #54 was not breathing and was not responding to her. LPN #288 stated she continued to attempt to reinsert the trach cannula and then she started chest compressions on the resident when she could not obtain a pulse. LPN #288 stated it was a short time later RT #236 came back into the facility to the resident's room with EMS and RT #236 took over care of the resident by reinserting the trach cannula and then getting the Ambu-bag hooked up to oxygen. LPN #288 verified at no time from the time she found Resident #54 with her cannula out to the time RT #236 arrived at the resident's bedside was LPN #288 able to supply any oxygen to Resident #54. Per LPN #288 she did not know where the crash cart or the Ambu-bag was in the facility. LPN #288 verified she did have a current CPR certification at the time of the incident. During an interview on [DATE] at 2:57 P.M., Respiratory Therapy Manager (RTM) #242 stated respiratory therapists are scheduled for all day shifts from 6:00 A.M. to 6:00 P.M. and some night shifts but due to census may not be scheduled for a whole 12-hour shift, 6:00 P.M. to 6:00 A.M. RTM #242 stated on [DATE], RT #236 was told to clock out at 12:00 A.M. per the schedule. RTM #242 stated it was the facility's unwritten protocol for the RT to ask the nurses working on nightshift if they were comfortable taking care of the ventilated residents prior to the RT leaving the facility. RTM #242 stated it was reported to her LPN #288 told RT #236 she was fine taking care of Resident #54 when RT #236 left the facility. RTM #242 verified there was no official training for agency nurses on caring for residents with tracheostomy on the ventilators but stated it was in the care plans on what to do if the resident becomes decannulated. During an observation on [DATE] at 8:28 A.M. Resident #08 was dependent on a ventilator supplying support via a tracheostomy cannula. There was an Ambu-bag, extra suction wand, extra tracheostomy cannula, and emergency supplies located in a grey basket attached to the resident's ventilator. During an observation on [DATE] at 8:40 A.M, a crash cart was located outside of Resident #08's room in the hallway, painted red and clearly visible from the hallway on both sides. Emergency supplies were observed on the crash cart including an Ambu-bag, oxygen tank, suction wands, and emergency tubing. Review of the facility policy titled Emergency Procedures - Cardio-Pulmonary Resuscitation, revised February 2018, revealed when a resident is found unresponsive assess for absence of breathing. If a cardiac arrest is likely the rescuer will begin CPR. Following the initial assessment begin with chest compressions, after 30 chest compressions provide 2 breaths via the Ambu-bag or manually with a CPR shield. All rescuers trained in CPR should provide ventilations with a compression to ventilation ratio of 30:2. Review of the policy titled, In Case of Decannulation, undated, the policy stated call 911 and call for a crash cart. Attempt to re-insert trach or establish an airway by covering the stoma with gauze and tape, in the gray basket on vent cart. Put on appropriate oxygen device if spontaneously breathing (in bag with spare trach on vent cart). If no spontaneous breaths begin Ambu-bag with face mask at 15 liters of oxygen with 100% O2 (oxygen), located in each room with a ventilator/trach on the vent stand and tank is already turned on, turn flow liter to 15. Check all vitals, if no pulse, begin compression and continue CPR unless indicated otherwise. This deficiency represents noncompliance investigated under Complaint Numbers 2724849, 2698450, 2615090, and 1335680.

Based on medical record reviews, observations, resident interview, staff interview, review of Tuberculosis (TB) Risk Assessment, and review of policy, the facility failed to properly handle soiled linen for Resident #3. In addition, the facility failed follow enhanced barrier precautions for Residents #39 and #40. The facility failed to complete the TB risk assessment annually. This had the potential to affect all 47 residents. The facility census was 47.Findings include:1. Review of the medical record revealed Resident #3 was admitted on [DATE]. Diagnoses included acute and chronic respiratory failure with hypoxia, type two diabetes mellitus with hyperglycemia, and chronic kidney disease stage 3. Review of the Minimum Data Set (MDS), dated [DATE], revealed the resident was cognitively intact and required set-up/clean up assistance with toileting, showering, and personal hygiene. Review of the care plan, revised on 10/01/25, revealed Resident #3 has mixed bladder incontinence. Interview on 03/11/26 at 12:19 P.M. with Resident #3 revealed the odor is coming from the pile of soiled laundry in the corner of the resident room. Resident #3 stated every day she places soiled laundry on the floor in the corner for the aides to get. Resident #3 stated today housekeeping staff also picked up soiled laundry on the floor and added to the piled in the corner. Interview on 03/11/26 at 12:28 P.M. with Certified Nursing Assistant (CNA) #256 stated she did not know the soiled linen was on the floor and would collect it. After the laundry was collected, a follow-up interview at 12:55 P.M. with CNA #256 verified the laundry was saturated. Interview on 03/12/26 at 11:57 A.M, with Housekeeping #239 verified collected Resident #3's wet soiled laundry on 03/11/26 and placing it directly on the floor in the corner of the room for the aide to gather. 2. Review of the medical record for Resident #40 revealed an admission date of 09/29/2020 with medical diagnoses of cerebral palsy, profound intellectual disabilities, seizures, hypertension, and dysphagia. Review of an annual Minimum Data Set (MDS) assessment, dated 02/11/26, indicated Resident #40 had severe cognitive impairment and was dependent upon staff for all activities of daily living. Review of the physician orders for Resident #40 revealed an order dated 12/11/25 for Enhanced Barrier Precautions (EBP) and an order dated 12/11/25 Isosource 1.5 milliliter (ml) to administer 300 ml bolus five times per day. Observation on 03/16/26 at 1:18 P.M. revealed Certified Nursing Aide (CNA) #245 prepared Resident #40 for incontinence care by explaining the procedure, washing her hands, and applying gloves. The observation revealed an EBP sign posted on Resident #40's door and personal protective equipment (PPE), including gown, gloves, and googles, located in the room. CNA #245 proceeded to complete incontinence care for Resident #40. Observation on 03/16/26 at 1:34 P.M. revealed Licensed Practical Nurse (LPN) #202 observed to use hand sanitizer and apply gloves and then proceeded to administer the tube feeding and water flushes as ordered to Resident #40. Interview on 03/16/26 at 1:41 P.M. with CNA #245 and LPN #202 confirmed Resident #40 was on EBP, there was a sign posted on her bedroom door, and PPE was available in her room. CNA #245 and LPN #202 both confirmed they did not donn a gown when they provided incontinence care or administered the tube feedings. 