Every finding on record at Mansfield Medical Lodge

Based on observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen safety. 1. The facility failed to seal opened items in plastic bags in the dry pantry area on 09/23/25.2. The facility failed to seal opened items in plastic bags in the refrigerator area on 09/23/25.3. The facility failed to seal opened items in plastic bags and boxes in the freezer area on 09/23/25.4. The facility failed to ensure to have a use by date on items in zip loc bags in the freezer area on 09/23/25.5. The facility failed to ensure the dented can in the dry storage area with the other canned food were removed from the shelf on 09/23/25.These deficient practices could affect residents who received meals and/or snacks from the facility's only kitchen by placing them at risk for cross-contamination and other food-borne illnesses.Findings included:Observation of the facility's kitchen dry pantry, refrigerator, and freezer areas on 09/23/25 beginning at 9:25 AM, included the following food items were in unsealed packages and containers, and a dented can with other canned food: Dry pantry area:* 1 white plastic container of 11 lb. chocolate fudge icing was unsealed and exposed to air.* 1 plastic bag of brown sugar was unsealed in a zip loc bag and exposed to air.* 1 bag of 160 oz. pasta noodles was unsealed and exposed to air.* 2 bags of 10 lb. classic macaroni were unsealed and exposed to air.* 1 zip loc bag labeled, croutons was unsealed and did not have a use by date.* 2 packages labeled, tortilla was unsealed and exposed to air.* 1 box of instant food thickener was unsealed and exposed to air.* 1 dented 14 oz. can of sliced salad beans.Refrigerator area:* 1 clear plastic container of labeled, milk was unsealed and exposed to air.* 1 clear bowl of labeled, salad was unsealed and exposed to air.* 1 package of 5 lb. mozzarella cheese was unsealed and exposed to air.* 1 clear plastic cup labeled, milk was unsealed and exposed to air.* 1 clear plastic container labeled, orange juice was unsealed and exposed to air.* 2 bags of white sandwich bread were unsealed and exposed to air.Freezer area:* 1 box of chicken patties was unsealed and exposed to air.* 1 box of beef fritter patties was unsealed and exposed to air.* 1 box of flame broiled patties was unsealed and exposed to air.* 1 box of sugar frozen cookie dough was unsealed and exposed to air.* 1 plastic zip loc bag labeled, roast beef was dated 09/14 and did not have a use by date.* 1 plastic zip loc bag labeled, diced turkey was dated 09/21 and did not have a use by date.* 1 plastic zip loc bag labeled, sausage was dated 09/23 and did not have a use by date.* 1 plastic zip loc bag labeled, scrambled eggs was dated 09/23 and did not have a use by date.* 1 plastic zip loc bag labeled, m/s sausage was dated 09/23 and did not have a use by date.* 1 plastic zip loc bag labeled, cod fish was dated 09/23 and did not have a use by date.* 1 metal pan with 16 clear bowls labeled, cantaloupe was covered with parchment paper and exposed to air.* 1 white container of 5 oz. ricotta cheese was unsealed and exposed to air.In an interview with the Dietary Manager on 09/23/25 at 9:57 AM, reflected she had been employed at the facility for 7 months. The Dietary Supervisor stated that she supervised 11 employees in the kitchen, including 4 cooks and 7 Dietary Aides that work various shifts. She stated she was unaware there were unsealed items in the kitchen's dry storage, refrigerator, and freezer areas. The Dietary Manager stated she was unaware there was 1 dented can stored on the shelves with the other canned food in the dry pantry area. She stated all kitchen staff were responsible for ensuring all food items in the kitchen's dry pantry, refrigerator, and freezer areas were sealed, labeled, and checked for expiration dates. The Dietary Manager stated that the dented can in the dry pantry area should have been removed from the shelves with the other canned foods and should be placed in her office where there was an area designated for dented cans. The Dietary Manager stated that there should not be any food items in the kitchen's dry pantry, refrigerator, and freezer areas that were not labeled, sealed, expired, including any dented cans in the dry pantry area. The Dietary Manager stated that all zip loc plastic bags need to include the date that the item was stored and the use by date to ensure the shelf life of the food. The Dietary Manager stated that she provided monthly reeducation and retraining via In-Service Trainings for all kitchen staff and the trainings included proper food storage, labeling, and ensuring that there were not any dented cans in the facility's dry pantry, refrigerator and freezer areas. The Dietary Manager stated that the monthly In-Service Trainings included proper food handling and sanitization to prevent food-borne illness and safety per the facility's policy. The Dietary Manager stated that her expectation for the kitchen staff to immediately throw away any food items that were expired, unsealed, and exposed to air that were found in the kitchen's dry storage, refrigerator, and freezer areas. The Dietary Manager stated that that she trusted her staff to do the right thing and immediately throw away the items and then notify her about the item(s) that were thrown away and the where the item(s) was located. The Dietary Manager stated then she could retrain and reeducate staff about the situation to correct the same thing from not occurring again. The Dietary Manager stated that all kitchen staff were responsible for ensuring that the food items in the kitchen were labeled, dated, sealed, and not expired. The Dietary Manager stated that he performs a monthly audit of the kitchen's dry pantry, refrigerator, and freezer areas to ensure everything in all areas were labeled, dated, and sealed, which included checking the expiration dates on the food items. [JM1] The Dietary Manager was unable to provide a date for the last monthly audit in the kitchen's dry pantry, refrigerator, and freezer areas were conducted. The Dietary Manager stated the items found in the kitchen by the state surveyor were things that she missed during her monthly audits. The Dietary Manager stated on 09/23/25, she would immediately retrain and reeducate all kitchen staff via In-Service Trainings on food storage, labeling, checking for expired items, proper sealing of containers, bags, and packages in the kitchen. The Dietary Manager stated that all the items that the surveyor found in the kitchen would be immediately thrown away. The Dietary Manager stated that she would continue to reeducate the kitchen staff to ensure everyone knew what her expectations were the kitchen and to follow the guidelines in the facility's Food Storage Policy so that everyone would be on the same page. The Dietary Manager stated the risk of someone, which included a resident, eating food that was unsealed, exposed to air and from dented cans in the facility kitchen's dry storage, refrigerator and freezer areas were that someone could become ill and become sick due to eating something that could cause food-borne illnesses. The Dietary Manager stated there were risks of food borne illness anytime someone ingested food items from the kitchen any items that had not been labeled and stored properly and from dented cans. The Dietary Manager stated the harm of someone, which included a resident ingesting food from the facility kitchen's dry storage, refrigerator and freezer areas, expired foods, eating something from a dented can could cause someone to have stomach aches, vomit and become ill.In an interview with [NAME] A on 09/23/25 at 10:33 AM, reflected she stated that she had been employed at the facility for 9 months. She stated she was unaware there were unsealed items in the kitchen's dry storage, refrigerator and freezer areas. She stated she was unaware there was 1 dented can on the shelves with the other canned food items. [NAME] A stated all the staff were responsible for storing the items on the shelf and checking the expiration dates, dented cans to make sure there were not any unsealed items in the kitchen's dry storage, refrigerator and freezer areas. [NAME] A stated that if she found any item(s) in the kitchen's dry storage, refrigerator and freezer areas, she would immediately throw them away and notify the Dietary Manager of her findings and inform the location of her finding(s). [NAME] A stated that during her employment at the facility she had taken numerous In-Service training courses on food storage, labeling, dented cans, and ensuring that expired items are immediately thrown away. She stated that the In-Service Trainings included ensuring that dented cans are to be removed from the shelves and placed in the area labeled, dented cans in the Dietary Manager's office. She stated the In-Service training also included guidance on throwing away any food items in the kitchens dry pantry, refrigerator and freezer areas that are unsealed and cause the food become freezer burned. She stated that if anyone ingests food that unsealed packages or containers and that is not properly labeled and dated, their body could break down and become sick, vomit, have stomach issues and have an adverse reaction after ingesting the food. [NAME] A stated that if anyone ingests food from the kitchen from unsealed packages or containers, dented cans and they could be harmed by incontrollable vomiting and stomach cramps, which can make them ill.In an interview with the Dietary Manager on 09/23/25 at 12:35 PM, it was revealed that the sliced cantaloupe that was observed by the surveyor during the Initial Brief Tour of the kitchen was thrown away. The Dietary Manager stated that the sliced cantaloupe that was observed during the Dining Observation was prepared by the kitchen staff after the surveyor exited the kitchen for the Initial Brief Tour of the kitchen.Record review revealed that there was not any documentation in the kitchen of the Dietary Manager's monthly audits of the dry pantry, refrigerator and freezer areas.Record review of the facility's policy, Food Receiving and Storage, revised July 2014 reflected: Policy Statement:Foods shall be received and stored in a manner that complies with safe food handling practices. Policy Interpretation and Implementation1. Food Services, or other designated staff, will maintain clean food storage areas at all times.6. Dry foods that are stored in bins will be removed from original packaging, labeled and dated ( use by date).10. The freezer must keep frozen foods frozen solid. Wrappers of frozen foods must stay intact until thawing.12. Uncooked and raw animal products and fish will be stored separately in drip-proof containers and below fruits, vegetables and other ready-to-eat foods.13.e. Other opened containers must be dated and sealed or covered during storage. Record review of the U.S. Food and Drug Administration (FDA) Code (2022) revealed, PACKAGED FOOD shall be labeled as specified in LAW, including 21 CFR 101 FOOD Labeling, 9 CFR 317 Labeling, Marking Devices, and Containers, and 9 CFR 381 Subpart N Labeling and Containers, and as specified under S 3-202.18. FOOD shall be protected from contamination that may result from a factor or source not specified under Subparts 3-301 - 3-306.

Based on observations, interviews, and record reviews, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for two (Resident #38 and Resident #51) of five residents, reviewed for infection control. 1. The facility failed to ensure CNA B wore a PPE gown and performed hand hygiene during care for Resident #51.2. The facility failed to ensure CNA C performed hand hygiene during incontinence care for Resident #38 This failure placed residents at risk for healthcare associated cross contamination and infections.Findings included: 1. Review of Resident #51's Quarterly MDS Assessment, dated 08/14/25, reflected the resident was a [AGE] year-old female admitted to the facility on [DATE]. Her cognitive skills were intact. The resident had diagnoses including neurogenic bladder (misfunctioning bladder) with a supra-pubic catheter (tube inserted directly into the bladder to drain urine), diabetes, and multiple sclerosis (disorder where the immune system attacks nerve cells and disrupt communication between the brain and the rest of the body). The resident was dependent on staff for toileting. The resident was occasionally incontinent of stool. Review of Resident #51's Care Plans reflected:06/28/24 - Resident was on EBP related to a wound and supra-pubic catheter.Facility interventions: Provide patient standard precautions using gowns and gloves during dressing, bathing, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use and wound care. An observation on 09/23/25 at 10:46 AM with Resident #51 revealed she had PPE outside of her door and a sign posted for EBP. CNA B was in the resident's room wearing gloves. CNA B was not wearing a gown. CNA B leaned over the bed and fastened the resident's brief. CNA B's clothes touched the resident's bed. CNA B removed the gloves, did not perform hand hygiene, put on new gloves and straightened the resident's blankets. An interview on 09/23/2025 at 10:53 AM with CNA B revealed she said Resident #51 was not on EBP. CNA B was outside the resident's room during the interview and standing next to the EBP sign on the wall. CNA B said she was only required to wear gloves to provide care for the resident. She said she did not have to wear a gown to provide care unless she was emptying the resident's catheter and near the resident's wound. CNA B said she was in-serviced on EBP about a month prior. CNA B said she was supposed to perform hand hygiene between glove changes. She said she did not do it this time because she forgot and got busy. CNA B said failing to wear the correct PPE and performing hand hygiene could lead to contamination. 2. Review of Resident #38's Annual MDS Assessment, dated 08/21/25, reflected the resident was a [AGE] year-old female admitted to the facility on [DATE]. Her cognitive skills were intact. The resident had a Foley catheter and was occasionally incontinent of bladder. Her diagnoses included stroke and diabetes. The resident required substantial assistance with toileting. Review of Resident #38's Care Plans reflected:Revised 07/17/25 - Resident had an ADL self-care performance deficit.Facility interventions included:Resident was totally dependent on staff for personal hygiene. An observation on 09/24/25 at 2:05 PM of incontinence Care for Resident #38 by CNA C revealed she cleaned the resident's peri-area, changed gloves, and did not perform hand hygiene. The resident turned to her right side and CNA C cleaned the buttocks. The resident was dirty with a small amount of bowel movement. CNA C cleaned the bowel movement, changed her gloves, but did not perform hand hygiene. CNA C removed the soiled brief, did not change her gloves or hand hygiene, and placed a clean brief. CNA C applied barrier cream to the resident's buttocks, changed gloves, but did not perform hand hygiene. The resident turned to her back and CNA C fastened the brief. An interview on 09/24/25 at 2:20 PM with CNA C revealed she was supposed to perform hand hygiene between each glove change and had been trained to do so. She said she did not do it this time, because she forgot. CNA C said failure to perform hand hygiene could lead to infection. An interview on 09/25/25 at 11:10 AM with the DON revealed staff were supposed to perform hand hygiene between glove changes and wear a gown while positioning a resident and fastening a brief who was on EBP. The DON said hand hygiene and proper PPE use was required to reduce the risk for infection. The DON said she made observations of staff during care to ensure they were performing hand hygiene and glove changes. Record review of the facility policy, Infection Control, revised October 2018, reflected: The facility's infection control policies and practices are intended to facilitate maintaining a safe, sanitary and comfortable environment and to help prevent and manage transmission of disease and infections.Record review of the facility policy, Hand Hygiene, revised 12/22/23, reflected: 9. The use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections.

Based on observation, interview, and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 5 residents (Residents #93) reviewed for accident hazards. CNA D did not ensure Resident #93, who required 1:1 meal assistance, was positioned correctly while eating. This failure could place residents at risk for aspiration and choking related to eating in an improper position.The findings included: Record review of Resident #93's quarterly MDS assessment, dated 09/04/25, revealed the resident was a [AGE] year-old male admitted on [DATE]. His BIMs score was 99. He was sometimes understood and sometimes able to make himself understood. His diagnoses included aphasia (aphasia impairs the expression and understanding of language, as well as reading and writing), Parkinson's disease, stroke, and hemiplegia, seizure disorder, difficulty swallowing, and respiratory failure. The resident required supervision to eat. The resident required maximum assist for positioning to sit upright. Record review of Resident #93's Care Plan reflected:1. Date Initiated: 01/13/25Risk for Malnutrition Parkinson's DiseaseFacility interventions included:Ensure resident was in proper position for eating.2. Revised on: 04/30/2025The resident had an ADL self-care performance deficit.Facility interventions included:Eating: Resident requires assistance with eating.3. Revised on: 09/11/2025The resident had a swallowing problem related to complaints of difficulty or pain with swallowing.Facility interventions included:1:1 assist feeding at this time.Instruct resident to eat in an upright position, to eat slowly, and to chew each bite thoroughly.Keep head of bed elevated 45 degrees during meal and thirty minutes afterwards. An observation and interview on 09/23/25 from 12:28 PM - 12:35 PM revealed Resident #93 was sitting in a custom wheelchair. His head and body were slumped over the left side of the wheelchair. The resident was non-verbal. CNA D fed the resident a chopped diet while Resident #93 was slumped over. CNA D fed the resident two bites while the resident was slumped over to the left side. CNA D said the resident was not supposed to be slumped over to the left side while eating to prevent risk of choking. CNA D and CNA E removed the resident from the table and repositioned him to sit upright. An interview on 09/23/25 at 1:15 PM with CNA D revealed Resident #93 was fed while leaning over to the left side because that was the way the resident's posture was. CNA D said he had been trained to feed the resident and fed him anytime he came to the dining room. CNA D said the resident was not supposed to be slumped over to his left side while eating. CNA D said the resident was at risk for choking if he ate while being slumped over to the left side. CNA D said therapy had told him 2-3 weeks ago that the resident was supposed to sit up straight to eat. An interview on 09/24/25 at 11:05 AM with the Director of Rehab Therapy revealed the best case scenario for Resident # 93 to eat was in the upright position in his wheelchair. The Director of Rehab Therapy said feeding the resident while slumped over to the left side placed him at risk for aspiration and choking. The Director of Rehab Therapy said she did not train the staff to feed the resident and would defer to facility staff to complete the training. An interview with the DON on 09/25/25 at 11:05 AM revealed it was not okay for staff to feed Resident #93 while he was slumped over to his left side. She said staff were trained to feed residents but was not aware if staff had been trained to feed Resident #93. The DON said if staff noticed a resident leaning over, they needed to notify the DON and involve therapy to find a solution. The DON said she made observations of residents at meal times and the resident had a history of leaning over to his left side. The DON said staff would need to reposition the resident into an upright position before they fed him. The DON said the resident was at risk of not being able to swallow properly if he was fed in a slumped over position. Review of the facility policy, Safety and Supervision of Residents, revised July 2017, reflected: Resident safety and supervision and assistance to prevent accidents are facility-wide priorities.2. Resident supervision is a core component of the systems approach to safety. The type and frequency of resident supervision is determined by the individual resident's assessed needs and identified hazards in the environment.3. The type and frequency of resident supervision may vary among residents and over time for the same resident. For example, resident supervision may need to be increased when there are temporary hazards in the environment (such as construction) or if there is a change in the resident's condition.

Based on observations, interviews and records review, the facility failed to ensure residents with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for two (Resident #1 and Resident #2) of five residents reviewed for quality of care. 1. The facility failed to follow physician's order to cover Resident #1's wound with a dry dressing as needed for dislodgement of dressing on 06/03/25. 2. The facility failed to ensure Resident #1's had a low air loss mattress pump with the correct settings for appropriate pressure redistribution on 06/03/25. 3. The facility failed to provide wound care to Resident #2's sacral wound on 05/24/25, 05/25/25, 05/31/25 and 06/01/25. 4. The facility failed to ensure Resident #2 had a functioning low air loss mattress available to use to promote healing of her sacral wound on 06/03/25 and 06/04/25. These failures placed residents at risk of developing new or worsening pressure ulcers. Findings included: 1. Record review of Resident #1's Face Sheet dated 06/04/25 reflected she was an [AGE] year-old female who admitted to the facility on [DATE]. Resident #1's active diagnoses included memory deficit following cerebral infarction, dysphagia (difficulty swallowing), aphasia (loss of ability to understand speech), heart failure, kidney disease, Parkinson's disease (a progressive movement disorder of the nervous system) and overactive bladder. Resident #1 did not admit with any pressure ulcers. Record review of Resident #1's quarterly MDS assessment dated [DATE] reflected a BIMS score of 03 which indicated severe cognitive impairment. Resident #1 had no signs or symptoms of delirium, no negative mood issues, no potential indicators of psychosis and no rejection of care. Resident #1 used a wheelchair for mobility, had no range of motion impairment, required staff assistance for all ADLs and was occasionally incontinent of bowel and bladder. Resident #1 weighed 111 pounds and was five foot four inches tall. Resident #1 was at risk of developing pressure ulcers/injuries and one stage four pressure ulcer which the assessment reflected was present upon admission to the facility. Resident #1 had a pressure reducing device for bed, nutrition or hydration interventions to manage skin problems and pressure ulcer/injury care. Record review of Resident #1's care plan dated 07/02/24 and last revised 03/28/25 reflected no specific discussion of her sacral (triangular bone at the base of the spine ) wound. The care plan reflected only that she was at risk potential/actual impairment to skin integrity related fragile skin and she was at risk for enhanced barrier precautions related to wound/wound care and increased risk of multi-drug resistant organism acquisition. The care plan did not reflect her current wound identification or treatment needs. The care plan also did not reflect Resident #1 was receiving hospice services. Record review of Resident #1's Order Summary Report dated 06/03/25 did not include any orders for a low air loss mattress and reflected: -Cleanse pressure injury to sacrum with normal saline or wound cleaner, pat dry, apply [brand name-wound dressing impregnated with sodium chloride specifically designed for heavily draining and discharging wounds], cover with dry dressing daily and as needed for soilage or dislodgement for wound care (start date 05/20/25) -Enhanced Barrier Precautions for the following: Wounds every shift (start date 05/14/25) Record review of Resident #1's June 2025 TAR revealed the orders were implemented as written for daily care as evidenced by a checkmark and LVN A's initial on 06/03/25 (no time was indicated). The PRN TAR did not reflect any PRN wound care was done on 06/03/25 (6A-2P shift) when Resident #1's dressing was removed or became dislodged. Record review of Resident #1's online e-chart reflected no weights recorded under the vitals section for the past 90 days. Record review of Resident #1's most recent nutrition progress note dated 05/27/25 reflected a weight of 111 pounds and indicated her stage 4 sacral wound was improving (Stage 4 is the most severe and deepest stage of pressure ulcers. It is characterized by extensive tissue damage that extends beyond the skin, exposing muscle, tendon, or bone). The assessment stated, Resident continues on hospice care, no recent weight available. Wound noted as improving. Goal for comfort care. Record review of Resident #1's most recent wound care visit dated 06/02/25 reflected it was an evaluation of the wound on her Sacro coccyx (an injury or ulceration in the sacral (lower back) or coccygeal (tailbone) region) The wound measurements at that time were 2.0 cm x 1.3 cm x 0.7 cm with a surface area of 2.6 cm. There was tunnelling (a type of wound where a narrow channel extends from the main wound site into deeper tissues, forming a passageway under the skin) at 12 o'clock of 1.5 cm. The wound was noted to be acquired on 06/27/24 and was improving. There was 90% granulation (the process of new tissue and blood vessel formation within a wound during healing) and 10% slough . Resident #1's sacral wound required a daily dry dressing. An observation and interview on 06/03/25 at 10:39 AM of Resident #1 along with the charge nurse LVN A was conducted to check placement of her dressing and check for the date and initial of the staff who last changed it. Resident #1 was not interviewable or responsive to investigator questions. Resident #1's low air loss mattress was present with a control unit placed at the foot of the bed. The pump's power button was lit up and in the ON position and the weight setting pressure adjust knob was pointed between 280-300 pounds. When LVN A turned Resident #1 to look at the dressing, the sacral wound was exposed without a dressing on it. There was an open wound bed with a small piece of rolled up wound dressing gauze inside the wound. There was no drainage observed coming from the wound, it appeared clean with no redness or inflammation observed. LVN A stated she did not know the dressing was off and no one had told her it had come off on her shift that morning. LVN A stated there was no wound care nurse at the facility and they were in-between hiring a new one. She stated presently, ADON C did the wound care on the weekdays and weekends and the charge nurses who worked the floors did wound care as needed. An interview with the DON on 06/03/25 at 12:40 PM revealed Resident #1 was on hospice services and they probably came out and gave her a bath and the dressing came off and they did not tell the nurse. With missing treatment not documented as being provided on the TAR, the DON stated she would look into it and see what happened. An interview with ADON C on 06/03/25 at 3:54 PM revealed she was standing in as the wound care nurse since their wound care nurse quit three weeks ago. ADON C stated, The main thing is to make sure the wound care gets done and nothing gets infected. Regarding Resident #1, ADON C stated when a dressing was not on a resident, there was a PRN order to change it and put a new one on. She said the charge nurse on duty could do it and did not need to wait for herself or ADON D to change it. ADON C stated it was important to do a dressing change when it came off or was dislodged because the resident would be at risk for infection, you don't know what kind of microbes she was sitting on. When a dressing is not on a resident, it is a matter of reporting it, whoever sees it should report it to the charge nurse if they know it is not on. With Resident #1, ADON C stated the nurse was capable of looking in the resident chart to see what their current weight was to ensure the low air loss mattress was at the correct setting. ADON C stated when she rounded, she looked to see if the low air loss mattresses were set correctly. She said she did not do it every day, but she did glance at them. She stated once a resident was on hospice, they no longer got routinely weighed. ADON C stated if Resident #1's pressure was offset too much, meaning her weight was set too high for her body, it made the mattress firmer versus where it needed to be for optimized healing. ADON C stated she did not do wound care for residents on the weekends and that was the responsibility of the weekend charge nurses on duty. An interview with ADON D on 06/04/25 at 10:17 AM revealed she did not do wound care for Resident #1 the day prior on 06/03/25 but wanted to find out why there was no dressing on her sacrum during the investigator's observation at that time. ADON D stated she talked to the overnight CNA who told her the dressing was on Resident #1's sacrum when she did her last peri care on 06/03/25 before her shift was over at 6:00 AM. Then the 6A-2P CNA told ADON D that Resident #1's dressing was off when she saw it in the morning (time unknown). ADON D stated she then called Resident #1's hospice provider and they verified it was the hospice aide who removed the dressing because it was soiled when she came for her routine visit the early morning of 06/03/25. ADON D stated the hospice aide apparently left the dressing off because she was used to ADON C being at the facility every morning who would come in an do wound care after the hospice aide bathed Resident #1, so she left it off thinking ADON C would be coming in to dress imminently. However, ADON D said ADON C did not come into the facility that morning and was offsite. ADON D stated the hospice aide did not notify the charge nurse (LVN A) that the dressing was off, again, assuming [ADON C] was going to do it soon. So the charge nurse did not know the dressing was off, or she would have done it. A follow up observation of Resident #1 on 06/04/25 at 10:33 AM (after investigator intervention) revealed she was in bed awake but not responsive to questions. Her low air loss mattress setting had been changed to a weight of 120 pounds. 2. Record review of Resident #2's Face Sheet dated 06/04/25 reflected was an [AGE] year-old female who admitted to the facility on [DATE]. Resident #2's active diagnoses included mechanical complication of internal right knee prosthesis, dysphagia (difficulty swallowing), morbid obesity, neuropathy (nerve damage that can lead to pain, weakness, numbness, or tingling in one or more parts of the body), spinal stenosis (a condition where the spaces within the spinal column narrow, potentially compressing the spinal cord or nerve roots), fibromyalgia (a chronic condition causing widespread pain, fatigue, and other symptoms like sleep disturbances and cognitive difficulties), chronic kidney disease (a progressive condition where the kidneys gradually lose their ability to filter waste and excess fluid from the blood, leading to a buildup of these substances in the body), presence of pacemaker and presence of artificial knee joint. Resident #1's face sheet did not include any presence of skin problems or pressure ulcers. Record review of Resident #2's admission MDS assessment dated [DATE] reflected a BIMS score of 15, which indicated no cognitive impairment. Resident #2 required staff assistance for ADLs and was frequently incontinent of bowel and bladder. Resident #2 weighed 254 pounds and was five foot six inches tall . Resident #2 was at risk of developing pressure ulcers/injuries and had one stage three pressure ulcer that was noted to be present upon admission. Resident #2's MDS also noted that she had surgical wounds, required a pressure reducing device for bed, nutrition or hydration interventions to manage skin problems, pressure ulcer/injury care, surgical wound care and applications of ointments/medications. Resident #2's care plan initiated 05/11/25 and last revised 05/23/25 revealed it did not address her sacral wound or any other skin integrity issues. Record review of Resident #2's order summary dated 06/04/25 reflected the following treatment orders: -Cleanse pressure injury to sacrum with normal saline, pat dry, apply collagen and cover with a dry dressing daily and as needed for soilage or dislodgement as needed for wound care and everyday shift for wound care (start date 05/20/25) -Turn and reposition per policy or as appropriate, monitor every shift related to decreased mobility, incontinence, High Risk breakdown and skin integrity (start date 05/09/25) -May have pressure reducing mattress unless otherwise indicated (start date 05/09/25). Record review of Resident #2's nursing progress note dated 05/09/25 reflected, Patient was admitted with right knee surgical repair enclosed by brace and ace wrap, right buttock skin breakdown, left buttock skin breakdown and bruises to bilateral (affecting both sides) arms and right thigh, treatment order is in place. Record review of Resident #2's May 2025 TAR reflected no documented evidence that wound care was provided to her sacrum as ordered on the weekends of 05/24/25, 05/25/25 and 05/31/25 . On those dates, the TAR was blank with no initials or check marks. Record review of Resident #2's initial wound evaluation dated 05/12/25 by MD B reflected she had one stage three pressure wound on her sacrum that measured 1.5 cm x 0.6 cm x 0.3 cm with a surface area of 0.9 cm2, a wound base with 90% granulation , 10% slough, light serosanguineous ( a type of wound drainage that is thin, watery, and pale red or pink in color) and no signs of infection. Resident #2 was noted to be at high risk of wound incidence due to impaired mobility, co-morbid conditions and incontinence. MD B's recommendations included, Implement pressure relieving measures and offloading as tolerated; Low air loss mattress-alternating pressure (group 2 mattress) - verify appropriate function and setting as per manufacturer guidelines; Continue to reposition the patient regardless of the support surface in use; Implement pressure relieving measures, offloading and repositioning as tolerated; Establish turning frequency based on the characteristics of the support surface and the patient's response. Record review of Resident #2's subsequent wound care visits by MD B on 05/19/25, 05/26/25 and 06/02/25 revealed her wound was improving at each visit. MD B continued to recommend that Resident #2 have a pressure relieving low air loss mattress at each visit. Record review of Resident #2's June 2025 TAR reflected no documented evidence that wound care was provided to her sacrum as ordered on Sunday 06/01/25 . On that date, the TAR was blank with no initial or check mark. An interview and observation with Resident #2 on 06/04/25 at 9:55 AM revealed she was in bed in her room but she did not have a low air loss mattress on her bed. Resident #2 stated she used to have one but a couple weeks ago a staff member accidentally dislodged the control unit at the foot of the bed and after that, it would not work so the staff removed it from her bed. Resident #2 stated she could not feel the difference in her comfort leave and was not in any pain because the wound on her sacrum was almost healed. Resident #2 felt her wound was still healing after the low air loss mattress was removed so she was okay with it. Resident #2 was asked if she had received wound care the past two weekends and she said she could not remember for sure, But on the weekends, there is not much of any care happening. Resident #2 assumed she did not get wound care the past two weekends and said every now and then she will get physical therapy on a Saturday, but that was it. Resident #2 stated she was not tended to as well on the weekends and felt the staff provided much less can that during the weekdays. 3. An interview with LVN E on 06/04/25 at 10:13 AM revealed ADON C currently did all wound care in the facility, unless a dressing was soiled or dislodged, then the charge nurses could do it as needed, but everything else, the wound care nurse completes. An interview with central supply staff (CS F) on 06/04/25 at 10:49 AM revealed she was responsible for ordering a resident's low air loss mattress and had a company she rented them from who could usually supply them to the facility on the same day once ordered. CS F stated Resident #2's low air loss mattress pump got dislodged and the facility had ordered her another one but claimed Resident #1 did not want it and said it was uncomfortable. CS F stated, With the mattress, they [residents in general] don't like that they can't have all the extra bedding on it. With setting a low air loss mattress to the correct setting, CS F stated that was determined by the weight of the resident and the nurse was the one who usually set it. CS F stated, I can do it, but most of the time I go plug them up and then the nurse or treatment nurse will adjust it to the correct setting. A follow up interview with the DON on 06/04/25 at 11:36 AM revealed for Resident #2, the missing TAR documentation of wound care being provided was part of the reason why the previous wound care nurse had to go. The DON stated the previous wound care nurse was clicking and signing off on the pain section of the TAR which was right above the box to indicate wound care was provided. She said the previous wound care nurse was clicking that she was assessing the resident's pain but was not going back into the TAR to indicate that she completed the wound care. The DON stated on the weekends, usually there was a nurse weekend supervisor who did the wounds, but that nurse had taken time off due to a family issue, so the charge nurses were having to complete it. She said, We make sure they do it because we check the dressings to see that they are dated with a signature since they did not click it off [chart on e-TAR]. We do run audits in [e-chart] and I address it with the nurses and med aides every morning. The DON stated she was always in the facility halls rounding and did not stay in her office a lot. She stated in the mornings, she checked her documentation at home to see what was not done as the e-charts had a system in place to audit missed medications/treatments. She stated on the weekends, I call up to the facility and check in on them. The DON stated for the past four days, ADON C (who currently does wound care) had been out of the facility because she was currently in school and was off on the mornings. With low air loss mattresses, the DON stated the charge nurses needed to know settings as well as the wound care nurse, they need to check to make sure because family members come around and fiddle with it. The DON stated the purpose of a low air loss mattress was to give the resident support and that whatever they were lying on was not preventing blood flow to boney areas. The DON stated she knew about Resident #2 not wanting a low air loss mattress and said her wound was still healing. The DON stated if a resident did not want a low air loss mattress, the protocol was to let the family member know and then educate the resident and family to let them know the risks and benefits of not using one. The DON stated, I am sure they told the [family member] but you know these days, if people don't want it, that's okay, but we explain why they need it. 4. Record review of the facility's policy titled, Wound Care, last revised November 2017 reflected, Steps in the Procedure- . 11. Remove dry gauze. Apply treatments as indicated; 12. Dress wound. Pick up sponge and apply directly to area. [NAME] tape with initials, time, and date and apply to dressing.Documentation-The following information should be recorded in the resident's medical record: 1) The type of wound care given; 2)The date and time the wound care was given; 3) The name and title of the individual performing the wound care; 4) Any change in the resident's condition; 5) All assessment data (i.e., wound bed color, size, drainage, etc.) obtained when inspecting the wound; 6) Any problems or complaints made by the resident related to the procedure; 7) If the resident refused the treatment and the reason(s) why; 8) The signature and title of the person recording the data.

Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for one (Resident #2) of five residents reviewed for care plans. The facility failed to ensure Resident #1's comprehensive care plan addressed a stage three sacral wound and pacemaker interventions. This failure could place residents at risk of receiving inadequate interventions not individualized to their health care needs. Findings included: Record review of Resident #2's Face Sheet dated 06/04/25 reflected the resident was an [AGE] year-old female who admitted to the facility on [DATE]. Resident #2's active diagnoses included mechanical complication of internal right knee prosthesis, dysphagia (difficulty swallowing), morbid obesity, neuropathy (nerve damage that can lead to pain, weakness, numbness, or tingling in one or more parts of the body), spinal stenosis (a condition where the spaces within the spinal column narrow, potentially compressing the spinal cord or nerve roots), fibromyalgia (a chronic condition causing widespread pain, fatigue, and other symptoms like sleep disturbances and cognitive difficulties), chronic kidney disease (a progressive condition where the kidneys gradually lose their ability to filter waste and excess fluid from the blood, leading to a buildup of these substances in the body), presence of pacemaker and presence of artificial knee joint. Resident #1's face sheet did not include any presence of skin problems or pressure ulcers. Record review of Resident #2's admission MDS assessment dated [DATE] reflected a BIMS score of 15, which indicated no cognitive impairment. Resident #2 had no signs/symptoms of delirium, no potential indicators of psychosis and no rejection of care issues. Resident #2 required staff assistance for ADL's and was frequently incontinent of bowel and bladder. Resident #2 was at risk of developing pressure ulcers/injuries and had a stage 3 pressure wound upon admission (A stage 3 pressure wound is characterized by full thickness loss of skin where the wound has broken through the top two layers of skin and extends into the fatty tissue below, resembling a hole or crater), surgical wounds, required a pressure reducing device for bed, nutrition or hydration interventions to manage skin problems, pressure ulcer/injury care, surgical wound care and applications of ointments/medications. Resident #2's care plan initiated 05/11/25 and last revised 05/23/25 revealed it did not address her sacral (triangular bone at the base of the spine) wound or any other skin integrity issues. For her pacemaker, the care plan identified it as a care area on 05/12/25, however, under the interventions section, it was incomplete and reflected, The resident's Pacemaker information: Manufacturer:(SPECIFY) Model: (SPECIFY) Serial #: (SPECIFY) Date implanted: (SPECIFY) Name of cardiologist: (SPECIFY). Record review of Resident #2's order summary dated 06/04/25 reflected the following treatment orders: -Cleanse pressure injury to sacrum with normal saline, pat dry, apply collagen and cover with a dry dressing daily and as needed for soilage or dislodgement as needed for wound care and everyday shift for wound care (start date 05/20/25). Additionally, record review of Resident #2's order summary did not include a order for a pacemaker or pacemaker monitoring. It only reflected under the diagnoses section, Presence of cardiac pacemaker. Record review of Resident #2's nursing progress note dated 05/09/25 reflected, Patient was admitted with right knee surgical repair enclosed by brace and ace wrap, right buttock skin breakdown, left buttock skin breakdown and bruises to bilateral (both sides) arms and right thigh, treatment order is in place. Record review of Resident #2's May 2025 TAR reflected no documented evidence that wound care was provided to her sacrum as ordered on the weekend of 05/24/25, 05/25/25 and 05/31/25. On those dates, the TAR was blank with no initial or check mark. Record review of Resident #2's initial wound evaluation dated 05/12/25 by MD B reflected she had one stage three pressure wound on her sacrum that measured 1.5 cm x 0.6 cm x 0.3 cm with a surface area of 0.9 cm2, a wound base with 90% granulation (the appearance of new tissue during wound healing) , 10% slough (dead tissue that needs to be removed from a wound to promote healing), light serosanguineous (clear fluid that leaks out of wounds) and no signs of infection. Resident #2 was noted to be at high risk of wound incidence due to impaired mobility, co-morbid conditions and incontinence. MD B's recommendations included, Implement pressure relieving measures and offloading as tolerated; Low air loss mattress-alternating pressure (group 2 mattress) - verify appropriate function and setting as per manufacturer guidelines; Continue to reposition the patient regardless of the support surface in use; Implement pressure relieving measures, offloading and repositioning as tolerated; Establish turning frequency based on the characteristics of the support surface and the patient's response. An interview with ADON C on 06/03/25 at 3:54 PM revealed she was currently standing in as the wound care nurse for the past three weeks. She stated that care planning wounds was the responsibility of the MDS nurses, which included new wounds acquired in the facility as well as residents who admitted with wounds. ADON C stated it was important to care plan wounds because the care plan tells you about the patient. An interview and observation with Resident #2 on 06/04/25 at 9:55 AM revealed she was in bed in her room, but she did not have a low air loss mattress on her bed. Resident #2 stated she used to have one but a couple weeks ago a staff member accidentally dislodged the control unit at the foot of the bed and after that, it would not work so the staff removed it from her bed. Resident #2 stated she could not feel the difference in her comfort leave and was not in any pain because the wound on her sacrum was almost healed. Resident #2 felt her wound was still healing after the low air loss mattress was removed so she was okay with it. Resident #2 was asked if she had received wound care the past two weekends and she said she could not remember for sure, but on the weekends, there is not much of any care happening. Resident #2 assumed she did not get wound care the past two weekends and said every now and then she would get physical therapy on a Saturday, but that was it. Resident #2 stated she was not tended to as well on the weekends and felt the staff provided much less care than during the weekdays. An interview with MDS LVN G on 06/04/25 at 10:32 AM revealed when a resident admitted to the facility with wounds, the admitting nurse was responsible for care planning the wound(s) and each department was responsible for care planning their focus areas. She stated since wounds fell under the nursing department's responsibility, the ADONs as well as the MDS nurses could also care plan wounds if they had the wound care doctor's notes to reference. MDS LVN G stated care planning a resident's wounds was very important as it helped show the guidelines for maintaining the skin's integrity and was a plan that was created for the resident to have a good outcome. With pacemakers, MDS LVN G stated the MDS nurse could care plan those when they did the comprehensive care plans but the baseline care plan which covered the resident's first 14 days at the facility but could be done by anyone in the nursing department. MDS LVN G stated when care planning issues that were generated by a CAA, she tried to ensure it was checked off and care planned, but no system is perfect. MDS LVN G stated when the management had daily clinical staff meetings, they discussed skin integrity changes and any new wounds. If there was a new wound identified, the nursing staff could care plan the wound at that time on the care plan meeting if the DON requested it. Review of the facility's policy titled, Comprehensive Care Plans, revised January 2025 reflected, Policy Statement: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident.7. The comprehensive, person-centered care plan: a. includes measurable objectives and timeframes; b. describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, . (3) which professional services are responsible for each element of care; c. includes the resident's stated goals upon admission and desired outcomes; d. builds on the resident's strengths; and e. reflects currently recognized standards of practice for problem areas and conditions. Review of the facility's policy titled, Baseline Care Plans, revised 11/13/23 reflected, .2. The Interdisciplinary Team will review the healthcare practitioner's orders (e.g., dietary needs, medications, routine treatments, etc.) and implement a baseline care plan to meet the resident's immediate care needs including but not limited to: a. Initial goals based on admission orders; b. Physician orders; c. Dietary orders; d. Therapy services; e. Social services; and f. PASARR recommendation, if applicable.

Based on interview and record review the facility failed to permit each resident to remain in the facility, and not transfer or discharge the resident from the facility unless the resident failed, after reasonable and appropriate notice, to pay for a stay at the facility for 1 of 6 residents (Resident #1) reviewed for transfer and discharged rights. The BOM failed to submit Resident #1's Long Term (Medicaid) application and provided bank statements when she and her family expressed interest in applying for Medicaid prior to her discharge from the facility on 09/12/24. This deficient practice could place residents at risk of not being able to remain at the facility, resulting in violation of their rights. The findings include: Record review of Resident #1's, undated, face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE], Resident #1 had diagnoses which included muscle wasting and atrophy, cognitive communication deficit, dysphagia, type 2 diabetes mellitus with hypoglycemia, congestive heart failure, unspecified dementia, other viral pneumonia, chronic kidney disease, and essential hypertension. Record review of Resident #1's care plan, initiated on 08/16/24, reflected the following: Focus: Admit to SNF D/T self-care deficit: Resident requires 24-hour nursing care and has no plans to discharge at this time. Resident will remain long term for nursing services. Record review of the physician order tab of Resident #1's electronic health record reflected the following physician order created on 09/11/24: May discharge home with all medications and personal belongings. Home Health to eval and treat for PT OT ST and nursing. DME as indicated Record review of the progress notes tab of Resident #1's electronic health record reflected the following note, created on 09/19/24 by the SSA: D/C home 9/12/24, transported by [the facility].; [home health agency and contact information]. Wheelchair and 3-1 commode from [DME Company and contact information]. Family will make follow up appt (per clinic request). D/C all meds and personal belongings. Record review of the financial notes tab of Resident #1's electronic health record reflected the following notes made by the BOMA: - a note dated 08/23/24, Spoke with [family member] over MCP if they are wanting LTC, stated [the family member] needed to speak with [family members] to discuss if it will be the right decision. I told [family member] we are on a time crunch to see if she would meet eligibility as we still have not seen any financials and since we have a CC on file she will continue to make the weekly payments for 150 for the copays she is in. [The family member] stated they understood and hopefully by next week and will have a decision. - a note on 09/09/24, spoke with [family member] again over LTC and BO hasn't received any financials to determine eligibility. [Family Member] stated they weren't followed up with by the BO still wanting financials. I told him was he not seeking LTC for [Resident #1] as discussed and [family member] stated yes. I told him we have yet to receive any financial information and BO is needing ASAP, as [Resident #1] will be receiving a NOMNC this week and will have to be DC. [Family member] was upset and stated they would try to get everything in by the end of the week. In an interview on 09/20/24 at 8:26 AM, Resident #1's family member stated Resident #1 was discharged abruptly from the facility on 09/12/24. The family member stated they had been in communication with the facility regarding Resident #1's stay. The family member stated they received a call on 09/09/24 or 09/10/24 from the BOMA stating Resident #1's stay at the facility would no longer be covered. The family member stated they discussed payment options for Resident #1's copays and applying for long term Medicaid. The family member stated after speaking with the family, it was decided to apply for Medicaid for Resident #1. The family member stated they provided the application and bank statements to the facility's business office. The family member stated he received a call from the facility and was told Resident #1 should be seen by her physician before her Medicaid application was processed, as it could help her eligibility. The family member stated they could not recall who they spoke to. The family member stated roughly a week after that call, they received an additional call requesting additional financial information regarding property, life insurance policies and vehicles. The family member stated they notified the facility they would try to get the additional information in and gave verbal payout amounts for the life insurance policy. The family member stated the facility advised him Resident #1 would not qualify for Medicaid and her discharge would continue as planned. In an interview on 09/20/24 at 3:09 PM, the BOM stated when the facility received a NOMNC for a resident, the resident and their representative and notified of their right of an appeal. The BOM stated if the resident was seeking long term care, they would assist in the application process. The BOM stated if financials were not provided to accompany the Medicaid application, the facility would continue with the discharge especially if the resident was given a NOMNC. The BOM stated if a Medicaid application was filed, the resident could not be discharged until a decision was made. The BOM stated a 30-day notice would be required to discharge a resident after a Medicaid application was submitted. The BOM stated Resident #1 was issued a NOMNC on 09/09/24, with the last covered service date being 09/12/24. The BOM stated Resident #1 appealed the NOMNC and lost the appeal on 09/10/24. The BOM stated Resident #1 and her family were notified they could request a 2nd level appeal, which would take roughly 2 weeks and they would have to pay out of pocket until an appeal decision was made. The BOM stated the family was unable to afford the required payments but did express interest in applying for Medicaid. The BOM stated the family submitted the resident bank statements and she was found to have a few properties, life insurance policies and vehicles in her name. The BOM stated she received a verbal payout figure of the life insurance policy from Resident #1's family member and advised the family member Resident #1 would not qualify after referencing the Medicaid income and resource limits. The BOM stated she had not submitted the Medicaid application because she generally did not submit Medicaid applications she did not believe they would qualify. In an interview on 09/25/24 at 12:10 PM, the BOMA stated discharges were planned at admission. The BOMA stated when residents were issued a NOMNC, they were told of their right to appeal, the facility's payment policies and if the resident wanted to apply for Medicaid, they were assisted. The BOMA stated she believed Resident #1 did not get approved for Medicaid due to the properties in her name and life insurance policies. The BOMA stated the facility would submit Medicaid applications with all supporting documents to determine their eligibility. The BOMA stated they would submit the application to the case worker and if additional documentation was received. The BOMA stated if additional documentation was needed the case worker would let the facility know and give the resident 10 days or so to submit the documentation. The BOMA stated she was uncertain if Resident #1's application was submitted but she could recall the resident had a life insurance policy that was over the resource limit and had properties in her name. In an interview on 09/25/24 at 4:30 PM, the ADMIN stated Medicaid applications were handled by the facility on a case-by-case basis. He stated the facility went by Medicaid guidelines to determine eligibility. The ADMIN stated if the resident did not provide all required documentation, the resident would become a private pay resident. The ADMIN stated the responsibility to submit Medicaid applications fell on the resident and their families, so he was not aware Resident #1's Medicaid application was not submitted, and he believed the BOM misspoke when she stated Medicaid applications were not submitted if they believed they would not be approved. The ADMIN stated he believed the facility did all they could do to assist Resident #1 in applying for Medicaid but the family failed to provide the required documentation to the business office. The ADMIN could not recall when the financial documentation was requested from Resident #1's family. When asked if the BOM should have submitted Resident #1's Medicaid application, the ADMIN stated nursing facilities were a business first and he did not believe Medicaid applications that they know would not be approved should be submitted by the facility. The ADMIN stated when their business office manager and lawyers review the documentation and they find the resident would not qualify, the resident was discharged and referred to independent lawyers to help residents apply for Medicaid. The ADMIN stated he would speak with the BOM about the submission of Medicaid applications in the future. A related facility policy was requested from BOM and ADMIN on 09/20/24 at 3:09 pm and on 09/25/24 at 4:30 pm but was not provided upon exit.

Based on interview and record review the facility failed to notify the resident and the resident's representative (s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understood and failed to send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman for one of four residents (Resident #1) and one of one month (August 2024) reviewed for transfer and discharge. 1. The facility failed to send a transfer or discharge notice in writing to the facility's Ombudsman as soon as practicable when Resident #1 was discharged home on 09/12/24. 2. The facility failed to ensure the facility's Ombudsman was notified, at least 30 days in advance of the discharge, or as soon as practicable before transfer or discharge for all discharges during the month of August 2024. These failures could place residents at risk of being discharged and not having access to available advocacy services, discharge/transfer options, and the appeal processes. The findings include: Record review of Resident #1's, undated, face sheet reflected a [AGE] year-old female who admitted to the facility on [DATE]. Resident #1 had diagnoses which included muscle wasting and atrophy, cognitive communication deficit, dysphagia, type 2 diabetes mellitus with hypoglycemia, congestive heart failure, unspecified dementia, other viral pneumonia, chronic kidney disease, and essential hypertension. Record review of Resident #1's care plan, initiated on 08/16/24, reflected the following: Focus: Admit to SNF D/T self-care deficit: Resident requires 24-hour nursing care and has no plans to discharge at this time. Resident will remain long term for nursing services. Record review of the physician order tab of Resident #1's electronic health record reflected the following physician order created on 09/11/24: May discharge home with all medications and personal belongings. Home health to eval and treat for PT OT ST and nursing. DME as indicated Record review of the progress notes tab of Resident #1's electronic health record reflected the following note, created on 09/19/24 by the SSA: D/C home 9/12/24, transported by[the facility].; [home health agency and contact information]. Wheelchair and 3-1 commode from [DME Company and contact information]. Family will make follow up appt (per clinic request). D/C all meds and personal belongings. Record review of the facility's discharge logs from 06/01/24 to 09/20/24, indicated there were 24 residents who discharged from the facility in the month of August 2024. In a telephone interview on 09/25/24 at 10:02 AM, the Ombudsman stated she typically received notification of the facility's discharges by email. The Ombudsman stated she would receive monthly emails which listed the residents who were discharged from the facility. The Ombudsman stated she had no report of Resident #1's discharge and she believed she was last notified of discharges in July 2024. In an interview on 09/25/24 at 11:56 AM, the DON stated the facility hired a new social worker in July 2024. The DON stated the previous social worker did not notify the Ombudsman of the facility's discharges for the Month of August and neither did the facility's current social worker. The DON stated she attempted to call the Ombudsman to confirm the last month of discharges she was notified, but her call was unsuccessful. The DON stated the current social worker would email Augusts discharged to the Ombudsman immediately. In an interview on 09/25/24 at 12:52 PM, the SW stated she had been the facility's social worker for roughly 8 weeks. The SW stated she was still learning the facility's procedures and she did not know she had to notify the Ombudsman of the facility's discharges, but she would notify the Ombudsman of the facility's discharges. In an interview on 09/25/24 at 4:30 PM, the ADMIN stated he was not aware the Ombudsman was not notified of resident discharges since July 2024. The ADMIN stated the SW was solely responsible for notifying the Ombudsman of the facility's discharges. The ADMIN stated discharges should be reported to the Ombudsman monthly, unless a 30-day notice was issued, and a copy of the notice was sent to the Ombudsman the same day the notice was provided to the resident. The ADMIN stated he was unsure of what the Ombudsman did with the discharge notifications, so he was uncertain of how not receiving a discharge notification could affect the residents being discharged . The ADMIN stated he would in-service the SW and monitor discharge notifications to ensure the Ombudsman was notified appropriately in the future. A related policy was requested from the DON and ADMIN on 09/25/24 at 11:56 am and 4:30 pm but was not provided upon exit. t.

