Every finding on record at Lonoke Health and Rehab Center, LLC

Based on record review and interview, it was determined the facility failed to ensure the minimum data set (MDS) accurately reflected on section A1500 the preadmission screening and assessment resident record (PASRR) a serious mental illness and/or intellectual disability affecting 2 (Residents #4 and #44) sampled residents with a level II PASRR. The findings are: 1. Review of the Medical Diagnosis revealed Resident #4 has a diagnoses of respiratory failure, schizophrenia, and psychotic disorder. a. The Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/19/2024 suggested a Brief Interview for Mental Status (BIMS) score of 15 (13-15 indicates cognitively intact). b. Per record review on 07/23/24 at 10:00 AM, the Admission Minimum Data Set (MDS) from 02/19/2024, section A1500 revealed resident does not have a mental health or intellectual disability, and Admission MDS with an ARD of 06/07/2016 showed Resident #4 has a level II PASRR. c. On 07/24/24 at 8:25 AM, LPN #14/ MDS Nurse provided a letter from State Designated Professional Associates that stated change of condition, no PASRR required, dated 06/14/2012. A letter from State Designated Professional Associates dated 01/21/15 says resident was approved for nursing home placement. Letter from State Designated Professional Associates dated 4/26/16 that said a level 1 was submitted and was considered a change of condition. No review was required at that time. d. On 07/24/24 at 8:35 AM, the Surveyor, MDS nurse, and Administrator reviewed the Admission MDS from 06/07/2016 showing resident was a level II, and recent Admission MDS dated [DATE] where section A1500 shows resident does not have a mental illness or intellectual disability. The administrator confirmed Resident #4 has a level II PASRR. 2. A review of Medical Diagnosis revealed Resident #44 had diagnoses of major depressive disorder, bipolar disorder, and schizophrenia. The Quarterly MDS with an ARD of 05/11/2024 suggested a BIMS score of 4 (0-7 indicates severe cognitive impairment). a. On 07/23/24 at 3:52 PM, during a review of the Annual MDS with an ARD of 02/09/2024, section A1500 shows 0, indicating Resident #44 does not have a serious mental health disability, or intellectual disability or related condition. b. On 07/24/24 at 8:05 AM, the Administrator provided a level II evaluation from the state designated authority dated 2/24/23 showing Resident #44 did not require any specialized services, and recommended a structured environment that is found at the facility. 3. During an interview on 07/24/2024 at 11:50 AM, the MDS Nurse confirmed Resident #4 and #44 had a Level II PASRR, section A1500 of the MDS was not coded correctly, it could affect the care plan, and could cause Residents #4 and #44 to not get recommended services. The MDS Nurse e MDS nurse confirmed that she uses the RAI manual to guide her in coding to the MDS.

Based on record review and interview, the facility failed to develop a comprehensive care plan for 2 (Resident #26 and #44) of 3 sampled residents to ensure residents received appropriate care. The findings are: 1. A review of medical diagnosis revealed Resident #44 had diagnoses of major depressive disorder, bipolar, and schizophrenia. a. The Quarterly minimum data set (MDS) with an assessment reference date (ARD) of 05/11/2024 suggested a brief interview for mental status (BIMs) score of 4 (0-7 indicates severe cognitive impairment). b. A review of a Physicians Order dated, 02/06/2024 Novolin R Injection Solution 100 UNIT/ML (Insulin Regular (Human) Inject subcutaneously before meals and at bedtime related to type II diabetes mellitus with hyperglycemia c. A review of a Physicians Order dated, 03/04/2024 Trulicity Subcutaneous Solution Pen-injector 1.5 MG/0.5 ML (Dulaglutide) Inject 1 dose subcutaneously one time a day every Monday related to type II diabetes mellitus with hyperglycemia. Leave needle inserted for 5 to 10 seconds until hear 2nd click. d. During an interview with the Minimum Data Set (MDS) Nurse on 07/24/2024 at 1:13 PM, the Surveyor asked the MDS Nurse to find insulin or diabetic care on resident's care plan. The MDS Nurse checked Resident #44's medical records and confirmed diabetes and insulin were not care planned, and it is important because it is a serious illness, and staff needs to know what to look for. MDS Nurse told the surveyor she is solely responsible for care plans. e. On 07/24/2024 at 1:30 PM, the Director of Nursing (DON) was asked if a resident is a diabetic and takes insulin should staff include diabetes on their care plan. The DON said yes because it is part of their care and should be care planned, and DON confirmed the facility does not have a MDS or care plan policy, and staff should follow the RAI manual for care planning. 2. A review of medical diagnosis for Resident #26 reveals diagnoses of stroke, metabolic encephalopathy, and anxiety. a. The significant change MDS with an ARD of 06/18/2024 indicated a BIMS score of 00 (0-7 suggest severe cognitive impairment). Section O0110 showed resident is on oxygen. a. A review of the Order Summary revealed Oxygen at 2 liters via nasal cannula as needed for shortness of breath. b. On 07/22/2024 at 12:11 PM, Resident #26 was observed on 3 liters of oxygen. The Surveyor was unable to find oxygen on Resident #26's care plan. c. On 07/23/2024 at 12:06 PM, the Surveyor asked Licensed Practical Nurse (LPN) #17 for assistance findings oxygen on Resident #26's care plan and was referred to the closet care plan. LPN #11 said nursing tells each other about residents. After multiple requests for LPN #17 and LPN #11 to assist in pulling up Residents #26's care plan, LPN #18 demonstrated to staff where to find care plans, and told the Surveyor that oxygen is not listed on the care plan, and that is where she goes to find plans of care, and interventions. d. On 07/24/2024 at 01:40 PM, the Assistant Director of Nursing (ADON) provided an in-service book revealing All staff are to look/follow a residents closet care plan before providing care. e. During an interview with the Director of Nursing (DON) on 07/24/2024 at 02:00 PM, the DON confirmed that closet care plans are geared towards CNAs, and not nursing, and nurses are expected to use the computer for care plans and interventions.

Based on observation, record review and interview, it was determined the facility failed to properly lift and lower residents with the legs open on a mechanical lift for 1 (Resident #28). The findings are: 1. Record review of Medical Diagnosis for Resident #28 revealed diagnoses of polyneuropathy, heart failure, and major depression disorder. a. The Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/18/2024 suggested a Brief Interview for Mental Status score of 14 (13-14 indicates cognitively intact). Section GG0110 does not indicate resident requires a mechanical lift, and the Quarterly MDS with an ARD of 07/19/2024 is not complete. b. A review of Care Plan for Resident #28 indicated, .Resident #28 has an ADL self-care performance deficit related to unsteadiness on feet (Revised, 05/06/2024) . TRANSFER: The resident requires Mechanical Lift .with 2 staff assistance for transfers . c. On 07/22/2024 at 12:31 PM, Resident #28 was observed resting in a lift pad hoovering above the bed in a mechanical lift with the lift's legs in the closed position. Certified Nursing Assistant (CNA #16 confirmed the legs of the mechanical lift would go in the open position under Resident #28's bed. CNA #16 was asked if it is standard practice to open the legs before lifting or lowering residents and CNA #8 confirmed the legs of the mechanical lift should be in the open position to balance the lift out when raising or lowering a resident in the mechanical lift. d. On 07/24/2024 at 2:00 PM, DON told the Surveyor they do not have a mechanical lift policy or procedure. They use the (Named) manual. e. Per record review of the mechanical lift guide provided by the DON on 07/24/24 at 02:10 PM, [Named] manual revealed .Lifting the patient WARNING When using an adjustable base lift, the legs MUST be in the maximum Open/Locked position before lifting the patient .[named] does not recommend the locking of rear casters of the patient lift when lifting an individual. Doing so could cause the lift to tip and endanger the patient and assistance. [Named] does recommend that the rear casters be left unlocked during lifting procedures to allow the patient lift to stabilize itself when the patient is initially lifted from a chair, bed, or any stationary object .

Based on observations, interviews, and record reviews the facility failed to ensure that 2 (Resident #14 and #17) sampled resident received peri care in a manner that was sanitary to promote good hygiene and/or prevent infection. The findings include: 1. A review of Medical Diagnosis revealed Resident #17 had a diagnosis of dehydration and Methicillin Resistant Staphylococcus Aureus Infection. a. A review of Resident #17's Care Plan (revision date 03/30/2023) revealed the resident had bowel and bladder incontinence related (r/t) immobility. b. A review of Annual Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 02/24/2024 revealed Resident #17 scored 15 indicating cognitive intact and Resident frequently had urinary incontinence and always incontinence of bowel. c. On 07/23/2024 at 1:05 PM, the Surveyor observed Certified Nursing Assistant (CNA) #1 and #2 did not use proper technique while providing perineal care to Resident #17 and did not use supplies in the correct manner to promote cleanliness. d. On 07/23/2024 at 1:50 PM, CNA #2 voiced she did not know if she cleaned Resident #17 correctly. 2. A review of Medical Diagnosis revealed that Resident #14 had a diagnosis of urinary tract infection (UTI). a. A review of Resident #14's Care Plan (initiate date 01/19/2024) revealed that Resident #14 had bowel and bladder incontinence related to immobility. b. A review of Quarterly Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 07/05/2024 revealed Resident #14 scored 08 indicating severe cognitive impairment and Resident #14 was always incontinence of bowel and bladder. c. On 07/23/2024 at 1:29 PM, the Surveyor observed CNA #1 did not use proper technique while providing perineal care to Resident #14 and did not use enough supplies to promote cleanliness. d. On 07/23/2024 at 1:45 PM, CNA #1 confirmed that proper technique was not used while providing incontinence care to Resident #14 e. On 07/24/2024 at 1:30 PM, the Director of Nursing confirmed that the techniques used to provide perineal care to Residents #14 and #17 did not align with the training provided.

Based on observation, record review and interview, it was determined that the facility failed to ensure oxygen was administered at the physician ordered rate for 2 (Resident #26 and #50) residents to prevent respiratory complications. The findings include: 1. A review of Medical Diagnosis for Resident #26 reveals diagnoses of stroke, metabolic encephalopathy, and anxiety. a. The significant Minimum Data Set (MDS) with an assessment reference (ARD) date of 06/18/2024 with a brief interview for mental status (BIMS) score of 00 (0-7 suggest severe cognitive impairment). Section O0110 showed resident is on oxygen. b. A review of the Order Summary reveals .dated, 06/28/2024 Oxygen at 2 liters via nasal cannula as needed for shortness of breath. c. On 07/22/2024 at 12:11 PM, Resident #26 was observed on 3 liters of oxygen. d. On 07/22/2024 at 2:45 PM, Resident #26 observed resting quietly on 3 liters nasal cannula. e. On 07/23/2024 at 11:48 AM, the Surveyor observed oxygen concentrator was set on 3 liters. f. On 07/23/2024 at 11:54 AM, Licensed Practical Nurse (LPN) #17 accompanied the Surveyor to Resident #26's room and confirmed the concentrator was set on 3 liters of oxygen. LPN #17 pulled up Resident #26's orders and confirmed Resident #26 should be on 2 liters of oxygen, and confirmed being on the incorrect dosage could interfere with a resident's breathing. LPN #17 said that nursing is responsible for checking the oxygen concentrators. g. During an interview with the Director of Nursing (DON) on 07/24/2024 at 2:00 PM, the DON revealed they do not have an oxygen policy that addresses oxygen rate, and signage. DON confirmed that nursing staff are responsible for checking resident orders, and oxygen concentrators when in a resident's room, and all staff are expected to watch for oxygen signage. 2. A review of Resident #50's physician orders showed oxygen at 2 liters via nasal cannula as needed every shift. a. A review of Resident #50's Care Plan with a revision date of 07/17/2024, noted Resident #50 was receiving oxygen therapy related to respiratory illness b. An admission MDS with the ARD of 06/12/2024 noted Resident #50 scored 02 on the BIMS, indicating severe cognitive impairment and was receiving oxygen therapy. c. On 07/22/2024 at 12:03 PM, the Surveyor observed Resident #50 lying in bed receiving oxygen therapy via nasal cannula per concentrator at 3 liters. The Surveyor did not note any signage at or around the door indicating oxygen in use. d. On 07/23/2024 at 12:33 PM, the Surveyor observed Resident #50 sitting in wheelchair in room receiving oxygen therapy via nasal cannula per concentrator at 3 liters. The Surveyor did not note any signage at or around the door indicating oxygen in use. e. On 07/23/2024 at 2:10 PM, the Surveyor observed Resident #50 sitting in wheelchair in room receiving oxygen therapy via nasal cannula per concentrator at 3 liters. The Surveyor did not note any signage at or around the door indicating oxygen in use. f. On 07/23/2024 at 2:15 PM, Licensed Practical Nurse #11 confirmed Resident #50 was receiving oxygen at 3 liter, order was for 2 liters and there was no signage posted. 48977 49413

Based on record review and interviews, the facility failed ensure the system used for records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation was implemented for one (Resident #33) sampled resident. The findings include: A review of diagnosis Resident #33 had a diagnosis of chronic pain. A review of the physician's orders Resident #33 had an order for Hydrocodone-Acetaminophen 10-325 milligram (MG) an opioid used to manage pain. A review of Resident #33's Care Plan (revision date 11/23/2020) revealed Resident #33 had a diagnosis of chronic pain, and behaviors were potentially present when the resident has a higher level of pain. A review of an annual Minimum Data Set (MDS) with the Assessment Reference Date (ARD) 05/18/2024 revealed Resident #33 scored 11 on Brief Interview of Mental Status (BIMS) indicating moderately impaired cognition, and Resident #33 was taking a medication classified as an opioid. On 07/23/24 at 10:06 AM, the Surveyor completed a random reconciliation of controlled medications with Licensed Practical Nurse (LPN) #11 and noted 50% of Resident #33's Hydrocodone/Acetaminophen 10/325 milligram (MG) the controlled medication legend noted 11 pills on hand, but the actual number of pills on hand was 10. On 07/23/24 at 10:06 AM, LPN #11 voiced another nurse had given Resident #33's hydrocodone and had not signed it out and may have expected her to do so. On 07/23/24 at 12:18 PM, LPN #11 confirmed the controlled medication log should accurately reflect the medication on hand and it was not accurate when the reconciliation was completed with the Surveyor. LPN #11 confirmed that potential negative outcome if the controlled medication log does not match what is on hand could have an impact on the resident if the nurse did not give the medication and a nurse could take the medication. On 07/24/24 at 2:30 PM, the Director of Nursing (DON) confirmed the controlled medication log was not accurate.