3. Review of Resident #39's medical record revealed an admission date of 09/06/22. Diagnoses listed included hemiplegia, type two diabetes mellitus, bladder dysfunction, and hypertension. Review of a quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #39 was cognitively intact, had an indwelling urinary catheter, and had received an antibiotic. Review of physician orders revealed an order dated 05/24/25 for EBP for extended-spectrum beta-lactamases (ESBL) and indwelling catheter. Follow EBP protocols when providing care. Observation of Certified Nurse Aide (CNA) #230 and CNA #282 providing care to Resident #39 on 03/12/26 revealed they did not follow EBP protocols. CNA #230 and CNA #282 entered Resident #39 on 03/12/26 at 7:28 A.M. and donned gloves but did not don any gowns. CNA #230 and CNA #282 then assisted Resident #39 with dressing and transfer to a wheelchair using a sit to stand lift (hydraulic lift device). CNA #282 moved Resident #39's urinary catheter collection bag from bedside, hung it on her pants leg pocket, attached it to the lift, then attached it to a wheelchair after transfer. CNA #282 then handed a washcloth to Resident #39 to have him wash his face. During an interview on 03/12/26 at 7:37 A.M. CNA #230 confirmed Resident #39 was on EBP and gowns should be used during care. CNA #230 confirmed a sign alerting staff of EBP and personal protective equipment (PPE) were on Resident #39's entrance door. During an interview on 03/12/26 at 7:39 A.M. CNA #282 confirmed Resident #39 was on EBP and gowns should be used during care. CNA #230 confirmed a sign alerting staff of EBP and PPE were on Resident #39's entrance door. Interview with Infection Preventionist (IP) #246 on 03/12/26 at 7:55 A.M. confirmed Resident #39's was ordered to be in EBP and CNA #230 and CNA #282 should have donned gowns when providing care. Review of the facility's policy titled Enhanced Barrier Precautions dated revised 09/08/25 revealed EBP is indicated for residents with the following conditions when contact precautions (contact, droplet, airborne, etc.) would not otherwise apply. Wounds, this generally includes residents with chronic wounds, and not those with only shorter-lasting wounds, such as skin breaks or skin tears covered with a Band-aid or similar dressing. Indwelling medical devices such as catheters, drains, etc., all intravenous (IV) access points regardless of use (except for peripheral intravenous lines, gastronomy tube (G-tube) or jejunostomy tube (J-tube), tracheostomies or ventilators, and infection or colonization with a multidrug resistant organism (MDRO). PPE includes the use of gloves and gown for high contact care activities. High contact care activities include dressing, bathing/shower/hygiene, transferring in the patient's room, changing linens, toileting/changing briefs, indwelling device care, wound care, and therapy sessions. Use face/eye protection if splash/spray possible. 4. Review of the facility Tuberculosis (TB) Risk Assessment revealed it was completed on 03/12/26. The facility did not have documentation to of TB Risk Assessment completed in 2025. Interview on 03/12/26 at 8:13 A.M. with Infection Preventionist (IP) #246 confirmed the facility did not have documentation to support a TB Risk assessment had been completed in 2025. Review of the facility policy titled, Tuberculosis Risk Assessment, revised October 2010 stated the purpose of the TB risk assessment is to help evaluate the risk of transmission of TB within the facility, and to help establish appropriate administrative, environmental and respiratory protection controls for the recognition and/or prevention of TB transmission. The policy stated the TB risk assessment shall be conducted annually to determine appropriate administrative, environmental, and respiratory protection controls needed for the facility based on the current TB risk classification. This deficiency represents non-compliance under Complaint Numbers 2568764, 2615090, and 2698450.

Based on review of the facility's assessment and staff interview, the facility failed to assess the staffing needed to ensure resident receive the necessary care and treatment in the annual facility assessment. This has the potential to affect all 47 residents residing in the facility. The current census is 47. Findings include: Review of the facility assessment updated March 2026 revealed no staffing levels were included in the assessment. The facility assessment did not contain any documented information on staffing levels to ensure that there are a sufficient number of staff with appropriate competencies and skill sets necessary to care for residents' required care. The facility assessment lacked any documentation regarding specific staffing needs for each resident unit in the facility and adjustments necessary based on changes to its resident population. The facility assessment had no documentation of considerations on specific staffing needs for each shift based on any changes to its resident population.Interview on 03/17/26 at 2:00 P.M. with the Administrator verified the facility assessment did not contain the required information regarding specific staffing required for the resident population in the facility.

Based on medical record review, observation, staff interview, review of manufacturer instructions, and review of facility policy the facility failed to administer medications per physician order and administer ophthalmic drugs as recommended. This affected two (#22 and #24) of four residents reviewed for medication administration. The facility census was 47.Findings include:1. Review of the medical record revealed Resident #22 was admitted on [DATE]. Diagnoses included unspecified dementia moderate without behavioral disturbance, essential hypertension, chronic kidney disease, mixed hyperlipidemia, unspecified glaucoma. Review of the MDS assessment, dated 02/26/26, revealed the resident was severely cognitively impaired. Review of physician order, dated 11/29/25, revealed an order for brimodidine tartrate ophthalmic solution 0.1% with instructions to instill one drop in both eyes two times a day for eye drop. Review of physician order, dated 01/27/26, revealed an order for dorzolamide hci-timolol mal ophthalmic solution 2-0.5% with instructions to instill one drop in both eyes two times a day for glaucoma. Review of brimonidone tartrate ophthalmic solution manufacturer instructions, no revised date, revealed if more than one topical ophthalmic drug is being used, the products should be administered at least five minutes apart. Review of dorzolamide hydrochloride ophthalmic solution manufacturer instructions, no revised date, revealed if more than one topical ophthalmic drug is being used, the drugs should be administered at least five minutes apart. Interview on 03/11/26 at 11:48 A.M. with Licensed Practical Nurse (LPN) #202 revealed she does not know if she is supposed to wait five minutes between giving eye drops. LPN #202 stated she does not wait and no one when training her waited in between eye drop applications. Observation on 03/11/26 at 11:50 A.M. of LPN #202 provide Resident #22 with brimonidone tartrate ophthalmic solution and immediate after administered the dorzolamide hydrochloride ophthalmic solution. Interview on 03/11/26 at 11:53 A.M. with LPN #202 verified she did not wait five minutes between eye drop solutions. 