Based on observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for kitchen sanitation. The facility failed to ensure food was properly stored (moldy food in the fridge, food exposed to air, food on the floor) in the facility's kitchen. This failure could place residents at risk for food-borne illness. Findings Included: Observation of the facility's refrigerator on 08/06/24 beginning at 8:55 AM revealed: - 1 tomato with a black spot and 1 withered tomato; - 7 withered strawberries and 1 strawberry with a brownish green spots; - 5 green bell peppers with black spots; - 1 sweet potato with fuzzy green and white spots; and - 1 frozen bag of mixed berries thawing on top of a box on the second shelf from the top. Observation of the facility's dry storage on 08/06/24 beginning at 9:18 AM revealed: -1 container of ground cinnamon open and exposed to air; - 1 container of onion powder with the expiration date of May 9th (year was missing); and - white powder substance on the floor. Observation of the facility's open area in the kitchen on 08/06/24 beginning at 9:27 AM revealed: -1 unclean container under a prep table next to two hot plate covers; - 1 deep fryer with residue on the exterior of the machine; and - the floor under the juice machine had black residue. Observation of the facility's freezer on 08/06/24 beginning at 9:38 AM revealed: -1 box of cookie dough open and exposed to air; - 1 box of homestyle yeast rolls open and exposed to air; - 1 box of sugar cookie dough open and exposed to air; and - 4 cups of ice cream on the floor. In an interview with the Dietary Supervisor on 08/08/24 at 1:26 PM, revealed the refrigerator was cleaned weekly and spills were cleaned immediately. She stated when produce came in, she would check them to make sure there was no mold. She stated all kitchen staff were responsible for ensuring produce was fresh. She stated food was supposed to be thawed on the bottom shelf on a pan. She stated dietary staff had been in-serviced monthly and as needed. She stated everyone maintained the dry storage. She stated she ensured items were dated, closed, and the floor was swept on a weekly basis. She stated the deep fryer was cleaned once a week and sometimes more when used back-to-back to fry different foods. She stated the unclean bucket was the grease bucket used for the deep fryer. She stated the grease bucket should have been cleaned before it was placed back underneath the table. She stated the floor in the kitchen was cleaned twice a day, once during each shift. She stated she ensured the floors were being cleaned. She stated she checked the floor after the first shift and the cooks checked the floor after the second shift. She stated items in the freezer were supposed to be sealed so no air could get to it. She stated twice a week she made rounds and checked the freezer during inventory. She stated improper food storage could cause harm to residents such as contamination and food borne illnesses. Record review of the facility policy titled Food Receiving and Storage, dated July 2014, revealed Foods shall be received and stored in a manner that complies with safe food handling practices. Review of the Food and Drug Administration Food Code, dated 2017, reflected, .3-305.11 Food Storage. (A) .food shall be protected from contamination by storing the food: (1) In a clean, dry location; (2) Where it is not exposed to splash, dust, or other contamination .

Based on observation, interview, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 of 4 nurses' medication carts (medication cart on 200 hall) reviewed for pharmacy services. The facility failed to discard expired glucometer control solution (used to test and calibrate the glucometer machines) from 200 hall medication cart. This failure placed the residents at risk of incorrect labeling of drugs and biologicals. Findings included. During an observation and interview on [DATE] at 10:15 AM, RN B identified the 200 hall nurse's medication cart. The cart contained a box of control solutions used to calibrate two glucometers which were also stored in the cart. No other control solutions were found within the cart. The box of control solutions reflected an expiration date of [DATE]. No open date was noted on the box. RN B stated he was unaware of the expired control solutions and it was the responsibility of the 10 pm to 6 AM nurse to use the solutions to calibrate the glucometers daily. RN B stated the risk for using expired control solutions included decreased efficacy of the solutions could make the calibration inaccurate which could lead to inaccurate results when testing resident's glucose levels. RN B provided the control logs completed by the 10 PM to 6 AM nurse. During an interview on [DATE] at 10:51 AM, the DON stated the 10:00 PM to 6:00 AM nurses were responsible for calibrating the glucometers on their carts. She stated she, the charge nurses, and the ADON were responsible for ensuring the calibrations were completed and items in the medication carts were up to date. She stated she was surprised to hear about the expired control solution and stated the pharmacy consultant also checked the carts. The DON checked the cart with RN B who showed her the expired solution. He had marked the box as DO NOT USE. The DON instructed RN B to retrieve new test strips and control solutions, re-calibrate the glucometers, and re-test the residents. She stated the risk of using expired solutions for calibration was inaccurate glucose readings when testing residents. On [DATE] at 2:51 PM, attempt to conduct a telephone interview with LVN C , who worked the 10:00 PM to 6:00 AM shift and signed the Glucometer Daily Quality Control Record on [DATE] through [DATE] and [DATE] through [DATE] was unsuccessful. During an interview on [DATE] at 2:52 PM, LVN D stated she began working at the facility in [DATE] and had performed glucometer calibrations while working the 10:00 PM to 6:00 AM shift on the 200 Hall. She stated she had been trained in performing the calibration tests and the solutions were used to test the machines for high and low readings. LVN D stated she recalled using the control solutions but did not recall checking for an expiration date on the box. In a telephone interview on [DATE] at 3:10 PM, ADON A stated it was her responsibility to ensure the glucometer calibrations were completed properly. She stated the nurses had been trained and should have known to check the expiration dates on the strips and control solutions prior to using them. She stated she routinely checked the medication carts for expired items as did the pharmacy consultant. ADON A stated she was not sure what had happened or if one of the nurses possibly grabbed a box of solution from somewhere else. She stated the risk of using expired solution was it could be ineffective for calibration and could cause incorrect glucose readings for the residents. Record review of the facility's policy titled, Obtaining a Fingerstick Glucose Level dated, revised [DATE] reflected: Purpose: The purpose of this procedure is to obtain a blood sample to determine the resident's blood glucose level. Preparation- .3. Assemble equipment and supplies needed. 4. Ensure that the equipment and devices are working properly by performing any calibrations or checks as instructed by the manufacturer or this facility . Record review of the glucometer manufacturer documentation for their control solution dated Revised ,d+[DATE] reflected: [Company name] Glucose Control Solutions .Intended Use- The purpose of the control solution test is to validate the performance of the [Company Name] Blood Glucose Monitoring System using a testing solution with a known range of glucose. A control test that falls within the acceptable range indicates the user's technique is appropriate and the test strip and meter are functioning properly .Summary- The [Company Name] Control are solutions containing a measured amount of glucose. The solutions are used with your [Company Name] Blood Glucose Test Strips to confirm the acceptance performance of the test strips and the meter .Warnings and Precautions .Always check the expiration date. DO NOT use control solutions if they have expired .

Based on observation, interview, and record review, the facility failed to provide pharmaceutical services including procedures that assure the accurate dispensing and administering of all drugs and biologicals to meet the needs of each resident for 1 (Resident #71) of 4 residents reviewed for pharmaceutical services. RN A failed to follow the facility policy for administering medication through gravity when administering medications via Resident #71's g-tube. These failures could put residents who received medications via g-tube at risk for aspiration. Findings included: Review of Resident #71's MDS assessment, dated 03/26/23, revealed the resident was a [AGE] year-old male admitted to the facility on [DATE]. The assessment reflected Resident #71 had severely impaired cognition and had diagnoses which included unspecified severe protein-calorie malnutrition and on peg tube for nutritional approach. Review of Resident #71's May 2023 Physician Orders reflected there were no orders for medication administration method. Observation on 05/18/23 at 8:13 AM revealed RN A pulled the following medications and placed them in a separate cup: - Aspirin 81 mg, 1 tablet daily by g-tube (blood pressure) - Acidophilus 1 capsule, daily by g-tube (supplement) - Amiodarone 200 mg, 1 tablet daily by g-tube (low blood pressure) - Coreg 25 mg, 1 tablet daily by g-tube (blood pressure) - Diltiazem 90 mg, 1 tablet daily by g-tube (blood pressure) - Gabapentin 100 mg, 1 capsule three times by g-tube (neuropathy) - Hydralazine 10 mg, 1 tablet daily by g-tube (blood pressure) - Keppra 500 mg, 1 tablet daily by g-tube (seizure) - Lisinopril 20 mg, 1 tablet daily by g-tube (blood pressure) - Prostat 60 ml, daily by g-tube (supplement) - Sertraline 25 mg, daily by g-tube (depression) - Lasix 40 mg, daily by g-tube (edema) - Simethicone 80 mg, daily by g-tube (gastrointestinal) - Loratadine 10 mg daily by g-tube (allergy); and - Tramadol 50 mg daily by g-tube (pain). RN A crushed all the medications together and mixed with 60 ml water. RN A had orders to cocktail the medications. RN A went to Resident 71's room, positioned Resident #71, checked for the g-tube placement and residual, and flushed the g-tube with 15 ml of water. RN A was observed administering medication by pushing through the g-tube with a plunger than allowing the mixed medication to flow by gravity. She then flushed the g-tube with 15 ml water by plunging with a syringe. Interview on 05/18/23 at 8:36 AM with RN A revealed she was aware there was no order to administer medication through g-tube by gravity for Resident #71, but she did not call the doctor or notify the DON. She stated she knew she was supposed to go through the orders before medication administration and verify the route of administration. She stated she had been pushing the medication with a plunger because administering by gravity was slow. She stated it was her responsibility and best nursing standard of practice to check the orders before administration of any medication. RN A stated failure to check orders and administering medication through plunging could lead to aspiration. She stated she had done training on medication administration via gastrostomy tube. Interview on 05/18/23 at 9:10 AM with the DON revealed her expectation was for the nurses to follow the physician orders and check the orders before medication administration. The DON stated RN A was not supposed to use a plunger without a physician order. She stated she was not sure what their policy stated. The DON stated the resident did not have orders for either to administer through gravity or push. She stated RN A reported it to her, and they contacted the doctor since Resident #71 did not have orders. She stated they were issued orders reflecting they could push the medications. The DON stated it was the nurses' responsibility to clarify orders before they administered medications, and RN A failed to clarify. She stated she had trained the nurses on medication administration via g-tube. The DON stated the risk of plunging the medication was that it could cause Resident #71 to experience distress and aspiration. Review of the facility's current policy entitled Administering Medication Through Enteral Tube, dated March 2015 reflected the following: .1. Verify that there is physician's medication order for this procedure. .11. confirm placement of feeding tube. .17. Reattach syringe (without plunger) to the end of the tubing. 18. Administer medication by gravity flow . a. Pour diluted medication into the barrel of the syringe while holding the tubing slightly above the level of insertion. b. Open the clam and deliver medication slowly. c. Clamp tubing (or begin flush) before the tubing drains completely .

Based on observation, interview and record review, the facility failed to permit the resident to remain in the facility, and not transfer or discharge the resident from the facility unless the transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility for one (Residents #2) of five residents reviewed for facility-initiated discharges. The facility failed to permit Resident #2 to remain in the facility by initiating a 30-day discharge that was not based upon the facility's ability to meet the resident's needs or necessary for the resident's welfare. The failure could affect residents by placing them at risk of not having access to adequate care in a nursing home facility. Findings included: Review of Resident #2's Face Sheet, dated 05/19/23, reflected the resident was an [AGE] year-old- female, who admitted on [DATE], with diagnoses of hemiplegia, affecting right dominant side, muscle weakness, lack of coordination, contracture right knee, contractor left knee, Type 2 diabetes mellitus (high blood sugar), anxiety disorder, depression, open-angle glaucoma, hypertension (high blood pressure), and anemia. Review of Resident #2's MDS assessment, dated 03/20/23, reflected the resident had a BIMS score of 99, which reflected the resident was unable to complete the interview. Section C0700 reflected the resident had a memory problem. Resident #2 required extensive assistance with two persons for bed mobility, transfer, and toilet use, extensive assistance with one person for personal hygiene, eating, dressing and locomotion on and off unit. The resident required physical help in part of bathing activity. Resident #2 had an impairment on one side of her upper extremities (shoulder, elbow wrist, hand) and impairment on both sides of her lower extremities (hip, knee, ankle, foot) with limitation in her range of motion. Review of Resident #2's undated care plan reflected the following care areas: [Resident #2] had an Electronic Monitoring /Camera in room per resident and family request - managed by family; resident dignity will be maintained and protected through next as evidence by no documented or reported breach to provision of resident dignity. Goal: care will be met and uninterrupted via use of camera. Interventions: continue to provide customary/usual privacy practices during care, obtain consent from roommate and RP when indicated, refer to Social Services and /or Administrator as indicated, Placement of the camera to ensure privacy during care for resident and roommate, Keep sign posted on door of room regarding electronic monitoring in place.: [Resident #2's] ADL functions: Requires extensive assist with 1-2 staff members with bed mobility, dressing, personal hygiene, bathing, transfers, set up help with meals and assist X1 when needed. Goal: Will maintain a sense of dignity by being clean, dry, odor free and well-groomed over the next 90 days. Interventions: Encourage independence, praise when attempts are made, Assist with ADLs as needed. *Repeated criticism of staff from family Goal: Family will state realistic expectations regarding patient care Interventions: Convey acceptance of resident to resident, Provide consistency in direct care providers when possible, Allow resident to verbalize feelings and listen in non-judgmental manner, Social Services to evaluate resident and speak with family monthly, Encourage family/responsible party to visit resident at least weekly, Monitor and document resident behavior, Allow resident opportunities to make choices regarding cares, Encourage social conversations with resident and family. Review of Resident #2's Occupational Therapy Treatment Encounter Notes dated 01/13/23 written by Director of Therapy reflected: .Patient reports new signs/symptoms? No Precautions: Fall Risk Contraindications: No contraindications present Is skilled therapy needed to address pain? No Extensive care plan with Responsible Party, client, Social Worker, and nursing admin to review family concerns with [Resident #2] care. Responsible Party reported she was not getting up out of bed and not getting showers on consistent basis. Nursing was able to provide shower sheets to validate client participation and refusals. Responsible Party did not agree with the evidence provided and insisted on filing a grievance to further investigate the findings. Response to session interventions: complaint with adaptions. Review of Resident #2's Progress note dated 01/13/23 at 4:29 PM written by Social Worker reflected: Care plan meeting arranged for Responsible Party and Resident #2. IDT members present. Responsible Party expressed some concerns which are being reviewed and addressed. Review of Resident #2's Progress notes dated 01/16/23 at 10:53 AM written by Social Worker reflected: the Responsible Party was no longer allowed in the building, and he was made aware this morning. There was a sexual abuse allegation with a staff member that has been made. Staff member was uncomfortable and fearful of this incident. Police report made. Corporate partners have been consulted. Ombudsman, has been made aware . Review of Resident #2's Notice of Resident Transfer/Discharge, dated 02/13/23, revealed Power of Attorney-Health Care for Resident #2 was issued this letter to inform him of the facility's intent to transfer/discharge Resident #2 thirty (30) days from 02/13/23 for the following reasons: 1. The transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility. 2. The safety of individuals in the facility is endangered by the resident being there. Responsible Party will be consulted by phone. Review of Resident #2's Progress note dated 01/16/23 at 11:57 AM written by Social Worker reflected: . a call made to Responsible Party, he filed three grievances: camera not operational since 4:37 PM on Friday, false accusation of sexual harassment, and would like a certified letter [NAME] him from the premises. Social Worker and team will follow up. Review of Resident #2's progress note dated 03/06/23 at 10:03 AM written by Social Worker reflected: a referral was sent to other long term care facilities for [Resident #2]. On 02/13/23 Responsible Party and Ombudsman was issued a 30-day Involuntary Discharge Notice via email and post office. No response received to date concerning the proclamation Responsible Party has voiced being not pleased with care given to [Resident #2]. Responsible Party was aggressive with staff and became quite agitate during meeting in January. Due to public information concerning his behavior, it has become quite uncomfortable for staff members providing care. He has been asked not to come into the building since last meeting. Apparently, a police report was filed by an employee related to sexual harassment and feeling uncomfortable with his reaction during the meeting. He has requested emails for communication purposes. It has been explained that nursing will call with information as they do not have access to email. Administration will address Responsible Party as needed. Review of Resident #2's progress note dated 03/06/23 at 3:37 PM written by Social Worker reflected: This writer referred [Resident #2] to six different nursing home facilities, awaiting decision to approval packet and accept resident. Review of Notice of Hearing dated 03/21/23 revealed the hearing was scheduled for 05/02/23 at 9:30 AM; however, a second Notice of Hearing dated 04/27/23 revealed the hearing was rescheduled for 05/11/23 at 9:30 AM. Interview on 05/17/23 at 9:25 AM with the Ombudsman revealed she had just acquired the facility in the last month. During a visit in May 2023, she was notified by the facility Resident #2 was issued an involuntary discharge notice. The Ombudsman stated the hearing was completed on 05/11/23 and was awaiting the outcome. The Ombudsman stated she did not think the hearing would result in the discharge (in favor of the facility) due to Resident #2 not having anything to do with the reason for the discharge. Interview with the Social Worker on 05/19/23 at 4:27 PM revealed Resident #2 was a great resident with some mental health concerns with hallucinations. The Social Worker stated when she began employment with the facility, she thought the 30-day discharge plan was already in place; however, she was instructed by the Administrator to move forward with 30-day discharge and it was then issued on 02/13/23. The Social Worker stated the 30-day discharge was requested because it was difficult to work with Resident #2's Responsible Party. The Social Worker stated during a meeting on 01/13/23 the Responsible Party became difficult to manage, very hostile and at times had hostile undertones. The Social Worker stated staff felt threatened by Responsible Party after she presented him with information regarding care; he then became verbally aggressive. The Social Worker stated the hearing was completed on 05/11/23, and the facility had not received a response so far. The Social Worker stated she did not feel the decision from the hearing would result in a discharge due to the hearing not being anything Resident #2 did but was for the actions of the Responsible Party who was Resident #2's power of attorney. The Social Worker stated along with this decision the Responsible Party was asked: not to return to the building, to communicate by phone, and to allow another family member to become Resident #2's Responsible Party. The Social Worker stated the facility would also install a buzzer at the front entrance. Interview with the DON on 05/19/23 at 5:36 PM revealed Resident #2 had a history of refusing care and hallucinating or remembering her past. She stated they got psychiatry involved. The DON stated the resident's responsible party became very aggressive with staff and began making sexual comments during a care plan meeting back in January 2023. The DON stated, What was shared with me was that he got aggressive and threatening so staff sent for the Administrator to join the meeting. The DON stated once the Administrator entered the room the Responsible Party calmed down, police came in, and took a report because of the Responsible Party's history. The DON stated the facility could and did meet Resident #2's needs but with the Responsible Party's aggressive demeanor during the care plan meeting, public news that he killed his family members, and the threats to the staff the 30-day discharge was initiated for the staff and residents' safety. The DON stated they had sent out referrals before; however, the referrals were denied due to the Responsible Party's behavior. The DON stated actions were taken to prevent Responsible Party from entering the facility, did active shooter trainings, and increased police rounding. The DON stated the facility was in the process of putting a buzzer system in place and changed the codes on all doors. The DON further stated Resident #2 had not done anything that put herself or others in danger, the 30-day discharge was issued due to the Responsible Party's actions and behavior. Interview with the Administrator on 05/19/23 at 6:52 PM revealed there were no issues with the facility being able to care for Resident #2; however, the facility could not meet the Responsible Party's definition of care for the resident and that was the reason for the 30-day discharge, along with him harassing my staff to death and for staff that left their jobs due to his history. The Administrator stated the Responsible Party complained about everything. The Administrator stated during the last care plan meeting the Responsible Party created a hostile environment, alleged false accusations, and made mention of sexual innuendos towards staff. The Administrator stated he did confide and communicated with the Ombudsman and his legal departments which encouraged him to move forward with the 30-day discharge. The Administrator stated moving forward with the 30-day discharge did not affect Resident #2 because she was still cared for, and the facility would continue to meet the resident's care needs. Review of facility policy entitled Transfer or Discharge Notice dated 12/01/22 reflected: .Our facility shall provide a resident and/or the resident's representative (sponsor) with appropriate notice as described in the stated administrative code of an impending transfer or discharge. The facility must permit each resident to remain in the facility and must not transfer or discharge the resident from the facility unless: a. The transfer is necessary for the resident's welfare and the resident's needs cannot be met in the facility. b. The transfer or discharge is appropriate because the resident's health has improved sufficiently so the resident no longer needs the services provided by the facility c. The safety of individuals in the facility is endangered due to the clinical or behavioral status of the resident .

Based on observation, interview, and record review, the facility failed to ensure residents fed by enteral means received the appropriate treatment and services to prevent complications of enteral feedings for one (Resident #14) of eight residents reviewed for enteral nutrition, in that: The facility failed to schedule a gastroenterologist consult for removal of g-tube (feeding method to deliver formula through feeding tube) for Resident #14 according to physician orders. This failure could place residents at risk for adverse reactions, health complications, and a decreased quality of life. Findings included: Record review of Resident #14's Face Sheet, dated 05/19/23, revealed the resident was a [AGE] year-old female who admitted to the facility on [DATE]. The resident had diagnoses that included dysphagia (swallowing difficulties) following cerebral infarction (stroke). Record review of Resident #14's Quarterly MDS assessment, dated 05/01/23, revealed a BIMS score of 14 which indicated the resident's cognition was intact. The assessment reflected Resident #14 nutritional approach was therapeutic diet. The MDS had no indication of feeding tube being used. Record review of Resident #14's care plan, revised 06/21/22, reflected the following: *Problem: RESOLVED NOTHING BY MOUTH I have difficulty swallowing. Goal: I will not suffer any complications of dysphagia, aspiration pneumonia. Achieved: 08/09/22 Approaches: Nothing to eat or drink by mouth. Refer me to speech therapy for a bedside [swallowing] evaluation. *Problem: Resident is on a regular diet but has a history of protein malnutrition and had a g-tube. Goal: Resident will have stable weights and labs and will have no serious side effects. Approaches: Notify MD as needed. Monitor for serious side effects. Administer medications as ordered. Monitor weights and labs as ordered. 04/18/23 Dietician spoke with patient and family about loss and recommendations. Continue to offer enhance meals to meet nutritional needs. Monitor meal intake and record every meal. Diet as ordered. *Resident has a PEG tube due to dysphagia and is at risk for aspiration. Resident does not allow staff to flush or use tube for feeding. Goal: Resident will have stable weights and labs and will have no s/s of aspiration 08/02/23. Approaches: Keep head of bed elevated during feeding. Monthly weights, Site care qd, notify MD as needed Review of Resident #14's physician order summary reflected: TF: Diabetisource calorie liquid 60 ml per hour times 22 hours via pump was discontinued 10/21/2022. Resident #14's medications were discontinued via g-tube on 01/23/23. Review of Resident #14's physician chart order for 04/04/23 revealed a physician order to obtain a GI consult for removal of the resident's g-tube. Observation and interview on 05/18/23 at 9:35 AM revealed Resident #14 was lying in bed. Resident #14 stated she had a g-tube; however, she no longer needed it. Resident #14 stated she could eat by mouth. She stated she had been able to eat by mouth for months now. She stated she could take her medications by mouth and drank fluids by mouth. She stated she had requested for her g-tube to be removed but did not know the status of her request. Resident #14's g-tube appeared to be intact. Resident #14 stated she did not like looking at the g-tube, and she wanted it taken out. Resident #14 stated she had told the nurses; however, she could not recall which nurse she had told or how long it had been since she mentioned it to a nurse. Interview on 05/19/23 at 11:38 AM with the RD revealed she acquired the facility November 2022. The RD stated Resident #14 had been non-compliant with her g-tube. She stated Resident #14's g-tube had not been in use, and the resident took everything by mouth. The RD stated Resident #14's weight was stable. The RD stated back in November 2022 Resident #14 was eating 75%-100% of her meals and was only receiving water flushes and medications via g-tube. The RD stated Resident #14's feedings were stopped prior to November 2022. She stated Resident #14's flushes were discontinued 03/27/23, due to the resident refusing the flushes. The RD stated Resident #14 had informed her several times she no longer wanted the g-tube. The RD stated she was not aware Resident #14 still had her g-tube. The RD stated once flushes were discontinued the plan was to remove the g-tube. The RD stated she recommended for the g-tube to be removed back in March 2023. The RD stated the risk for the resident to continue to have the g-tube was that it could affect her quality of life. The resident did not need the g-tube if she was able to eat and drink by mouth. Interview on 05/19/23 at 12:06 PM with LVN B revealed Resident #14's g-tube was not in use. She stated Resident #14 could eat, drink, and take medications by mouth. LVN B stated she could not recall how long Resident #14's g-tube was not in use. LVN B stated she was not sure if they had a referral for a GI consult. LVN B stated it was the ADON's responsibility to follow-up with referrals and scheduling appointments. LVN B stated there was no risk to the resident to still have a g-tube. Interview on 05/19/23 at 12:12 PM with the ADON revealed she was responsible for residents on the 100 Hall. She stated Resident #14 still had a g-tube; however, the g-tube was not being used. The ADON stated Resident #14 had been able to eat by mouth for about four months. The ADON stated Resident #14 had been refusing flushes, and the flushes had been discontinued for over a month. The ADON stated she had not seen Resident #14 recently and was not aware that Resident #14 wanted her g-tube removed. The ADON stated Resident #14 did have a referral for a GI consult but was unsure when it was provided. She stated she contacted a GI doctor; however Resident #14 was denied because the doctor was not accepting new patients. The ADON stated she had not scheduled an appointment yet due to her still gathering paperwork. When asked what paperwork was she referring to, the ADON stated insurance. She stated the facility was still looking for a GI doctor. The ADON stated she was not sure when the referral was provided; however, she stated she would look for the referral and would provide it to surveyor. Follow-up interview on 05/19/23 at 3:05 PM with the ADON revealed she reviewed Resident #14's clinical record, and she had located the written referral which was provided 04/04/23. The ADON stated as of 01/06/23 Resident #14's medications via g-tube were discontinued and the flushes were discontinued in March 2023 per the Dietitian. The ADON stated she was responsible for following up with referrals. She stated she did not have any documentation regarding her contacting the GI doctor when the referral was first written. Since Resident #14 was denied, she had not followed up with the referral. The ADON stated since there was no immediacy for the g-tube to be removed there was no risk to the resident. The ADON left the office and returned stating Resident #14 was seen by the MD today and was sent to the hospital to get the g-tube removed. The ADON stated Resident #14 requested her g-tube be removed. Interview on 05/19/23 at 4:17 PM with the MD revealed he was aware Resident #14's g-tube was not being used. The MD stated Resident #14 could eat, drink, and take medications by mouth. The MD stated he had provided a referral on 04/04/23 for a GI consult; however, the facility was having problems with finding a GI doctor. The MD stated he visited Resident #14 today and ordered for resident to go to the ER to remove the g-tube. Interview on 05/19/23 at 4:54 PM with the DON revealed according to staff documentation Resident #14 had been refusing water flushes, and the water flushes were discontinued 03/27/23. The DON stated Resident #14 was able to eat and take medication by mouth for months now. The DON stated it was mentioned today (05/19/23) that Resident #14 wanted her g-tube removed; however, prior to today there was a GI consult referral. The DON stated she was only aware that the ADON was working on the referral but was having issues scheduling the appointment. The DON stated it was the ADON's responsibility to follow-up with referrals; however, she was unsure what happened on this situation. The DON stated her expectation was to follow-up with the referral and if the resident was denied the ADON needed to continue to try different providers. She stated it was her responsibility to check on the status of the referrals. The DON stated the risk of not following up with referrals was that it could cause a delay in service. A facility policy regarding referrals was requested; however, it was not provided prior to exit.