Based on observation, record review and interview, the facility failed to ensure meals were prepared and served according to the planned written quantified recipe and menu to meet the nutritional needs of the residents for 2 of 2 meals observed. This failed practice had the potential to affect 10 residents who received pureed diets and 17 residents who received enhanced food diets from 1 of 1 kitchen according to a list provided by the Dietary Manager on 07/23/2024 at 1:33 pm. The findings are: 1. The menu for lunch documented the residents who received pureed diets were to receive 1 #8 scoops (1/2 cup) of vegetable blend, #16 scoop (1/4 cup) of pureed bread, #8 scoop (1/2 cup) of pureed cake, #8 scoop (1/2 cup) of strawberry topping. 2. The menu for breakfast 07/23/2024 documented that residents who received pureed diets were to receive pureed purred hot cereal, #16 scoop (1/4 cup) of pureed biscuit/toast. 3. On 07/22/2024, the facility recipe for angel food cake puree documented for 10 residents: use 10 squares 2/3 inches, 1.25 cup 2% milk, 2 tablespoons and 1.5 teaspoons of food thickener. Note states: amount of thickener required may vary relative to liquid content of cooked product. For best results, alternate adding thickener with processing, checking product consistency periodically. A) On 7.22.2024 at 11:18 AM Dietary [NAME] #3 placed 13 pieces of angel food cake into blender. Dietary [NAME] #3 added half and half to the angel food cake in blender, without measuring half and half. Recipe calls for 1.25 cup of 2 milk and 2 tablespoons + 1.5 teaspoons of thickener. When asked the size of each piece of cake, she stated, They are an inch. The menu specified pieces of cake to be 2/3 inches. B) Dietary cook #3 used #16 scoop (1/4 cup) to add 6 servings of strawberry topping onto of puree instead of 1/4 cup of strawberry topping each as specified on the menu. At 1:05 PM Surveyor asked Dietary [NAME] #3 what size was cake she said, like 1 inch. When asked what scoop was used for mechanical soft meat she stated, number 16. When asked how many servings she gave to each resident she stated 1. When shown menu and asked why strawberries were not given to the resident she stated, I did not look at menu, I did not know they were supposed to have 1/2 cup of strawberry topping. 4. On 07/22/24 at 11:53 AM, Dietary [NAME] #3 used #10 to place 6 servings of vegetable blend with plenty of juice into blender, added two cups of tap water, added 1/4 cup of thickener, pureed. Added another 1/4 cup of thickener and pureed. At 11:55 AM, she added another 1/4 cup of thickener and pureed. She poured purred into pan and placed into oven. The consistency of purred vegetable was lumpy with pieces of thickener that were not fully blended in and were visible in mixture. Vegetable puree was too runny and not formed according to dietary staff when asked by surveyor. 5. On 07/22/2024 at 12:17 PM, a pan of mashed potatoes was observed on steam table. The surveyor asked Dietary [NAME] (DC) #3 how the mashed potatoes were prepared, she stated they were fortified, super potatoes. The surveyor asked how were the mashed potatoes prepared, she stated I sprinkled half and half, about half a cup of butter. When asked how much she would consider a sprinkle to be , she stated, I don't use a recipe. The facility recipe for enhanced mashed potatoes documented: potato pearls 1 lb-6 oz, whole milk (heated) 9-1/4 cups, margarine, or corn oil 12 tablespoons, salt 1 teaspoon, sour cream 1-1/2 cup. Nutrient data documented 232 calories. a. All 17 residents who required enhanced food diet were served incomplete enhanced mashed potatoes. 6. The facility menu for lunch meal documented for residents on puree diet were to receive: #8 scoop (1/2 cup) of pureed hashbrown. On 07/22/24 at 1:03 PM the residents on puree diet did not receive pureed hashbrown for lunch, as specified on menu. On 07/22/24 at 1:05 PM, Surveyor asked Dietary [NAME] #3 cook why the residents on the puree diet did not receive the hashbrown casserole, she stated Probably because I forgot to puree it. 7. On 07/23/2024, the menu provided by the facility specified for the lunch meal residents on puree diet were to receive: #16 scoop (1/4 cup) of pureed bread. On 07/22/24 at 1:03 PM, the residents on puree diets did not receive pureed bread for lunch, as specified on menu. 07/22/24 at 1:05 PM Surveyor asked Dietary [NAME] #3 cook why no bread was purred for the residents on a puree diet she stated, I did not know I was supposed to puree regular bread, I thought I was only supposed to puree garlic bread and cornbread. 8. On 07/23/2024 the menu for the breakfast meal provided by the facility specified residents on puree diet were to receive: #8 scoop (1/2) cup of pureed hot cereal. a. 07/23/24 7:43 AM, the residents on the puree diet were served regular oatmeal instead of pureed. b. Production recipe for cereal fortified oatmeal provided by Dietary Supervisor at 1:33 PM documented under ingredients for 20 portions: water 3.75 cup, nonfat dry milk 1.5 cup 1 tablespoon, evaporated milk 1/4 cup 2 tablespoons. Mix water nonfat dry milk and evaporated milk, bring to a boil. Add dry oatmeal cereal 1.25 quart. Pour in oatmeal and cook until done. Add margarine bulk 9.25 ounce, light brown sugar 3/4 cup, granulated sugar 3/4 cup, evaporated milk 3/4 cup. Stir until creamy. 9. On 07/23/2024 the menu provided by the facility specified for the breakfast meal residents on puree diets were to receive: #16 scoop (1/4 cup) of pureed biscuit or toast. On 07/23/24 7:43 AM, the residents on pureed diets were not served bread. On 07/23/24 at 07:52 AM, Dietary [NAME] #10 was asked if the residents on puree diets were supposed to get bread, she stated No, they get biscuits and gravy, but we did not have biscuits this morning. They are not supposed to get bread. When asked what was served to the residents on puree diet this morning for breakfast, she stated, They only have puree oatmeal, puree egg, and puree sausage.

Based on observation, record review and interview, the facility failed to ensure meals were served in a method that maintained the nutritive value and flavor that were acceptable to the residents to improve palatability and encourage good nutritional intake during 1 of 1 meal observed. This failed practice had the potential to affect 9 residents who receive pureed meal trays from 1 of 1 kitchen. The findings are: 1. On 07/22/2024 the facility recipe for angel food cake puree documented for 10 residents: use 10 squares 2/3 inches, 1.25 cup 2% milk, 2 tablespoons and 1.5 teaspoons of food thickener. Note states: amount of thickener required may vary relative to liquid content of cooked product. For best results, alternate adding thickener with processing, checking product consistency periodically. A) On 7/22/2024 at 11:18 AM, Dietary [NAME] #3 placed 13 pieces of angel food cake into blender. Dietary [NAME] #3 added half and half to the angel food cake in blender, without measuring half and half. Recipe calls for 1.25 cup of 2 milk and 2 tablespoons + 1.5 teaspoons of thickener. When asked the size of each piece of cake, she stated, They are an inch. The menu specified pieces of cake to be 2/3 inches. B) Dietary [NAME] #3 used #16 scoop (1/4 cup) to add 6 servings of strawberry topping onto of puree instead of 1/4 cup of strawberry topping each as specified on the menu. At 1:05 PM, Surveyor asked Dietary [NAME] #3 what size was cake she said, like 1 inch. When asked what scoop was used for mechanical soft meat she stated, number 16. When asked how many servings she gave to each resident she stated 1. When shown menu and asked why strawberries were not given to the resident she stated, I did not look at menu, I did not know they were supposed to have 1/2 cup of strawberry topping. 2. On 07/22/2024, review of the facility's quantified recipe for vegetable blend for 10 residents on puree diet documented: 10.5 cup of prepared vegetable blend. 3 tablespoons + 1 teaspoons of thickener. Process adding 1 teaspoon of thickener per serving. Note states: amount of thickener required may vary relative to liquid content of cooked product. For best results, alternate adding thickener with processing, checking product consistency periodically. On 07/22/24 at 11:53 AM Dietary [NAME] #3 used #10 to place 6 servings of vegetable blend with plenty of juice into blender, added two cups of tap water, added 1/4 cup of thickener, pureed. Added another 1/4 cup of thickener and pureed. At 11:55 AM, she added another 1/4 cup of thickener and pureed. She poured purred into pan and placed into oven. The consistency of purred vegetable was lumpy with pieces of thickener that were not fully blended in and were visible in mixture. Vegetable puree was runny and not formed. On 07/23/24 at 9:23 AM, the surveyor asked Dietary [NAME] #3 why the pureed vegetable was thin, she said, Maybe because I used too much broth. I used two cups of water. When asked if water covered the vegetables she said, yes. The surveyor asked how much thickener was used in the pureed vegetable, she said, 1/4 cup, three times. Surveyor asked how does food taste when you add too much thickener, she said, It would probably taste like thickener. Surveyor asked did you look at the recipe, she said, I did not, I never use recipes. Surveyor asked how many servings of vegetables did you use, she said six. Surveyor asked Dietary [NAME] #3 what is the reason you should not add extra liquid when pureeing vegetables, she said, Because it will be too thin. On 07/23/24 at 9:37 AM, Surveyor asked Dietary Supervisor why should extra liquid not be used when pureeing vegetable, she said Because it will make it too thin. Surveyor asked Dietary Supervisor what happens when too much thickener is used in food, she said It will alter taste and it may not come out the right constancy and someone could choke.

Based on observation and interview, the facility failed to ensure pureed food items were blended to a smooth, lump free consistency to minimize the risk of choking or other complications for those residents who required pureed diets for 2 of 2 meals observed. The failed practice had the potential to affect 9 residents who received pureed diet. The findings are: The following observations were made during lunch and breakfast meal services. 1. On 07/22/24 at 11:18 AM, Dietary [NAME] #3 placed 13 small pieces of cake (1 inch each) and added 6 spoons of strawberries, 1/2 cup of thickener and purred. At 11:20 AM, another 1/2 cup of thickener was added and pureed. At 11:22 AM, Dietary [NAME] #3 used number 10 scoop to scoop pureed desert into 11 bowls. The consistency of pureed desert was thick with pieces of strawberries throughout. 2. On 07/22/24 at 11:53 AM, Dietary [NAME] #3 used #10 to place 6 servings of vegetable blend with plenty of juice into blender, added two cups of tap water, added 1/4 cup of thickener, pureed. Added another 1/4 cup of thickener and pureed. At 11:55 AM, she added another 1/4 cup of thickener and pureed. Poured purred into pan and placed into oven. The consistency of purred vegetable was lumpy with pieces of thickener that were not fully blended in and were visible in mixture. Vegetable puree was too runny and not formed according to dietary staff when asked by surveyor. 3. On 07/22/24 at 1:05 PM, Surveyor asked Dietary Manger and Dietary [NAME] #3 to describe puree food served to residents for lunch, both stated Pureed meat was thick and lumpy. Not smooth. 4. On 07/22/24 at 1:05 PM, the strawberry angel food cake desert was Too thick and has strawberry pieces in it. 5. On 07/22/24 at 1:28 PM, the Surveyor observed Certified Nursing Assistant (CNA) #1 exiting the resident upon entering the resident the Surveyor observed that cake was a different consistency. CNA #1 voiced that she mashed the dessert up with the strawberries. 6. On 07/22/24 at 1:34 PM, the Surveyor asked CNA #2 who set up the resident's tray? CNA #2 voiced she set up the resident's tray. The Surveyor asked CNA #2 did you notice the resident's dessert was not pureed? CNA #2 voiced she did not notice the dessert was not puree. The Surveyor asked what is the consistency of the cake? CNA #2 voiced the dessert looks smashed. The Surveyor asked CNA #2 does the dessert look pureed? CNA #2 voiced it did not look pureed. The Surveyor asked CNA#2 why is it important to ensure that what the residents are served matched the meal order? CNA #2 said so they don't get choked. 7. The following observations were made during the breakfast meal service: On 07/23/24 at 7:43 AM, during the breakfast meal in the dinner room the following foods were observed being served to the residents on puree diet: a. puree oatmeal. The consistency of oatmeal was lumpy and runny and not smooth. b. puree sausage. The consistency of the sausage was lumpy and was not smooth and was runny. On 07/23/24 7:45 AM, the surveyor asked CNA #3, who was assisting residents with their meal in the dining room to describe the consistency of the oatmeal served to the residents. She stated, lumpy. 8. On 07/23/24 at 7:46 AM. the surveyor asked CNA#8, who was assisting residents with their meal in the dining room, to describe the consistency of the oatmeal served to the residents. She stated, lumpy. 9. On 07/23/24 at 7:48 AM, Dietary [NAME] #10 was asked how she prepared oatmeal. She stated, I used two tablespoons of butter, two tablespoons of half and half and a half a bag of brown sugar. 10. On 07/23/24 at 7:56 AM. the surveyor asked Dietary Aid #4, Dietary Aid #7, and Dietary [NAME] #10 to describe the consistency of oatmeal served to the residents on puree diet and they stated, lumpy and loose. When asked to describe the consistency of the sausage served to the residents on the puree diet they stated, It is lumpy and runny. When asked why residents are on a puree diet they stated, Because they cannot chew or swallow regular food.