2. Record review for Resident #24 revealed the resident was admitted to the facility on [DATE]. Diagnoses for Resident #24 include fracture of the pelvis, chronic pain, post-traumatic stress disorder, depression, epilepsy, and hypertension. Review of the MDS assessment dated [DATE] comprehensive quarterly assessment revealed the resident had intact cognition. Review of Resident #24's care plans dated 04/29/25 revealed a focus for cerebral vascular accident related to hypertension. Interventions include to monitor vital signs and notify physician of significant abnormalities, and administer medications as ordered. Review of physician orders dated 11/21/25 revealed Resident #24 was to be administered clonidine (anti-hypertensive medication) 0.1 milligrams, (mg) tablet by mouth every 8 hours as needed for systolic blood pressure (SBP) greater than 170. Review of Resident #24's Medication Administration Records (MAR) dated December 2025 revealed documentation the resident's SBP on 12/19/25 was 219, no documentation of the resident receiving the as needed clonidine medication was noted in the MAR. On 01/15/26 the SBP was documented as 206 with no documentation of the clonidine administered. On 02/06/26 the resident's SBP was documented as 183 with no documentation of clonidine administered. On 02/17/26 the SBP was documented as 172 with no documentation of clonidine administered. On 02/27/26 the SBP was documented as 175 with a notation the blood pressure was out of normal limits and 'see notes' in the MAR, no documentation of the administration of the clonidine was in the MAR for 02/27/26. Further review of Resident #24's progress notes revealed there to be no documentation for the administration of the as needed clonidine medication in the progress notes dating from December 2025 to February 2026. Interview on 03/09/26 at 9:00 A.M. and on 03/16/26 at 8:30 A.M. with Resident #24 revealed the resident stated he was concerned due to many times he felt his blood pressure was too high. Resident #24 stated staff are monitoring his blood pressure, but when he goes to see his cardiologist he is being told no one from the facility is reporting to the physician any abnormalities with his blood pressure. Resident #24 stated he could not recall receiving any medications for his high blood pressure being administered. Interview on 03/11/26 at 3:50 P.M. with the DON #264 verified there was no documentation of Resident #24 receiving his as need blood pressure medications in the medical records for the dated of 12/19/25, 01/15/26, 02/06/26, 02/17/26, and no notations for the 'see notes' on 02/27/26. Review of the facility policy titled, Pharmacy Services Policy, dated 06/21/17, revealed a pharmaceutical service is available to provide residents with prescription and non-prescription medications, infusion therapy products and related equipment, supplies and services. This deficiency represents non-compliance under Complaint Numbers 2568764, 2615090, and 2621295.

Based on medical record review, observation, resident interview, staff interview, resident food list review, and review of facility policy, the facility failed to ensure resident meals were free from choking hazards. This affected Resident #34 with the potential to affect an additional seven (#3, #4, #8, #15, #21, #41, and #46) residents who were served soup. In addition, the facility failed to ensure the facility followed the fall policy and provided documentation of the fall in the medical record. This affected one (#6) of seven residents reviewed for falls. The facility census was 47.Findings include: 1. Review of the medical record revealed Resident #34 was admitted on [DATE]. Diagnoses included chronic obstructive pulmonary disease, heart failure, type two diabetes mellitus without complications, hypothyroidism, and major depressive disorder. Review of the Minimum Data Set (MDS) assessment, dated 12/07/25, revealed the resident was cognitively intact and set-up/clean-up for eating. Observation on 03/10/26 at 12:13 P.M. of Resident #34 ate lunch in her room with the door closed. Observation of the completed lunch meal revealed an approximate two inch chicken bone in the soup bowl. Subsequent interview with Resident #34 verified having chicken noodle soup and finding a chicken bone in the soup while eating. Interview on 03/10/26 at 12:29 P.M. with [NAME] #212 verified there was an approximate two inch chicken bone in Resident #34's soup bowl. Interview on 03/10/26 at 12:31 P.M. with Dietary Manager #226 revealed there was left over fried chicken from a recent meal and dietary staff deboned the chicken for the soup. Review of a facility provide resident list revealed on 03/10/26 eight (#3, #4, #8, #15, #21, #34, #41, and #46) were served chicken noodle soup for lunch. Review of policy titled, Purpose and Objectives of the Food and Nutrition Services Department, date 2021, verified the food will be prepared in a form to accommodate resident allergies, intolerances, and personal, religious, and cultural preferences based on reasonable efforts. Provided food and drink will be nutritious, palatable, attractive, and at a safe and appetizing temperature to meet individual needs. 2. Review of Resident #6's medical record revealed an admission date of 01/25/22. Diagnoses listed included chronic respiratory failure, obstructive sleep apnea, delusional disorders, and anxiety. Review of a quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #6 was cognitively intact and had two or more falls. Review of interdisciplinary team (IDT) notes dated 11/17/25 at 10:48 A.M., revealed a fall investigation was completed with interventions being reviewed. The note did not include any time or date of a fall, Resident #6's condition after the fall, or staff involved. Review of IDT notes dated 11/19/2025 10:48 A.M., revealed a fall investigation was completed with interventions being reviewed. The note did not include any time or date of any fall, Resident #6's condition after the fall, or staff involved. Review of nurse's notes revealed no documentation of falls related to the IDT notes on 11/17/25 and 11/19/25. Review of Risk Management documents revealed Resident #6 had an unwitnessed fall on 11/14/25 and on 11/17/25. On the bottom of each Risk Management page, a statement was printed Privileged and Confidential - Not part of the Medical Record - Do not Copy. Interview with the Director of Nursing (DON) on 03/11/26 at 3:05 P.M. confirmed no documentation in nursing notes related to IDT notes dated 11/17/25 and 11/19/25. The DON stated those falls were documented in Risk Management and would not be able to be seen in the electronic medical record. During an interview on 03/16/2026 at 9:05 A.M., with the Assistant Director of Nursing (ADON) #210 confirmed per the facility's fall policy, a nurse should document a resident's fall in the nurse's notes. Review of the facility's policy titled Resident Falls, dated revised May 2023, revealed the nurse's notes should include head to toe assessment of the resident, the position observed, from bed or chair, in room, bathroom, etc, and what the resident was doing; transferring from bed to chair, attempting to walk to the bathroom, etc. Describe any injury observed; skin tear, laceration, bruising, swelling, limited range of motion, suspected fracture. This deficiency represents non-compliance investigated under Complaint Number 2698450 and 2568764.