Based on observation, record review, and interview, the facility failed to provide pharmaceutical services, including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals, to meet the needs of each resident for three (Hall 100, 200 and 400 Medication Cart) of four medication carts and one refrigerator reviewed for pharmacy services. 1. The facility failed to ensure expired medications in nurse medication carts for Hall 100, 200, 400 and refrigerator were removed and destroyed. 2. The facility failed to ensure insulin were dated with opening dates. The failure placed residents at risk of receiving medications that were ineffective due to having expired medications on the cart, in the refrigerator and due to not putting opening date on insulin pens/vials. Findings included: 1. Observation on 05/18/23 at 4:22 PM of the nurse's medication cart used for the 100 Hall with LVN C revealed two insulin vials of glargine 100 unit/ml with an opening date of 03/30/23 and 03/23/23 that were opened and partially used. Interview on 05/18/23 at 4:35 PM with LVN C revealed it was all nurses' responsibility to check the carts for expired medications every shift and put them in the destruction boxes. She stated she did not check the cart after it being handed over to her because she forgot. She stated the insulins were good for 28 days after being opened. She stated the side effects of giving expired medication would be that it was not effective. She stated she had completed training on labeling and storage of medications. 2. Observation on 05/18/23 at 4:40 PM of the nurse's medication cart used for the 200 Hall with LVN D revealed, one insulin pen of Levemir was open, partially used, and without an opening date. 3. Observation on 05/18/23 at 4:46 PM of the nurse's medication cart used for the 400 Hall with LVN E revealed, one insulin aspart flex pen opened and partially used with no open date and one Lispro insulin pen with open date of 04/14/23 that was opened and partially used. Interview on 05/18/23 at 4:51 PM with LVN D revealed it was all nurses' responsibility to put an opening date on insulin vial/pen after removing from the refrigerator. She stated she was supposed to check her cart at the beginning of the shift, but she did not check, she forgot. She stated the insulins are good for 28 days after being opened. She stated the effects of not putting opening date on insulin vials/pen they would not be sure when it expired. She stated she had completed training on labeling and storage of insulin. Interview on 05/19/23 at 11:19 AM with the DON revealed her expectation was that all nurses checked their carts for expired medications every shift. The DON stated it was all nurses' responsibility to ensure insulin had an open date when they removed it from the refrigerator. She stated the insulins were good for 28 days after opening. She stated the insulins that did not have open dates and those that were expired were destroyed, and they ordered more from pharmacy. The DON stated failure to put an open date on insulins would result in staff not being able to tell when the insulin expired. The failure to remove the expired insulin from the cart was that if they were administered to residents then they would not be effective. The blood sugars would not be controlled appropriately. She stated ADONs were supposed to check the carts and the refrigerator once a week for expired medications and dates and labeling. 4. Observation on 05/19/23 at 11:55 AM of the facility only refrigerator revealed two Tylenol 650 mg suppository, with use by date 04/26/23. with instruction to discard 04/17/23. Interview on 05/19/23 at 12:00 PM with LVN B revealed it was all nurses' and managers' responsibility to check and ensure medications were labeled and not expired. She stated the side effects of giving expired medication was they would not work and would not be effective. She stated all expired medications were supposed to be removed from the refrigerator and carts and put in destruction boxes for the Pharmacist to destroy. She stated she had done training on storage and labelling of medications. Interview on 05/19/23 at 12:34 PM with the DON revealed her expectation was for all nurses to check the refrigerator for expired medications and the ADONs to follow -up. The DON stated she checked the refrigerator and verified the temperature logs, but she did not go through each medication in the refrigerator because she expected the nurse and the ADON to check each medication for expiry dates. She stated if staff were not checking the refrigerator for expired medications and medications were administered to residents, they would not be effective. She stated she had done training on refrigerator monitoring with staff on 09/06/22. Interview on 05/19/23 at 12:47 PM with ADON G, who was responsible for monitoring the 300 and 400 halls, revealed it was her responsibility to go behind the nurses to check whether they are removing the expired medications on carts and refrigerators and to ensure the insulins have open dates. ADON G stated she had checked the carts and refrigerator, but she did not check on expiry dates. She stated she only checked whether they were clean and organized because she was busy with other duties. ADON G stated failure to check for the expired medication and put open dates on insulin could result in the staff not knowing whether the medications were still potent for resident use. Interview on 05/19/23 at 3:20 PM with ADON F, who was responsible for monitoring the medication carts on 100 and 200 Hall, revealed it was her responsibility to check the nurses' carts for expired medications and open dates for the insulins. ADON F stated it was her expectation that nurses checked their carts and the refrigerator every shift and before they administered any medication. She stated failure to check the carts and refrigerator for expired medications could result in the medications being ineffective. ADON F stated insulin were good for 28 days. She stated she had not done training on expired medications. Record review of the facility's current Storage of Medication policy, revised April 2019, reflected the following: .5. Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed .

Based on interview and record review the facility failed to conduct COVID-19 testing of residents and facility staff based on parameters set forth by the Secretary, including but not limited to testing conducted in a manner that was consistent with current standards of practice for conducting COVID-19 testing for 7 (Residents #1, #2, #3, #4, #5, #6, and #7) 7 of residents reviewed for COVID-19 testing. The facility failed to perform followup outbreak testing for residents and staff after Housekeeper A tested positive for COVID-19. The facility failed to document in the clinical record that COVID-19 tests were offered, completed and the results for Residents #1, #2, #3, #4, #5, #6, and #7. This deficient practice could place residents at-risk for exposure to the COVID-19 virus which could result in serious illness or hospitalization . Findings included: An interview with the Administrator and DON on 01/05/2023 at 8:40 AM revealed no residents were positive for COVID-19 in the facility. They stated Housekeeper A tested positive for COVID-19 on 12/28/2022 and last worked on 12/26/2022 when she tested negative and showed no signs or symptoms for COVID-19. The DON said Housekeeper A began to show symptoms of COVID-19 on 12/27/2022 and called the Maintenance Director to inform him of her symptoms. The DON said Housekeeper A had not worked in the facility on 12/27/2022 then came to the facility on [DATE] to test and was positive for COVID-19 and sent home. She said she felt there was no need for outbreak testing because Housekeeper A was not in the facility when she tested positive for COVID-19. The Administrator stated the facility did test staff and residents for COVID-19 on 12/28/2022 and 12/29/2022. He said there were no additional positive COVID-19 residents or staff at that time and thought there was no need for further testing. The administrator and DON said they did not have a record of staff or residents testing as they used rapid tests and threw them away. The said they did not think they needed to track COVID-19 testing. An interview with the DON on 01/05/2023 at 1:39 PM revealed Housekeeper A had not been in the facility when she tested positive for COVID-19 and therefore the facility was not in outbreak testing. She stated Housekeeper A worked on 400 hall and wore a mask when she worked on 12/26/2022. The DON said she consulted with the Quality Improvement Nurse, and they concluded since there were no other staff or residents who tested positive on 12/28/2022 and 12/29/2022, contact tracing revealed Housekeeper A was exposed and contracted COVID-19 outside the facility. The DON stated contact tracing was sufficient and testing once with no new positives did not require follow-up testing. She stated there was no documentation of resident testing or results in the clinical record for testing on 12/28/2022, 12/29/2022 or any day after. She said she did not feel the need to record testing since they were not in outbreak. When asked how COVID-19 was tracked, she stated only positive test results would be recorded in the clinical record. In an interview on 01/05/2023 at 2:37 PM the Administrator stated he did not feel the facility needed to engage in outbreak testing because Housekeeper A was not in the facility when she tested positive for COVID-19. He said as a housekeeper, she did not have direct contact with any residents. When asked if she entered resident's rooms and interacted with other staff in the facility, he said she did. He said Housekeeper A could have been exposed in the facility or could have exposed anyone working or living in the facility when she worked on 12/26/2022. He said not following through with further testing placed residents at risk of contracting COVID-19 because there was no sure way to know where Housekeeper A contracted COVID-19. When asked about documenting COVID-19 testing and results, he said they would document a positive result but not a negative one. An interview on 01/05/2023 at 2:55 PM with the Quality Improvement Nurse revealed she did not recall discussing Housekeeper A's positive COVID-19 test with the DON or Administrator. She said she was informed the facility had not followed up with outbreak testing when she arrived at the facility in the morning on 01/05/2023. She stated the facility followed CMS and CDC guidance and a single resident or staff's positive COVID-19 test triggered an outbreak investigation. She said although Housekeeper A started to show signs and symptoms on 12/27/2022, her day off, she did work on 12/26/2022 and could have exposed facility residents and/or staff. She said follow-up testing was important to catch any additional positives stemmed from the initial positive. She stated the facility should have followed up with testing 48 hours after the initial testing they completed on 12/28/2022 and 12/29/2022, spurred from Housekeeper A's positive test. She said she expected a record of testing and test results for residents and staff because that was the facility's policy. An interview with the Maintenance Director on 01/05/2023 at 4:00 PM revealed he performed the COVID-19 test on Housekeeper A on 12/28/2022 and confirmed the test was positive. He said Housekeeper A returned to work on 01/02/2023. An interview with Housekeeper A on 01/05/2023 at 4:12 PM revealed she worked on 12/26/2022. She said she worked cleaning rooms in the 400 hall and then whet to assist laundry staff with folding and stocking linens. She said she began to have COVID-19 symptoms in the morning on 12/27/2022 and called the facility to inform them. She stated she went to the facility on [DATE] and tested positive for COVID-19. She said two household members also tested positive on the same day. She stated she could have contracted COVID-19 while shopping but was not sure. She said she returned to work on 01/02/2023 without any symptoms and was not tested prior to returning. Record review of the clinical record for Residents #1, #2, #3, #4, #5, #6, and #7 revealed no documentation that COVID-19 test results. There was no documentation that tests were offered or administered. Record review of CDC Guidance dated 09/17/2020 and revised 09/23/2022 revealed ,An outbreak investigation is initiated when a single new case of COVID-19 occurs among residents or staff to determine if others have been exposed. To swiftly detect cases, we remind facilities to adhere to CMS regulations and guidance for COVID-19 testing, including routine staff testing, testing of individuals with symptoms, and outbreak testing. When a new case of COVID-19 among residents or staff is identified, a facility should immediately (but not earlier than 24 hours after the exposure, if known) begin outbreak testing in accordance with CMS and CDC guidelines. Record review of the facility's Outbreak Testing Policy revised 09/29/2022 revealed an outbreak investigation is initiated when a single new case of COVID-19 occurs among residents or staff to determine if others have been exposed. If the facility is unable to identify all close contacts, they should investigate the outbreak at the facility level. Perform testing for all residents and staff immediately but not sooner than 24 hours, and, if negative, again 48 hours after the first negative test, and, if negative, again after 48 hours of the second negative test. Testing should be repeated every 7 days until no new cases are identified for at least 14 days.

Based on observation, interview, and record review the facility failed to ensure assessments accurately reflected the status for 1 of 5 residents (Resident #1) reviewed for MDS assessment accuracy. The facility failed to ensure the Quarterly MDS dated [DATE] reflected an accurate assessment of Resident #1's functional status for ADLs. This deficient practice could place residents at risk of inappropriate care, due to inaccurate information about the resident being used to determine care. Findings Included: Record review of Resident #1's Face Sheet, dated 05/11/22, reflected she was an [AGE] year-old female who admitted to the facility on [DATE]. Her diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #1's Quarterly MDS assessment dated [DATE] revealed the following: Section G Functional Status G Activities of Daily Living (ADL) Assistance Box H. Eating was coded as a 2 in box 1, which indicated Resident #1 was limited assistance- resident highly involved in activity; staff provide guided maneuvering of limbs or other non-weight bearing assistance. Record review of Resident #1's Quarterly MDS assessment dated [DATE] revealed Resident #1's BIMS score was 5, which indicated resident's cognition was severely impaired. Section G Functional Status G Activities of Daily Living (ADL) Assistance Box H. Eating was coded as a 4 in box 1, which indicated Resident #1 was total dependence- full staff performance every time during entire 7-day period. An observation and interview on 05/11/22 at 12:58 PM revealed CNA A encouraged Resident #1 to eat more food. CNA A stated Resident #1 feeds herself and she assisted as needed . She stated when Resident #1 first admitted she couldn't feed herself and she was dependent on staff. CNA A stated she worked with therapy and now she was able to feed herself with assistance. CNA A stated she always checked her tray before picking it up and if she didn't eat much, then she encouraged her to eat more. In an interview on 05/11/22 at 2:02 PM, CNA B stated she regularly worked on Resident #1's hall. She stated Resident #1 was not totally dependent on staff for eating. CNA B stated Resident #1 required assistance with eating, but she was able to feed herself. She stated since she had worked the hall, that had always been Resident #1's status for eating. In an interview on 05/11/22 at 02:41 PM, RN C stated she was responsible for completing Resident #1's MDS. She stated Resident #1 was totally dependent on staff for eating. RN C was informed Resident #1 was observed feeding herself and staff stated she was not total dependence for eating and only required assistance. RN C stated there must be a discrepancy with Resident #1's MDS and she would have to look into it. In a follow up interview on 05/12/22 at 9:38 AM, RN C stated Resident #1's MDS was coded incorrectly. RN C stated when she completed Resident #1's MDS she had to look only within the 7-day period and in their system the CNAs had not coded Resident #1's ADLs. She stated she spoke with Resident #1's family and they told her the staff feeds Resident #1. RN C stated she never asked the CNAs about Resident #1's ADL and she listened to Resident #1's family. She stated Resident #1's previous quarterly MDS was a 2 for eating but she didn't compare Resident #1's previous quarterly MDS because she is supposed to only look at the 7-day period the resident is being observed. RN C stated going from a 2 to a 4 would be a significant change. RN C stated she should have observed Resident #1's eating patterns and should have spoken to staff before coding her MDS. She stated by coding the MDS incorrectly, residents may not receive the correct care. In an interview on 05/12/22 at 11:14 AM, the DON stated she spoke to the corporate office and the facility does not have a MDS policy. She stated she expected the resident's MDS to be completed correctly because if they were not, resident may not receive the correct care. Review of CMS RAI Version 3.0 Manual (dated October 2019) revealed In addition, an accurate assessment requires collecting information from multiple sources, some of which are mandated by regulations. Those sources must include the resident and direct care staff on all shifts and should also include the resident ' s medical record, physician, and family, guardian, or significant other as appropriate or acceptable. It is important to note here that information obtained should cover the same observation period as specified by the MDS items on the assessment and should be validated for accuracy (what the resident ' s actual status was during that observation period) by the IDT completing the assessment. As such, nursing homes are responsible for ensuring that all participants in the assessment process have the requisite knowledge to complete an accurate assessment. Accessed on 05/17/2022 from Minimum Data Set (MDS) 3.0 Resident Assessment Instrument (RAI) Manual | CMS

Based on observation, interview and record review, the facility failed to consult with the resident's physician when there was a significant change in the resident's physical status for one (Resident #52) of five residents reviewed for notification of changes. The facility failed to notify Resident #52's physician of a significant change in condition for Resident #52, when she continued to not tolerate her bolus feedings after she was sent to the hospital for aspiration pneumonia on 01/17/22. An Immediate Jeopardy was identified on 03/10/22. While the Immediate Jeopardy was removed on 03/11/22, the facility remained out of compliance at a scope of pattern and a severity level of actual harm that is not Immediate Jeopardy, due to the facility's continuation of in-servicing and monitoring the plan of removal. These failures could place residents at risk for a delay in treatment or diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings included: Review of Resident #52's MDS assessment dated [DATE] reflected the resident was an [AGE] year-old female admitted to the facility on [DATE] with the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . The assessment further reflected Resident #52 usually understands-misses some part/intent of message but comprehends most conversation. She required total dependence on feeding/staff perform every time during entire 7-day period. The assessment also reflected the resident had a feeding tube seven days for proper calories. Review of Resident #52's care plan reflected the she had a peg tube as was at risk for aspiration with an onset of 03/09/20. Approaches included to monitor for s/s of aspiration, fever, cough, rales/rhonchi, wheezing, and altered mental status. The approaches also included notifying the MD as needed. Review of Resident #52's Nurse Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] TF [MEDICATION(S)] 1.5 calorie liquid formula bolus give two cartons (500ml) via g-tube twice daily 8A, 3A, and one carton (250ml) once a day at 11P with a start date of 01/24/22. Observation of Resident #52's bolus feeding on 03/08/22 at 3:00 PM given by Agency Nurse A revealed the resident tolerated the first 250 ml carton of formula and began to tap her hand on the feeding syringe half way through the second carton. At that time Agency Nurse A stopped the feeding and asked the resident if she was feeling ok and Resident #52 nodded her head no. The agency nurse asked the resident if she was feeling uncomfortable and full and the resident nodded her head yes. Resident #52 then began to grimace and gag and appeared as though she was going to vomit. Agency Nurse A stated she was going to call the doctor and document the incident as this was the first time working with the resident. Review of Resident #52's nurses notes dated 01/17/22 documented by RN B revealed the following: Late entry 01/16/22 at 16:30 [4:30 PM] while administering bolus via gtube half way through second carton resident reached up to stop me but right as she touched me she began to vomit severely. Emesis appeared to be all tube feeding. Continued to monitor resident frequently and noted resident covered in emesis on her neck and chest around 9 PM. Resident continued to nod her head when asked if [NAME] as not feeling well. RN held evening meds and 11 PM bolus due to continued vomiting and nausea. 01/17/2022 4:10 AM RN continued making frequent round to monitor this resident due to n/v with gtube and inability to verbalize help along with answering questions as well as before v/s: 185/108 89% on room air O2 applied at 2 lpm via n/c Lung sounds clear to bilateral upper lobes but completely diminished through lower lobes daughter notified and requested to have resident transferred to the ER Review of Resident #52's hospital records revealed she was admitted to the hospital on 01/17/22 with the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was discharged and transferred back to the facility on [DATE]. Review of the unsigned 24-hour report on the following dates for Resident #52 revealed: 02/06/22 - not tolerating 2 cartons of gtube bolus, becomes congested, coughs, asks you to stop. etc. dietary referral for higher calorie, less volume feeding? 02/07/22 - not tolerating 2 cartons of gtube bolus, becomes congested, coughs, asks you to stop, etc. dietary referral for higher calorie, less volume feeding? 02/08/22 - not tolerating 2 cartons of feeding becomes congested coughs. Dietary referral for increased calorie decreased volume. Interview on 03/09/22 at 1:46 PM with RN B revealed she was the nurse who sent Resident #52 to the hospital. During her 3:00 PM bolus feeding, the resident put her hand up and told her to stop her feeding during her second formula carton (250 ml) so she stopped. Resident #52 began to vomit right away and there had been times the resident was not able tolerate the 2 cartons (500 ml) of formula and the resident always let her know when she was full. After Resident #52 vomited, she cleaned her up, and she and the aides began to monitor her more frequently and she called the NP about an hour after the incident and she was not able to get in touch with him. She further stated she should have tried contacting the medical director if she was not able to get in touch with the NP. Later that night around 9:00 PM, RN B found Resident #52 with emesis again and she did not appear well and did not know long it had been since the resident had vomited as the last time she remember checking on her was around 8:00 PM. At that time RN B called Resident #52's family and they asked the resident be sent out to the hospital. RN B further stated she should have tried to contact the resident's physician after she was not able to get in touch with the NP but had let ADON C know about the incident. RN B said she wrote the vomit incident in the 24 hour report for the resident to have higher calories and less volume and she thought the communication would make to dietary. She also said LVN E had continued the communication form and put an entry to reduce the volume of Resident #52 was receiving. RN B also said resident ran the risk of aspiration if they were not able to tolerate a bolus feeding. RN B had not let anyone else know the resident was not tolerating her feeding because it had only happened to her once or twice before. Interview on 03/11/22 at 8:45 AM with LVN D revealed she cared for Resident #52 and administered her bolus feedings and never had a problem giving them to her. She further stated she was not aware the resident was not tolerating the volume of her bolus feedings or she would have contacted the physician. Interview on 03/10/22 at 2:30 PM with ADON D revealed she took the position of ADON mid-January 2022. She stated she had cared for Resident #52 and administered her bolus feedings a few times and the resident was able to let staff know when she was full by putting her hand up but she never vomited or gagged during her feedings and this would occurred halfway through the second carton formula. ADON D stated she was aware Resident #52 had been sent out to the hospital in January after vomiting and she had returned with no new feeding orders. ADON D further stated the 24-hour reports were taken to the staff morning meetings and reviewed but she did not recall seeing/reading the entries of Resident #52, asking for a decreased volume due to not tolerating the feedings and does not know why they were missed but should not have been. If they would have seen the entries they would have called the doctor to let him know. Interview on 03/10/22 at 3:46 PM with the Interim DON revealed she took over as interim DON on 02/15/22 and she was not aware Resident #52 was not tolerating her bolus feedings. If Resident #52 was not tolerating her feedings, the doctor or RD should have been contacted to adjust her feedings. She further stated the 24 hour reports were taken to the morning meetings daily and the nursing staff or the ADON would review it for any changes. The Interim DON further stated risk of residents not tolerating a feeding or fluid overload could lead to weight loss, aspiration pneumonia, and weight loss. Interview on 03/09/22 at 12:00 PM with the RD revealed she was just notified today, 03/09/22, Resident #52 was not tolerating her feedings due to fluid overload. He said if this occurrence was happening more than once would have needed to know so he could assess and adjust the feedings because there was a risk of becoming overloaded with fluid. The RD further stated risk of fluid overload could cause diarrhea and emesis and if the resident was vomiting that could lead to aspiration. He also stated if he would have been made aware of Resident #52's first incident in January 2022, when the resident was sent out to the hospital, he would have made changes at that time. Interview on 03/10/22 at 10:27 AM with the NP revealed he was made aware two days prio on 03/08/22 that Resident #52 was not tolerating two cartons of formula during her bolus feedings. He stated he would have expected to have been called if the resident was vomiting due to the risk of aspiration pneumonia because it the pneumonia was not treated it could be fatal. Interview on 03/10/22 at 9:33 AM with the Physician revealed he had never seen a resident receive 500 ml for one feeding and he would normally suggest 250 ml to 360 ml in one feeding, but he usually left that decision to the RD. He stated he or the NP should have been called if Resident #52 was not tolerating her feeding more than once so changes could have been made to lower her fluid volume due to the risk of getting pneumonia from aspirating. Review of the facility's policy and procedure entitled, Acute Condition Changes - Clinical Protocol revised March 2018 reflected the following: 1. The Physician and/or Nurse Practitioner will help identify individuals with a significant risk of having acute changes of condition during their stay 3. Direct care staff will be trained in recognizing subtle but significant changes in the resident and how to communicate these changes 8. The nursing staff will contact the physician based on the urgency of the situation they will call and page the physician and request prompt response An Immediate Jeopardy/Immediate Threat was identified on 03/10/22. The Administrator and Interim DON were notified of the Immediate Jeopardy on 03/10/22 at 1:45 PM. The facility was asked to provide a Plan of Removal to address the Immediate Jeopardy. The Facility's Plan of Removal for Immediate Jeopardy was accepted on 08/04/20 at 3:16 PM and reflected the following: The Registered Dietitian will educate licensed nursing staff on the following procedure for notification of the RD on 03/10/22. For emergent request the RD should be consulted via phone for assistance. If the RD does not respond to the message/voicemail within one hour, the facility should contact the Nutritional Life Styles (NLS) office for assistance. NLS has a senior manager on call every day. The facility can also reach out to their corporate RD account manager for assistance. Staff should contact their RD withing 24 hours of admission on an enteral feeding for review The Director of Nursing or designee will review 24 hour reports and nurses notes the following day to ensure notification had been completed. All Registered Dietitian referrals will be place on the consultant referral form and kept in the NLS binder. Licensed nurses will be in-serviced by Regional Quality Improvement Nurse on Acute Change in Condition and related to tube feeding intolerance on 03/10/22. The Director of Nursing or designee will review 24 hour reports and nurses noted daily to ensure Physician notification has occurred timely. In-servicing will be completed by 03/10/22. Education will consist of the following procedure: Stop the tube feeding Assess the resident Notify the Physician Notify the Registered Dietitian Notify the on-call nurse (ADON D and Interim DON) New agency nurses will be educated through Agency Orientation Checklist All non-present nurses will be in-serviced prior to next scheduled shift or via phone The Registered Dietitian will review current tube feeding residents by 03/10/22 then monitor clinical records nurse's notes bi-weekly times three months then monthly on-going. The Director of Nursing or designee with oversight from the Administrator will monitor the above listed processes daily times two then weekly times six. Discrepancies will be addressed immediately and QAPI will be updated and addressed. Monitoring of the facility's Plan of Removal included the following: Interviews were conducted on 03/11/22 starting at 8:45 AM and continued through 1:56 PM with ten staff members from various shifts regarding in-services which included bolus g-tube proficiency, assessment, physician notification, and Registered Dietitian when a resident is not tolerating a bolus feeding. The staff members were able to: Assess the resident during and after bolus feeding. What to do if resident has an emergent tube feeding change in condition. Who to notify in case a resident is not tolerating a feeding. When the RD should be contacted when a resident admits. What to do if a resident need a general referral. Where and what to document the incident if a resident does not tolerate a feeding. Interviewed staff members from various shifts were: LVNs C, E, G, K, L, H and RNs B, F, I, J ADON D and Interim DON were provided in-service training on how often the 24-hour reports were to be reviewed and monitored. The Administrator was notified on 03/11/22 at 3:30 PM, the Immediate Jeopardy was removed. While the immediacy was removed on 03/11/22, the facility remained out of compliance at a scope of pattern and a severity level of actual harm that is not Immediate Jeopardy, due to the facility continuing in-servicing and monitoring the Plan of Removal.