Based on observation, record review and interview, the facility failed to ensure dirty trash cans were stored away from the food storage racks to prevent potential cross contamination, to ensure the ice machine and ice scoop were maintained in clean and sanitary condition to prevent potential growth of harmful bacteria that could be transferred to the residents food, failed to ensure opened food items in the refrigerator, freezer, and storage room were covered, sealed, and dated to maintain freshness and prevent potential cross contamination, that expired food items foods were promptly removed from stock to maintain freshness and prevent potential cross contamination, failed to ensure dietary staff practiced good hand washing techniques to potential cross contamination of food and clean dishes, and failed to ensure hot food item was maintained at the required temperature on the stove and serving line to prevent potential foodborne illness. This failed practice had the potential to affect 71 residents who received meals from the kitchen. The findings are: 1. On [DATE] at 9:48 AM, an open trash can that contained trash with no lid was leaning against a spice rack. 2. On [DATE] at 10:06 AM, an ice scoop was observed affixed to a wall with ice scoop laying inside. The surveyor asked the Dietary Manager to wipe the ice scoop and ice scoop holder with a white napkin. When wiped the ice scoop and ice scoop holder yielded orangish residue that easily transferred to the napkin. The surveyor asked the Dietary Manager how staff clean the ice machine and who uses the ice from the ice machine. Dietary Manager stated, Monday or Tuesday of every week. We use it to fill the beverages for the residents at mealtimes. Surveyor asked Dietary Manager to describe the residue on the napkin, she stated It's an orangish matter. 3. On [DATE] at 10:07 AM, the following observations were made on a shelf in the 2- door freezer: a. An open of biscuits with no open date. b. An open box of cream cheesecake, the box was not covered. 4. On [DATE] at 10:09 AM, an open bottle of half and half was on the food preparation counter. The manufacturer specification on box documented to refrigerate after opening. 5. On [DATE] at 10:29 AM, an open bag of sweet rolls was on the bread rack without an open date. 6. On [DATE] at 10:31 AM, the following observations were made on shelf of walk-in refrigerator with no open date: a. container of cucumber onion salad with no received by date. b. bag of shredded salad with no open date. c. container of enchilada sauce with no open date. d. container of BBQ sauce with no open date. e. An uncovered and unsealed box of sausage. 7. [DATE] 10:36 AM, the following observations were made on the freezer: a. box of hamburger patties was uncovered, partially sealed, with no open date. b. open box of stake fingers with no open date. c. box of cookie dough with no open date. d. box of chicken strips with no open date. e open box of garlic with no open date. 8. On [DATE] 10:38 AM, the following observations were made on a shelf below the food preparation counter: a. gallon of Worcestershire sauce with no open date. b. gallon of Teriyaki sauce with no open date. c. bottle of grill and griddle spray with expiration of [DATE]. 9. On [DATE] 10:44 AM, an open bottle of salt uncovered was observed on the spice rack. 10. On [DATE] 10:49 AM, the right-side panel of the ice machine had white, orange residue that dripped down halfway to the ice. The surveyor asked Dietary Supervisor to wipe the area, and a white and orange residue easily transferred to tissue. The Dietary Supervisor stated the machine gets cleaned Monday or Tuesday of every week. The Dietary Supervisor stated the CNAs use the ice in machine for resident's room water pitchers. 11. [DATE] 10:52 AM, the following observations were made in the storage room: a. A Bag of corn chips were on a rack with an expiration date of [DATE]. b. Two of two bags of lime gelatin were on rack with no received date. c. Two of two bags of mushrooms were on rack with no received date. 12. [DATE] 11:09 AM, the following observations were made on spice rack: a. container of ground Basil with expiration date of [DATE]. b. container of white pepper [DATE]. c. container of Mediterranean style ground oregano with expiration date of [DATE]. d. container of nut [NAME] with expiration date of [DATE]. e. container of dill of expiration date of [DATE]. f. open container of chicken and beef base with no open date. 13. On [DATE] at 11:19 AM, Dietary Aid #5 went to walk-in refrigerator and grabbed two tomatoes, a bag of shredded cheese, boiled egg, and a bag of lettuce and placed it all on top of the food preparation area. She picked up a pan and placed it on the counter, with fingers inside of pan. She placed gloves on hand and emptied lettuce into the pan. Without changing gloves or washing hands, she picked up tomatoes, without washing tomatoes first she sliced and placed the tomatoes on top of shredded lettuce. Dietary aid used same gloved hands to slice boiled egg to place on top of shredded lettuce and tomatoes. She opened bag of shredded cheese with same contaminated gloved hands and placed shredded cheese on shredded lettuce, tomato, and boiled egg. At 11:26 AM, Dietary Aid #5 removed gloves and threw them away. Without washing hands, she placed new gloves on her hands and tossed salad mixture. The surveyor immediately asked dietary aid what she should have done when moving between food items and before handling clean food items, she stated Wash my hands. 14. On [DATE] at 11:37 AM, Dietary Aid #7 picked up two cartons of half and half and placed on food preparation counter, then picked up lid that fell on floor and threw lid away. Without washing her hands, she picked up clean glasses by rims and poured supplement chocolate shake into cups and served to residents who received supplement as part of diet. Surveyor asked what you should have done after picking up milk cartons and after picking up things from floor, she stated I should have washed my hands. 15. On [DATE] at 12:07 PM, Dietary Aid #6 pushed cart that contained glasses of beverages out of refrigerator. He pushed cart by cabinet close to the steam table. Without washing hands, he picked up glasses by their rims and placed them on the cart to be used to serve residents. The surveyor asked Dietary Aid #6 what he should have done after handling dirty objects and before touching clean objects, he stated Wash my hands. 16. On [DATE], a milk grate that contained 41 containers of buttermilk was taken out of the milk refrigerator by the Dietary Manager on [DATE]. She sated They do not use buttermilk for residents, it's used to make cornbread. 17. On [DATE], the facility policy titled Hand Washing provided by Dietary Supervisor Misty [NAME] at 1:33 PM documented: staff will wash hands to clean hands and exposed portions of their hands to removed contamination after; eating or drinking, handling soiled utensils or equipment, during food preparation, before donning gloves for working with food, after engaging in other activities that contaminate the hands.

Based on observations, interviews and record reviews, the facility failed to ensure staff used proper hand hygiene while providing peri care to 1 (Resident #17) sampled resident. The facility failed to provide hand hygiene during meal service to prevent cross contamination for 3 sampled (Residents #16, #24, #66). The findings include: A review of medical diagnosis revealed Resident #17 had diagnoses of dehydration and methicillin resistant staphylococcus aureus infection. A review of Resident #17's Care Plan (revision date 03/30/2023) revealed bowel and bladder incontinence related to immobility. A review of the Annual Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 02/24/2024 revealed Resident #17 scored 15 on a Brief Interview for Mental Status (BIMS) indicating cognitively intact and that Resident #17 frequently had urinary incontinence and always incontinence of bowel. On 07/23/24 at 01:05 PM, the Surveyor observed Certified Nursing Assistant (CNA) #2 did not use proper hand hygiene while providing perineal care to Resident #17 and contaminated furniture and reusable items. On 07/23/24 at 01:50 PM, CNA #2 confirmed proper hand hygiene was not used while providing perineal care and that items were potentially contaminated. On 07/24/24 at 01:30 PM, the Director of Nursing confirmed the techniques used to provide perineal care did not reflect proper hand hygiene and potentially contaminated reusable items. During observation of meal service on 07/24/24 at 07:10 AM, CNA #8 was observed walking into the dining area, and assisting Resident #66 to sit up straight, and was observed scratching their right ear, and resting both hands against her back while awaiting a food tray, then proceeded to provide meal set up touching napkins, plates, and the handles of silverware without performing hand hygiene for Residents #16, #24, and #66. On 07/24/2024 at 7:15 AM, CNA #21 was observed with his arms crossed while scratching both arms and placing his left thumb in his pocket while standing at the kitchen window waiting on a food tray. He then provided meal set up touching the napkin, plates, and silverware without performing hand hygiene. On 07/24/2024 at 7:20 AM, the Surveyor asked CNA #8 the procedure for hand hygiene during meal service. CNA #8 confirmed the concern was cross contamination, and confirmed she should have sanitized her hands between residents, and after touching her back and ear. On 07/24/2024 at 7:24 AM, during an interview with CNA #21 the Surveyor asked what should staff do after scratching their skin or touching the uniform during meal service. CNA #21 confirmed it caused a risk of cross contamination. During an interview with DON on 07/24/24 at 2:00 PM, the DON stated that staff are expected to wash their hands during meal service, and after touching themselves or the uniform to prevent cross contamination.

Based on interviews and record reviews the facility failed to ensure quarterly statements were provided to residents who are their own trust account representative and to properly record each transaction for one (Resident #28) sampled resident. This practice has the potential to affect 20 sampled residents. The findings are: On 07/22/2024 at 2:18 PM, Resident #28 informed the surveyor that quarterly bank statements are not provided, and the facility handles Resident #28's funds. On 7/24/2024 at 7:43 AM, the Administrator provided trust transaction history for dates of 4/4/2024 through 7/17/2024 which shows 4/16/2024 Cash Withdrawal (for) $50.00 dollars The Administrator was unable to provide a receipt for the transaction. On 7/24/2024 at 10:30 AM, the Administrator provided receipts for Resident #28 which shows 5/31/2024 Receipt #314463 was written to Resident #28 for $20.00. This withdrawal was not on the trust transaction history. On 07/24/2024 at 2:43 PM, the Director of Nursing (DON) confirmed the Business Office Manager does not keep individually acknowledged quarterly statements that were received by residents. The Business Office Manager will place resident's trust quarterly statements in the resident's room. The Business Office Manager does not require a signature from residents. Business Office Manager maintains a Verification of Trust Quarterly Statements with a statement of I attest that the above information is accurate, and that quarterly trust statements have been mailed out for this quarter. On 7/24/2024 at 3:10 PM, the DON provided two documents from the Administrator which showed: a. Administrator spoke with Business Office Manager at times Resident #28 will take money out on a Friday and for different occasions and will bring it [the money] back to put in her [Resident #28] trust, in which at this time she [Business Office Manager] states she [Business Office Manager] must have forgotten to go back and void the receipt. [Administrator] I looked through all other resident's account to make sure it was not taken from another resident on accident, and nothing was found in this amount. The trust was reconciled on 06/04/2024 in which all reconciled with no money under or over in residents trust fund cash box. b. Reivew of Resident #28's withdrawal dated 07/17/2024 showed Shopping for 07/17/2024 in the amount of $51.00. This was written as a check with multiple other residents for shopping at Anita's (Named) shop for jewelry and clothing. On 7/25/2024 at 8:30 AM, Resident #28 could not confirm neither the documented trust transaction withdrawal on 4/16/2024 for $50.00 nor the undocumented trust transaction for withdrawal on 5/31/2024 from facility receipt book for receipt #314463.

Based on observations, interviews, and record reviews the facility failed to ensure resident's personal and medical records were protected. This failed practice had the potential to affect all 75 residents. The findings include: On 07/24/24 at 10:00 AM, the Surveyor observed an unattended laptop computer with the screen unlocked with the resident's profile. The Surveyor was able to see the resident's name, room number, date of birth, age, physician's name, allergies, code status, vital signs including weight, and orders on the screen. On 07/24/24 at 10:14 AM, Licensed Practical Nurse (LPN) #15 voiced the resident's name and date of birth was displayed on the screen. LPN #15 confirmed someone obtain the resident's information, such as the date of birth. On 07/24/24 at 2:30 PM, the Director of Nursing (DON) said nurses should make sure the medication carts are locked, computer screen are locked, and there is no medications left on top of the cart prior to walking away. DON confirmed if the computer screens are left unlocked information can be seen by other residents, family members, and staff not involved in the resident's care. On 07/24/24 at 03:16 PM, Resident Rights was provided and noted The Right to Privacy and Confidentiality, including the right to: To know that they are assured private and confidential treatment of all information contained in their medical records, including photographs, and that their consent, or the consent of their legal representative, is required for the release of information to persons not otherwise authorized to receive it.