Based on medical record review, census list review, observation, resident interview, staff interview, and review of facility policy, the facility failed to ensure residents were provided a clean and sanitary environment. This directly affected Resident #3 and potentially 14 additional residents (#2, #4, #9, #12, #13, #17, #21, #25, #33, #34, #35, #40, #42, #49) who resident on the same hall as Resident #3. The facility census was 47.Findings include:Review of the medical record revealed Resident #3 was admitted on [DATE]. Diagnoses included acute and chronic respiratory failure with hypoxia, type two diabetes mellitus with hyperglycemia, and chronic kidney disease stage 3.Review of the Minimum Data Set (MDS), dated [DATE], revealed the resident was cognitively intact and required set-up/clean up assistance with toileting, showering, and personal hygiene. Review of the care plan, revised on 10/01/25, revealed Resident #3 has mixed bladder incontinence. Interventions include to check frequently and as required for incontinence (wash, rinse, and dry perineum), apply barrier cream, and change clothing as needed after incontinence episodes, resident does not wear briefs, preference- encouraged resident to have chux pad then open brief in chair while up during the day to help contain incontinent episodes, and patient to let staff know if she needs assistance with changing when soiled. Observation on 03/09/26 during the initial tour revealed the 600 hall had a strong pervasive urine odor.Observation on 03/11/26 at 12:15 P.M. revealed upon entering the 600 hall there was a strong pervasive urine odor. Interview on 03/11/26 at 12:17 P.M. with Licensed Practical Nurse (LPN) #202 verified the odor was coming from Resident #3's room. Observation on 03/11/26 at 12:19 P.M. revealed Resident #3's room had a pile of laundry near the door. Consecutive interview with Resident #3 revealed every day she places soiled laundry on the floor near the door and an aide will collect them. Resident #3 stated the pile of laundry had been there since earlier this morning and when housekeeping came to clean additional soiled laundry in the room was added to the pile. Interview on 03/11/26 at 12:23 P.M. with Certified Nursing Assistant (CNA) #223 and CNA #282 verified the 600 hall was malodorous and verified the soiled clothing. CNA #223 and CNA #282 revealed there is a bagged soiled down comforter in Resident #3's room that she will not allow the facility to launder and is waiting for pick-up by a family member. Interview on 03/11/26 at 12:28 P.M. with CNA #256 verified the odor on the 600 hall, adding that it is always a problem. CNA #256 revealed some residents on the hall have asked to have their door shut due to the odor. CNA #256 stated she did not know the soiled linen was on the floor and would collect it.Interview on 03/11/26 at 12:35 P.M. with Resident #34 verified she likes her door shut and at times it is due to the odor in the hall.Interview on 03/11/26 at 12:55 P.M. with CNA #256 verified when she collected the laundry from Resident #3's floor the laundry was saturated.Review of the facility census list revealed 14 residents (#2, #4, #9, #12, #13, #17, #21, #25, #33, #34, #35, #40, #42, #49) resided on the same hall as Resident #3.Review of the policy titled, Homelike Environment, dated 2021, verified residents are provided with a safe, clean, comfortable, and homelike environment. The facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a homelike settings including pleasant, neutral scents. This deficiency represents non-compliance investigated under Complaint Number 2568764 and 2615090.

Based on record review and staff interview, the facility failed to document a resident's discharge information in the medical records including appropriate information for a resident's discharge to a hospital. This affected one (#56) of six residents reviewed for discharges. The current census is 47.Findings include:Record review for Resident #56 revealed the resident was admitted to the facility originally on 06/06/24, re-admitted after a hospital stay on 09/25/25 and discharged to the hospital on [DATE]. Diagnoses for Resident #56 included chronic pain, end stage renal disease requiring hemodialysis, and heart disease.Review of Resident #56's comprehensive Minimum Data Set (MDS)assessment dated [DATE] revealed the resident had mildly impaired cognition.Review of Resident #56's family representative contact information revealed the resident's first contact was his sister followed by another sister and as the 3rd contact his brother.Review of Resident #56's progress notes dated 11/11/25 at 6:18 A.M., revealed the nurse found the resident at 3:45 A.M. to be unresponsive in his room. Cardio-Pulmonary Resuscitation was initiated with emergency services being notified. Per the note the staff attempted to notify the resident's brother and then sister as the resident was being transferred to the hospital. The nurse documented a follow-up call with the receiving hospital informing the nurse the resident had passed away at 5:30 A.M.Further review of Resident #56's medical records including uploaded documentation, progress notes, and evaluations documents revealed there was no documentation regarding the resident's transfer to the hospital. There was no further documentation of the resident's representative being notified of the discharge in writing. No discharge/transfer summary was noted in the resident's records.Interview on 03/17/26 at 9:00 A.M. with Social Worker (SW) #284 verified there was no discharge summary in Resident #56's records. SW #284 stated the social worker was training at the time Resident #56 was discharged and was unaware of any family representative of the resident being notified by the facility of the resident's transfer/discharge information and any collection of the resident's belongings after the resident had passed. SW #284 verified there was no further documentation in the resident's records of any contact after the transfer date with the family regarding the discharge. Interview on 03/17/26 at 11:00 A.M., with the Assistant Director of Nursing, (ADON) #210 verified there was no discharge summary in Resident #56's medical records. ADON #210 verified there was no evidence of the required documentation of the transfer included in the medical records for the resident.

Based on review of medical records, staff interview, and review of facility policy, the facility failed to have documentation of a resident's discharge disposition in the medical record. This affected one (#53) of three closed records reviewed for discharge. The census was 47. Findings include:Review of Resident #53's closed medical revealed and admission date of 09/27/24. Diagnoses listed included breast cancer, hypertension, major depressive disorder, and osteoarthritis. Resident #53 was discharged on 08/19/25.Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #53 was cognitively intact.Further review of Resident #53's closed medical record revealed no documentation of Resident #53's discharge disposition. There was not a documented recapitulation of Resident #53's stay and there weren't any progress notes concerning discharge arrangements.Interview with the Director of Nursing (DON) on 03/11/26 at 3:05 P.M. confirmed there was not any documentation of Resident #53's discharge disposition in her medical record. The DON confirmed there was not a documented recapitulation of stay or nursing notes about Resident #53 discharge disposition. A post-discharge plan was not documented.Review of the facility's policy titled Transfer or Discharge, Preparing a Resident for, dated revised 2016, revealed a post-discharge plan is developed for each resident prior to his or her transfer or discharge. This plan will be reviewed with the resident, and/or his or her family, at least twenty-four (24) hours before the resident's discharge or transfer from the facility. Nursing services is responsible for obtaining orders for discharge or transfer, as well as the recommended discharge services and equipment, preparing the discharge summary and post-discharge plan, and completing discharge note in the medical record.