Based on observation, interview and record review, the facility failed to ensure that a resident who was fed by enteral feeding received the appropriate treatment and services to prevent complications for one (Residents #52) of five residents reviewed for tube feedings. The facility failed to notify Resident #52's Physician and the Dietitian when she was not tolerating her 3:00 PM 500 ml bolus feeding. The resident was seen gagging during her feeding and tapping on the feeding syringe, alerting staff to stop her feeding. Resident #52 was admitted to the hospital on 01/17/22 with pneumonia possibly from aspiration when she was found in vomit about five hours after her 3:00 PM bolus feeding. An Immediate Jeopardy was identified on 03/10/22. While the Immediate Jeopardy was removed on 03/11/22, the facility remained out of compliance at a scope of pattern and a severity level of actual harm that is not Immediate Jeopardy, due to the facility's continuation of in-servicing and monitoring the plan of removal. These failures placed residents at risk if aspiration pneumonia due to fluid overload or even death. Findings included: Review of Resident #52's MDS assessment dated [DATE] reflected the resident was an [AGE] year-old female admitted to the facility on [DATE] with the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . The assessment further reflected Resident #52 usually understands-misses some part/intent of message but comprehends most conversation. She required total dependence on feeding/staff perform every time during entire 7-day period. The assessment also reflected the resident had a feeding tube seven days for proper calories. Review of Resident #52's care plan reflected she had a peg tube and was at risk for aspiration with an onset of 03/09/20. Approaches included to monitor for s/s of aspiration, fever, cough, rales/rhonchi, wheezing, and altered mental status. The approaches also included notifying the MD as needed. Review of Resident #52's Nurse Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] TF [MEDICATION(S)] 1.5 calorie liquid formula bolus give two cartons (500ml) via g-tube twice daily 8A, 3A, and one carton (250ml) once a day at 11P with a start date of 01/24/22. Review of Resident #52's nurses notes dated 01/17/22 documented by RN B revealed the following: Late entry 01/16/22 at 16:30 [4:30 PM] while administering bolus via gtube half way through second carton resident reached up to stop me but right as she touched me she began to vomit severely. Emesis (vomit) appeared to be all tube feeding. Continued to monitor resident frequently and noted resident covered in emesis on her neck and chest around 9 PM. Resident continued to nod her head when asked if she was not feeling well. RN held evening meds and 11 PM bolus due to continued vomiting and nausea. 01/17/2022 4:10 AM RN continued making frequent round to monitor this resident due to n/v with gtube and inability to verbalize help along with answering questions as well as before v/s: 185/108 89% on room air O2 applied at 2 lpm via n/c Lung sounds clear to bilateral upper lobes but completely diminished through lower lobes family member notified and requested to have resident transferred to the ER Review of Resident #52's hospital records revealed she was admitted to the hospital on 01/17/22 with the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was discharged and transferred back to the facility on [DATE]. Review of the unsigned 24-hour report on the following dates for Resident #52 revealed: 02/06/22 - not tolerating 2 cartons of gtube bolus, becomes congested, coughs, asks you to stop. etc. dietary referral for higher calorie, less volume feeding? 02/07/22 - not tolerating 2 cartons of gtube bolus, becomes congested, coughs, asks you to stop, etc. dietary referral for higher calorie, less volume feeding? 02/08/22 - not tolerating 2 cartons of feeding becomes congested coughs. Dietary referral for increased calorie decreased volume. Observation and interview of Resident #52's bolus feeding on 03/08/22 at 3:00 PM given by Agency Nurse A revealed the resident tolerated the first 250 ml carton of formula and began to tap her hand on the feeding syringe halfway through the second carton. At that time Agency Nurse A stopped the feeding and asked the resident if she was feeling ok and Resident #52 nodded her head indicating no. The agency nurse asked the resident if she was feeling uncomfortable and full and the resident nodded her head indicating yes. Resident #52 then began to grimace and gag and appeared as though she was going to vomit. Agency Nurse A stated she was going to call the doctor and document the incident as this was the first time working with the resident. Interview on 03/09/22 at 9:30 AM with LVN C revealed she cared for Resident #52 during the 6:00 AM to 2:00 PM shift and she never had any concerns with the resident's gtube feeding during her shift. She stated she heard about a month ago, the weekend staff were saying Resident #52 was not tolerating her feeding but did not get more information to the time of the feeding or the staff caring for the resident. Interview on 03/09/22 at 1:46 PM with RN B revealed, she was the nurse who sent Resident #52 to the hospital on 01/17/22. She said during her 3:00 PM bolus feeding the resident put her hand up and told her to stop her feeding during her second formula carton (250 ml) so she stopped. Resident #52 began to vomit right away and there had been times the resident was not able tolerate the 2 cartons (500 ml) of formula and the resident always let her know when she was full. After Resident #52 vomited, she cleaned her up, and she and the aides began to monitor her more frequently and she called the NP about an hour after the incident, and she was not able to get in touch with him. Later that night around 9:00 PM, RN B found Resident #52 with emesis again and she did not appear well and did not know long it had been since the resident had vomited as the last time she remembered checking on her was around 8:00 PM. At that time, RN B called Resident #52's family and they asked the resident be sent out to the hospital. RN B further stated she should have tried to contact the resident's physician after she was not able to get in touch with the NP but had let ADON C know about the incident. RN B said she wrote the vomit incident in the 24-hour report for the resident to have higher calories and less volume and she thought the communication would make to dietary. She also said LVN E had continued the communication form and put an entry to reduce the volume of Resident #52 was receiving. RN B also said resident ran the risk of aspiration if they were not able to tolerate a bolus feeding. RN B had not let anyone else know the resident was not tolerating her feeding because it had only happened to her once or twice before. Interview on 03/11/22 at 8:45 AM with LVN D revealed she cared for Resident #52 and administered her bolus feedings and never had a problem giving them to her. She further stated she was not aware the resident was not tolerating the volume of her bolus feedings. Interview on 03/10/22 at 2:30 PM with ADON D revealed she took the position of ADON mid-January 2022. She stated she had cared for Resident #52 and administered her bolus feedings a few times and the resident was able to let staff know when she was full by putting her hand up but she never vomited or gagged during her feedings and this would occurred halfway through the second carton formula. ADON D stated she was aware Resident #52 had been sent out to the hospital in January after vomiting and she had returned with no new feeding orders. ADON D further stated the 24-hour reports were taken to the staff morning meetings and reviewed but she did not recall seeing/reading the entries of Resident #52, asking for a decreased volume due to not tolerating the feedings and does not know why they were missed but should not have been. She said if they would have seen the entries they would have called the doctor to let him know. Interview on 03/10/22 at 3:46 PM with the Interim DON revealed she took over as interim DON on 02/15/22 and she was not aware Resident #52 was not tolerating her bolus feedings. She said if Resident #52 was not tolerating her feedings, the doctor or RD should have been contacted to adjust her feedings. She further stated the 24-hour reports were taken to the morning meetings daily and the nursing staff or the ADON would review it for any changes. The Interim DON further stated risk of residents not tolerating a feeding or fluid overload could lead to weight loss and aspiration pneumonia. Interview on 03/09/22 at 12:00 PM with the RD revealed she was just notified today, 03/09/22, that Resident #52 was not tolerating her feedings due to fluid overload. He said if this occurrence was happening more than once, he would have needed to know so he could assess and adjust the feedings because there was a risk of becoming overloaded with fluid. The RD further stated risk of fluid overload could cause diarrhea and emesis and if the resident was vomiting that could lead to aspiration. He also stated if he would have been made aware of Resident #52's first incident in January 2022, when the resident was sent out to the hospital, he would have made changes at that time. Interview on 03/10/22 at 10:27 AM with the NP revealed he was made aware two days prior on 03/08/22 that Resident #52 was not tolerating two cartons of formula during her bolus feedings. He stated he would have expected to have been called if the resident was vomiting due to the risk of aspiration pneumonia because it the pneumonia was not treated it could be fatal. Interview on 03/10/22 at 9:33 AM with the Physician revealed he had never seen a resident receive 500 ml for one feeding. He stated he would normally suggest 250 ml to 360 ml in one feeding, but he usually left that decision to the RD. He stated he or the NP should have been called if Resident #52 was not tolerating her feeding more than once so changes could have been made to lower her fluid volume due to the risk of getting pneumonia from aspirating. Review of facility's policy and procedure entitled Enteral Tube Feeding via Syringe (Bolus) revised November 2018 reflected the following: Purpose The purpose of this procedure is to provide nutritional support to residents unable to obtain nourishment orally Reporting 1. Report complications promptly to the supervisor and the Attending Physician. An Immediate Jeopardy/Immediate Threat was identified on 03/10/22. The Administrator and Interim DON were notified of the Immediate Jeopardy on 03/10/22 at 1:45 PM. The facility was asked to provide a Plan of Removal to address the Immediate Jeopardy. The Facility's Plan of Removal for Immediate Jeopardy was accepted on 08/04/22 at 3:16 PM and reflected the following: The Registered Dietitian will educate licensed nursing staff on the following procedure for notification of the RD on 03/10/22. For emergent request the RD should be consulted via phone for assistance. If the RD does not respond to the message/voicemail within one hour, the facility should contact the Nutritional Life Styles (NLS) office for assistance. NLS has a senior manager on call every day. The facility can also reach out to their corporate RD account manager for assistance. Staff should contact their RD withing 24 hours of admission on an enteral feeding for review The Director of Nursing or designee will review 24 hour reports and nurses notes the following day to ensure notification had been completed. All Registered Dietitian referrals will be place on the consultant referral form and kept in the NLS binder. Licensed nurses will be in-serviced by Regional Quality Improvement Nurse on Acute Change in Condition and related to tube feeding intolerance on 03/10/22. The Director of Nursing or designee will review 24 hour reports and nurses noted daily to ensure Physician notification has occurred timely. In-servicing will be completed by 03/10/22. Education will consist of the following procedure: Stop the tube feeding Assess the resident Notify the Physician Notify the Registered Dietitian Notify the on-call nurse (ADON D and Interim DON) New agency nurses will be educated through Agency Orientation Checklist All non-present nurses will be in-serviced prior to next scheduled shift or via phone The Registered Dietitian will review current tube feeding residents by 03/10/22 then monitor clinical records nurse's notes bi-weekly times three months then monthly on-going. The Director of Nursing or designee with oversight from the Administrator will monitor the above listed processes daily times two then weekly times six. Discrepancies will be addressed immediately and QAPI will be updated and addressed. Monitoring of the facility's Plan of Removal included the following: Interviews were conducted on 03/11/22 starting at 8:45 AM and continued through 1:56 PM with 10 staff members from various shifts regarding in-services which included bolus g-tube proficiency, assessment, physician notification, and Registered Dietitian when a resident is not tolerating a bolus feeding. The staff members were able to: Assess the resident during and after bolus feeding. What to do if resident has an emergent tube feeding change in condition. Who to notify in case a resident is not tolerating a feeding. When the RD should be contacted when a resident admits. What to do if a resident needed a general referral. Where and what to document the incident if a resident does not tolerate a feeding. Interviewed staff members from various shifts were: LVNs C, E, G, K, L, H and RNs B, F, I, J ADON D and Interim DON were provided in-service training on how often the 24-hour reports are to be reviewed and monitored. The Administrator was notified on 03/11/22 at 3:30 PM, the Immediate Jeopardy was removed. While the immediacy was removed on 03/11/22, the facility remained out of compliance at a scope of pattern and a severity level of actual harm that is not Immediate Jeopardy, due to the facility continuing in-servicing and monitoring the plan of removal.

Based on observation, interview and record review, the facility failed to maintain an infection prevention and control program designated to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infection for three (Residents #2, #16, and #66) of three residents reviewed for infection control. MA M failed to disinfect the blood pressure cuff in between blood pressure checks for Residents #2, #16, and #66. These failures could place residents at-risk of cross contamination which could result in infections or illness. Findings included: Observation on 03/09/22 at 8:27 AM of MA M revealed she failed to disinfect the reusable blood pressure cuff with a disinfecting wipe between blood pressure readings on Residents #2, #16, and #66. Interview on 03/09/22 at 10:02 AM with MA M revealed she was aware of the requirement to disinfect the blood pressure cuff between residents, but the presence of the surveyor made her nervous. She revealed that not disinfecting equipment between residents can cause infections to be passed from one to another. Interview on 03/09/22 at 10:15 AM with the DON revealed the expectation was that staff would disinfect all reusable medical equipment between each resident use, to avois cross contamination. The DON stated staff had disinfecting wipes available to them, and they were usually stocked on the stand holding the blood pressure monitor. She revealed she completed a staff in-service training in February of 2022 on disinfection of reusable medical equipment. Review of facility in-service sign in sheet for Disinfection of Reusable Medical Resources, dated February 2022, revealed MA M had signed the sign-in sheet. Review of facility's undated policy on Disinfection of Reusable Patient Equipment revealed that all reusable medical equipment is required to be disinfected between each resident use, using EPA approved disinfectant. Review of disinfecting wipes stocked on the stand holding the blood pressure cuff revealed they are effective against [CONDITION(S)] COVID-19, with a 1-minute dwell time, according to the Environmental Protection Agency registration number when it was checked against the EPA website.