Based on observation, record review, and interview, it was determined that the facility failed to incorporate the PASRR level II evaluation into the care plan of 2 of 2 sampled (Resident #4, and Resident #44) to ensure residents received any recommended services. The findings are: 1. Per review of the Medical Diagnosis revealed Resident #4 has a diagnoses of respiratory failure, schizophrenia, and psychotic disorder. The Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/19/2024 suggested a Brief Interview for Mental Status (BIMS) score of 15 (13-15 indicates cognitively intact). a. On 07/24/24 at 8:35 AM, during an interview the Administrator confirmed that Resident #4 has a level II PASRR. b. During an interview on 07/24/2024 at 11:45 AM, the MDS Nurse was asked to check the care plan and she confirmed Resident #4's Level II PASRR was not documented on the care plan, and confirmed she cannot find the level II evaluation. The MDS Nurse confirmed she is responsible for coding to the MDS, but the Business Office Manager (BOM) receives the Level II evaluation. The Surveyor asked if there was a process for making sure the MDS Nurse was notified when the facility received a level II PASRR from the state designated authority, and there was no response. 2. A review of Medical Diagnosis revealed Resident #44 major depressive disorder, bipolar, and schizophrenia. The Quarterly minimum data set (MDS) with an assessment reference date (ARD) of 05/11/2024 suggested a BIMS score of 4 (0-7 indicates severe cognitive impairment). a. On 07/23/24 at 3:52 PM, the Surveyor checked Resident #44's care plan and did not find the PASRR level II, or recommendations implemented on the care plan. b. On 07/24/24 at 8:05 AM, the Administrator provided a level II evaluation from the state designated authority dated 2/24/23 that revealed Resident #44 did not require any specialized services and recommended a structured environment including Mental Health Evaluation, Master Treatment Plan, Pharmacologic Management by a Physician, and Periodic Review of the Master Treatment Plan. The MDS Nurse checked and confirmed the Level II PASRR with recommendations was not on Resident #44's care plan. c. During an interview on 07/24/2024 at 11:50 AM, the MDS Nurse confirmed Residents #4 and #44 had a level II PASRR, and that this not being reflected on Residents #4 and #44's care plans could have affected interventions and recommended services. The MDS confirmed she was responsible for coding to the MDS and confirmed that she uses the Resident Assessment Instrument (RAI) manual as a guide. d. During an interview with the Director of Nursing (DON) on 07/24/24 at 2:00 PM, the DON confirmed care plans are an important part of a resident's care, they do not have a MDS policy or procedure, and confirmed the MDS nurse is expected to follow the RAI manual.

Based on observations, interviews and record reviews, the facility failed to implement interventions put in place to prevent weight loss. The findings include: A review of physician's orders for Resident #14 revealed an order for thickened vegetable juice, creamed soup, and fortified potatoes with lunch and dinner. A review of Resident #14 Care Plan (initiate date 11/02/2023) revealed that Resident#14 had an unplanned/unexpected weight loss related to acute illness and diuretic use. Resident #14 (revision on: 03/28/2024) had nutritional problem or potential nutritional problem related to acute illness. A review of nutrition assessment (completed date 07/10/2024) noted Resident #14 was to have the following supplements: creamed soup, vegetable juice, boost and fortified potatoes. A review of Quarterly Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 07/05/2024 revealed Resident #14 scored 08 indicating severe cognitive impairment and Resident #14 was a loss of 5% or more in the last month or loss of 10% or more in last 6 months not on physician-prescribed weight-loss regimen. On 07/22/24 at 01:21 PM, the Surveyor observed Resident #14 lying in bed eating lunch and noted that the resident had a puree meal. The Survey did not note a shake or soup on the resident's meal tray despite those items being noted on the meal slip. On 07/22/24 at 01:28 PM, Certified Nursing Assist #1 voiced Resident #14 did not have soup and shake, because the resident did not like or consume the soup or shake. On 07/23/24 at 12:55 PM, the Surveyor observed Social Services assisting with the passing of meal trays. The Surveyor observed Social Service look at the meal card and send a staff member to the kitchen to retrieve items missing from Resident #14 meal tray. On 07/23/24 at 12:58 PM, Social Serviced confirmed whatever is on the card should be on the resident's tray. Social Services confirmed the items on the meal card were interventions for weight loss and if the items are not on the meal tray it does not help the resident with weight loss. Social Services voiced if the resident does not like a soup severed another soup should be retrieved or a different intervention should be put in place to prevent further weight loss. On 07/24/24 at 02:30 PM, the Director of Nursing (DON) confirmed the purpose of the notes section on the meal slip was for list of supplements usually for interventions put in place due to weight loss and should be on the resident's meal tray. The DON confirmed if those items are not on the tray it could have a negative impact on the resident's weight.

Based on observation and interview, the facility failed to ensure food items stored in the refrigerator and freezer were covered and sealed; leftover food items were prepared and used to maintain food quality; dietary staff washed their hands when contaminated to decrease the potential for food borne illness for residents receiving food from 1 of 1 kitchen; 1 of 2 ice scoop holders and 1 of 2 ice machines were maintained in a clean and sanitary condition and dietary staff washed their hands before handling clean equipment or food items to prevent potential food borne illness for residents who received meals from 1 of 1 kitchen. The failed practices had the potential to affect 64 residents who received meals from the kitchen (total census: 69) as documented on a list provided by the Dietary Supervisor on 06/29/23 at 8:33 AM. The findings are: 1. On 06/27/23 at 9:28 AM, the following observations were made on a shelf in the walk-in refrigerator. a. An opened box of sausage was not covered or sealed. b. A ziplock bag that contained a leftover mixture of ground sausage and whole sausage. c. A pan of leftover pureed sausage. d. A pan of leftover pureed eggs. e. The surveyor asked the Dietary Supervisor what the leftover pureed eggs, pureed sausage, ground, and whole sausage were used for. She stated, We use them the next day for the pureed. 2. On 06/27/23 at 9:29 AM, the following observations were made on a shelf in the walk-in freezer. a. An opened box of fish sticks was not covered or sealed. b. An opened box of cookie dough was not covered or sealed. c. An opened box of cinnamon rolls was not covered or sealed. 3. On 06/27/23 at 9:44 AM, Dietary Employee (DE) #1 opened the milk refrigerator and placed a container of milk in it. Without washing his hands, he picked up clean glasses by their rims and placed them on a rack to be used in serving beverages to the residents for lunch. 4. On 06/27/23 at 10:20 AM, DE #2 used her blouse to wipe her face, contaminating her hands. Without washing her hands, she removed gloves from the glove box and placed them on her hands, contaminating the gloves. She then placed the gloves on her hands, contaminating the gloves. She picked up spaghetti with her contaminated gloved hand and when she was about to place it in a pan, the Surveyor immediately stopped her. The Surveyor asked what she should have done after touching dirty objects and before handling food items. She stated, Changed gloves and washed my hands. 5. On 06/27/23 at 10:40 AM, DE #1 sanitized dishes and placed them on the cart. He pushed the cart towards the plate warmer. Without washing his hands, he picked up clean plates, and placed them in the plate warmer to be used in portioning food items to be served to the residents for lunch with his fingers inside the plates. 6. On 06/27/23 at 10:50 AM, DE #3 turned on the hand washing sink faucet and washed her hands. After washing her hands, she turned off the sink faucet with her hands, and pulled out tissue papers and dried her hands, contaminating her hands. She then picked up trays that contained stacks of clean bowls from under the counter and placed them on the counter. She grabbed the bowls with her fingers inside the bowls and placed them on the cart to be used in portioning mixed fruit to be served to the residents for lunch. At 1:29 PM, the Surveyor asked DE #3 what she should have done after touching dirty objects and before handling clean equipment. She stated, I should have washed my hands. 7. On 06/27/23 at 11:30 AM, DE #1 used a rag to wipe off a utility cart, contaminating his hands. Without washing his hands, he picked up clean glasses by their rims and placed them on the cart to be used in serving lunch beverages to the residents. At 1:28 PM, the surveyor asked DE #1 what he should you have done after touching dirty objects and before handling clean equipment. He stated, Washed my hands. 8. On 06/27/23 at 11:42 AM, DE #2 turned off the food preparation sink faucet with her bare hand, contaminating her hand. Without washing her hands, she picked up a clean blade and attached it to the base of the blender to be used in pureeing food items to be served to the residents on pureed diets. 9. On 06/27/23 at 12:02 PM, DE #4 turned on the hand washing sink faucet and washed her hands. After washing her hands, she turned off the faucet with tissue paper, she used the same contaminated tissue paper to dry her hands. She then picked up cups that contained beverages by their rims to be served to the residents with their lunch meal and placed them on the cart. At 1:23 PM, the Surveyor asked DE #4 what she should have done after touching dirty objects and before handling clean equipment. She stated, Washed my hands. 10. On 06/27/23 at 1:02 PM, the ice scoop holder on the wall by the ice machine facing the nurses' station had wet yellow residue on it. The ice scoop was setting directly in contact with the residue. The Surveyor asked the Dietary Supervisor to wipe the yellow residue inside the scoop holder. She did so, and the yellow substance easily transferred to the paper towel. The Dietary Supervisor stated, It has yellow residue. 11. On 06/27/23 at 1:04 PM, the interior surfaces of the ice machine had an accumulation of sage green/black residue on it. The Surveyor asked the Dietary Supervisor to wipe the yellow residue inside the scoop holder. She did so, and the wet sage green and wet black substance easily transferred to the paper towel. The Dietary Supervisor stated, It has sage/black residue. The Surveyor asked the Dietary Supervisor who used the ice from the ice machine and how often do you clean ice machine and scoop holder. She stated, CNAs [Certified Nursing Assistants] use it for the water pitchers in the residents' rooms. We clean it once a week. 12. The facility policy titled, Hand Washing, provided by the Dietary Supervisor on 06/28/23 at 11:20 AM documented, .Purpose: To remove contamination after entering the kitchen handling soiled utensils or equipment, during food preparation, before donning gloves for working with food, and after engaging in other activities that contaminates the hands. Shut off the water faucet without contaminating clean hands (i.e., by using a paper towel . 13. The facility policy titled, Usage and Storage of Leftover Foods , provided by the Dietary Supervisor on 06/28/23 at 11:20 AM documented, .It is suggested all mechanically altered foods (grounds, mechanical soft, puree) are discarded from the steam table to help control food quality. 44852 14. On 06/28/23 12:40 PM, CNA #2 rubbed her forehead with her hand just prior to assisting Resident #65 with his lunch. Without sanitizing her hands, she then proceeded to Resident #2, picking up the resident's utensil and bringing the food to the resident's mouth for consumption. CNA #4 hovered over her rolling stool, using both hands to move the stool into position and sat down. Without sanitizing her hands CNA #4 began to assist Resident #24 with their lunch meal. CNA #4 obtained the utensil, dipped it into the food and then placed the utensil into the resident's mouth. Without sanitizing her hands CNA #4 immediately began the same task for Resident #29. CNA #1 placed each hand on the sides of her rolling stool to adjust placement prior to sitting down between residents ' . Without sanitizing her hands, CNA #1 repeatedly assisted Resident #6 and Resident #63 moving back and forth, offering bites of food to each resident without sanitizing her hands between residents. 15. On 06/29/23 at 1:09 PM, the Surveyor asked CNA #7 what should take place between assisting residents with their meals. She stated, You should sanitize your hands. The Surveyor asked CNA #4 what should take place between each resident when providing assistance to multiple residents during meals. CNA stated, You should talk to them. When prompted for additional information she stated, You should offer them a drink. At this time the Director of Nursing (DON) joined the conversation and was asked what should take place when providing assistance to multiple residents during meals. The DON indicated that she was unaware of the answer to the question. When the Surveyor offered sanitize hands as the answer to the question, the DON stated, We have never been told that before, but now that you say that it makes sense.