Based on medical record review, observation, staff interview, and review of facility policy, the facility failed to ensure residents were free from physical restraint. This affected one (#30) of one resident reviewed for phyiscal restraint. The facility census was 47. Findings include:Review of the medical record revealed Resident #30 revealed an admission date of 10/06/23. Diagnoses included unspecified dementia, hyperlipidemia, major depressive disorder recurrent, anxiety disorder, and cognitive communication deficit. Review of the Minimum Data Set (MDS) assessment, dated 02/02/26, revealed the resident is severely cognitively impaired and requires set-up/clean-up assistance with eating. Resident #30 is dependent for toileting, showering, and personal hygiene. Resident #30 had occasionally behaviors of physical aggression, verbal aggression, and other behaviors in addition to rejection of care and wandering. Observation on 03/11/26 at 10:34 A.M. revealed Resident #30 was alert in a wheelchair sitting at the dining room table. Resident #30's wheelchair was locked on the left side. Observation on 03/11/26 at 11:49 A.M. revealed Resident #30 at the dining room table eating lunch at the same location as the previous observation. Resident #30's wheelchair was noted to be locked on the left side. Interview on 03/11/26 at 2:22 P.M., with Certified Nursing Assistant (CNA) #279 verified Resident #30 is not able to lock or unlock her wheelchair. CNA #279 stated locking Resident #30's wheelchair was to ensure she remained at the table and does not wander throughout the facility during meals. CNA #279 verified the staff are not supposed to lock the wheelchair. Review of the undated facility policy titled, Abuse, Mistreatment, Neglect, Injuries of Unknown Source and Misappropriation of Resident Property, revealed the facility will not tolerate mistreatment, abuse, exploitation, or neglect of its residents or misappropriation of resident property by anyone. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. This deficiency represents non-compliance investigated under Complaint Number 2698450.

Based on record review, resident and staff interviews, and policy review, the facility failed to ensure staff notified the physician and family representatives of residents' changes in condition. This affected two (#24 and #51) of two residents reviewed for notification. The current census is 47.Findings include:1. Record review for Resident #24 revealed the resident was admitted to the facility on [DATE]. Diagnoses for Resident #24 include fracture of the pelvis, chronic pain, post-traumatic stress disorder, depression, epilepsy, and hypertension. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had intact cognition. Review of Resident #24's care plans dated 04/29/25 revealed a focus for cerebral vascular accident related to hypertension. Interventions include to monitor vital signs and notify medical doctor of significant abnormalities, give medications as ordered. Review of physician orders dated 11/21/25 revealed Resident #24 was to be administered clonidine 0.1 milligrams, (mg) tablet by mouth every 8 hours as needed for systolic blood pressure greater than 170. Review of Resident #24's vital signs dated from 11/2025 to 03/2026 revealed Resident #24 had on 02/27/26 a systolic blood pressure (SBP) of 171, on 02/22/26 SBP was 174, on 01/15/26 SBP was 206, and on 12/19/25 SBP was 219. Review of Resident #24's progress notes dated from 12/01/2025 to 03/12/2026 revealed there was no documentation of any notification to the physician of Resident #24's blood pressure being out of normal limits on 01/15/26 or 12/19/25. Interview on 03/09/26 at 9:00 A.M. and on 03/16/26 at 8:30 A.M. with Resident #24 revealed the resident stated he was concerned due to many times he felt his blood pressure was too high. Resident #24 stated staff are monitoring his blood pressure, but when he goes to see his cardiologist he is being told no one from the facility is reporting to the physician any abnormalities with his blood pressure. Interview on 03/12/26 at 2:00 P.M. with Director of Nursing, (DON) verified there was no documentation in Resident #24's medical records of the facility notifying the primary physician or cardiologist of Resident #24's high blood pressures. 2. Review of the medical record for Resident #51 revealed an admission date of 05/14/24 with diagnoses including diabetes mellitus, Down's Syndrome, Hirschsprung's disease, and morbid obesity. Resident #51 discharged to the hospital on [DATE] and did not return to the facility. Review of an annual Minimum Data Set (MDS) assessment, dated 05/18/25,indicated Resident #51 had severe cognitive impairment and was dependent upon staff for activities of daily living. Further review revealed a weight loss note dated 06/27/25 which stated Resident #51 had a significant weight loss. The note stated Resident #51's weight was 241 pounds on 02/05/25, 238 pounds on 04/02/25, and 183.7 pounds on 06/25/25. The medical record did not have documentation to support the facility notified the physician of Resident #51's significant weight loss. Interview on 03/16/26 at 10:34 A.M, with the Assistant Director of Nursing (ADON) #210 confirmed the medical record for Resident #51 did not have documentation supporting the facility notified the physician of the significant weight loss on 06/27/25. Review of the facility policy titled, Nutrition (impaired)/Unplanned Weight Loss, revised September 2017, stated staff would report to the physician any significant weight gains or losses or any abrupt or persistent change from baseline appetite or food intake. This deficiency represents non-compliance investigated under Complaint Number 2698450.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, review of an Emergency Medical Services (EMS) squad run report, review of a facility investigation, interviews with staff and the Medical Director, review of facility policy and review of information from Medscape, the facility failed to monitor a residents' bowel status and seek timely medical attention when a resident experienced a significant change in condition. This resulted in Immediate Jeopardy when one resident (#1), with a history of recurrent bowel ileus' (blockage of the intestine), was placed at risk for serious life-threatening harm when the facility failed to monitor the residents' bowel status by implementing their bowel protocol when the resident did not have a bowel movement for seven days, the resident began experiencing increased abdominal distension, emesis and was not assessed. Subsequently, Resident #1 coded, the resident was transported to the hospital and passed away. This affected one (#1) of six residents reviewed for change in condition. The facility census was 44. On [DATE] at 3:10 P.M., the Administrator, Corporate Nurse #21 and Corporate Nurse #22 were notified that Immediate Jeopardy began on [DATE] when Resident #1 did not have a bowel movement for seven days. Resident #1 was readmitted from the hospital on [DATE] at approximately 9:30 P.M. related to a bowel ileus. Resident #1 received five 240 milliliter (ml) bolus tube feedings each day and routine laxatives from [DATE] to [DATE]; however, the resident did not experience a bowel movement for those seven days. On [DATE] at approximately 4:00 A.M., Resident #1 was experiencing increased abdominal distension, the nurse gave the resident an ordered bolus tube feeding, and approximately 30 to 60 minutes after the tube feeding the aides laid the resident flat in bed to provide care and the resident had an emesis. On [DATE] at approximately 6:05 A.M., Resident #1 had a second emesis, he became unresponsive, coded, required cardiopulmonary resuscitation (CPR) and was sent to the hospital for evaluation and passed away. The Immediate Jeopardy was removed on [DATE] but continued at a Severity Level 2 (no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy) until it was corrected on [DATE] when the facility implemented the following corrective actions: · On [DATE] at 6:12 A.M., EMS was contacted regarding