Based on observations, interviews and record reviews, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of COVID-19 for four (Resident #1, #2, #3, and #4) of eight residents and two (CNA B and COTA E) of five staff reviewed for infection control. 1. CNA B failed to use hand hygiene practices while passing lunch trays to both COVID-19 positive and negative residents. 2. COTA E failed to change gloves and perform hand hygiene after physically touching Resident #1 (who was COVID-19 positive) and then assisting Resident #4 (who was COVID-19 negative). 3. Staff were not informed Resident #2 was COVID-19 positive and were caring for him without donning/doffing appropriate PPE. 4. The facility failed to ensure both Resident #1 and Resident #3 (who were COVID-19 positive) stayed on the COVID-19 units. An Immediate Jeopardy (IJ) was identified on 01/13/22 at 5:55 PM. While the IJ was removed on 01/15/22, the facility remained out of compliance at a severity level of potential for more than minimal harm that was not immediate jeopardy and a scope of pattern because the facility was still monitoring the effectiveness of their Plan of Removal. These failures could place residents at risk of exposure to COVID-19, which could result in serious illness, hospitalization , and/or death. Findings included: 1. Review of the facility's census, dated 01/12/22, revealed the following resident rooms on the 300-hall were COVID-19 positive: 301, 306, 307, 309, 310, 312, 313, 314, 315, and 316. Review of the facility's census, dated 01/12/22, revealed resident rooms 302, 303, 304, 305, and 311on the 300-hall had a COVID-19 status of unknown or negative In an observation of the 300-hall on 01/13/22 at 9:30 AM revealed red tape on the ground in front of rooms [ROOM NUMBERS] with signs posted on the doors behind the tape indicating those rooms were designated hot zones. Before the red tape, there was a three-drawer bin with PPE inside including disposable gowns, gloves, face shields, and masks. In an observation of the 300-hall on 01/13/22 between12:26 PM to 1:00 PM revealed CNA B passing lunch trays to residents. CNA B was wearing a reusable gown, face shield, and an N95 mask. CNA B took a tray into room [ROOM NUMBER] (a COVID-19 positive room), walked back to the hall cart and then took an additional tray back into room [ROOM NUMBER]. CNA B did not perform hand hygiene. CNA B then took a tray into rooms [ROOM NUMBERS] (COVID-19 positive rooms). CNA B did not perform hand hygiene. At 12:33 PM CNA B took a lunch tray into room [ROOM NUMBER] (a COVID-19 negative room). CNA B did not perform hand hygiene. CNA B then took two trays into room [ROOM NUMBER] (a COVID-19 negative room). CNA B did not perform hand hygiene. CNA B then took a tray into room [ROOM NUMBER] (this resident had been identified earlier as COVID-19 positive but there was no sign on the door indicating such). CNA B did not perform hand hygiene. CNA B then took a tray into room [ROOM NUMBER] (a COVID-19 positive room). CNA B did not perform hand hygiene. CNA B continued down the hall to the other COVID-19 positive resident rooms without performing hand hygiene. CNA B never donned any additional PPE or doffed any PPE during the observation. In an interview on 01/13/22 at 1:09 PM with CNA B revealed she was the aide assigned to work the 300-hall. CNA B said she knew all residents on the 300-hall were positive except the front ones and identified rooms [ROOM NUMBER] as being COVID-19 negative. CNA B said she did not perform hand hygiene between residents when she was passing trays to them because she only did that before and after she was finished with passing all the trays. CNA B said she only performed hand hygiene when it was convenient or if she came in physical contact with a resident, so since she was only dropping trays off in their rooms it was not necessary for her to perform hand hygiene between each resident. CNA B did not define what convenient meant to her. CNA B said she knew she could find hand sanitizer in hallway, use the shower room to wash her hands in the sink, and use the resident's bathrooms as well to perform hand hygiene. CNA B said she did pass trays to COVID-19 positive residents at the end of the hall and then to the COVID-19 negative residents at the front of the hall without performing hand hygiene or changing any of her PPE. CNA B said she knew when going into COVID-19 positive resident rooms where she would come in physical contact with them, she was supposed to put on a disposable gown over her reusable gown and don gloves. CNA B said when she was leaving the COVID-19 positive resident rooms she was to doff the disposable gown and gloves and perform hand hygiene. CNA B said she was not sure if she was expected to put on a disposable gown over her reusable gown if she was going into the COVID-19 positive resident's room to drop off their meal tray . In an interview on 01/13/22 at 2:25 PM with the DON/IP revealed staff working on the 300-hall with both COVID-19 positive and negative residents should be donning a disposable gown before entering and taking it off when exiting. The DON/IP said staff should be performing hand hygiene after exiting the resident's room regardless of COVID-19 status but especially after leaving a COVID-19 positive resident's room since it was considered a hot zone. The DON/IP said staff have access to hand sanitizer in the hallway and have sinks with available soap in the resident's bathrooms. The DON/IP said staff should be performing hand hygiene between residents when passing trays to them . In an interview on 01/04/22 at 3:05 PM with the Administrator revealed part of the 300-hall had COVID-19 positive residents on it so staff should be putting on a disposable gown when entering those rooms and removing it prior to leaving and performing hand hygiene. The Administrator said staff had access to hand sanitizer on the walls and soap in the resident's bathrooms. The Administrator said staff should be using the general infection control practice with hand hygiene during passing trays to residents, regardless of their COVID-19 status. The Administrator said he expected staff to use hand sanitizer or wash their hands between all residents. The Administrator said if staff were not performing hand hygiene between residents, especially while working with both COVID-19 positive and negative residents, the concern was that they could be spreading COVID-19 to the negative residents. 2.Review of the facility's census, dated 01/12/22, revealed Resident #1 was COVID-19 positive and resided at the end of the 300-hall and Resident #4 was COVID-19 negative and resided at the front of the 300-hall. In an observation on 01/13/22 at 1:46 PM revealed Resident #1 walking down the 300-hall with her surgical mask below her chin. Resident #1 walked by COTA E who was standing in the doorway of Resident #4's room with gloves on and a paper covered straw in his hands. COTA E stopped Resident #1 and pulled her surgical mask over her nose for her. COTA E then (with the same gloves on) opened the paper covered straw, went to Resident #4's bedside, put the straw in a cup with pink liquid, and put the cup with the straw to Resident #4's mouth so that he could drink. COTA E never changed his gloves or performed hand hygiene. COTA E was observed making Resident #4's bed and then transferred the resident with the same gloves on. COTA E exited the room, took the gloves off, and then used hand sanitizer in the hallway. In an interview on 01/13/22 at 1:55 PM with COTA E revealed he was in the middle of assisting Resident #4 when he saw Resident #1 walking down the hall with her mask below her chin. COTA E said he stepped in the hallway to assist with redirecting her and while wearing gloves, he pulled her mask up over her nose. COTA E said he then opened a straw for Resident #4 and assisted him with drinking from it with the same gloves on. COTA E said he should have changed his gloves and performed hand hygiene after assisting Resident #1 with her mask. COTA E said he knew Resident #1 was COVID-19 positive and Resident #4 was negative. COTA E said he was concerned about Resident #1 leaving the 300-hall because she needed constant redirection to stay in the area. COTA E said the risk to Resident #4 was he has been exposed to COVID-19 directly now. In an interview on 01/13/22 at 2:25 PM with the DON/IP revealed staff were expected to remove their gloves if they used them to physically touch a COVID-19 positive resident and perform hand hygiene prior to moving to another resident. The DON/IP said if staff were using the same gloves to care for both COVID-19 positive and negative residents, the negative resident could have had COVID-19 spread to them. The DON/IP said staff should remove their gloves and perform hand hygiene before moving to another resident regardless of their COVID-19 status. In an interview on 01/13/22 at 3:05 PM with the Administrator revealed staff interacting with a COVID-19 positive resident should take off their disposable PPE, including gloves, and perform hand hygiene. The Administrator said if a staff member physically touched a COVID-19 positive resident and then cared for a negative resident the second resident could now have COVID-19 spread to them. The Administrator said the staff member should have taken their gloves off, perform hand hygiene, and put new gloves on before assisting the second resident. Review of the facility's policy Handwashing/Hand Hygiene revised August 2019 reflected: 2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. 3. Hand hygiene products and supplies (sinks, soap, towels, alcohol-based hand rub, etc.) shall be readily accessible and convenient for staff use to encourage compliance with hand hygiene policies 6. Wash hands with soap (antimicrobial or non-antimicrobial) and water for the following situations: a. When hands are visibly soiled; and b. After contact with a resident .7. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations .b. Before and after direct contact with residents .f. Before donning sterile gloves .m. after removing gloves .n. Before and after entering isolation precaution settings .o. Before and after eating or handling food .8. Hand hygiene is the final step after removing and disposing of personal protective equipment. 9. The use of gloves does not replace hand washing/hand hygiene. Review of the facility's undated policy, COVID-19 Implementation and Guidance- TX reflected: .The general strategies CDC recommends to prevent the spread of COVID-19 in LTCF are the same strategies our facilities use every day to detect and prevent the spread of other respiratory viruses like influenza Education: Wash your hands often with soap and water for at least 20 seconds .Hand washing before and after contact with residents, after contact with contaminated surfaces or equipment and after removing personal protective equipment (PPE). 3.Review of Resident #2's Face Sheet, dated 01/15/22, revealed he was a [AGE] year-old male who admitted to the facility on [DATE]. His diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #2's MDS Assessment, dated 12/02/21, revealed he had a BIMS score of 13, indicating the resident was cognitively intact. In an observation on 01/13/22 at 11:30 AM revealed Resident #2's door was open and did not have a sign posted on it indicating to staff that he was on isolation precautions. In an interview on 01/13/22 at 10:00 AM with the DON revealed Resident #2 had tested positive as of this morning (01/13/22). In an interview on 01/13/22 at 1:09 PM with CNA B revealed she was the aide assigned to work the 300-hall. CNA B said she knew all residents on the 300-hall were positive except the front ones and identified rooms 302, 303 (Resident #2's room), and 304 as being COVID-19 negative. CNA B said she had not been told there were any additional positive residents during her shift. CNA B said she would have been told by the nurse if a resident had tested positive for COVID-19 during her shift or there would be a sign posted on the door indicating they were COVID-19 positive. In an interview on 01/13/22 at 1:29 PM with RN C revealed she was working the 300-hall with both COVID-19 positive and negative residents. RN C said the positive resident rooms were separated with red tape on the floor and a sign on their door identifying the room as a hot zone. RN C said the resident rooms in front of the red tape were known to be negative except for the resident in room [ROOM NUMBER] who tested positive for COVID-19 yesterday (01/12/22). RN C said she had not been told any other residents in front of the red tape were COVID-19 positive (including Resident #2) as far as she knew, they were negative. RN C said she would usually be told by the DON if a resident tested positive during her shift. In an interview on 01/13/22 at 2:25 PM with the DON/IP revealed staff on the 300-hall knew who was COVID-19 positive based on a sign that was put on the resident's door indicating the room was a hot zone. The DON/IP said if a resident did not have a sign on their door that indicated to staff the resident was COVID-19 negative. The DON/IP said they tested Resident #2 earlier today and he was positive for COVID-19 and should have a sign on his door indicating such. The DON/IP said she also told staff working on the 300-hall that Resident #2 was COVID-19 positive earlier in the day after they tested him around 10 o'clock. The DON/IP said she could not remember who she told that information to. The DON/IP said the concern with staff not knowing who was COVID-19 positive and who was negative meant they might unknowingly spread COVID-19 to other residents. In an interview on 01/13/22 at 3:05 PM with the Administrator revealed all staff were informed about new COVID-19 positive residents verbally by the DON and by the sign on the resident's door. The Administrator said the sign on the door would tell the staff they were entering a hot zone and to see the nurse before entering the room. The Administrator said all COVID-19 positive residents should have this sign on their door to let staff know they are COVID-19 positive. The Administrator said the concern with staff not knowing a resident was COVID-19 positive was they could unknowingly spread COVID-19. Review of the facility's policy, revised August 2019, and titled Isolation- Notices of Transmission Based Precautions reflected: 1. When transmission-based precautions are implemented, the Infection Preventionist (or designee) determines the appropriate notification to be placed on the room entrance door so that personnel and visitors are aware of the need for and type of precautions. 2 The following may be used to indicate: .c. Droplet Precautions: (1) A notice at the doorway instructing visitors to report to the nurse's station before entering the room . Review of the facility's policy, revised October 2018, and titled Isolation- Categories of Transmission-Based Precautions reflected: 5. When a resident is placed on transmission-based precautions, appropriate notification is placed on the room entrance door .so that personnel and visitors are aware of the need for and the type of precaution. A. The signage informs the staff of the type of CDC precaution(s), instructions for use of PPE, and/or instructions to see a nurse before entering the room. B. Signs and notifications comply with the resident's right to confidentiality or privacy Droplet Precautions, 1. Droplet precautions may be implemented for an individual documented or suspected to be infected with microorganisms transmitted by droplets (large-particle droplets .that can be generated by the individual coughing, sneezing, talking, or by the performance of procedures such as suctioning) .3. Masks will be worn when entering the room. 4. Gloves, gown and goggles should be worn if there is risk of spraying respiratory secretions. Review of the facility's undated policy, titled COVID-19 Implementation and Guidance- TX reflected: .The general strategies CDC recommends to prevent the spread of COVID-19 in LTCF are the same strategies our facilities use every day to detect and prevent the spread of other respiratory viruses like influenza Isolation: Post signs on each resident door of what type of precautions they are on and to see the nurse prior to entering the room. 4.Review of the facility's census, dated 01/12/22, revealed Resident #1 was residing on the 300-hall and Resident #3 was residing on the 200-hall. The 200-hall was for only COVID-19 positive residents only while the 300-hall had half the hallway designated as COVID-19 positive. Residents #1 and 2 were COVID-19 positive. Review of Resident #3's Face Sheet, dated 01/15/22, revealed she was an [AGE] year-old female who admitted to the facility on [DATE]. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #3's MDS Assessment, dated 01/03/22, revealed she had a BIMS score of 7, indicating severely impaired cognition . Review of Resident #3's Admission Care Plan, dated 01/15/22, revealed it did not address her wandering behaviors . Review of Resident #3's Departmental Notes dated 01/05/22 indicated: .Walking wandering around from room to room .[sic]. Review of Resident #3's Departmental Notes dated 01/08/22 indicated Confused, walking around, wandering from room to room, said, wants to go home .continue redirect to her room .[sic]. Review of Resident #3's Departmental Notes dated 01/11/22 indicated Resident continue on COVID unit, confused/alert, stable and exit seeking, Resident wondering from room to room, easy to redirect .[sic]. In an observation of the 200-hall COVID-19 unit on 01/13/22 at 2:10 PM revealed Resident #3 was walking down the hall to the nurse's station without a mask on in her nightgown asking where the beauty salon was located. Resident #3 was redirected by staff back to the 200-hall COVID-19 unit. In an observation of the 200-hall COVID-19 unit on 01/13/22 at 2:15 PM revealed Resident #3 walking down the hall to the nurse's station again without a mask on. Resident #3 was redirected by staff back to the 200-hall COVID-19 unit. In an interview on 01/13/22 at 2:19 PM with MA D revealed she assisted Resident #3 back to the 200-hall COVID-19 unit because Resident #3 was positive, did not have a mask on, and was not supposed to leave the unit. MA D said she was not sure if that was the first time Resident #3 had left the COVID-19 positive unit or not. In an interview on 01/13/22 at 2:23 PM with Central Supply revealed she had seen Resident #3 attempt to leave the COVID-19 positive unit a few times and had to redirect her back to the 200-hall. Central Supply said Resident #3 was very confused and did not know where she was. Review of Resident #1's Face Sheet, dated 01/15/22, revealed she was an [AGE] year-old female who admitted to the facility on [DATE]. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's MDS Assessment, dated 01/16/22, revealed she her BIMS score was not scored since the MDS was not due yet . In an observation of the 300-hall on 01/13/22 at 12:12 PM revealed Resident #1 was walking down the hallway with her walker. Resident #1 appeared confused. In a continuous observation of the 300-hall on 01/13/22 at 12:46 PM revealed Resident #1 was walking down the hallway with her walker and a surgical mask below her nose. Resident #1 walked off of the hallway and sat next to a male resident (who was wearing a surgical mask) in front of the nurse's station; the residents were within arm's reach of each other. At 12:54 PM Resident #1 walked around the nurse's station to another chair and sat down. At 12:59 PM Resident #1 got up and walked around the nurse's station again to the 400-hall (COVID-19 negative) still with her mask below her nose. Resident #1 came in contact with various staff walking by, and a male resident sitting in his wheelchair who did not have a mask on. At 1:02 PM, two therapy staff intervened and brought her back to the 300-hall. In an interview on 01/13/22 at 1:09 PM with CNA B revealed Resident #1 had been wandering down the hallway a few times during her shift and she was trying her best to keep an eye on Resident #1. CNA B said she had tried closing Resident #1's door to keep her on the COVID-19 unit because Resident #1 was COVID-19 positive. CNA B said Resident #1 was very confused and had to be redirected often. In an interview on 01/13/22 at 1:29 PM with RN C revealed Resident #1 had been wandering down the hallway and was COVID-19 positive. RN C said staff were attempting to redirect her back to her room, but she was very confused. RN C said she and the aide were trying to keep her on the 300-hall. RN C said she did see Resident #1 had made it around the nurse's station to another hallway where COVID-19 negative residents were and was not sure how it happened. In an interview on 01/13/22 at 2:25 PM with the DON/IP revealed she knew Resident #1 had been wandering off the 300-hall and staff had been trying to redirect her. The DON/IP said Resident #1 had admitted to the facility the evening prior (01/12/22) because Resident #1 had tested positive. The DON/IP said Resident #1 had dementia and it was difficult to keep her on the 300-hall. The DON/IP said she had not been told Resident #1 went to another hall earlier and came in contact with other residents or staff. The DON/IP said she knew Resident #3 on the 200-hall COVID-19 positive unit had wandered off as well earlier in the day because someone told her. The DON/IP said Resident #3 was confused and staff had redirected her back to her room on the COVID-19 positive unit. The DON/IP said the concern with Resident #1 and Resident #3 leaving their COVID-19 positive areas was that they could be spreading COVID-19 to others in the facility . In an interview on 01/13/22 at 3:05 PM with the Administrator revealed he had heard there were two residents on the COVID-19 units who were wandering out of their areas. The Administrator said staff were redirecting them back to their rooms because they were COVID-19 positive but the residents were confused. The Administrator said the concern with these two residents leaving their areas was that they could be spreading COVID-19 throughout the rest of the facility . Review of the facility's policy, revised March 2019, and titled Wandering and Elopements reflected: 2. If identified as at risk for wandering, elopement, or other safety issues, the resident's care plan will include strategies and interventions to maintain the resident's safety .4. The following items will be used to increase staff awareness of residents at risk to wander/elope: Orientation of all staff to potential wanderers will be performed on an on-going basis. Review of the facility's undated policy, titled COVID-19 Implementation and Guidance- TX reflected: .The general strategies CDC recommends to prevent the spread of COVID-19 in LTCF are the same strategies our facilities use every day to detect and prevent the spread of other respiratory viruses like influenza. The administrator was informed of the immediate jeopardy (IJ) on 01/13/22 at 5:55 PM and was provided with the IJ template. A Plan of Removal (POR) was also requested at that time. The facility's POR was accepted on 01/14/22 at 3:55 PM and reflected the following: [Facility Name] Plan of Removal for Immediate Jeopardy called related to Infection Control 01/14/2022 Identified Concern: There are two residents on either COVID-19 unit who have wandered off the unit into warm zones where residents are known to be negative or unknown. Immediate Plan of Correction: Regional Vice President, initiated an in-service of all staff on 1/13/22 over the policy and procedure on how to identify residents at risk for wondering and elopement and how to maintain the hot zone boundaries utilizing community based observation. All new staff, agency staff, and staff out on leave will be in-serviced by the Administrator, Director of Nursing, or designee. Administrator and the Director of Nursing will ensure completion and understanding of in-servicing with facility staff on-going until compliance has been achieved. In-service completion date: 1/14/22 Director of Nursing and Minimum Data Set Nurse initiated an re-assessment of all positive residents for wandering and elopement risk on 1/13/2022. Any Identified residents that were identified were relocated to the community based observation hall. All new positive Covid residents will be assessed for wandering and elopement risk by the charge nurse. All new positive Covid admitting residents will be assessed for wandering and elopement risk by the charge nurse. Facility staff with oversight from the Administrator and Director of Nursing will be conducting community observation to maintain hot zone boundaries. Identified Concern: A CNA was observed to have passed lunch trays to positive residents and then negative residents without changing any of her PPE and/or performing hand hygiene. Immediate Plan of Correction: The Regional Vice President, initiated in-servicing with facility staff on 1/13/22 over Policy and Procedure - hand hygiene and proper donning and doffing of PPE with droplet precaution residents, specifically COVID-19 patients. All new staff, agency staff, and staff out on leave will be in-serviced by the Administrator, Director of Nursing, or designee. One on one education with the identified Certified Nurse Assistant initiated on proper infection control when transitioning to and from COVID positive patients to unidentified or negative patients. Administrator, and the Director of Nursing, will ensure completion and understanding of in-servicing with the Certified Nurse Assistant and facility staff on-going until compliance has been achieved. In-service completion date: 1/14/22 Identified Concern: A COTA was observed pulling up a positive resident's mask with gloves on and without performing hand hygiene or changing gloves, he then assisted a negative resident with drinking from a straw. Immediate Plan of Correction: The Regional Vice President, initiated in-servicing with facility staff on 1/13/22 over Policy and Procedure - hand hygiene and proper donning and doffing of PPE with droplet precaution residents, specifically COVID-19 patients. All new staff, agency staff, and staff out on leave will be in-serviced by the Administrator, Director of Nursing, or designee. One on one education with the identified COTA initiated on proper infection control when transitioning to and from COVID positive patients to unidentified or negative patients. Administrator, and the Director of Nursing, will ensure completion and understanding of in-servicing with facility staff and on-going until compliance has been achieved. In-service completion date: 1/14/22 Identified Concern: There was a resident who tested positive this morning (on 01/13/22) and staff caring for him did not know he was positive until surveyor intervened and the facility put a sign on his door alerting that the room was considered a hot zone. Immediate Plan of Correction: Regional Vice President, initiated in-servicing with facility staff on 1/13/22 over Policy and Procedure - Isolation notices of transmission based precautions with a focus on droplet precautions and over identifying boundaries of a hot zone. All new staff, agency staff, and staff out on leave will be in-serviced by the Administrator, Director of Nursing, or designee. The Administrator, and the Director of Nursing, will ensure completion and understanding of in-servicing with the facility staff on-going until compliance has been achieved. In-service completion date: 1/14/22 Completion of this deficiency will be completed by 1/14/22 The following interviews, and record reviews were conducted to verify the implementation of the facility's Plan of Removal and revealed the following: Review of a report, dated 01/15/22, revealed all COVID positive residents' Elopement Risk Assessments were completed. Review of Resident #3's Elopement Risk Assessment, dated 01/15/22, revealed it was completed on 01/13/22 by the DON. Review of Resident #1's Elopement Risk Assessment, dated 01/15/22, revealed it was completed on 01/13/22 by LVN F. Review of an in-service started on 01/13/22 revealed staff were trained and educated on PPE. Review of an in-service started on 01/13/22 revealed staff were trained and educated on COVID-19 positive residents who wander. Review of an in-service started on 01/13/22 revealed staff were trained and educated on hand hygiene. Review of an in-service started on 01/13/22 revealed staff were trained and educated on the initiation of isolation or transmission-based precautions. Interviews were conducted with staff across multiple shifts from 01/13/22 to 01/15/22 including: 3 MA's, MDS Coordinator, BOM, Medical Records, Activity Director, Central Supply, Dietary Manager, Clinical Liaison, Marketer, HR, Receptionist, Admissions Coordinator, ADON, 5 LVN's, DA, 9 CNA's, 1 RN, 1 HK, 1 ADA, 1 PTA, the DON, and the Administrator. They were all able to verbalize the appropriate understanding of hand hygiene, PPE, isolation/transmission-based precautions, and COVID-19 positive residents who were at risk of wandering. Observations made on 01/14/22 at 5:45 PM of the dinner meal tray service on the 300-hall revealed staff were donning the appropriate PPE and doffing prior to exiting the COVID-19 positive rooms. Staff were observed wearing gloves and performing hand hygiene between residents. Staff passed dinner trays to the COVID-19 negative residents first and then the COVID-19 positive residents after. There were also signs posted on the COVID-19 positive residents' room doors. Observation made on 01/15/22 at 12:00 PM revealed staff were redirecting both Resident #1 and Resident #3 back to their rooms on the 300-hall since they were COVID-19 positive. Observation made on 01/15/22 at 12:15 PM of the 300-hall revealed staff were donning the appropriate PPE and doffing prior to exiting the COVID-19 positive rooms. Staff were observed wearing gloves and performing hand hygiene between residents. Staff passed dinner trays to the COVID-19 negative residents first and then the COVID-19 positive residents after. There were also signs posted on the COVID-19 positive residents' room doors. An Immediate Jeopardy (IJ) was identified on 01/13/22 at 5:55 PM. While the IJ was removed on 01/15/22, the facility remained out of compliance at a severity level of potential for more than minimal harm that was not immediate jeopardy and a scope of pattern because the facility was still monitoring the effectiveness of their Plan of Removal.

Based on interview and record review, the facility failed to conduct COVID-19 testing of facility staff based on parameters set forth by the Secretary, including but not limited to testing frequency for two (DA F and CNA G) of five facility staff reviewed for COVID-19 testing. The facility failed to ensure DA F and CNA G were tested twice per week due based on positivity rate of COVID-19 in the county being greater than 10%. This deficient practice could place residents at risk for exposure to COVID-19 virus which could result in serious illness or hospitalization . Findings included: Review of the facility's list of staff's vaccination status revealed DA F was listed under Exemption and CNA G was listed under Unvaccinated. Review of DA F's timesheet revealed she worked 12/25/21-12/31/21 and 01/01/22- 01/13/22. Review of CNA G's timesheet revealed she worked on 12/28/21, 12/30/21, 01/03/22, and 01/07/22. Review of the facility's log for staff tested on [DATE] revealed CNA G was not listed. Review of the facility's log for staff tested on [DATE] revealed DA F and CNA G were not listed. Review of the facility's log for staff tested on [DATE] revealed DA F and CNA G were not listed. Review of the facility's log for staff tested on [DATE] revealed DA F and CNA G were not listed. Review of the facility's log for staff tested on [DATE] revealed CNA G was not listed. In an interview on 01/15/22 at 12:42 PM with the DON/IP revealed staff were supposed to be tested on Mondays and Wednesdays of each week. The DON/IP said when staff entered the building to be screened for their shift, they were expected to swab themselves afterwards and put the sample in a box for the Receptionist to log into the database for the lab. The DON/IP said if the staff member's name was not on the report from that testing day it meant they were not tested . The DON/IP said she knew the county percentage rate for the transmission of COVID-19 was high and there was a concern staff could be spreading COVID-19 to residents. In an interview on 01/14/22 at 11:10 AM with the Receptionist revealed she was responsible for entering all staff's swabbed samples into the system to generate the report of who was tested that day or not. The Receptionist said she was not responsible for following up on who was tested or not that day. In an interview on 01/15/22 at 1:30 PM with the Administrator revealed staff were expected to be tested twice per week. The Administrator said staff were supposed to test on Mondays and Wednesdays of each week. The Administrator said the purpose of staff testing twice a week was to catch positive COVID-19 cases before it had the chance to spread to residents . Review of the facility's undated policy titled Testing Requirements for Residents and Staff- TX reflected: 7. Routine testing of unvaccinated staff will be based on the extent of the virus in the community. Facilities will use their community transmission level as the trigger for staff testing frequency. [If the] level of COVID-19 Community Transmission [was] High [that indicated the] Minimum Testing Frequency of unvaccinated staff [was] twice a week. Record review of https://data.cms.gov/stories/s/COVID-19-Nursing-Home-Data/bkwz-xpvg/, dated 10/4/20, revealed: COVID-19 Testing: As part of CMS' commitment to protecting nursing home residents, and to boost the surveillance of COVID-19, nursing homes are now required to conduct testing of unvaccinated staff. These guidelines include testing unvaccinated staff on a certain frequency based on the COVID-19 Level of Community Transmission rate for the county the nursing home resides in. Facilities should monitor these rates every other week and adjust staff testing accordingly. The positivity rates listed for the county the facility was in revealed a substantial or high rate since 07/20/21.