Based on observation, record review and interview, the facility failed to ensure the enteral feeding bag and the water flush bag were dated and timed for 2 Residents, (Residents #4 and #25) and failed to ensure proper procedure was followed when attempting to resolve clogging prior to water flush and medication administration for 1 (Resident #22) of 3 (Residents #4, #22 and #25) sampled residents who received tube feedings according to a list provided by the Director of Nursing (DON) on 06/28/23 at 1:06 PM. The findings are: 1. On 06/27/23 at 10:01 AM, observed Resident #25 lying in bed with the head of bed elevated. A feeding pump was running at 85 milliliters (ml) per hour with a water flush at 45 ml every hour. Neither bag was labeled with the date or time when started. a. On 06/28/22 at 3:00 PM, a review of the Medical Record revealed Resident #25 had a Physicians Order dated 06/15/23 which documented the resident was to receive Diabetisource AC @ (at) 85 ml/hr (milliliters per hour) continuous via peg (percutaneous endoscopic gastrostomy) tube x (times) 8 hours from 2200-0600 (10:00 PM to 6:00 AM) with H2O (water) flush at 45 ml/hr every hour. 2. On 06/27/23 at 10:48 AM, observed Resident #4 lying in bed with the head of the bed elevated. A feeding pump was running Isosource 1.5 at 95 ml per hour with a water flush at 45 ml every hour. Neither bag was labeled with the date or time when started. a. On 06/28/23 at 3:10 PM, a review of the Medical Record revealed Resident #4 had a Physicians Order for an enteral feed one time a day ISOSOURCE 1.5 @ 95 ml/hr x 13 hours, 0600-1900 (6:00 AM to 7:00 PM) with 40 ml/hr H2O flush every hour. 3. On 06/29/23 at 10:50 AM, the Surveyor asked Licensed Practical Nurse (LPN) #3 what was important to remember when installing a new container of formula. She stated, Check the expiration date, make sure it is the right kind and be sure to put the date and time on it. The Surveyor asked why that was important. LPN #3 stated, To keep up with how often you are changing it and the intake. 4. On 06/29/23 at 11:00 AM, the Surveyor asked LPN #4 what was important to remember when hanging a new container of formula. LPN #4 stated, Well, you have to put the date and time. The Surveyor asked LPN #4 to discuss the importance of this practice. LPN #4 identified the need to know how long the feeding was in place and how much was consumed. 47912 5. Resident #22 had a diagnosis of Dysphagia following Unspecified Cerebrovascular Disease and Moderate Protein-Calorie Malnutrition. a. A Care Plan with an initiated date of 07/19/18 and a revision date of 03/01/21 documented, .Administer tube feeding formula and flushes as ordered . Report to the physician: Complications/side effects of tube feeding . b. A Physician's Order dated 04/28/23 documented Enteral Feed . every shift related to Dysphagia following Unspecified Cerebrovascular Disease . Glucerna 1.5 @ 65 ML/HR with 30 ML/HR H2O Flushes via pump **May disconnect for all ADL's [activities of daily living] . c. On 06/27/23 at 12:33 PM, observed LPN #1 attempt to administer medications through Resident #22's feeding tube, which was clogged. LPN #1 stated, Her tubing gets clogged a lot. Observed LPN #1 squeeze the tube, and stated I can feel it, it's right here., indicating the part of the tube closest to the resident's body. The Surveyor asked LPN #1 what they do when the peg tube gets clogged. LPN #1 stated, We have these de-cloggers, that will be my next course of action. Let me try to flush this. I will hook it back up and not run it. LPN #1 attempted to flush unsuccessfully, reconnected the tubing, and placed the syringe back into the bag, which was dated, but had no initials or time marked on it. LPN #1 left Resident #22's room at 12:47 PM. The Surveyor heard LPN #1 in the hallway stating, I need a de-clogger! d. On 06/27/23 at 12:50 PM, LPN #1 returned to Resident #22's room with LPN #2. Observed LPN #2 disconnect the tubing from the pump and attempted to flush the tube connected to Resident #22 with water unsuccessfully. LPN #2 removed the clog by milking the tube between her gloved fingers. A paste like yellowish substance that had visible white colored specks was expressed out of the end of the tubing and onto a paper towel sitting underneath the tubing on Resident #22's abdomen. e. On 06/28/23 at 12:45 PM, the Surveyor asked the DON if it was standard practice to milk a clogged feeding tube. The DON stated, Way back when it was, when I was in school. I'm not sure what they are teaching now. We do have de-cloggers. They are different French sizes and lengths. It's just a tube you can put in the tube and clean it, like you are cleaning a straw without the bristles. Back in the day they did teach us to do that milking. f. On 06/29/23 at 11:19 AM, the Surveyor asked the DON to provide documentation of any complications of Resident #22 ' s feeding tube issues. The DON answered, It's probably not documented, they only document if they can't get it unclogged. 6. On 06/28/23 at 1:06 PM, the DON provided a policy and procedure titled, Enteral Feedings, Administration via Gastrostomy. Under Procedure 9. Initiate Feeding A. Gastrostomy Tube . g. Clean syringe, replace protector on tip. Store in plastic bag. Label with date, time and initials. Number 2. Intermittent Feeding - Gravity a. Fill gavage bag with feeding solution. (Label bag with date, time and initials.) 3. Intermittent Feeding - Enteral Pump a. Hang filled gavage bag on IV pole, (Label bag with date, time and initials). 4. Continuous Feeding b. Prime tubing and clamp. Label bag with date, time and initials.

Based on observation, record review and interview, the facility failed to ensure meals were prepared and served according to the planned written quantified recipe and menu to meet the nutritional needs of the residents for 1 of 1 meal observed. This failed practice had the potential to affect 10 residents who received pureed diets from 1 of 1 kitchen according to a list provided by the Dietary Supervisor on 06/28/23. The findings are: 1. The menu for lunch documented the residents who received pureed diets were to receive 2 #8 scoops (1 cup) of pureed spaghetti with a tablespoon of parmesan cheese and for all residents to receive a slice of bread each. 2. The facility quantified recipe documented for 10, 8 ounce, servings of spaghetti with meat sauce the following: 1. Prepare according to regular recipe. Food thickener bulk 2 tablespoon plus 11/2 teaspoon. Stock beef/soup base 11/4 cup. 2. Prepare slurry. 3. Process until smooth adding 1 oz slurry per portion. 3. On 06/27/23 at 11:44 AM, during the noon meal preparation Dietary Employee (DE) #2 used a #8 scoop (4-ounce or 1/2 cup) to place 7 servings of spaghetti with meat sauce into a blender. At 11:45 AM, DE #2 removed 5 slices of bread from the bread bag and placed them on the spaghetti. She then pressed down on the coffee maker handle and obtained 2 cups of hot water in a measuring cup and poured it on the spaghetti with bread. She pureed the mixture of spaghetti and bread into a pan to be served to the residents on pureed diets for lunch. The recipe specified to use 11/4 cup of stock. 4. On 06/27/23 at 11:56 AM, the Dietary Supervisor placed 8 servings of garlic bread into a blender and added Italian seasoning, instead of 10 slices of garlic bread as per the written menu. At 11:56 AM, DE #2 added 4 cups of water from the coffee maker and puree. She poured the pureed bread with water on the pan liner inside a pan and placed it on the steam table. 5. On 06/27/23 at 12:43 PM, the following observations were made during the noon meal service. a. DE #2 used a #8 scoop (1/2 cup) to serve a single portion of pureed spaghetti with meat sauce to the residents on pureed diets. There was no pureed parmesan cheese added to the pureed spaghetti when prepared and or when served to the residents. The menu specified for each resident on pureed diets to receive two #8 scoops (1 cup) of pureed spaghetti and tablespoon of parmesan cheese. At 1:27 PM, the Surveyor asked DE #2 what scoop size she used to serve the pureed spaghetti and how many servings did she give to each resident. She stated, I used a gray scoop which is 1/2 cup and I gave one serving each. The Surveyor asked if she looked at the menu. She stated, That's what I was told to use. b. DE #4 used a tong to serve a small portion of tossed salad to the residents. At 1:23 PM, the Surveyor asked DE #4 to measure the same amount of tossed salad she served to the residents who were on a mechanical soft diet and the residents on regular diets into an 8 ounce spoon which is equivalent to one cup. She did and stated, It was 1/2 cup. I should have used #8 spoon.

Based on observation, record review and interview the facility failed to ensure that call light was within reach for 1 (Resident #25) of 5 (Residents #4, #25, #46, #49 and #62) sampled residents who resided on the 100 Hall and had the ability to utilize their call lights according to a list provided by the Administrator on 06/29/23 at 9:50 AM. The findings are: 1. On 06/27/23 at 10:50 AM, observed Resident #25 lying in bed. The Surveyor asked if she could locate her call light. She began to move her hand around on top of the blanket attempting to locate the call light. At this time her roommate stated, I told them that since she can only use one hand, to tie the call light to the string hanging from the light so she could find it, but they never did do it. The call light cord extended from the wall connection down below the edge of the bed. The call light was located between the wall and the bed that prevented the resident from accessing it. 2. On 06/28/23 at 2:55 PM, observed Resident #25 sitting up in her bed. The Surveyor asked her to locate her call light. Resident #25 used her hand and attempted to locate the call light underneath the blanket. Resident #25 was unable to locate the call light. The call light was extended from the wall connection down below the edge of the bed. The call light was located between the wall and the bed that prevented the resident from accessing the call light. 3. On 06/28/23 at 3:01 PM, a review of the Resident #25's Care Plan with an initiated and revision date of 02/18/21 revealed an intervention of, Anticipate and meet needs. Be sure call light is within reach and respond promptly to all requests for assistance. 4. On 06/28/23 at 3:05 PM, the Surveyor asked Certified Nursing Assistant (CNA) #6 if Resident #25 had the ability to use her call light to ask for assistance. CNA #6 stated, Yes, I know she has used it in the past. The Surveyor asked where the call light should be located. She stated, Where the resident can reach it. The Surveyor asked what could happen if the call light was out of reach. CNA #6 stated, Well they wouldn't be able to ask for help and that could be dangerous. 5. On 06/29/23 at 9:10 AM, the Surveyor asked CNA #2 if Resident #25 had the ability to use her call light. CNA #2 stated, Oh yes, she knows what her call light is for. She doesn't use it very often, but she can. 6. On 06/29/23 at 9:50 AM, the Administrator advised that there was no policy and procedure available addressing the placement of the call light.

Based on observation, record review and interview, the facility failed to ensure staff followed standard precautions for infection control during medication administration via peg tube to prevent potential spread of infection for 1 (Resident #22) of 3 (Residents #4, #22, and #25) sampled residents who received medications via peg tube according to a list provided by the Director of Nursing (DON) on 06/28/23 at 1:06 PM. The findings are: a. On 06/27/23 at 12:33 PM, observed Licensed Practical Nurse (LPN) #1 enter Resident #22's room holding two clear cups, one with clear liquid, the other with light yellow colored liquid substance. LPN #1 spoke to Resident #22 about giving her medications. The Surveyor asked LPN #1 what medications were mixed in the clear cup. LPN #1 answered, Acidopihilus, Metoprolol, Lactulose, and Reglan are mixed in the water. That's why it's that yellowish color. The Surveyor observed LPN #1 place the 2 cups, onto the floor at the head of the resident's bed. There was no bedside table on Resident #22's side of the room. b. The Surveyor observed LPN#1 pick up the cup of clear liquid from the floor, sit it on the resident's abdominal area touching the bottom of the cup to the resident, the tubing, and the bed covers. The cup was in her left hand, the tubing and syringe in her right. LPN #1 attempted to flush the tubing with approximately 30 cc of clear liquid. LPN #1 stated, Her tubing gets clogged a lot, and began squeezing the tube and stated, I can feel it, it's right here. LPN #1 then picked up the cup of the medication mixture from the floor and poured it into the syringe after removing the plunger. The medication mixture would not flow through the tube. LPN #1 then poured the medication solution from the syringe back into the cup. The Surveyor asked LPN #1 what could happen if the cups were on the floor, or if there was an issue with sitting cups on floor. She answered, Well, they could spill or, I know I shouldn't have done that. I know. c. On 06/28/23 at 12:45 PM, the Surveyor asked the Director of Nursing (DON) if there were issues with sitting supplies that are going to be used for flushing the feeding tube on the floor. The DON answered, Yes there is an issue. Everything should be laid out on a bedside table. Our nurses have been trained. The Surveyor asked what specific issues could occur. The DON answered, It would be like dropping a cracker on the floor and picking it up and eating it. The Surveyor asked what could happen. The DON answered, Depending upon the bacteria from the dirty surface, you could introduce that into the stomach from the dirty surfaces, or it could cause nausea or vomiting. d. On 06/29/23 at 1:50 PM, the Administrator provided a Policy and Procedure entitled, Infection Prevention and Control, which documented, .Standard precautions shall be used when caring for residents at all times regardless of their suspected or confirmed infection status .