Resident #1's condition. At 6:17 A.M. EMS arrived at the facility and took over care. The resident was transported to the hospital at 6:32 A.M. · On [DATE], the Quality Assessment and Assurance (QA&A) committee met, discussed the circumstances involved and began an investigation. Staff on duty were contacted, interviewed and witness statements were requested and received. · On [DATE], Licensed Practical Nurse (LPN) #70 was suspended indefinitely. · On [DATE], the Director of Nursing (DON), Corporate Nurse #21 and Corporate Nurse #22 assessed all residents regarding their bowel status and any change in condition. No concerns were identified. · On [DATE], the DON, Corporate Nurse #21 and Corporate Nurse #22 began in-service training with all nurses and aides regarding changes in condition, prompt assessment and response during a change in condition and the facilities bowel protocol. The in-service training was completed on [DATE]. · On [DATE], the DON and Corporate Nurse #21 began completing daily audits regarding bowel activity and reviewed nurse's notes for changes in condition. The daily audits continued through [DATE]. No further concerns were identified. · On [DATE] the QA&A committee met and planned to continue the daily audits for 30 additional days and then re-evaluate. Results of the audits will be shared with the QA&A committee. · [DATE] and [DATE], five (#6, #8, #38, #39, #40) additional residents were sampled for record review, observations and/or interviews regarding bowel activity and change of condition. No concerns were identified. · On [DATE] between 2:30 P.M. and 2:35 P.M., LPN #75, LPN #79, State tested Nursing Assistant (STNA) #63 and STNA #69 were interviewed regarding receiving in-service training relative to change of condition and bowel activity. The staff confirmed they received the in-service training and were knowledgeable regarding the training. No concerns were identified. Findings include: Review of Resident #1's medical record revealed the resident was admitted to the facility on [DATE] and had a more recent readmission on [DATE]. [DIAGNOSES REDACTED]. Additionally, the resident had a [MEDICAL CONDITION] and a gastrostomy. Review of Resident #1's quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated the resident had severely impaired cognitive skills for decision making and required extensive assistance with activities of daily living including bed mobility, dressing, toilet use, eating and personal hygiene. The resident was always incontinent of bowel and bladder. Review of Resident #1's care plan dated [DATE] revealed the resident had the potential for alteration in nutrition due to tube feeding and dependence on staff for nutrition and dysphagia from [MEDICAL CONDITION]. Interventions included nurses to monitor for symptoms of gastrointestinal intolerance such as nausea, feelings of fullness, and abdominal pain. Check residual per protocol and report persistently elevated amounts. Interventions for nurse aides included to report any changes to the nurse and keep the head of the bed elevated at least 35 degrees. Review of the ,[DATE] physician orders [REDACTED]. The resident also had orders for polyethylene [MEDICATION NAME] twice per day, neostigmine [MEDICATION NAME] 0.5 milligram (mg)/one milliliter (ml) subcutaneous twice per day, [MEDICATION NAME] 10 mg suppository daily and senna 8.6 mg tablet twice per day for constipation. The resident had been hospitalized from [DATE] until [DATE] due to an ongoing recurrent problem with abdominal ileus (blockage of the intestine). The hospital history and physical dated [DATE] indicated the resident was non-verbal and was bed bound following a [MEDICAL CONDITION]. The resident was also on tube feedings. The resident was sent to the hospital with reports of abdominal distention over the last two days. While at the hospital, the resident's tube feeding was held and [MEDICATION NAME] nutrition was provided until the tube feeding (TF) could be restarted. At the hospital, the resident was restarted on bolus tube feedings instead of his prior continuous TF. According to the hospital documentation it is suspected Resident #1 has [DIAGNOSES REDACTED] (acute dilation of the colon in the absence of any mechanical obstruction). Review of the resident's Medication Administration Record [REDACTED].M. revealed the resident received his 240 ml bolus TF five times each day and received his four medications for constipation each day. Review of the resident's bowel movement (BM) record dated [DATE] to [DATE] revealed the resident did not have a bowel movement. Further review of nurse's notes revealed an entry by LPN #79 on [DATE], [DATE] and [DATE] documenting that Resident #1 was incontinent of bowel and bladder; however, LPN #79 was interviewed on [DATE] at 9:58 A.M. and verified she wrote those entries and stated her note did not indicate the resident had a bowel movement at those times but rather it was a general statement on the resident's functional condition. Review of a progress note by Respiratory Therapist (RT) #50 dated [DATE] indicated at around 5:40 A.M. RT #50 went in to suction Resident # 1 because he was said to be throwing up. Further review of a nurse's note entry by LPN #70 indicated at approximately 5:00 A.M. a nurse aide alerted this nurse that Resident #1 was vomiting and the head of the bed had been elevated. RT #50 assessed the resident and reported no signs or symptoms of aspiration at this time. The nurses notes did not reflect any assessment by the nurse of Resident #1. Review of Resident #1's medical record lacked documentation of any notification to the physician of the resident's lack of bowel movements, his abdominal distention or of the resident's emesis. Review of the EMS squad run report dated [DATE] indicated the emergency squad arrived at Resident #1's room on [DATE] at 6:17 A.M. The resident was in bed and staff were performing CPR. The resident was covered in fecal matter. EMS took over Resident #1's care and the resident was transported to the hospital. Further review of Resident #1's medical record revealed the resident passed away at the hospital on [DATE]. Review of hospital records revealed Resident #1 presented to the emergency department on [DATE] for evaluation of a witnessed [MEDICAL CONDITION]. At 6:00 A.M., Resident #1 vomited and went into [MEDICAL CONDITION]. Nursing home staff initiated CPR immediately. The resident arrived via EMS. Resident #1's son reports the resident was recently discharged from a hospital admission for an ileus. Resident #1 was unresponsive. Review of the history and physical examination [REDACTED]. After administration of [MEDICATION NAME] and [MEDICATION NAME] (drugs administered during CPR to reverse [MEDICAL CONDITION]), Resident #1 was declared deceased on [DATE] at 6:51 A.M. Review of the facility's investigation included a written witnesses statement from RT #51 which indicated on [DATE] at approximately 6:00 A.M., Resident #1 became unresponsive. STNA #68 came to RT #51 and stated immediate assistance was needed in Resident #1's room. RT #51 stated within seconds she went to the resident's room. Resident #1 was not responding and was covered in emesis from the mouth and [MEDICAL CONDITION]. The resident's stomach was noticeably distended. LPN #70 entered the room and CPR was initiated. As CPR was being performed, LPN #70 was worried about the feces that was coming from the resident getting on her. There was a lot of panic coming from LPN #70 which led to increased anxiety in the room. During the survey an attempt to interview RT #51 by phone was unsuccessful. During an interview on [DATE] at 5:07 A.M., RT #50 stated she worked the third shift on [DATE] to [DATE] when Resident #1 coded and was taken to the hospital by EMS. RT #50 stated at about 5:00 A.M., LPN #70 stated she had just given Resident #1 a bolus tube feeding and later when the aides went to change him and roll him over the resident puked. LPN #70 asked RT #50 to suction the resident. RT #50 stated she then suctioned him and the resident was responsive. RT #50 stated