Based on interview and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan and the residents' choices for one, (Resident #1) of four residents reviewed for quality of care. LVN B failed to call 911 and failed to immediately notify the physician on [DATE] at approximately 06:20 a.m. when she found Resident #1 in respiratory distress. LVN C failed to call 911 on [DATE] at approximately 8:00 p.m. when she received an order from the Nurse Practitioner (NP) to send Resident #1 to the hospital for respiratory distress. LVN D failed to call 911 after confirming Resident #1 was confused with a low oxygen saturation on [DATE], and being told by LVN C there was an order to send the resident to the emergency room (ER). LVN E failed to call 911 on [DATE] at approximately 11:00 p.m. at change of shift, when LVN C told him Resident #1 had been in respiratory distress during her shift and the NP had ordered the resident be sent to the emergency room (ER), and after observing the resident to be in distress himself at approximately midnight after the shift change. The facility failed to monitor LVN C and ensure the NP's orders were carried out. These failures could affect residents by placing them at risk of not receiving prompt medical attention based on the orders from the Medical Director or NP and placed residents at risk of serious physical harm, injury, and/or death. An Immediate Jeopardy (IJ) was identified on [DATE]. While the Immediate Jeopardy was removed on [DATE], the facility remained out of compliance at severity level of actual harm and a scope of isolated because the facility was still monitoring the implementation of the Plan of Removal. Findings included: Resident #1's MDS assessment dated [DATE] revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident had moderately impaired cognition and was easily distracted. His speech was clear, and he was able to be understood and understand others. He required the assistance of one staff member with activities of daily living and transfers. He utilized a walker and wheelchair for mobility. Review of Resident #1's care plan dated [DATE] revealed the resident had [MEDICAL CONDITIONS]. Interventions included to monitor for signs and symptoms of acute respiratory insufficiency including: anxiety, confusion, restlessness, shortness of breath (SOB) at rest, change in color and extreme sleepiness. He was to receive continuous oxygen. The resident was not care-planned for a history of removing his oxygen. Review of Resident #1's physician's orders [REDACTED]. He required continuous oxygen by nasal cannula at 2 liters per minute (Lpm). Review of the MAR indicated [REDACTED]. The resident received breathing treatments on the following days and times and they were administered by the indicated nurse. [DATE] 6:12 a.m. LVN B [DATE] 5:43 p.m. LVN C [DATE] 12:26 a.m. LVN J Review of a physician's telephone order dated [DATE] revealed [MEDICATION NAME], breathing treatment, one vial via nebulizer every 6 hours for 7 days. Review of Resident #1's (MONTH) (YEAR) Medication Administration Record [REDACTED] -The resident's oxygen saturation level (a measurement of the amount of oxygen dissolved in the blood), was measured on each shift from [DATE] through [DATE] and was documented to be between 92% and 98% while on oxygen at 2 Lpm. -Start date [DATE] [MEDICATION NAME] solution 0.5 - 2.5mg/3ml 1 vial every 4 hours as needed for [MEDICAL CONDITION] A physician's orders [REDACTED]. Review of Resident #1's Progress Notes dated [DATE] at 2:51 a.m. revealed, LVN E received a change of shift report from LVN C (on [DATE] at approximately 11:00 p.m.) that Resident #1 had experienced respiratory distress during her shift. LVN E made his rounds (between 11:30 p.m. and midnight) and found Resident #1 experiencing shortness of breath and utilizing his abdominal muscles to breathe. An oxygen mask was in place at 3 Lpm, his oxygen saturation was 90%, the head of the bed was elevated, and a breathing treatment was administered @025 (12:25 a.m.). Pt being monitored closely @0040, (12:40 a.m.) @045 (12:45 a.m.) (the) power went off in the facility due to lightening/rain, as soon as power returns, Nurse made round to pt (patient) room to check that equipts (equipment) are (sic) functioning well, found pt. without pulse . CPR was initiated and 911 was called. Review of the emergency room physician's Notes dated [DATE] revealed Resident #1 arrived in the ER at 1:21 a.m. in [MEDICAL CONDITION], with CPR in progress. Upon exam he was noted to have diffuse rhonchi and crackles with bagging (indicating fluid in all lung fields was auscultated while staff manually inflated the resident's lungs). He was pronounced dead at 1:29 a.m. The facility investigation report dated [DATE] revealed, on [DATE], Resident #1 was non-compliant with wearing his oxygen cannula and his oxygen levels would drop. Since he was non-compliant, the nurse practitioner gave an order to send the resident to the ER. The nurse (LVN C) felt since she re-applied his nasal cannula and his oxygen levels came back to normal, he did not need to be sent out. She thought she would need the approval of the DON to send the resident out. LVN C's employment was terminated. Review of the Confidential Employee Corrective Action Form dated [DATE] revealed LVN C was terminated for failure to follow doctor's orders. Review of a witness statement dated [DATE] by LVN C revealed on [DATE] at approximately 5:20 p.m. Resident #1 experienced difficulty breathing, his nasal cannula was off, and his oxygen saturation was 86%. The LVN administered a breathing treatment and contacted the NP who advised her to monitor the resident to ensure he kept his oxygen on. The resident continued to pull his oxygen off. LVN C administered a second breathing treatment; however, Resident #1 continued to experience breathing difficulty. LVN C contacted the NP again and he order the resident be sent to the ER. She notified the DON at 7:55 p.m. the resident was having difficulty breathing and the NP had ordered to transfer the resident to the ER. The DON stated, You cannot send him out because he is pulling NC (nasal cannula) off. LVN C indicated she did not send the resident to the ER because an in-service on [DATE] indicated she needed the DON's permission to send a resident to the ER and she believed she did not have approval. Review of a witness statement dated [DATE] by LVN K, revealed, she was orienting with LVN E on [DATE]. They received report from LVN C who told them of Resident #1's breathing condition and to monitor. At approximately 11:30 p.m. they made rounds and found Resident #1 short of breath. A breathing treatment was administered at approximately 12:00 a.m. with a plan to re-evaluate the resident in 15 minutes and continue treatment and notify the DON and physician of the resident's condition and get an order to send him out. Pt. coded 10 minutes later before re-evaluation . Review of a witness statement by LVN E dated [DATE] revealed, on [DATE] at approximately 11:30 p.m., he received report from LVN C who informed him of Resident #1's Breathing Conditions and to Monitor. After performing a narcotic count, he and his orientee made rounds. Shortly after 11:30 p.m. they found Resident #1 experiencing shortness of breath and the resident was trying to pull off his oxygen mask. A breathing treatment was administered at approximately midnight. LVN E intended to re-assess the resident in 15 minutes and depending on our evaluation, send Pt Out to ER if there is no improvement and notify the DON and Dr (physician). However, in between their (sic) was lightening/thunder that shot off the lights/power in facility, as soon as power came back in a few minutes we immediately made rounds in pt room and check and make sure equipment was working fine. On getting to pt room, we noticed that pt O2 (oxygen) was on and in a red plug running but pt have (sic) coded (dead). Review of Resident #1's Progress Notes dated [DATE] at 2:08 p.m. revealed LVN B noted Resident #1 was alert and oriented with some confusion. He had 1+ [MEDICAL CONDITION] (on a rating of 1 - 4 + [MEDICAL CONDITION] with 1+ being minor [MEDICAL CONDITION] and 4+ being severe) to both lower legs, he was ambulatory to the bathroom with assistance. There was no documented difficulty breathing. Review of Resident #1's Progress Notes dated [DATE] at 08:47 a.m. revealed LVN B had discovered the resident in respiratory distress earlier that morning. He had removed his oxygen and his oxygen saturation was low at 75%. The resident's respiratory rate was rapid at 26 per minute, his blood pressure (BP) was elevated at ,[DATE] and his heart rate was rapid at 107 beats per minute. He was wheezing and gurgling. He had 2+ [MEDICAL CONDITION] to his left lower leg and 1+ [MEDICAL CONDITION] to his right lower leg. LVN B elevated the head of the bed to ease breathing and administered a breathing treatment. Post treatment, his vital signs were BP ,[DATE], oxygen saturation 92% while on oxygen at 3Lpm. Further review of the resident's Progress Notes revealed on [DATE], LVN B documented she administered breathing treatments to Resident #1 at 06:12 a.m. and again at 08:01 a.m. On [DATE] at 2:37 p.m. LVN B documented she had informed the NP the resident had experienced respiratory distress that morning. The NP gave a new order for [MEDICATION NAME] (diuretic) 40 mg daily for 3 days. Interview on [DATE] at 12:55 p.m. with LVN B revealed on [DATE] she worked from 6:00 a.m. to 2:00 p.m. and was caring for Resident #1. She stated the resident was usually alert and oriented and required continuous oxygen at 3 Lpm by nasal cannula. She stated the resident did not usually remove his oxygen and she had never seen him experience any difficulty with his breathing. When she evaluated Resident #1 on [DATE], shortly after 06:00 a.m., he was in respiratory distress, he was restless and squirming, and he had pulled his oxygen off. He was trying to speak but was having difficulty due to shortness of breath. The resident was wheezing and gurgling. She immediately administered a breathing treatment and it was effective. She stated the resident had experienced a change in condition, but she did not notify the resident's physician, or anyone, of his change in status because the nurse practitioner (NP) was scheduled to come to the facility that afternoon. She did not call 911 because she felt the breathing treatment had been effective. When questioned, she stated she did not remember if she administered a second breathing treatment to Resident #1 at 08:00 a.m., as she had documented in the Progress Notes, and she did not know why this was not reflected on the resident's MAR. Review of the Nurse Practitioners visit note dated [DATE] at 1:16 p.m. revealed Resident #1 had swelling of both lower extremities. This has been present for 3 days .The degree of [MEDICAL CONDITION] has been getting worse recently. Associated symptoms include .exertional dyspnea (shortness of breath with activity). A resident exam revealed his respiratory rate was mildly increased with a decrease of breath sounds noted in the lung bases. His heart rate was slightly irregular, and he had bilateral lower extremity [MEDICAL CONDITION]. Current Problems included Decompensated (increased severity) [MEDICAL CONDITION]. The NP ordered [MEDICATION NAME] for lower extremity [MEDICAL CONDITION], elevation of the legs with use of support hose and a reduction of dietary salt intake. Review of Resident #1's Progress Notes dated [DATE] at 10:55 p.m. revealed LVN C discovered Resident #1 in respiratory distress with shallow breathing and use of abdominal muscles to breathe. His nasal cannula was off, and his oxygen saturation was 88% on room air. LVN C raised the head of the bed and administered a breathing treatment. The resident pulled off his nasal cannula three times, and the LVN applied an oxygen mask at 4 Lpm and the resident's oxygen saturation rose to 91%. The head of the bed was lowered, and the resident's oxygen saturation decreased to 82%. LVN C contacted the NP and received an order to send the resident to the ER. DON notified awaiting approval. Pt (patient) stable in bed with HOB (head of bed) elevated, O2 (oxygen saturation) 93% .Night nurse notified to F/U (follow up) with care. Interview by phone with LVN C on [DATE] at 12:45 PM revealed she received orders to send the resident to the hospital from the NP about 8:00 PM and then called the DON and was told by the DON to not send the resident out. The DON asked to speak to the 300-hall nurse and she thought they were conferring about Resident #1. She said the resident's condition improved during her shift and his oxygen was good when she left for the day at 11:00 PM. At that time, she thought she did not have permission to send the resident out even though the NP had ordered this. An interview on [DATE] at 6:25 p.m. with LVN C, revealed she worked on [DATE] from 2:00 p.m. to 10:00 p.m. and cared for Resident #1. This was the first time she had cared for the resident. She stated the resident kept removing his nasal cannula, and his oxygen saturation would drop. She did not ask the resident why he was removing it. At approx. 8:00 p.m. the resident was in respiratory distress, and she asked the CNA to stay with the resident and keep the nasal cannula on him and she contacted the NP. The NP told her to send Resident #1 to the ER. She then contacted the DON and notified her of the resident's change in status and the NP's order to send the resident to the ER. The DON said the LVN could not send the resident to the ER for removing his cannula. The DON then asked her to text her the resident's name and room number. LVN C stated she was checking on the resident every 15 minutes and he appeared to be doing better at change of shift. She wrote the incident on the 24-hour report, and wrote the order for transfer to theER on a physician's paper order and also in the computer and flagged the order. She gave report to LVN E, the on-coming nurse, and told him the resident had experienced respiratory distress and the NP had ordered him to be sent to the ER. She informed LVN E the DON had told her she should not send the resident to the ER for pulling off his cannula. She told LVN E she would attempt to contact the NP and DON again prior to leaving the facility, but she was unable to get through to either of them. She stated LVN E did not comment on her report. LVN C stated that at an in-service conducted on [DATE], staff was notified they must receive approval from the DON prior to sending a resident to the ER, even if they had an order from the physician. She said she was afraid to go against the DON's wishes, so she did not send the resident to the ER. Telephone interview on [DATE] at 09:50 a.m. with the charge nurse LVN E revealed he was working 10:00 p.m. - 6:00 a.m. on [DATE]. However, he did not arrive at work until approximately 11:00 p.m. that night. He received report from LVN C who advised him Resident #1 had experienced respiratory distress and the NP had ordered he be sent to the ER. LVN C told him she was awaiting approval from the DON and she would attempt to call the DON again. At some time between 11:30 p.m. and midnight, LVN E said he discovered Resident #1 in respiratory distress; the resident was unable to speak, he was not alert and did not appear to realize the LVN was in the room. The resident was restless and pulling off his oxygen mask. The LVN administered a breathing treatment and left the room. In the hallway, a CNA told him a diabetic resident was not doing well; the resident was sweating, so he checked the resident's blood sugar and learned it was not too low, so he gave the resident some food. Then the lights went off for a few minutes due to the lightening. LVN E stated that whenever the generator engaged, staff must check all residents who utilized oxygen concentrators to ensure they had come back on. When he went to check Resident #1, the resident had no pulse and he was not breathing. He called for help and started CPR. Another staff member contacted 911. LVN E stated, approximately three weeks ago, some staff had received an in-service which implied they must contact the DON before anyone was sent to the ER and he thought that may be why LVN C had not called 911. He stated in the same situation, he would have immediately called 911 and contacted the DON later. When questioned why he did not call 911 when he found Resident #1 in respiratory distress at change of shift, he stated he was going to, but was side-tracked when the diabetic resident was having problems. Then he had intended to get Resident #1's paperwork ready prior contacting 911 but the lights went out, and when he re-checked Resident #1, he was deceased . When asked to clarify what he would do if a resident was experiencing a life-threatening emergency, he stated he would call the doctor, call 911 if needed, then call the DON. Interview on [DATE] at 3:17 p.m. with LVN D revealed she had worked 2:00 p.m. to 10:00 p.m. on [DATE]. LVN C had told her she had an order from the NP to send Resident #1 to the ER but she had not received approval from the DON. LVN C had asked LVN D to see Resident #1 on that day. She followed LVN C to the resident's room where she found Resident #1 in respiratory distress. He was lying flat on his bed, he was confused, and his oxygen saturation was dropping. She told LVN C to raise the head of the bed and told her to send the resident to the ER. She said she told LVN C that she did not need approval from the DON if she had a physician's orders [REDACTED]. Interview on [DATE] at 3:45 p.m. with the DON revealed she had requested the charge nurses give their staff an in-service on the importance of calling the DON prior to sending residents to the ER because several residents had been sent to the ER that could have been cared for in the facility. She did not know ADON A had given an in-service on [DATE] and she thought the ADON must have made up the in-service herself. LVN E told her he suspected LVN C had not sent Resident #1 to the ER because the in-service had said the DON's approval was required before sending residents to the ER. She stated LVN C contacted her on [DATE] at approximately 8:00 p.m. and told her the resident kept pulling off his nasal cannula and his oxygen saturation kept dropping. The DON said she had asked if the resident needed to be placed on one-on-one monitoring and the LVN said she had an order from the NP to send the resident to the ER. The DON said she had replied ok and asked her to send her the resident's name and room number, then asked her to let the DON speak to another nurse. The DON stated ADON A no longer worked at the facility, but her resignation was not related to the in-service. Interview on [DATE] at 10:34 a.m. with LVN J revealed she had not attended the in-service given [DATE]. Following review of the in-service she stated that, based on the information given, a nurse may think she is supposed to contact the DON before calling 911. She further stated, if she had a resident who had an emergency, that information would not stop her from calling 911 first and sending the resident out. She again reviewed the in-service and stated, this is confusing. She revealed if a resident was not doing well, she would notify the DON and get her opinion, and then call the physician if needed. If the resident was not doing well at all then she would call the physician first, then notify the DON. Interview on [DATE] at 10:55 a.m. with LVN O revealed if she had a resident in severe respiratory distress she would call 911, then notify the physician and DON. Following review of the in-service from [DATE], she changed her statement by saying she was wrong and, this in-service is saying I need to notify the DON before sending someone out. Interview on [DATE] at 2:33 p.m. with LVN I revealed she attended the in-service on [DATE] that said staff was to call the DON prior to sending a resident to the hospital, or even calling 911. She stated ADON A brought the in-service to the nurses' station, read the in-service and staff signed attendance. LVN I stated the DON wanted to make sure anything that can be done in the facility is done prior to sending someone to the ER. Interview on [DATE] at 3:02 p.m. with LVN H revealed if she had a resident in severe respiratory distress she would call 911, then notify the physician and DON. She stated she did not attend the [DATE] in-service. LVN H read the in-service and said it appeared confusing because it seemed the DON needed to be called prior to calling 911. However, she stated she would call 911 if needed and notify the DON later. Interview with ADON A on [DATE] at 1:35 PM revealed she wrote the in-service delivered on [DATE], but the intent of the training was notification, not permission, and that the DON would be notified after 911 was called while waiting for the ambulance to arrive. She said any nurse had the authority to send out a resident as needed. At times, the DON had not been notified in the past and the facility felt that this had to be forcefully changed. She said she could not understand why LVN C did not follow the instructions she had received from the NP. Interview with the NP on [DATE] at 10:30 AM revealed he received a call from LVN C on [DATE] at 5:45 PM. He was told Resident #1 was pulling his oxygen off and he told the LVN to monitor closely. He received another call at 7:57 PM with the same problem and oxygen level reading too low. He said he instructed the LVN to send the resident out to the hospital right away. He said he only found out the next morning that his instructions were not followed. He said the resident was in very bad condition with stage four [MEDICAL CONDITION]. A further interview on [DATE] at 3: 12 pm revealed on [DATE],. He stated LVN B had not notified him on [DATE] when she found Resident #1 in respiratory distress on the 6:00 a.m. to 2:00 p.m. shift. He did not remember if the nurse told him the resident was in respiratory distress. He stated if a resident was in respiratory distress the resident needed to go to the ER because the resident would need to be intubated and there were no tools at the Nursing Facility to do that. The NP also read the [DATE] in-service and said, it is not right that nurses are intimidated into not calling 911. He provided questions and answers related to identifying respiratory distress for a staff quiz Interview with the DON on [DATE] at 9:40 AM revealed she received a call on Friday, [DATE] at 8:00 PM from LVN C regarding the condition of Resident #1. She said she was aware that the NP had ordered the resident to be sent out and she agreed. She said she received another call from the facility at 1:30 AM on [DATE] but missed the call. She called the facility at 2:30 AM and learned the resident had not been sent out as ordered, was having trouble breathing at 11:30 PM and was given a breathing treatment, was found unresponsive at 12:00 AM with CPR administered by night nurse LVN E, sent out at 12:30 AM, and passed away at the hospital at 1:29 AM. She said LVN C's explanation for not sending the resident out was that his oxygen had stabilized, and she thought he was all right. She said LVN C was suspended immediately after the incident and then terminated on [DATE] for failure to follow instructions. Interview with the DON on [DATE] at 12:30 PM revealed LVN C did not need her permission to send out any resident, especially when she had direct orders from the NP to do so. She said the in-service given on [DATE] was without her knowledge, but she had done a similar in-service on [DATE] about the importance of notifying her of changes in condition. She said this did not imply that any nurse needed permission to send a resident out. She said the expectation was that she would be called in any emergency right after the 911 call. She said she never told any nurse not to send a resident out, or to cancel a 911 call after it had been made. In an Interview on [DATE] at 4:24 p.m. with the DON She stated LVN E contacted her at approximately 1:30 a.m. on [DATE] to tell her he had found Resident #1 unresponsive and he had called 911. She was surprised the resident was still at the facility because LVN C had an order to send him to the ER. The DON stated she had come to the facility the night of [DATE] and asked LVN E why he had not sent Resident #1 to the ER and he said LVN C had told him she was waiting for approval from the DON. He said he and the nurse in training, LVN K, had made initial rounds of his residents and Resident #1 was not in any distress; but, if the resident had been in distress he would have called the DON and the physician. The DON stated she understood Resident #1 was wheezing at change of shift, so was administered a breathing treatment by LVN E. She could not remember which nurse told her. Rain and lightning had caused the generator to activate, and LVN K said she had remained on the medication cart while LVN E went back to check on the resident. That was when he found the resident unresponsive. The DON stated she did not know who called 911, and she was not sure who remained in the resident's room until EMS arrived. She stated LVN B should have contacted her on [DATE] at 8:00 a.m. when Resident #1 had a change in status and she should have immediately contacted the NP. The DON stated she had contacted the NP the morning of [DATE] and he said LVN C called him at 6:00 p.m. and again later that evening. Both times the LVN had said the resident was removing his oxygen and his oxygen saturation would fall. She did not tell him the resident was in distress. Interview with the Administrator on [DATE] at 9:15 AM revealed LVN C failed to send Resident #1 out to the hospital after being ordered to do so by the nurse practitioner and the DON. Her explanation was that the resident had improved and was stable. She did not think he needed to go to the hospital. He also said no policy existed for following orders of the Medical Director or NP. Asked about the power outage on [DATE] at 12:45 AM, he said the power was only off a few seconds till the generator came on and the power outage was not a factor in the change in Resident #1's condition. A further interview on [DATE] at 5;13 p.m. with the administrator revealed he did not know if the facility's investigation of the incident on [DATE] involved a review of care of Resident #1 on any shift other than the 2:00 p.m. to 10:00 p.m. shift. He had not reviewed the witness statements but understood from the DON that Resident #1 was in no distress when LVN E assumed care at change of shift. He said he could see why there may have been confusion because LVN C had said she thought she needed authorization from the DON before she sent a resident out to the hospital. Review of Record of In-Service regarding Change in Condition or Injury Protocol, facilitated by ADON A and dated [DATE] revealed, This will serve as a verbal warning to all nurses .For any resident that is to be sent to ER the DON must be consulted with before not after the patient is to be sent out if this facility. If any resident .has a fall with or without injury, the DON must be notified in person or by phone call. If there is a reportable incident, the DON must be notified in person or by phone immediately (ie: elopement, abuse, any incident with major injury) If the DON does not answer, keep calling. Text messages will not be acceptable as a form of notification. From this day forward any nurse that text the DON regarding any of the above with the above will be terminated immediately per DON. Review of Record of In-service regarding Reporting Change in Condition, facilitated by the DON and dated [DATE] revealed All falls and change in condition will be reported to the DON I don't care what time of day, you will report . Review of one on one in-services facilitated by the DON following the incident on [DATE], revealed several nurses had documented their understanding of the in-service as follows: -One on One In-service dated [DATE] and signed by the DON and LVN L revealed If patient is in distress, having difficulties breathing, notified the MD (Medical Doctor). If unable to reach the MD or the DON, Nurse should send patient out to ER or call 911 . -One on One In-service dated [DATE] and signed by the DON and LVN M revealed .5 Use your nursing judgement If no answer from DON or MD and the pt is critical send to ER -One on One In-service dated [DATE] and signed by the DON and LVN N revealed if a 911 call Dr, send out to hospital when order given, notify DON after resident safe, esp. (especially) fall with c (with) injury, resp. (respiratory) difficulty! Nurse follow(s) Doctor(s) Orders -One on One In-service dated [DATE] and signed by the DON and LVN O revealed Emergency: call 911. DON Notification: Always notify the DON first to use all available resources before notifying the Dr. but any critical situation like resp distress, fall with injury, altered level of consciousness (AMS), then call the Dr first . -One on One In-service dated [DATE] and signed by the DON and LVN Q revealed If you can't get hold of the Dr. send the pt out and notify the DON, M.D. after. Review of Record of In-service regarding Carrying out physician's orders [REDACTED]. Review of the facility's Acute Condition Changes-Clinical Protocol revised (MONTH) (YEAR), revealed: .For emergencies, they (nurses) will call or page the physician and request a prompt response (within approximately one-half hour or less).8 .a. The staff will notify the Medical Director for additional guidance and consultation if they do not receive a timely or appropriate response .Treatment/Management 1. The physician will help identify and authorize appropriate treatments .2.If it is decided, after sufficient review, that care or observation cannot reasonably be provided in the facility, the Attending physician will authorize transfer to an acute hospital, emergency room , or another appropriate setting . The Protocol did not include any direction on when it would be appropriate for the nurse to call 911 prior to contacting the physician or in the event they received no response from the physician. Review of the facility's Abuse and Neglect Clinical Protocol revised (MONTH) (YEAR) revealed .Neglect . means the failure of the facility, it's employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress . An IJ was identified on [DATE] at 6:00 p.m. The Administrator and DON were notified of the IJ at that time and a plan of removal was requested. The facility's Plan of Removal reflected: Summary: On (MONTH) 22th, (YEAR) the Administrator was made aware that Resident (name) Resident #1 had passed away early that morning. The DON reported that, the evening nurse the day before failed to follow the Nurse Practitioners v