Complaint # (AR 582) was substantiated, all or in part, with these findings. Based on observation, record review and interview, the facility failed to ensure necessary care and services were provided for management of post-[MEDICAL CONDITION] complications, as evidenced by failure to ensure precautions and instructions from the [MEDICAL CONDITION] treatment provider were care planned, readily available to nursing staff, and implemented; failure to ensure assessments were conducted and documented upon the resident's return from [MEDICAL CONDITION] therapy appointments; failure to promptly initiate the physician-ordered treatment for [REDACTED].#3) of 1 case mix resident who was receiving [MEDICAL CONDITION] treatments to the anal area. The failed practice resulted in actual harm to Resident #3, who experienced unrelieved pain due to a delay in initiating the prescribed treatment for [REDACTED]. The findings are: Resident #3 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Admission Minimum Data Set (MDS) with an Assessment Reference Date of 9/5/17 documented the resident scored 14 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status (BIMS), required extensive assistance of 1 person for transfer, dressing and bathing, was frequently incontinent of bowel and bladder, was at risk for skin breakdown and was receiving [MEDICAL CONDITION] and [MEDICAL CONDITION] therapy while a resident, had other skin treatment, had pressure reducing device and had almost constant pain with an intensity rate of 8. a. An Admission Care Plan dated 8/23/17, which had been updated on 9/5/17 as the Comprehensive Care Plan, did not address [MEDICAL CONDITION] therapy, or any necessary precautions, assessments or care instructions related to [MEDICAL CONDITION] therapy. b. The Care Area Assessment (CAA) dated 9/5/17 documented, .Resident has potential for skin breakdown due to incontinence and [MEDICAL CONDITION] Treatment . Resident is monitored at the oncology clinic for skin problems. 1.) On 10/11/17 10:30 a.m., the Director of Nursing (DON) was asked if the facility had any documentation regarding precautions for the resident, related to the [MEDICAL CONDITION] treatments. The DON was unable to provide any documentation at this time. 2.) On 10/11/17 at 2:42 p.m., the DON was asked about the Care Plan for Resident #3 and stated, The Admission Care Plan that we had was updated and is the resident's Care Plan. The DON was asked if the Care Plan addressed the resident's [MEDICAL CONDITION] treatments. The Care Plan was reviewed by the DON at this time, and there was no documentation regarding [MEDICAL CONDITION] or any necessary treatment or precautions related to [MEDICAL CONDITION] therapy. The DON was informed that, per the surveyor's review of the clinical record, the resident was receiving [MEDICAL CONDITION] therapy. The DON stated, Yes, he goes to [MEDICAL CONDITION] Monday through Friday. c. As of 10/10/17, there was no documentation in the clinical record of a specific appointment schedule for [MEDICAL CONDITION] treatments or of any post-[MEDICAL CONDITION] assessments upon the resident's return from his appointments. On 10/11/17 at 2:42 p.m., the DON was informed that the surveyor had been unable to locate documentation in the Nurses' Notes, or elsewhere in the clinical record, of when the resident left the facility for [MEDICAL CONDITION] appointments, when he returned, or of post-[MEDICAL CONDITION] assessments. The DON was then asked, Should there be a documented assessment when the resident returns from [MEDICAL CONDITION] therapy? The DON stated, Yes. d. On 10/11/17, the weekly skin audit documentation and the facility's response to changes in the resident's skin condition were reviewed with the following findings: 1.) The Nursing Weekly Skin Audit completed by the Treatment Nurse, on 10/3/17 documented, Right iliac crest (front) - [MEDICAL CONDITION] mark. Left iliac crest - [MEDICAL CONDITION] mark. Left buttock - Pressure 1.4 cm (centimeters) x (by) 1.4 cm x 0.1 cm stage II . right shoulder front port. Other bruising LFA (left forearm) . 2.) The Nursing Weekly Skin Audit completed by the Treatment Nurse and dated 10/5/17 documented, Right buttock type Pressure (no measurements). Bruising LFA . 3.) The Nursing Weekly Skin Audit completed by the Treatment Nurse and dated 10/11/17 documented, Right antecubital - bruising, Groin - [MEDICAL CONDITION] Burn, Left hand (back) - bruising, Left Buttock - Pressure (no measurements documented), Sacrum- [MEDICAL CONDITIONS]. 4.) Progress Notes dated 10/11/17 documented, Resident seen today by (Physician Name) at ([MEDICAL CONDITION] Therapy Provider) . RN reported leakage from anus is normal after [MEDICAL CONDITION] Treatment. Also red areas to peri-area . excoriation from leakage. New order for [MEDICATION NAME] 1% Cream to be applied to peri area three times a day, but to not apply 4 hours before [MEDICAL CONDITION] treatment. 5.) A faxed Physician order [REDACTED]. Do not apply prior to ([MEDICAL CONDITION]) treatment within 4 hrs (hours). 6.) The October 2017 Medication Administration Record [REDACTED]. Do not apply prior to [MEDICAL CONDITION] treatment within 4 hr (hours). The Pharmacy delivery invoice documented the [MEDICATION NAME] Cream was delivered to the facility on [DATE] at 11:23 p.m., approximately 11 hours after it was ordered; however, there was no documentation the cream was applied upon receipt of the medication. As of 10/12/17 at 11:30 a.m., there was still no documentation to indicate the [MEDICATION NAME] Cream had been applied. 7.) On 10/12/17 at 11:30 a.m., Licensed Practical Nurse (LPN) #1 was asked about the care for (Resident #3). She stated she had cared for Resident #3 and was not aware of any skin issues until the [MEDICAL CONDITION] therapy provider's physician had ordered the [MEDICATION NAME] Cream. The LPN was asked if she had assessed the resident and stated, No, he was seen at ([MEDICAL CONDITION] Therapy Provider). The LPN was asked if she had applied the [MEDICATION NAME] Cream on 10/11/17 and stated, No, it hadn't come in, and I passed it on to the next shift. She was asked, Did you put the order in the computer. The LPN stated, Yes. 8.) On 10/12/17 at 11:40 a.m., the Treatment Nurse was asked about the resident's care. She stated she had done a body audit before the resident left for [MEDICAL CONDITION] treatments, .yesterday and today. I assessed him prior to him leaving on yesterday, a little before 9:00 a.m. The sacral area and the posterior area of scrotum were reddened . had the appearance of a sunburn. I sent a note with the resident to ([MEDICAL CONDITION] Therapy Provider). The Treatment Nurse was asked when the order for [MEDICATION NAME] Cream was received from the Physician and stated, I'm not sure; you would have to check with the Charge Nurse. The Treatment Nurse was asked if she had first noted the reddened areas on 10/11/17 and stated, Yes, to the extent that they were. The Treatment Nurse was asked if she had measured the areas and stated, No. The Treatment Nurse was asked to clarify her assessment that documented, groin redness. The Tx Nurse stated, I should have corrected that; it wasn't the groin area, it was the posterior side of the scrotum. 9.) On 10/12/17 at 11:50 a.m., the DON was informed by the surveyor that the physician order [REDACTED].? The DON stated, Yes. The DON was asked if the [MEDICATION NAME] Cream should have been applied on 10/11/17 and stated the facility's, new system didn't flag the nurses to alert them to apply the [MEDICATION NAME] Cream. The DON was again asked if the [MEDICATION NAME] Cream should have been applied and again stated, It's a new system, and it didn't flag. The DON was asked, Is this appropriate treatment? The DON did not respond. 10.) On 10/12/17 at 2:53 p.m., the resident was asked if he was experiencing pain to his [MEDICAL CONDITION] site and stated, Yes. The resident was asked if he had reported the pain to the Nurse and stated, Yes. The resident was asked if the nursing staff had applied anything to the area. The resident pointed to the bedside table and stated, The cream that's in that drawer; it helped a little, but not much. The cream in the drawer of the bedside table was later identified as a barrier cream (refer to paragraph d. 12). below). 11.) On 10/12/17 at 2:58 p.m., LPN #3 applied [MEDICATION NAME] Cream to the affected areas. The coccyx area had a red, sunburned appearance that extended bilaterally to the buttocks and downward to the posterior side of the scrotum. The reddened area measured approximately 10 centimeters in diameter. 12.) On 10/12/17 at 3:50 p.m., Certified Nursing Assistant (CNA) #1 was asked if she had taken care of Resident #3 last night. The CNA stated, Yes. The CNA was asked if the resident had complained of pain to his bottom and stated yes, and that, We put the cream we normally use . on the affected areas. The CNA showed the surveyor a tube of Moisture Barrier Cream from the drawer of the resident's bedside table The ingredients documented on the label documented the cream contained Zinc Oxide and Dimethicone. 13.) The Current Oncology Journal, v.17(4), August 2010, article titled, [MEDICATION NAME] and management of acute [MEDICAL CONDITION]-induced skin reactions: a systematic review of the literature, located at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC 36/ documented, .During or after [MEDICAL CONDITION] treatment, avoid the use of metallic-based topical products, zinc oxide creams or deodorants with an aluminum base, for instance, because they may increase the surface dose to skin . 14.) On 10/12/17 at 4:31 p.m., LPN #2 was interviewed via telephone. The LPN stated she had cared for the resident on the previous night shift (10/11/17). The LPN was asked if the resident had complained of pain. The LPN stated, I'm not sure - I think it might have been his back - you would have to check my notes. The LPN was asked if she was aware of the [MEDICATION NAME] Cream order. The LPN stated, It was ordered to start on the 12th. The resident's clinical record was again reviewed at this time, and there were no notes documented by LPN #2 for the 10/11/17 night shift. The physician order [REDACTED]. 15.) On 10/12/17 at 5:00 p.m., the Assistant Administrator provided, The [MEDICAL CONDITION] treatment of [REDACTED].Do not use lotion, ointment or cream on the treated skin unless prescribed by your Doctor . 16.) On 10/12/17 at 6:25 p.m., the resident was asked when the pain in his bottom first started. The resident stated, Last night; (pain was) real bad last night.