she left to attend to another resident and afterwards went back to again check on Resident #1. The resident could not speak but he could shake his head to communicate. RT #50 asked if he was not feeling good and he shook his head no, like he wasn't feeling well. RT #50 stated between 5:45 A.M. and 5:50 A.M. she left the resident's room and then during shift change around 6:05 A.M. to 6:10 A.M. an aide (RT #50 did not know her name) came out and asked for the nurse. At that time both LPN #70 and RT #51 went into his room and CPR was started within three to five minutes of the aide coming out to get LPN #70. During an interview on [DATE] at 5:30 A.M. STNA #65 verified she had taken care of Resident #1 the night before and the morning he passed away. STNA #65 stated the resident was acting fine at the beginning of the shift but around 4:30 A.M. the resident vomited on himself. STNA #65 stated she cleaned him up and reported it to LPN #70. LPN #70 told her she had just given the resident a bolus tube feeding. LPN #70 further told STNA #65 that she had caused the resident to vomit by turning him when she changed him. STNA #65 stated around 6:00 A.M. she was giving report to the oncoming day shift (STNA #68). She told her the resident had thrown up and she had placed a towel on his chest. STNA #65 stated she went in to his room to check on him and he had thrown up again. She turned the light on to clean him up and saw his eyes were rolled back and he was a little grayish. He was alive because she could see him breathing but he was not responding. STNA #65 told STNA #68 to go tell the nurse. It was not more than five minutes before the nurse (LPN #70) came in. LPN #70 came in by herself. She lowered the head of the bed and started to do chest compressions and in a few seconds RT #51 came in and assisted with CPR until paramedics came in and took over. STNA #65 further stated the only thing that really bothered her was the nurse did not check on Resident #1 or do vitals after it had been reported to her that the resident had vomited the first time. During an interview on [DATE] at 8:55 A.M., LPN #75 stated on [DATE] LPN #70 called him to ask if he was coming into work as he was running late and arrived at the facility around 6:04 A.M. LPN #75 stated he clocked in and there were a couple of aides in tears outside Resident #1's room. LPN #75 stated the aides were motioning him to come over. LPN #75 stated he went into Resident #1's room. RT #51 and LPN #70 were performing CPR. LPN #75 stated when he got into the resident's room his abdomen was more distended than normal and during chest compressions bowel movement was coming out from around his diaper. LPN #75 further stated he felt like if the resident's condition/situation had been addressed after the first emesis, the resident would be in a different situation. LPN #75 stated STNA #61 questioned him if the nurse (LPN #70) should have given the resident the bolus tube feeding with how distended the resident's abdomen appeared. LPN #75 stated Resident #1 has trouble with motility and he would get backed up. Recently the resident was in the hospital for an ileus and they changed him to bolus feedings. During an interview on [DATE] at 12:00 P.M. the DON verified Resident #1 had a history of [REDACTED]. The DON confirmed Resident #1's bowel record had indicated the resident had not had a bowel movement since his readmission on the evening of [DATE]. The DON further verified the facility policy is to notify the physician whenever a resident goes three days without a bowel movement and confirmed the facility had no documentation that the physician was notified. During an interview on [DATE] at 12:40 P.M., STNA #68 stated when she came in at shift change on [DATE] at approximately 6:00 A.M. she did report with third shift STNA #65. STNA #65 told her Resident #1 had been vomiting and the nurse had not assessed him. STNA #68 and STNA #65 went into check on Resident #1. STNA #68 stated she could tell from standing out in the hallway that Resident #1's stomach was distended. When she went into Resident #1's room she noticed he had again vomited all over himself and he was unresponsive. STNA #68 stated STNA #170 who was out in the hallway was asked to go get the nurse. During an interview on [DATE] at 10:03 A.M., LPN #70 stated on [DATE] between 5:00 A.M. to 5:20 A.M. after medication pass, an aide (she did not know her name) told her Resident #1 had just vomited and LPN #70 told her she had just given him his tube feeding. LPN #70 asked respiratory to assess him and he had no signs of aspiration. LPN #70 stated she did not assess the resident but she did go to the room when he vomited. The aides (she did not know their names) were changing him and they had the head of the bed flat. LPN #70 told the aides to put the head of the bed up. During a telephone interview on [DATE] at 11:07 A.M., STNA #61 stated she went into change Resident #1 between 5:00 A.M. and 5:15 A.M. and she asked him if he did not feel well because he did look good. He nodded his head indicating that he did not feel good. STNA #61 stated her and STNA #65 laid the head of the bed down flat to change the resident and then he vomited. STNA #65 went out to get LPN #70. LPN #70 was giving another resident a bolus feeding but came to the resident's room after she was finished. It was five to ten minutes before LPN #70 arrived in Resident #1's room; however, the nurse did not assess him. LPN #70 just told us to put the head of the bed back up and then walked out of the room. During an interview on [DATE] at 1:37 P.M., Corporate Nurse #21 stated the facility does not have a formal policy regarding change of condition. Corporate Nurse #21 further stated her expectation when there is a change in condition with a resident is the nurse would assess the situation and provide emergency care. Corporate Nurse #21 further stated based on what she knows of the situation with Resident #1 she was disappointed and she did not think LPN #70 did an adequate assessment. Corporate Nurse #21 stated the aide documented bowel and bladder information into the facility's electronic medical record; however, the system does not flag or identify to the nurse when the resident has not had a bowel movement for three days. Corporate Nurse #21 verified Resident #1 did not have a bowel movement for seven days and went unnoticed by the nurses. During an interview with the Medical Director on [DATE] at 1:38 P.M. via telephone he stated normally the facility will notify him if a resident goes three days without a bowel movement. He stated he did not remember if he was notified about Resident #1 not having a bowel movement for seven days and stated Resident #1 was difficult because he had trouble with gastroparesis (slow gastric emptying). The resident had been hospitalized several times for an ileus and he was on several different medications for constipation but sometimes the resident could just not get the bowel movement to go through. The Medical Director stated Resident #1 may have had [DIAGNOSES REDACTED] (acute dilation of the colon in the absence of any mechanical obstruction). Review of the facility's Bowel Protocol dated ,[DATE] indicated STNA's will monitor and record resident's bowel movements. The nurse will monitor the documented results and will notify the physician if diarrhea is present for 24 hours or if the resident has not had a bowel movement in three days. Review of the facility's Enteral Feeding Protocol dated ,[DATE] indicated the head of bed should remain elevated at 30 to 45 degrees for at least 30 minutes after a TF to minimize aspiration risk. Review of information from Medscape revealed [DIAGNOSES REDACTED], or acute colonic pseudo-obstruction (ACPO), is a clinical disorder with the signs, symptoms, and radiographic appearance of an acute large bowel obstruction but with no evidence of distal colonic obstruction. The colon may become massively dilated; if not decompressed, the patient risks perforation, peritonitis, and death. This deficiency substantiates Complaint Number OH 913.