Based on interview and record review, the facility failed to insure the services provided or arranged by the facility, as outlined by the comprehensive care plan, met professional standards of quality for one (Resident #1) of seven residents reviewed for profession standards. LVN B failed to call 911 and failed to immediately notify the physician on [DATE] at approximately 06:20 a.m. when she found Resident #1 in respiratory distress. LVN C failed to follow the NP's orders to send Resident #1 to the hospital when his oxygen level dropped after he continued to remove his oxygen. The level fell because of his removing the cannula himself. LVN D failed to call 911 after confirming Resident #1 was confused with a low oxygen saturation on [DATE], and being told by LVN C there was an order to send the resident to the emergency room (ER). LVN E failed to call 911 on [DATE] at approximately 11:00 p.m. at change of shift, when LVN C told him Resident #1 had been in respiratory distress during her shift and the NP had ordered the resident be sent to the emergency room (ER), and after observing the resident to be in distress himself at approximately midnight after the shift change. Resident #1 remained in the facility for 4 to 5 hours before being transferred to the hospital when found in his room unresponsive. Resident #1 expired in the emergency room eight minutes after arrival. The facility failed to monitor LVN C and ensure the NP's orders were carried out. These failures could affect residents by placing them at risk of not receiving prompt medical attention based on the orders from the Medical Director or NP. An Immediate Jeopardy (IJ) was identified on [DATE]. While the Immediate Jeopardy was removed on [DATE], the facility remained out of compliance at severity level of actual harm and a scope of isolated because the facility was still monitoring the implementation of the Plan of Removal. Findings included: https://www.bon.texas.gov/pdfs/law_rules_pdfs/rules_regulations_pdfs/bon_rr_Sept2018.pdf reflected, §217.11. Standards of Nursing Practice: The Texas Board of Nursing is responsible for regulating the practice of nursing within the State of Texas for Vocational Nurses, Registered Nurses, and Registered Nurses with advanced practice authorization. The standards of practice establish a minimum acceptable level of nursing practice in any setting for each level of nursing licensure or advanced practice authorization. Failure to meet these standards may result in action against the nurse's license even if no actual patient injury resulted. (1) Standards Applicable to All Nurses. All vocational nurses . (B) Implement measures to promote a safe environment for clients and others; (C) Know the rationale for and the effects of medications and treatments and shall correctly administer the same . (G) Obtain instruction and supervision as necessary when implementing nursing procedures or practices . (N) Clarify any order or treatment regimen that the nurse has reason to believe is inaccurate, non-efficacious or contraindicated by consulting with the appropriate licensed practitioner and notifying the ordering practitioner when the nurse makes the decision not to administer the medication or treatment Resident #1's MDS assessment dated [DATE] revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident had moderately impaired cognition and was easily distracted. His speech was clear, and he was able to be understood and understand others. He required the assistance of one staff member with activities of daily living and transfers. He utilized a walker and wheelchair for mobility. Review of Resident #1's care plan dated [DATE] revealed the resident had [MEDICAL CONDITIONS]. Interventions included to monitor for signs and symptoms of acute respiratory insufficiency including: anxiety, confusion, restlessness, shortness of breath (SOB) at rest, change in color and extreme sleepiness. He was to receive continuous oxygen. The resident was not care-planned for a history of removing his oxygen. Resident #1's care plan dated [DATE] revealed he was at risk for acute pain related to both lung and [MEDICAL CONDITION]. He was also resistant to care and had removed his oxygen cannula himself. Facility interventions included monitoring the resident and educating on the need to comply with O2 orders. Review of Resident #1's physician's orders [REDACTED]. He required continuous oxygen by nasal cannula at 2 liters per minute (Lpm). The admission orders [REDACTED]. Review of the MAR indicated [REDACTED]. The resident received breathing treatments on the following days and times and they were administered by the indicated nurse. [DATE] 6:12 a.m. LVN B [DATE] 5:43 p.m. LVN C [DATE] 12:26 a.m. LVN J Review of a physician's telephone order dated [DATE] revealed [MEDICATION NAME], breathing treatment, one vial via nebulizer every 6 hours for 7 days. Review of Resident #1's (MONTH) (YEAR) Medication Administration Record [REDACTED] -The resident's oxygen saturation level (a measurement of the amount of oxygen dissolved in the blood), was measured on each shift from [DATE] through [DATE] and was documented to be between 92% and 98% while on oxygen at 2 Lpm. -Start date [DATE] [MEDICATION NAME] solution 0.5 - 2.5mg/3ml 1 vial every 4 hours as needed for [MEDICAL CONDITION] A physician's orders [REDACTED]. Review of Resident #1's Progress Notes dated [DATE] at 2:51 a.m. revealed, LVN E received a change of shift report from LVN C (on [DATE] at approximately 11:00 p.m.) that Resident #1 had experienced respiratory distress during her shift. LVN E made his rounds (between 11:30 p.m. and midnight) and found Resident #1 experiencing shortness of breath and utilizing his abdominal muscles to breathe. An oxygen mask was in place at 3 Lpm, his oxygen saturation was 90%, the head of the bed was elevated, and a breathing treatment was administered @025 (12:25 a.m.). Pt being monitored closely @0040, (12:40 a.m.) @045 (12:45 a.m.) (the) power went off in the facility due to lightening/rain, as soon as power returns, Nurse made round to pt (patient) room to check that equipts (equipment) are (sic) functioning well, found pt. without pulse . CPR was initiated and 911 was called. Review of the emergency room physician's Notes dated [DATE] revealed Resident #1 arrived in the ER at 1:21 a.m. in [MEDICAL CONDITION], with CPR in progress. Upon exam he was noted to have diffuse rhonchi and crackles with bagging (indicating fluid in all lung fields was auscultated while staff manually inflated the resident's lungs). He was pronounced dead at 1:29 a.m. The facility investigation report dated [DATE] revealed, on [DATE], Resident #1 was non-compliant with wearing his oxygen cannula and his oxygen levels would drop. Since he was non-compliant, the nurse practitioner gave an order to send the resident to the ER. The nurse (LVN C) felt since she re-applied his nasal cannula and his oxygen levels came back to normal, he did not need to be sent out. She thought she would need the approval of the DON to send the resident out. LVN C's employment was terminated. Review of the Confidential Employee Corrective Action Form dated [DATE] revealed LVN C was terminated for failure to follow doctor's orders. Review of a witness statement dated [DATE] by LVN C revealed on [DATE] at approximately 5:20 p.m. Resident #1 experienced difficulty breathing, his nasal cannula was off, and his oxygen saturation was 86%. The LVN administered a breathing treatment and contacted the NP who advised her to monitor the resident to ensure he kept his oxygen on. The resident continued to pull his oxygen off. LVN C administered a second breathing treatment; however, Resident #1 continued to experience breathing difficulty. LVN C contacted the NP again and he order the resident be sent to the ER. She notified the DON at 7:55 p.m. the resident was having difficulty breathing and the NP had ordered to transfer the resident to the ER. The DON stated, You cannot send him out because he is pulling NC (nasal cannula) off. LVN C indicated she did not send the resident to the ER because an in-service on [DATE] indicated she needed the DON's permission to send a resident to the ER and she believed she did not have approval. Review of a witness statement dated [DATE] by LVN K, revealed, she was orienting with LVN E on [DATE]. They received report from LVN C who told them of Resident #1's breathing condition and to monitor. At approximately 11:30 p.m. they made rounds and found Resident #1 short of breath. A breathing treatment was administered at approximately 12:00 a.m. with a plan to re-evaluate the resident in 15 minutes and continue treatment and notify the DON and physician of the resident's condition and get an order to send him out. Pt. coded 10 minutes later before re-evaluation . Review of a witness statement by LVN E dated [DATE] revealed, on [DATE] at approximately 11:30 p.m., he received report from LVN C who informed him of Resident #1's Breathing Conditions and to Monitor. After performing a narcotic count, he and his orientee made rounds. Shortly after 11:30 p.m. they found Resident #1 experiencing shortness of breath and the resident was trying to pull off his oxygen mask. A breathing treatment was administered at approximately midnight. LVN E intended to re-assess the resident in 15 minutes and depending on our evaluation, send Pt Out to ER if there is no improvement and notify the DON and Dr (physician). However, in between their (sic) was lightening/thunder that shot off the lights/power in facility, as soon as power came back in a few minutes we immediately made rounds in pt room and check and make sure equipment was working fine. On getting to pt room, we noticed that pt O2 (oxygen) was on and in a red plug running but pt have (sic) coded (dead). Review of Resident #1's Progress Notes dated [DATE] at 2:08 p.m. revealed LVN B noted Resident #1 was alert and oriented with some confusion. He had 1+ [MEDICAL CONDITION] (on a rating of 1 - 4 + [MEDICAL CONDITION] with 1+ being minor [MEDICAL CONDITION] and 4+ being severe) to both lower legs, he was ambulatory to the bathroom with assistance. There was no documented difficulty breathing. Review of Resident #1's Progress Notes dated [DATE] at 08:47 a.m. revealed LVN B had discovered the resident in respiratory distress earlier that morning. He had removed his oxygen and his oxygen saturation was low at 75%. The resident's respiratory rate was rapid at 26 per minute, his blood pressure (BP) was elevated at ,[DATE] and his heart rate was rapid at 107 beats per minute. He was wheezing and gurgling. He had 2+ [MEDICAL CONDITION] to his left lower leg and 1+ [MEDICAL CONDITION] to his right lower leg. LVN B elevated the head of the bed to ease breathing and administered a breathing treatment. Post treatment, his vital signs were BP ,[DATE], oxygen saturation 92% while on oxygen at 3Lpm. Further review of the resident's Progress Notes revealed on [DATE], LVN B documented she administered breathing treatments to Resident #1 at 06:12 a.m. and again at 08:01 a.m. On [DATE] at 2:37 p.m. LVN B documented she had informed the NP the resident had experienced respiratory distress that morning. The NP gave a new order for [MEDICATION NAME] (diuretic) 40 mg daily for 3 days. Interview on [DATE] at 12:55 p.m. with LVN B revealed on [DATE] she worked from 6:00 a.m. to 2:00 p.m. and was caring for Resident #1. She stated the resident was usually alert and oriented and required continuous oxygen at 3 Lpm by nasal cannula. She stated the resident did not usually remove his oxygen and she had never seen him experience any difficulty with his breathing. When she evaluated Resident #1 on [DATE], shortly after 06:00 a.m., he was in respiratory distress, he was restless and squirming, and he had pulled his oxygen off. He was trying to speak but was having difficulty due to shortness of breath. The resident was wheezing and gurgling. She immediately administered a breathing treatment and it was effective. She stated the resident had experienced a change in condition, but she did not notify the resident's physician, or anyone, of his change in status because the nurse practitioner (NP) was scheduled to come to the facility that afternoon. She did not call 911 because she felt the breathing treatment had been effective. When questioned, she stated she did not remember if she administered a second breathing treatment to Resident #1 at 08:00 a.m., as she had documented in the Progress Notes, and she did not know why this was not reflected on the resident's MAR. Review of the Nurse Practitioners visit note dated [DATE] at 1:16 p.m. revealed Resident #1 had swelling of both lower extremities. This has been present for 3 days .The degree of [MEDICAL CONDITION] has been getting worse recently. Associated symptoms include .exertional dyspnea (shortness of breath with activity). A resident exam revealed his respiratory rate was mildly increased with a decrease of breath sounds noted in the lung bases. His heart rate was slightly irregular, and he had bilateral lower extremity [MEDICAL CONDITION]. Current Problems included Decompensated (increased severity) [MEDICAL CONDITION]. The NP ordered [MEDICATION NAME] for lower extremity [MEDICAL CONDITION], elevation of the legs with use of support hose and a reduction of dietary salt intake. Review of Resident #1's Progress Notes dated [DATE] at 10:55 p.m. revealed LVN C discovered Resident #1 in respiratory distress with shallow breathing and use of abdominal muscles to breathe. His nasal cannula was off, and his oxygen saturation was 88% on room air. LVN C raised the head of the bed and administered a breathing treatment. The resident pulled off his nasal cannula three times, and the LVN applied an oxygen mask at 4 Lpm and the resident's oxygen saturation rose to 91%. The head of the bed was lowered, and the resident's oxygen saturation decreased to 82%. LVN C contacted the NP and received an order to send the resident to the ER. DON notified awaiting approval. Pt (patient) stable in bed with HOB (head of bed) elevated, O2 (oxygen saturation) 93% .Night nurse notified to F/U (follow up) with care. Interview by phone with LVN C on [DATE] at 12:45 PM revealed she received orders to send the resident to the hospital from the NP about 8:00 PM and then called the DON and was told by the DON to not send the resident out. The DON asked to speak to the 300-hall nurse and she thought they were conferring about Resident #1. She said the resident's condition improved during her shift and his oxygen was good when she left for the day at 11:00 PM. At that time, she thought she did not have permission to send the resident out even though the NP had ordered this. An interview on [DATE] at 6:25 p.m. with LVN C, revealed she worked on [DATE] from 2:00 p.m. to 10:00 p.m. and cared for Resident #1. This was the first time she had cared for the resident. She stated the resident kept removing his nasal cannula, and his oxygen saturation would drop. She did not ask the resident why he was removing it. At approx. 8:00 p.m. the resident was in respiratory distress, and she asked the CNA to stay with the resident and keep the nasal cannula on him and she contacted the NP. The NP told her to send Resident #1 to the ER. She then contacted the DON and notified her of the resident's change in status and the NP's order to send the resident to the ER. The DON said the LVN could not send the resident to the ER for removing his cannula. The DON then asked her to text her the resident's name and room number. LVN C stated she was checking on the resident every 15 minutes and he appeared to be doing better at change of shift. She wrote the incident on the 24-hour report, and wrote the order for transfer to theER on a physician's paper order and also in the computer and flagged the order. She gave report to LVN E, the on-coming nurse, and told him the resident had experienced respiratory distress and the NP had ordered him to be sent to the ER. She informed LVN E the DON had told her she should not send the resident to the ER for pulling off his cannula. She told LVN E she would attempt to contact the NP and DON again prior to leaving the facility, but she was unable to get through to either of them. She stated LVN E did not comment on her report. LVN C stated that at an in-service conducted on [DATE], staff was notified they must receive approval from the DON prior to sending a resident to the ER, even if they had an order from the physician. She said she was afraid to go against the DON's wishes, so she did not send the resident to the ER. Telephone interview on [DATE] at 09:50 a.m. with the charge nurse LVN E revealed he was working 10:00 p.m. - 6:00 a.m. on [DATE]. However, he did not arrive at work until approximately 11:00 p.m. that night. He received report from LVN C who advised him Resident #1 had experienced respiratory distress and the NP had ordered he be sent to the ER. LVN C told him she was awaiting approval from the DON and she would attempt to call the DON again. At some time between 11:30 p.m. and midnight, LVN E said he discovered Resident #1 in respiratory distress; the resident was unable to speak, he was not alert and did not appear to realize the LVN was in the room. The resident was restless and pulling off his oxygen mask. The LVN administered a breathing treatment and left the room. In the hallway, a CNA told him a diabetic resident was not doing well; the resident was sweating, so he checked the resident's blood sugar and learned it was not too low, so he gave the resident some food. Then the lights went off for a few minutes due to the lightening. LVN E stated that whenever the generator engaged, staff must check all residents who utilized oxygen concentrators to ensure they had come back on. When he went to check Resident #1, the resident had no pulse and he was not breathing. He called for help and started CPR. Another staff member contacted 911. LVN E stated, approximately three weeks ago, some staff had received an in-service which implied they must contact the DON before anyone was sent to the ER and he thought that may be why LVN C had not called 911. He stated in the same situation, he would have immediately called 911 and contacted the DON later. When questioned why he did not call 911 when he found Resident #1 in respiratory distress at change of shift, he stated he was going to, but was side-tracked when the diabetic resident was having problems. Then he had intended to get Resident #1's paperwork ready prior contacting 911 but the lights went out, and when he re-checked Resident #1, he was deceased . When asked to clarify what he would do if a resident was experiencing a life-threatening emergency, he stated he would call the doctor, call 911 if needed, then call the DON. Interview on [DATE] at 3:17 p.m. with LVN D revealed she had worked 2:00 p.m. to 10:00 p.m. on [DATE]. LVN C had told her she had an order from the NP to send Resident #1 to the ER but she had not received approval from the DON. LVN C had asked LVN D to see Resident #1 on that day. She followed LVN C to the resident's room where she found Resident #1 in respiratory distress. He was lying flat on his bed, he was confused, and his oxygen saturation was dropping. She told LVN C to raise the head of the bed and told her to send the resident to the ER. She said she told LVN C that she did not need approval from the DON if she had a physician's orders [REDACTED]. Interview on [DATE] at 3:45 p.m. with the DON revealed she had requested the charge nurses give their staff an in-service on the importance of calling the DON prior to sending residents to the ER because several residents had been sent to the ER that could have been cared for in the facility. She did not know ADON A had given an in-service on [DATE] and she thought the ADON must have made up the in-service herself. LVN E told her he suspected LVN C had not sent Resident #1 to the ER because the in-service had said the DON's approval was required before sending residents to the ER. She stated LVN C contacted her on [DATE] at approximately 8:00 p.m. and told her the resident kept pulling off his nasal cannula and his oxygen saturation kept dropping. The DON said she had asked if the resident needed to be placed on one-on-one monitoring and the LVN said she had an order from the NP to send the resident to the ER. The DON said she had replied ok and asked her to send her the resident's name and room number, then asked her to let the DON speak to another nurse. The DON stated ADON A no longer worked at the facility, but her resignation was not related to the in-service. Interview on [DATE] at 10:34 a.m. with LVN J revealed she had not attended the in-service given [DATE]. Following review of the in-service she stated that, based on the information given, a nurse may think she is supposed to contact the DON before calling 911. She further stated, if she had a resident who had an emergency, that information would not stop her from calling 911 first and sending the resident out. She again reviewed the in-service and stated, this is confusing. She revealed if a resident was not doing well, she would notify the DON and get her opinion, and then call the physician if needed. If the resident was not doing well at all then she would call the physician first, then notify the DON. Interview on [DATE] at 10:55 a.m. with LVN O revealed if she had a resident in severe respiratory distress she would call 911, then notify the physician and DON. Following review of the in-service from [DATE], she changed her statement by saying she was wrong and, this in-service is saying I need to notify the DON before sending someone out. Interview on [DATE] at 2:33 p.m. with LVN I revealed she attended the in-service on [DATE] that said staff was to call the DON prior to sending a resident to the hospital, or even calling 911. She stated ADON A brought the in-service to the nurses' station, read the in-service and staff signed attendance. LVN I stated the DON wanted to make sure anything that can be done in the facility is done prior to sending someone to the ER. Interview on [DATE] at 3:02 p.m. with LVN H revealed if she had a resident in severe respiratory distress she would call 911, then notify the physician and DON. She stated she did not attend the [DATE] in-service. LVN H read the in-service and said it appeared confusing because it seemed the DON needed to be called prior to calling 911. However, she stated she would call 911 if needed and notify the DON later. Interview with ADON A on [DATE] at 1:35 PM revealed she wrote the in-service delivered on [DATE], but the intent of the training was notification, not permission, and that the DON would be notified after 911 was called while waiting for the ambulance to arrive. She said any nurse had the authority to send out a resident as needed. At times, the DON had not been notified in the past and the facility felt that this had to be forcefully changed. She said she could not understand why LVN C did not follow the instructions she had received from the NP. Interview with the NP on [DATE] at 10:30 AM revealed he received a call from LVN C on [DATE] at 5:45 PM. He was told Resident #1 was pulling his oxygen off and he told the LVN to monitor closely. He received another call at 7:57 PM with the same problem and oxygen level reading too low. He said he instructed the LVN to send the resident out to the hospital right away. He said he only found out the next morning that his instructions were not followed. He said the resident was in very bad condition with stage four [MEDICAL CONDITION]. A further interview on [DATE] at 3:12 pm revealed on [DATE], He stated LVN B had not notified him on [DATE] when she found Resident #1 in respiratory distress on the 6:00 a.m. to 2:00 p.m. shift. He did not remember if the nurse told him the resident was in respiratory distress. He stated if a resident was in respiratory distress the resident needed to go to the ER because the resident would need to be intubated and there were no tools at the Nursing Facility to do that. The NP also read the [DATE] in-service and said, it is not right that nurses are intimidated into not calling 911. He provided questions and answers related to identifying respiratory distress for a staff quiz Interview with the DON on [DATE] at 9:40 AM revealed she received a call on Friday, [DATE] at 8:00 PM from LVN C regarding the condition of Resident #1. She said she was aware that the NP had ordered the resident to be sent out and she agreed. She said she received another call from the facility at 1:30 AM on [DATE] but missed the call. She called the facility at 2:30 AM and learned the resident had not been sent out as ordered, was having trouble breathing at 11:30 PM and was given a breathing treatment, was found unresponsive at 12:00 AM with CPR administered by night nurse LVN E, sent out at 12:30 AM, and passed away at the hospital at 1:29 AM. She said LVN C's explanation for not sending the resident out was that his oxygen had stabilized, and she thought he was all right. She said LVN C was suspended immediately after the incident and then terminated on [DATE] for failure to follow instructions. Interview with the DON on [DATE] at 12:30 PM revealed LVN C did not need her permission to send out any resident, especially when she had direct orders from the NP to do so. She said the in-service given on [DATE] was without her knowledge, but she had done a similar in-service on [DATE] about the importance of notifying her of changes in condition. She said this did not imply that any nurse needed permission to send a resident out. She said the expectation was that she would be called in any emergency right after the 911 call. She said she never told any nurse not to send a resident out, or to cancel a 911 call after it had been made. In an Interview on [DATE] at 4:24 p.m. with the DON. She stated LVN E contacted her at approximately 1:30 a.m. on [DATE] to tell her he had found Resident #1 unresponsive and he had called 911. She was surprised the resident was still at the facility because LVN C had an order to send him to the ER. The DON stated she had come to the facility the night of [DATE] and asked LVN E why he had not sent Resident #1 to the ER and he said LVN C had told him she was waiting for approval from the DON. He said he and the nurse in training, LVN K, had made initial rounds of his residents and Resident #1 was not in any distress; but, if the resident had been in distress he would have called the DON and the physician. The DON stated she understood Resident #1 was wheezing at change of shift, so was administered a breathing treatment by LVN E. She could not remember which nurse told her. Rain and lightning had caused the generator to activate, and LVN K said she had remained on the medication cart while LVN E went back to check on the resident. That was when he found the resident unresponsive. The DON stated she did not know who called 911, and she was not sure who remained in the resident's room until EMS arrived. She stated LVN B should have contacted her on [DATE] at 8:00 a.m. when Resident #1 had a change in status and she should have immediately contacted the NP. The DON stated she had contacted the NP the morning of [DATE] and he said LVN C called him at 6:00 p.m. and again later that evening. Both times the LVN had said the resident was removing his oxygen and his oxygen saturation would fall. She did not tell him the resident was in distress. Interview with the Administrator on [DATE] at 9:15 AM revealed LVN C failed to send Resident #1 out to the hospital after being ordered to do so by the nurse practitioner and the DON. Her explanation was that the resident had improved and was stable. She did not think he needed to go to the hospital. He also said no policy existed for following orders of the Medical Director or NP. Asked about the power outage on [DATE] at 12:45 AM, he said the power was only off a few seconds till the generator came on and the power outage was not a factor in the change in Resident #1's condition. A further interview on [DATE] at 5;13 p.m. with the administrator revealed he did not know if the facility's investigation of the incident on [DATE] involved a review of care of Resident #1 on any shift other than the 2:00 p.m. to 10:00 p.m. shift. He had not reviewed the witness statements but understood from the DON that Resident #1 was in no distress when LVN E assumed care at change of shift. He said he could see why there may have been confusion because LVN C had said she thought she needed authorization from the DON before she sent a resident out to the hospital. Review of Record of In-Service regarding Change in Condition or Injury Protocol, facilitated by ADON A and dated [DATE] revealed, This will serve as a verbal warning to all nurses .For any resident that is to be sent to ER the DON must be consulted with before not after the patient is to be sent out if this facility. If any resident .has a fall with or without injury, the DON must be notified in person or by phone call. If there is a reportable incident, the DON must be notified in person or by phone immediately (ie: elopement, abuse, any incident with major injury) If the DON does not answer, keep calling. Text messages will not be acceptable as a form of notification. From this day forward any nurse that text the DON regarding any of the above with the above will be terminated immediately per DON. Review of Record of In-service regarding Reporting Change in Condition, facilitated by the DON and dated [DATE] revealed All falls and change in condition will be reported to the DON I don't care what time of day, you will report . Review of one on one in-services facilitated by the DON following the incident on [DATE], revealed several nurses had documented their understanding of the in-service as follows: -One on One In-service dated [DATE] and signed by the DON and LVN L revealed If patient is in distress, having difficulties breathing, notified the MD (Medical Doctor). If unable to reach the MD or the DON, Nurse should send patient out to ER or call 911 . -One on One In-service dated [DATE] and signed by the DON and LVN M revealed .5 Use your nursing judgement If no answer from DON or MD and the pt is critical send to ER -One on One In-service dated [DATE] and signed by the DON and LVN N revealed if a 911 call Dr, send out to hospital when order given, notify DON after resident safe, esp. (especially) fall with c (with) injury, resp. (respiratory) difficulty! Nurse follow(s) Doctor(s) Orders -One on One In-service dated [DATE] and signed by the DON and LVN O revealed Emergency: call 911. DON Notification: Always notify the DON first to use all available resources before notifying the Dr. but any critical situation like resp distress, fall with injury, altered level of consciousness (AMS), then call the Dr first . -One on One In-service dated [DATE] and signed by the DON and LVN Q revealed If you can't get hold of the Dr. send the pt out and notify the DON, M.D. after. Review of Record of In-service regarding Carrying out physician's orders [REDACTED].

Based on observation, interview and record review, the facility failed to ensure residents received adequate supervision to prevent accidents for one (Resident #1) of nine residents reviewed for accidents. The facility failed to assess Resident #1's ability to safely obtain hot coffee and her ability to safely drink the coffee and failed to supervise the resident when she was in the dining room getting freshly brewed coffee to prevent accidents. Resident #1 was admitted to the hospital with [REDACTED]. She subsequently was admitted to a burn hospital on [DATE] with a right sided breast burn from scald injury, deep and superficial burn to right chest wall, right abdomen and right thigh. She had a skin transplant (skin autografting). This failure could affect the 33 residents identified by the facility who had been drinking coffee and could place them at risk of injury and burns. Findings included: Review of Resident #1's Face Sheet, dated 02/12/18, revealed she was an [AGE] year old female admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Review of Resident #1's MDS assessment dated [DATE], revealed she had severe cognitive impairment. Resident #1 required the physical assistance of staff with bed mobility, transfers, dressing, toileting, personal hygiene, and bathing. Resident #1 required only supervision with set up help only for eating. Review of the facility's Incident report for (Resident #1), dated 02/10/18, revealed the following: . @ (at) about 4:20-4:50 pm (PM) while this nurse was doing blood glucose check on residents, this nurse's attention was called by the supervisor to the resident that she had poured hot coffee on her body in the dining room. This nurse took the resident to the room and assessed her. She stated, I got hot coffee from the coffee pot and the cup fell off my hand and the hot coffee poured on me. Resident was noticed to have burn on her upper chest thru her rt (right) breast, belly, and side of her rt (right) thigh. I got hot coffee from the coffee pot and the cup fell off my hand and the hot coffee poured on me. Review of the facility's Provider Investigation Report/Investigation Summary for (Resident #1), dated 02/10/18, revealed the following: Review of the video of the dining room revealed that the Resident was alone in the dining room at the time of the incident. A culinary aide had brought out the urn of coffee at 4:43 p (PM) and the Resident wheeled herself up to the urn and filled a large white cup at 4:44 p (PM). The camera has about 4 minutes where it went to sleep as it did not detect any motion. The camera returns at 4:48 p (PM) when a housekeeper has walked by the motion detector and the Resident was sitting back at the table from where she had come. There was coffee on the floor by the urn and the housekeeper is seen speaking with the Resident and that is when she retrieves the nurse and relays the Resident had spilled something on herself. The Weekend Supervisor retrieves the patient from the dining room and begins her assessments as the Resident told her that she spilled coffee on herself, then a few minutes later says that someone spilled coffee on her, and then ultimately cannot remember that a spill had occurred at all. The physician was notified and he gave the order to send the Resident to the hospital for further evaluation and she returned with no new Tx (treatment) orders and a follow-up with (the burn hospital). The Resident continued with the original orders from the Attending Physician. Review of Resident #1's nurses' notes revealed the following notes related to the burn that occurred on 02/10/18: 02/10/18 5:21 PM Before super around 1650 (4:50 p.m.) while this nurse was at the nurse station speaking with a family member, a laundry aide approached a mobile x tech (X-ray Technician) at nurses desk thinking he was an employee at the facility to tell him something. When this nurse was finished speaking to family member, the mobile x tech (X-ray Technician) voiced to me that the laundry aide told him that someone had spilled something on themselves in the dining room. This nurse immediately went to assess situation in dining room Resident was sitting in wheelchair at a table in dining room with apparent spill of liquid covering right side of shirt and large amount of liquid on floor by coffee station in ding room with a big gulp type cup on the ground by spill and the lid to the cup on the table that resident was seated at. When this nurse asked resident what happened and if she had spilled coffee on herself, the resident mumbled something that was incoherent. This nurse immediately took resident out the dining room and taken to the floor nurse to have nurse do a head to toe assessment on resident . Signed by RN A. 02/10/18 11:16 PM Assessment: Assessment was done, took clothing to the affected area off, run cold water to the affected area. V/S (Vital Signs) T (Temperature) 98.6, affected area. Resident rubbed was rubbing on the affected side vigorously stating that she is on fire. Blisters and open area noted on the rt abd (right abdomen) and rt (right) side of the thigh. Request: (the doctor) in house assessed resident and ordered resident to be sent out to ER for evaluation and to ensure she is not losing any fluid, report given to the ER charge nurse. Resident sent to ER via EMS at 10:19 PM, (family) notified, DON, administrator notified . Signed by LVN B. Review of Resident #1's MAR (Medication Administration Record) for the month of Feb (YEAR) revealed Resident #1 received a pain medication according to the physician order. Observation on 03/06/18 from 10:00 AM to 11:30 AM and from 2:00 PM to 4:30 PM during the investigation revealed none of the residents went to the dining room and tried to get the coffee without supervising. Except the meal times, the barrier post with retractable yellow sign had been in place during the investigation on 03/06/18. Observation on 03/06/18 around 12:00 PM, the staff poured the coffee, covered with lids, and gave to the residents in the dining room during lunch time. An interview with Dietary Aide F on 03/06/18 at 12:34 PM revealed she was working on the day of Resident #1's incident on 02/10/18. She stated the resident came to the dietary department and asked for the coffee and she told the resident to wait couple minutes for it to brew. Then, she stated she brought the coffee pot which was freshly brewed and hot and the temperature for the coffee could be around 170 degree F. She stated Resident #1 normally came and filled the coffee without any problem. In addition, the dietary department did not have any temperature measurement of hot coffee before serving to the residents but the staff had been measuring and keeping the coffee temperature log after the incident. She also added the staff should wait for the hot coffee cooling down and not to bring out the pot right away after brewing to prevent similar incident in the future. A telephone interview with RN C on 03/06/18 at 2:38 revealed she had worked at the facility as a weekend supervisor for two years. She stated she got a report from the X- ray technician that the laundry aide told him Resident #1 spilled hot coffee in the dining room while she was talking with the family member of another resident at the nurses' station. RN C stated she saw a large cup on the table and some liquid, sugar, and sweeter on the floor. She stated she instructed CNA B to take the resident to her room and she reported the incident to LVN A. She stated the resident told LVN A someone spilled coffee? on her, however, she did not see anyone in the dining area. A telephone interview with LVN A on 03/06/18 at 2:59 PM revealed she got report that Resident #1 spilled hot coffee on herself while she was checking blood sugars on other residents. LVN A stated Resident #1 was confused and the resident was trying to get coffee in the dining room and spilled it on herself. Then, she assessed the resident, notified the medical doctor and the DON, administered the pain medication and cream for the injury area, notified the family member, and sent the resident to the ER per physician order. An interview with CNA B on 03/06/18 at 3:52 PM revealed he was working on the floor when Resident #1 was in the dining room and spilled hot coffee on herself. He stated LVN A told him to take Resident #1 to her room and assisted in changing her clothes. He also added Resident #1 usually was able to move around with her wheelchair and got coffee in the dining room. However, he stated he did not see Resident #1 to the dining room and get coffee that day. Review of Resident #1's hospital record dated 02/10/18 revealed the resident was admitted to the hospital with [REDACTED]. In addition, the hospital record revealed Resident #1 was discharged with a stable condition on 02/11/18 and instructed to follow up with the Burn hospital. According to the U.S. National Library of Medicine second-degree burns: affect both the outer and underlying layer of skin. They cause pain, redness, swelling, and blistering. They are also called partial [MEDICAL CONDITION] third-degree burns: affect the deep layers of skin. They are also called full thickness burns. They cause white or blackened, burned skin. The skin may be numb. https://medlineplus.gov/ency/article/ 0.htm (accessed on 03/07/18). Review of Resident #1's Care Plan dated 02/12/18 revealed the care plan of skin alteration related to hot coffee spill for Resident #1 developed on 02/12/18. There was no evidence of care plan of skin alteration related to hot coffee spill prior to the incident. Review of Resident #1's wound care specialist evaluation dated 02/15/18 revealed Resident #1 had burn wound of the right breast with wound size (L x W x D): 10 x 27 x 0 cm with no exudate, burn wound abdomen with wound size (L x W x D): 11x 29 x 0 cm, burn wound of the right, upper thigh with wound size (L x W x D): 8.5 x 3.5 x 0 cm, and burn wound of the right, lower thigh with the wound size (L x W x D): 18 x 3.5 x 0 cm. An interview with LVN E on 03/06/18 at 1:15 PM revealed she had worked at the facility as a wound care nurse for ten years. She stated Resident #1 was alert and confused, able to move around with her wheelchair, and did not have any tremors. She stated Resident #1 was assessed by the facility's wound doctor on 02/15/18 and the resident had first and secondary degrees burns. Review of Resident #1's hospital record dated 02/16/18 revealed the resident was admitted to the burn hospital with right sided breast burn from scald injury, deep and superficial burn to right chest wall, right abdomen, and right thigh when hot coffee spilled on the resident at the nursing facility on 02/10/18. In addition, the record included the resident had the skin autografting of the right and left chest/breast on 02/18/18. Review of the facility document on coffee temperature record for the months of (MONTH) (YEAR) and (MONTH) (YEAR) revealed the facility did not have a record of coffee temperature taken prior to the incident. An interview with the Dietary Manager on 03/06/18 at 12:17 PM revealed she had worked at the facility for two years. She stated the facility did not record the hot coffee temperature prior to Resident #1's spilling incident. After the incident, she stated the dietary staff had been checking the coffee temperature three to four times, keeping the temperature logs, and making sure not to have hot coffee temperature more than 175 degrees F. She stated the normal temperature range for serving hot coffee was from 155 - 175 degrees F. In addition, she stated Resident #1 went to the dining room and got the coffee without assistance in the past with no problem. She stated the residents with cognitive impairment should not be un-attended at any time in the dining room? An interview with Receptionist D on 03/06/18 at 1:49 PM revealed she tried to help get a follow-up appointment for Resident #1's burn injury with the hospital and the appointment on 02/16/185 at 7:00 AM was the first available. An interview with the Administrator on 03/06/18 at 2:07 PM revealed RN C reported Resident #1's spilling hot coffee on herself incident. He stated the staff members on the duty followed the protocol for Resident #1's care after the burn incident. He stated Resident #1 was moving around in the dining room alone, filled up the coffee with a white cup from outside, and spilled it by herself after reviewing of the motion detection video recording. He stated the facility did not do assessments on the residents who consumed coffee before the incident. After the incident, the facility had done safety for drinking hot liquid, taking away all the cups without lids, and providing hot liquid cups with lids only. The Administrator stated the facility did not have a policy on how to prevent an accident such as spilling of hot liquid. The facility roster, dated 03/06/18 and provided by the administrator, reflected a total of 33 residents were drinking coffee and at risk of burn from spilling hot coffee.