Based on record review and interview, the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical well-being for Resident #16, in accordance with the comprehensive assessment and plan of care. The facility failed to ensure licensed staff, (Licensed Practical Nurse (LPN) #2 and LPN #3) immediately provided cardiopulmonary resuscitation (CPR) when the resident was found without vital signs for 1 (Resident #16) of 8 (Residents #4, #7, #9, #10, #11, #12, #13 and #16) case mix residents who had documented full code status in their clinical record. This failed practice resulted in Immediate Jeopardy, which caused or could have caused death to Resident #16, who had documented full code status in the clinical record and did not receive cardiopulmonary resuscitation (CPR) upon identification of a lack of vital signs. The failed practice also had the potential to cause more than minimal harm to 31 residents who had documented full code status in their clinical records, according to a list provided by the Administrator on [DATE] at 8:30 a.m. The facility was informed of the Immediate Jeopardy condition on [DATE] at 8:40 p.m. The findings are: 1. Resident #16 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set with an assessment reference date of [DATE] documented the resident scored 13 (,[DATE] indicates cognitively intact) on the Brief Interview for Mental Status (BIMS). a. The form titled, "CPR (Cardiopulmonary Resuscitation)" dated [DATE] documented, "Initial each box: (initialed) I, the undersigned person, understand that cardiopulmonary resuscitation (CPR) is an emergency intervention. I understand that in the nursing home, this basic life support consists of external chest compression and mouth-to-mouth ventilation until emergency services is able to arrive at the facility and take over... (x marked to select:) I Want CPR. I want cardiopulmonary resuscitation to be provided in the event I have a cardiac or respiratory arrest ..." The form was signed by the resident's responsible party (niece) and witnesses on [DATE]. b. The Care Plan dated [DATE] documented, "Problem: ...Request for CPR, Full Code Status ... Goal: Request for CPR/Full Code status will be honored..." c. A physician order [REDACTED]. As of [DATE] at 5:10 p.m., the face sheet information in the resident's closed clinical record documented, "Advanced Directives: Check all that apply: ...(check marked) Full Code ... Copy on file? (check marked)..." d. A Nurses Progress Note dated [DATE] at 6:15 a.m. documented, "Resident observed up on bed side looking out into hallway, moving her arms about on side rail." e. A Nurses Progress Note dated [DATE] at 9:30 a.m. documented, "CNA (Certified Nurse Assistant) came to nursing desk and said that resident look like that she is not breathing, 2 LPN (Licensed Practical Nurse) enter resident room observed on bed in supine position, right leg on floor dentures in her mouth respiration absent, pulse absent no audible B/P (blood pressure) skin moist and cool to touch, (doctor) notified of v/s (vital signs) absent (at) 0720 (7:20 a.m.), Coroner called (name of county coroner) notified resident pronounced deceased (at) 0743 (7:43 a.m.)..." There was no documentation that CPR was provided, or of an assessment to determine if rigor or lividity were present to justify withholding CPR. g. A Nurses Progress Note dated [DATE] at 3:42 p.m. documented, "0725 (7:25 a.m.) A.M. (Physician) notified per night shift nurse. 0743 a.m. resident pronounced by coroner. 07:29 a.m. next of kin... notified per night shift nurse..." h. On [DATE] at 5:45 p.m., the following interview was conducted with Licensed Practical Nurse (LPN) #2: The LPN was asked if she had gone to the resident's room on [DATE] when the CNA informed the nurses that the resident had problems. The LPN stated, "Yes." The LPN was asked what the CNA said was wrong with the resident. The LPN stated, "...She asked if we would go down and see (Resident #16) 'cause she thought she was dead, I believe she did say." The LPN was asked what happened next and stated, "We went down to her room. She was lying across the bed and her dentures were partially out of her mouth. We called her name and she didn't respond and (LPN #3), the other nurse, shook her and called her name. Then we started checking for pulse and blood pressure and her body was cool. We couldn't feel a pulse. Couldn't get a reading on a blood pressure. We called (Director of Nursing (DON)), (LPN #3) called (physician). While she was doing that, I was making copies of the paperwork we had to have." The LPN was asked if rigor (stiffening of extremities and body) was present and stated, "No, not rigor mortis. I remember her fingers being much colder than the rest of the body and they were kind of mottled." The LPN was asked if the eyes were checked to see if the pupils were fixed and dilated. The LPN stated, "I know I didn't. I can't remember if her eyes were partially opened. I can't remember if (LPN #3) did. I know I didn't." The LPN was then asked if the resident was checked for lividity and stated, "I didn't." The LPN was asked if knew what lividity was and stated, "That's where blood pools in the body." The LPN was asked what rigor was and stated, "That's when whatever position they are in, they are stiff and set up." The LPN was asked what code status the resident had and stated, "She was a full code." The LPN was then asked if CPR was initiated for the resident. The LPN stated, "No, we didn't ... when we went and found her and found she had no vital signs, I came out and checked the chart and I believe that's when (LPN #3) started making calls." The LPN was asked how long it took to go to the resident's room and stated, "Maybe a few seconds, 'cause the room was right there." The LPN was asked what the protocol was for a resident who was a full code and had no vital signs or for a resident who is a no code. The LPN stated, "I know if unwitnessed death, if rigor mortis, blood pooling, if pupils dilated." The LPN was asked how long pulse was to be checked and stated, "A minute." The LPN was asked how long respirations should be checked and stated, "A minute, too." The LPN was asked which pulse was to be checked and stated, "Carotid pulse, radial." The LPN was asked if she listened for breath sounds and stated, "No." LPN #2 was asked if she was certified in CPR and stated, "No, it's expired." The LPN was asked who would do CPR if it should be initiated for a resident with a full code and the LPN stated, "Hopefully all the nurses who would work with me, 'cause I don't know who knows CPR." The LPN was asked how do she determine and know a resident is a full code and stated, "It's there on their chart and on the MAR (medication Administration Record), if it is in an emergency I would start CPR anyway." The LPN was asked if a resident was found without vital signs, what was to be done and the LPN stated, "If I walk in, they don't have vital signs, I'm going to check if they are a code." The LPN was asked if staff should start emergency protocol if a resident was found without vital signs and the LPN stated, "No, 'cause was unwitnessed." The LPN was asked if the resident does not have rigor, lividity or fixed/dilated pupils, should CPR be started? The LPN stated, "Looking at it like that you should have done it (indicating CPR should have been initiated)." The LPN was asked who had oriented her on code procedures and stated, "I don't remember getting that orientation." The LPN was asked if she had asked what was to be done for a code and stated, "No." i. On [DATE] at 6:15 p.m., CNA #4 was asked if the resident was seen on the morning of [DATE] and stated, "I went in her room, but she wasn't deceased at 6:30 (a.m.)." The CNA was asked how the resident was when she last saw her and stated, "She was positioned in the bed a little different so, I helped position her in the bed... Her leg was kind of out of the bed." The CNA was again asked what time she was in the resident's room and stated, "6:30 a.m." The CNA was asked what the CNAs were supposed to do if a resident was found with a change in condition or problem and the CNA stated, "Run and get the nurse stat (immediately)." j. On [DATE] at 6:55 p.m., CNA #3 was asked what time she was in the resident's room on the morning of [DATE]. The CNA stated, "I'd say between 7:15 a.m. and 7:30 a.m." The CNA was asked how the resident was found and stated, "I knocked on the door, and she looked like she had been sitting up and laid back across the bed. She looked like she had passed." The CNA was asked what was done and stated, "I came back down the hall to the med (medication) room and told the nurse to come back down to the room, 'cause I thought she had passed. The night and the day nurse were both in the med rom and I told her and (LPN #3). They went in the room. I came out and shut the door..." The CNA was asked if the resident's eyes were opened or closed and stated, "I believe they were closed." k. On [DATE] at 7:15 p.m., the Director of Nursing (DON) was asked what was discussed about the resident on the morning of [DATE] when she spoke with the LPNs about Resident #16. The DON stated, "She (LPN #3) said she was cold, and I said, if she was cold, we've got to go by that rule and I had fixed them up a notebook with that card (criteria for withholding CPR), and I told them it had to meet that criteria. She (LPN #3) told me she (resident) was cold. I remember asking her (nurse) when was the last time she (nurse) saw her (resident), and she said when she (nurse) was down on that end giving 6:00 a.m. medicine, she (resident) was sitting on the side of the bed. That was pretty much it, and I got off the phone." The DON was asked what protocol was to be followed when a resident is a full code and has no vital signs. The DON stated, "They've got to be without respirations so many minutes, not have audible blood pressure, rigor set in, lividity. I made them (nurses) a notebook." The DON was asked where the notebook was kept and stated, "In the med room. I had one for each med cart." The DON was asked the resident's code status and stated, "She was a full code." The DON was asked if the protocol for withholding CPR should be followed for unwitnessed events and stated, "Well, if you are going by that new law, 'cause it was unwitnessed." The DON was asked what the reasons were for withholding CPR for this resident. The DON stated, "They told me she was cold, she was without pulse, without respirations, audible respirations." The DON was asked if the resident had rigor and if CPR should have been initiated. The DON stated, "They've got to meet that criteria." The DON was asked if it was expected of nursing staff to initiate CPR if vital signs were absent and the resident is a full code but rigor, lividity and fixed pupils were not present. The DON stated, "Yes." The DON was asked who was trained to do CPR if the resident required it and the DON stated, "The nurses are." On [DATE] at 7:55 p.m., record review of employee record had no information to indicate LPN #2 was certified in CPR, and LPN #3 was certified with a renewal date of ,[DATE]. l. On [DATE] at 7:30 p.m., the DON showed the surveyors a white notebook located at the Nurses Station, with a page that contained information that documented, "Protocol for Withholding CPR" and listed the criteria for withholding CPR should the death be unwitnessed and the body evidences dependent lividity, rigor, and that the conditions of absent respirations, carotid pulse, and lung sounds and nonreactive pupils. At 7:35 p.m., LPN #6 was at the nurses' station with the DON and surveyors present and was asked what was to be done for an unwitnessed event when the resident was without blood pressure, pulse, and respirations and was a full code. The LPN stated, "Attempt to get vitals, because if they have normal body temp (temperature), should initiate CPR and call for help." LPN #6 was asked where to go to find the criteria for not providing CPR. The LPN stated, "I'd have to ask and get back to you." The LPN was holding the notebook with the criteria information and the DON stated, "Right there in the cheat sheet book. That page right there I told you to read." m. On [DATE] at 7:37 p.m., the information form located in the notebook at the nurses' station documented, "ACT 718 of 2009 [DATE] of Arkansas Code documents 'The nursing facility shall document the presence of these listed conditions in the resident's record. Protocol for Withholding CPR Licensed nurses employed by nursing facilities may withhold cardiopulmonary resuscitation from residents of the facility, regardless of the presence of a Do Not Resuscitate (DNR) order, when: 1) The death of the resident was unwitnessed; and 2) The body evidences clear and unmistakable dependent lividity*; or 3) The body evidences clear and unmistakable rigor**. *Dependent lividity means clear demarcation of pooled blood within the body. **Rigor means that major joints such as the jaw, shoulders, elbows, hips, or knees are immovable. The following conditions also MUST be present for withholding CPR: 1) Respirations are absent for at least thirty (30) seconds. 2) Carotid pulse is absent for at least (3) seconds. 3) Lung sounds auscultated by stethoscope bilaterally are absent for at least thirty (3) seconds; and 4) Both pupils, if accessible, are nonreactive to light." 2. The Immediate Jeopardy was removed and the scope/severity reduced to G on [DATE] at 11:58 a.m., when the facility implemented the following Plan of Removal: a. On [DATE], the Administrator did an audit of current residents and found 31 with "Full Code" status. The audit consisted of a match back of the hard copy Code Status and the Electronic Health Record. The records were consistent and no discrepancies found. b. A new policy and procedure was written Full Code: CardioPulmonary (CPR) by the Nurse Consultant on [DATE] and adopted by the QA (Quality Assurance) Sub-committee. c. Licensed Nurses are in-serviced prior to their shift on the criteria/new policy for "not initiating CPR" by the DON or her Designee begun [DATE]. d. Licensed Nurses are in-serviced prior to their shift on "Procedures for Full Code" by the DON or her Designee begun [DATE]. e. CNA's are in-serviced prior to their shift on the location of the crash cart by the DON or her Designee begun [DATE]. f. Licensed Nurses and CNA's who did not receive in-service [DATE] will be in-serviced on "Procedures for Full Code" and location of the crash cart, respectively, prior to beginning their resident care when they come into work. This includes licensed nurses and CNA's that are on vacation or leave of absence. This in-service will be conducted by the DON or her Designee. g. The "Procedures for Full Code" will be added to orientation checklist for new licensed nurses by the Nurse Consultant on [DATE]. h. The licensed nurse will enter code status on the hard copy medical record and into the Electronic Health Record on admission or at the time the code status is changed. i. On [DATE], the Administrator did an audit of 57 current residents Electronic Health Records (EHR) and matched them back to the hard copy medical record for Code Status and found the EHR and the hard copy medical record matched in that there 31 current residents with "Full Code" status. The Administrator or her Designee will audit the hard copy medical record for Code Status five times a week for two weeks, three times a week for two weeks, and weekly until compliance is achieved. The Administrator or her Designee will audit new hires orientation packets for the "Procedures for Full Code" will be added to orientation checklist for new licensed nurses by the nurse consultant on [DATE]. The location of the crash cart will be added to the orientation checklist of the CNA by the Nurse Consultant on [DATE]. The Administrator or her Designee will perform this audit five times a week for two weeks then, three times a week for two weeks and weekly until compliance is achieved. The Administrator or her Designee will audit 20% of the licensed nurses and CNA's for knowledge of "Procedures for Full Code" and location of the crash cart, respectively five times a week for two weeks, three times a week for two weeks and weekly thereafter until compliance is achieved. The Administrator will report monthly to the QA Committee findings of the audit, to seek out additional recommendations if negative findings are identified through audits until compliance is achieved."