Based on observation, medical record review, staff and resident interview, and review of facility policy, the facility failed to ensure pressure ulcer wound care was completed as ordered, failed to provide ongoing adequate monitoring of the pressure ulcer, and failed to ensure the physician was notified when there was a change in pressure ulcer condition for one (#13) of three residents reviewed for pressure ulcer care. This resulted in actual harm when the pressure ulcer for Resident #13 increased in overall size, with the depth of the wound more than doubling in size from 1.5 centimeters (cm) to 4.0 cm. The facility identified eight residents with pressure ulcers. The facility census was 69. Findings include: Review of Resident #13's medical record revealed an admission date of [DATE]. Medical [DIAGNOSES REDACTED]. Review of the resident's Minimum Data Set (MDS) assessment, dated 07/06/16, revealed the resident had only mild cognitive impairment, no behaviors, and no rejection of care. The resident was totally dependent on staff for bed mobility, toileting, and bathing and required extensive assistance with dressing and personal hygiene. She was always incontinent of urine. She received scheduled and as needed pain medications. The resident had a stage four pressure ulcer present on admission measuring 4.0 centimeters (cm) long by 2.0 cm width by 2.0 cm depth. A review of the resident's care plan revealed she had a history of [REDACTED]. Interventions included educating the resident on negative outcomes related to non-compliance and notifying the physician non-compliance. Review of the resident's physician orders [REDACTED]. Do not shower, take baths or get wound wet, unless otherwise instructed by your wound care doctor. Pack wound with antimicrobial dressing (AMD) gauze, roll three gauze with tape of the margin and place between buttocks. Change four times daily. The resident's weekly skin grid pressure assessments for her stage four coccyx pressure ulcer were reviewed. On 06/18/16, the resident's pressure ulcer measured 2.0 centimeters (cm) by 2.0 cm by 1.5 cm with pink tissue. It was documented as a stage two and improvement was noted. On 06/21/16, the wound was 2.3 cm by 1.4 cm by 0.9 cm and was described as having a red wound bed with tissue loosely adherent and scant drainage. The pressure ulcer was staged as a three. On 06/28/16, the pressure ulcer measured 3.4 cm by 1.3 cm by 1.1 cm and was documented as a stage three with a pink wound bed with scant drainage. There were no further skin grid pressure assessments until 07/12/16. The wound measurement on 07/12/16 was 4.0 cm by 2.0 cm by 2.0 cm with a red wound bed and large amount of sanguineous drainage and continued to be documented as a stage three. Review of physician order [REDACTED]. On 09/06/16, an order was written to cleanse the wound with normal saline. Do not shower, take baths or get wound wet, unless otherwise instructed by your wound care doctor. Pack wound with AMD gauze, roll three gauze with tape of the margin and place between buttocks. Change each shift and as needed. There were no additional orders regarding pressure ulcer wound care between 04/28/16 and 09/06/16. Review of the resident's treatment administration records (TAR) for July, August and September 2016 revealed the treatment was being signed as completed only twice daily. The TAR revealed only one box being signed for day shift nurses and one box for night shift nurses to initial when the resident's dressing was completed. There were not four sign off boxes to indicate the dressing was completed four times daily as ordered. Additionally, the July 2016 TAR revealed the treatment had not been completed on first shift on 07/09/16, 07/10/16, 07/14/16, 07/18/16, 07/21/16, 07/26/16, 07/24/16, and 07/25/16. The dressing had not been completed on the second shift for 07/05/16,07/08/16, 07/09/16, 07/18/16, 07/20/16, and 07/26/16. In August the treatment was not signed as completed on first shift on 08/05/16, 08/13/16, 08/19/16 and 08/20/16, as well as the second shift on 08/29/16. In September the treatment was not documented as being completed on 09/02/16, 09/03/16, and 09/04/16 for the first shift. Review of the resident's nursing notes from 07/01/16 through 09/06/16 revealed no documentation indicating the resident had refused any dressing changes or any other treatments or interventions. Review of the skin grid dated 08/23/16 indicated the resident's coccyx wound was 4.0 cm by 3.5 cm by 4. 0 cm deep. The are was described as a stage three ulcer, bleeding with a red wound bed, and showing a declined condition. The physician was notified at this time of the declining condition of the wound. On 08/31/16, the wound was measured to be 3.9 cm by 3.5 cm by 4.0 cm deep. Further review of the medical record revealed no indication the physician was notified of deterioration of the resident's wound until 08/23/16 when an order was obtained to send the resident to an outside physician on 09/26/16 for a wound evaluation. Interview with Resident #13 on 09/06/16 at 12:35 P.M. revealed she was not aware she was to receive wound care four times daily. She stated the dressing to her coccyx area was changed in the morning on 09/06/16, but she could not recall when it had been completed prior to that. Observation of pressure ulcer care for Resident #13 on 09/06/16 at 2:35 P.M. revealed a stage four pressure ulcer to the resident's coccyx measuring 3.9 cm in length, 2.5 cm in width, and 3.9 cm depth. A moderate amount of bloody discharge was noted on the old packing. The resident experienced some discomfort during the dressing change but overall tolerated well. Interview with MDS Coordinator #41 on 09/07/16 at 11:19 A.M. verified Resident #13's pressure ulcer was a stage four and therefore the skin grid assessments were inaccurate as these assessments indicated the resident had a stage two and stage three pressure ulcer. Interview with the Director of Nursing (DON) on 09/07/16 at 1:25 P.M. verified Resident #13's TAR contained the above noted blank entries for July, August, and September 2016 pressure ulcer wound care. She also verified the nurses were signing off twice daily for wound care and not four times daily as ordered. The DON also verified there was a missing weekly assessment of the resident's wound care between 06/28/16 and 07/12/16 and the physician was not notified when the resident's wound increased in size on 07/12/16. Review of a facility policy titled Skin Care Plan Policy and Procedure, dated 04/11/16, revealed it was the facility policy to provide a comprehensive wound management program in order to promote the resident's highest level of functioning and well-being. Any resident with a wound receives treatment and services consistent with the resident's goals of treatment. The charge nurse is to assess wounds and document changes and responses to treatment in the progress notes. The charge nurse and/or administrative nurse is to notify the physician of changes in the wound, responses to treatments and non-compliance with interventions. This deficiency substantiates Complaint Number OH 398.