Based on record review and interview, the facility Administration and Nursing Administration failed to ensure licensed nursing staff were knowledgeable regarding the criteria for withholding cardiopulmonary resuscitation (CPR), which resulted in failure to provide CPR immediately upon discovering an unresponsive resident with no vital signs who had documented full code status in the clinical record for 1 (Resident #16) of 8 (Residents #4, #7, #9, #10, #11, #12, #13 and #16) case mix residents who had full code status documented in their clinical record. This failed practice resulted in Immediate Jeopardy, which caused or could have caused, death to Resident #16, who had full code status documented in the clinical record and was found in bed without vital signs, and had the potential to cause more than minimal harm to 31 residents who had documented full code status in their clinical records, according to a list provided by the Administrator on [DATE] at 8:30 a.m. The facility was informed of the Immediate Jeopardy condition on [DATE] at 8:40 p.m. The findings are: 1. The Job Description for the Administrator, received the Administrator in Training (AIT) on [DATE], documented, "The primary purpose of your job position is to direct the day-to-day functions of the facility in accordance with current federal, state, and local standards, guidelines, and regulations that govern long-term care facilities to assure that the highest degree of quality care can be provided to our residents at all times. Delegation of Authority: As the Administrator, you are delegated the administrative authority, responsibility, and accountability necessary for carrying out your assigned duties. Job Functions Every effort has been made to make your job description as complete as possible. However, it in no way states or implies that these are the only duties you will be required to perform. The omission of specific statements of duties does not exclude them from the position if the work is similar, related, or is a logical assignment to the position. ...Develop and maintain written policies and procedures for the operation of the facility. ...Interpret the facility's policies and procedures to employees, residents ...as necessary. Review the facility's policies and procedures periodically ...Assure that all employees ...follow established policies and procedures. ...Assure that an adequate number of appropriately trained professional and auxiliary personnel are on duty at all times to meet the needs of the residents. ...Assist department directors in the planning, conducting, and scheduling of in-service training classes, on-the-job training, and orientation programs to assure that current material and programs are continuously provided. ...Assure that all residents receive care in a manner and in an environment that maintains or enhances their quality of life without abridging the safety and rights of other residents..." 2. The Job Description for the Director of Nursing Services, received AIT on [DATE], documented, "The primary purpose of ...job position is to plan, organize, develop and direct the overall operation of our Nursing Services Department in accordance with current federal, state, and local standards, guidelines, and regulations that govern our facility, and as may be directed by the Administrator and the Medical Director, to ensure that the highest degree of quality care is maintained at all times. As the Director of Nursing Services, you are delegated the administrative authority, responsibility, and accountability necessary for carrying out your assigned duties. In the absence of the Medical Director, you are charged with carrying out the resident care policies established by this facility. ...Plan, develop, organize, implement, evaluate, and direct the Nursing Services Department, as well as its programs and activities, in accordance with current rules, regulations, and guidelines that govern the long-term care facility. ...Develop methods for coordination of nursing services with other resident services to ensure the continuity of the residents' total regimen of care. ...Review nurses notes to ensure that they are informative and descriptive of the nursing care being provided and that they reflect the resident's response to the care. ..." 3. The Job Description for Charge Nurse, received AIT on [DATE] documented, "The primary purpose of your job position is to supervise the day-to-day nursing activities of the facility... Such supervision must be in accordance with current federal, state, and local standards, guidelines, and regulations that govern our facility, and as may be required by the Director of Nursing Services, to ensure that the highest degree of quality care is maintained at all times. As Charge Nurse you are delegated the administrative authority, responsibility, and accountability necessary for carrying out your assigned duties... Direct the day-to-day functions of the nursing activities in accordance with current rules, regulations, and guidelines that govern the long-term care facility. ...Ensure that the Nursing Service Procedures Manual is followed by nursing service personnel, and that it reflects the day-to-day nursing care procedures used by this facility... Monitor seriously ill residents..." 4. Resident #16 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set with an assessment reference date of [DATE] documented the resident scored 13 (,[DATE] indicates cognitively intact) on the Brief Interview for Mental Status (BIMS). a. The form titled, "CPR (Cardiopulmonary Resuscitation)" dated [DATE] documented, "Initial each box: (initialed) I, the undersigned person, understand that cardiopulmonary resuscitation (CPR) is an emergency intervention. I understand that in the nursing home, this basic life support consists of external chest compression and mouth-to-mouth ventilation until emergency services is able to arrive at the facility and take over... (x marked to select:) I Want CPR. I want cardiopulmonary resuscitation to be provided in the event I have a cardiac or respiratory arrest ..." The form was signed by the resident's responsible party (niece) and witnesses on [DATE]. b. The Care Plan dated [DATE] documented, "Problem: Request for CPR, Full Code Status ... Goal: Request for CPR/Full Code status will be honored..." c. A physician order [REDACTED]. As of [DATE] at 5:10 p.m., the face sheet information in the resident's closed clinical record documented, "Advanced Directives: Check all that apply: ...(check marked) Full Code ... Copy on file? (check marked)..." d. A Nurses Progress Note dated [DATE] at 6:15 a.m. documented, "Resident observed up on bed side looking out into hallway, moving her arms about on side rail." e. A Nurses Progress Note dated [DATE] at 9:30 a.m. documented, "CNA (Certified Nurse Assistant) came to nursing desk and said that resident look like that she is not breathing, 2 LPN (Licensed Practical Nurse) enter resident room observed on bed in supine position, right leg on floor dentures in her mouth respiration absent, pulse absent no audible B/P (blood pressure) skin moist and cool to touch, (doctor) notified of v/s (vital signs) absent (at) 0720 (7:20 a.m.), Coroner called (name of county coroner) notified resident pronounced deceased (at) 0743 (7:43 a.m.)..." There was no documentation that CPR was provided, or of an assessment to determine if rigor or lividity were present to justify withholding CPR. f. A Nurses Progress Note dated [DATE] at 3:42 p.m. documented, "0725 (7:25 a.m.) A.M. (Physician) notified per night shift nurse. 0743 a.m. resident pronounced by coroner. 07:29 a.m. next of kin... notified per night shift nurse..." h. On [DATE] at 5:45 p.m., the following interview was conducted with Licensed Practical Nurse (LPN) #2: The LPN was asked if she had gone to the resident's room on [DATE] when the CNA informed the nurses that the resident had problems. The LPN stated, "Yes." The LPN was asked what the CNA said was wrong with the resident. The LPN stated, "...She asked if we would go down and see (Resident #16) 'cause she thought she was dead, I believe she did say." The LPN was asked what happened next and stated, "We went down to her room. She was lying across the bed and her dentures were partially out of her mouth. We called her name and she didn't respond and (LPN #3), the other nurse, shook her and called her name. Then we started checking for pulse and blood pressure and her body was cool. We couldn't feel a pulse. Couldn't get a reading on a blood pressure. We called (Director of Nursing (DON)), (LPN #3) called (physician). While she was doing that, I was making copies of the paperwork we had to have." The LPN was asked if rigor (stiffening of extremities and body) was present and stated, "No, not rigor mortis. I remember her fingers being much colder than the rest of the body and they were kind of mottled." The LPN was asked if the eyes were checked to see if the pupils were fixed and dilated. The LPN stated, "I know I didn't. I can't remember if her eyes were partially opened. I can't remember if (LPN #3) did. I know I didn't." The LPN was then asked if the resident was checked for lividity and stated, "I didn't." The LPN was asked if knew what lividity was and stated, "That's where blood pools in the body." The LPN was asked what rigor was and stated, "That's when whatever position they are in, they are stiff and set up." The LPN was asked what code status the resident had and stated, "She was a full code." The LPN was then asked if CPR was initiated for the resident. The LPN stated, "No, we didn't ... when we went and found her and found she had no vital signs, I came out and checked the chart and I believe that's when (LPN #3) started making calls." The LPN was asked how long it took to go to the resident's room and stated, "Maybe a few seconds, 'cause the room was right there." The LPN was asked what the protocol was for a resident who was a full code and had no vital signs or for a resident who is a no code. The LPN stated, "I know if unwitnessed death, if rigor mortis, blood pooling, if pupils dilated." The LPN was asked how long pulse was to be checked and stated, "A minute." The LPN was asked how long respirations should be checked and stated, "A minute, too." The LPN was asked which pulse was to be checked and stated, "Carotid pulse, radial." The LPN was asked if she listened for breath sounds and stated, "No." LPN #2 was asked if she was certified in CPR and stated, "No, it's expired." The LPN was asked who would do CPR if it should be initiated for a resident with a full code and the LPN stated, "Hopefully all the nurses who would work with me, 'cause I don't know who knows CPR." The LPN was asked how do she determine and know a resident is a full code and stated, "It's there on their chart and on the MAR (medication Administration Record), if it is in an emergency I would start CPR anyway." The LPN was asked if a resident was found without vital signs, what was to be done and the LPN stated, "If I walk in, they don't have vital signs, I'm going to check if they are a code." The LPN was asked if staff should start emergency protocol if a resident was found without vital signs and the LPN stated, "No, 'cause was unwitnessed." The LPN was asked if the resident does not have rigor, lividity or fixed/dilated pupils, should CPR be started? The LPN stated, "Looking at it like that you should have done it (indicating CPR should have been initiated)." The LPN was asked who had oriented her on code procedures and stated, "I don't remember getting that orientation." The LPN was asked if she had asked what was to be done for a code and stated, "No." i. On [DATE] at 6:15 p.m., CNA #4 was asked if the resident was seen on the morning of [DATE] and stated, "I went in her room, but she wasn't deceased at 6:30 (a.m.)." The CNA was asked how the resident was when she last saw her and stated, "She was positioned in the bed a little different so, I helped position her in the bed... Her leg was kind of out of the bed." The CNA was again asked what time she was in the resident's room and stated, "6:30 a.m." The CNA was asked what the CNAs were supposed to do if a resident was found with a change in condition or problem and the CNA stated, "Run and get the nurse stat (immediately)." j. On [DATE] at 6:55 p.m., CNA #3 was asked what time she was in the resident's room on the morning of [DATE]. The CNA stated, "I'd say between 7:15 a.m. and 7:30 a.m." The CNA was asked how the resident was found and stated, "I knocked on the door, and she looked like she had been sitting up and laid back across the bed. She looked like she had passed." The CNA was asked what was done and stated, "I came back down the hall to the med (medication) room and told the nurse to come back down to the room, 'cause I thought she had passed. The night and the day nurse were both in the med rom and I told her and (LPN #3). They went in the room. I came out and shut the door..." The CNA was asked if the resident's eyes were opened or closed and stated, "I believe they were closed." k. On [DATE] at 7:15 p.m., the Director of Nursing (DON) was asked what was discussed about the resident on the morning of [DATE] when she spoke with the LPNs about Resident #16. The DON stated, "She (LPN #3) said she was cold, and I said, if she was cold, we've got to go by that rule and I had fixed them up a notebook with that card (criteria for withholding CPR), and I told them it had to meet that criteria. She (LPN #3) told me she (resident) was cold. I remember asking her (nurse) when was the last time she (nurse) saw her (resident), and she said when she (nurse) was down on that end giving 6:00 a.m. medicine, she (resident) was sitting on the side of the bed. That was pretty much it, and I got off the phone." The DON was asked what protocol was to be followed when a resident is a full code and has no vital signs. The DON stated, "They've got to be without respirations so many minutes, not have audible blood pressure, rigor set in, lividity. I made them (nurses) a notebook." The DON was asked where the notebook was kept and stated, "In the med room. I had one for each med cart." The DON was asked the resident's code status and stated, "She was a full code." The DON was asked if the protocol for withholding CPR should be followed for unwitnessed events and stated, "Well, if you are going by that new law, 'cause it was unwitnessed." The DON was asked what the reasons were for withholding CPR for this resident. The DON stated, "They told me she was cold, she was without pulse, without respirations, audible respirations." The DON was asked if the resident had rigor and if CPR should have been initiated. The DON stated, "They've got to meet that criteria." The DON was asked if it was expected of nursing staff to initiate CPR if vital signs were absent and the resident is a full code but rigor, lividity and fixed pupils were not present. The DON stated, "Yes." The DON was asked who was trained to do CPR if the resident required it and the DON stated, "The nurses are." On [DATE] at 7:55 p.m., record review of employee record had no information to indicate LPN #2 was certified in CPR, and LPN #3 was certified with a renewal date of ,[DATE]. l. On [DATE] at 7:30 p.m., the DON showed the surveyors a white notebook located at the Nurses Station, with a page that contained information that documented, "Protocol for Withholding CPR" and listed the criteria for withholding CPR should the death be unwitnessed and the body evidences dependent lividity, rigor, and that the conditions of absent respirations, carotid pulse, and lung sounds and nonreactive pupils. At 7:35 p.m., LPN #6 was at the nurses' station with the DON and surveyors present and was asked what was to be done for an unwitnessed event when the resident was without blood pressure, pulse, and respirations and was a full code. The LPN stated, "Attempt to get vitals, because if they have normal body temp (temperature), should initiate CPR and call for help." LPN #6 was asked where to go to find the criteria for not providing CPR. The LPN stated, "I'd have to ask and get back to you." The LPN was holding the notebook with the criteria information and the DON stated, "Right there in the cheat sheet book. That page right there I told you to read." m. On [DATE] at 7:37 p.m., the information form located in the notebook at the nurses' station documented, "ACT 718 of 2009 [DATE] of Arkansas Code documents 'The nursing facility shall document the presence of these listed conditions in the resident's record. Protocol for Withholding CPR Licensed nurses employed by nursing facilities may withhold cardiopulmonary resuscitation from residents of the facility, regardless of the presence of a Do Not Resuscitate (DNR) order, when: 1) The death of the resident was unwitnessed; and 2) The body evidences clear and unmistakable dependent lividity*; or 3) The body evidences clear and unmistakable rigor**. *Dependent lividity means clear demarcation of pooled blood within the body. **Rigor means that major joints such as the jaw, shoulders, elbows, hips, or knees are immovable. The following conditions also MUST be present for withholding CPR: 1) Respirations are absent for at least thirty (30) seconds. 2) Carotid pulse is absent for at least (3) seconds. 3) Lung sounds auscultated by stethoscope bilaterally are absent for at least thirty (3) seconds; and 4) Both pupils, if accessible, are nonreactive to light." 5. On [DATE] at 5:35 p.m., the Administrator was asked who was responsible for ensuring the correct code status was on the resident's record and stated, "It falls back on me, but myself, (other staff) all do it by putting the admission packet information in matrix system." The Administrator was asked who ensured that if a resident was a full code and were found without vital signs, that emergency procedures are started. The Administrator stated, "That would be the DON." The Administrator was asked who was responsible for ensuring protocols for full codes were followed and stated, "That would be the Director of Nursing." The Administrator was asked who was responsible for ensuring that the staff knew when to withhold CPR and the Administrator stated, "DON." The Administrator was asked who trained or inserviced staff when changes occur and the Administrator stated, "DON oversees what they need as nurses for education." The Administrator was asked if licensed nurses were to be knowledgeable about code status for residents and stated, "Yes, that's correct." The Administrator was asked who was ultimately responsible for the residents' well-being stated, "Administrator." 6. The Immediate Jeopardy was removed and the scope/severity reduced to G on [DATE] at 11:58 a.m., when the facility implemented the following Plan of Removal: a. On [DATE], the Administrator did an audit of current residents and found 31 with "Full Code" status. The audit consisted of a match back of the hard copy Code Status and the Electronic Health Record. The records were consistent and no discrepancies found. b. A new policy and procedure was written Full Code: CardioPulmonary (CPR) by the Nurse Consultant on [DATE] and adopted by the QA (Quality Assurance) Sub-committee. c. Licensed Nurses are in-serviced prior to their shift on the criteria/new policy for "not initiating CPR" by the DON or her Designee begun [DATE]. d. Licensed Nurses are in-serviced prior to their shift on "Procedures for Full Code" by the DON or her Designee begun [DATE]. e. CNA's are in-serviced prior to their shift on the location of the crash cart by the DON or her Designee begun [DATE]. f. Licensed Nurses and CNA's who did not receive in-service [DATE] will be in-serviced on "Procedures for Full Code" and location of the crash cart, respectively, prior to beginning their resident care when they come into work. This includes licensed nurses and CNA's that are on vacation or leave of absence. This in-service will be conducted by the DON or her Designee. g. The "Procedures for Full Code" will be added to orientation checklist for new licensed nurses by the Nurse Consultant on [DATE]. h. The licensed nurse will enter code status on the hard copy medical record and into the Electronic Health Record on admission or at the time the code status is changed. i. On [DATE], the Administrator did an audit of 57 current residents Electronic Health Records (EHR) and matched them back to the hard copy medical record for Code Status and found the EHR and the hard copy medical record matched in that there 31 current residents with "Full Code" status. The Administrator or her Designee will audit the hard copy medical record for Code Status five times a week for two weeks, three times a week for two weeks, and weekly until compliance is achieved. The Administrator or her Designee will audit new hires orientation packets for the "Procedures for Full Code" will be added to orientation checklist for new licensed nurses by the nurse consultant on [DATE]. The location of the crash cart will be added to the orientation checklist of the CNA by the Nurse Consultant on [DATE]. The Administrator or her Designee will perform this audit five times a week for two weeks then, three times a week for two weeks and weekly until compliance is achieved. The Administrator or her Designee will audit 20% of the licensed nurses and CNA's for knowledge of "Procedures for Full Code" and location of the crash cart, respectively five times a week for two weeks, three times a week for two weeks and weekly thereafter until compliance is achieved. The Administrator will report monthly to the QA Committee findings of the audit, to seek out additional recommendations if negative findings are identified through audits until compliance is achieved."