Every finding on record at Midlands Health & Rehabilitation Center

Based on observation, interview, and facility policy review, the facility failed to ensure kitchen staff thoroughly cleaned and air-dried plates and bowls prior to storage. This failure had the potential to increase the risk of foodborne illness and had the potential to affect 72 of 86 residents who received dietary servicesFindings include:Review of the facility policy titled, Storage and Cleaning of Dishes and Utensils dated 07/21/23 revealed, Proper ware-washing and storage is also important in food safety . Inspect clean dishes for debris and send back through the dish machine as needed . Clean dishes, silverware, pots, pans, and utensils are stored in a clean dry area at least 6 [sic] [inches] off the floor. These items should be air dried before storing or they should be stored in a way that will allow them to air dry. Do not use a towel to dry dishes .During an observation and interview on 09/10/25 at 12:00 PM, the Dietary Manager (DM) confirmed 10 four-ounce (oz) bowls, which had been stacked on the food service line for use during lunch service, and 20 plates that were stacked in the plate warmer for use during lunch service were wet and some contained food remnants. The bowls and plates were not allowed to properly air dry prior to being stacked for use. The DM stated, The plates and bowls are wet and had not properly dried prior to stacking. They should not be stacked wet due to the increased risk of bacteria growth.

Based on record review, interview, review of the Centers for Disease and Prevention (CDC) recommendations, and facility policy review, the facility failed to ensure that 4 residents (Resident (R)6, R16, R25, and R46) out of 5 reviewed, were offered the COVID-19 vaccine booster out of a total sample of 26 residents. This failure had the potential for the residents and/or their responsible party of not being informed to make a decision if they wanted the vaccine and a potential risk of contracting COVID-19.Findings include:Review of the facility's policy titled, Infection Prevention and Control Policies and Procedures Subject: Immunization recommendations for patients/residents and health care workers revised 05/15/23 indicated .The facility will track all staff and resident vaccination status for the COVID-19 vaccine. Resident vaccination status will be documented in their medical record and include: 1) Education provided to the resident or resident representative regarding the benefits and potential risks associated with the COVID-19 vaccine (including date and name of representative) .Review of CDC recommendations for 2024-2025 COVID-19 vaccinations located at cdc.gov/covid/vaccines/stay-up-to-date.html as of May 29, 2025, the schedule incorporates the HHS [Health and Human Services] directive regarding COVID-19 vaccine recommendations . for adults 19-26, 27-29, and 50-64 was to receive one or more doses of 2024-2025 vaccine and for adults older than [AGE] years of age should receive two or more doses of 2024-2025 vaccine .Review of R6's Face Sheet located in the Electronic Medical Record (EMR) under the Resident tab indicated that she was originally admitted to the facility on [DATE]. R6 was [AGE] years old.Review of R6's Care Plan located in the resident's EMR under the Care Plan tab and updated 09/10/25 included R6 being at risk for infections with need for vaccinations.Review of R6's Preventive Health Care tab located in the EMR indicated that on 11/20/24 the COVID-19 vaccine status was Other - pending consent.Review of R16's Face Sheet located in the EMR under the Resident tab indicated that he was originally admitted to the facility on [DATE]. R16 was [AGE] years old.Review of R16's Care Plan located in the resident's EMR under the Care Plan tab and updated 09/10/25 included R6 being at risk for infections with need for vaccinations.Review of R16's Preventive Health Care tab located in the EMR indicated that on 11/20/24 the COVID-19 vaccine status was Other - pending consent.Review of R25's Face Sheet located in the EMR under the Resident tab indicated that she was admitted to the facility on [DATE]. R25 was [AGE] years old.Review of R25's Care Plan located in the resident's EMR under the Care Plan tab and updated 08/18/25 did not include an immunization status.Review of R25's Preventive Health Care tab located in the EMR had no information.Review of R46's Face Sheet located in the EMR under the Resident tab indicated that she was admitted to the facility on [DATE]. R46 was [AGE] years old.Review of R46's Care Plan located in the resident's EMR under the Care Plan tab and updated 09/10/25 included R46 being at risk for infections with need for vaccinations.Review of R46's Preventive Health Care tab located in the EMR indicated that on 11/19/24 the COVID-19 vaccine status was Other - pending consent.During an interview on 09/11/25 at 5:55 PM, the Administrator stated she felt that multiple turnovers for the infection preventionist role contributed to the lack of identification of COVID-19 immunizations and/or boosters not being offered. The Administrator confirmed there was no evidence in the four residents' (R6, R16, R25, and R46) records of being offered a COVID-19 vaccine or booster.

Based on observation, record review, interview, and facility policy review, the facility failed to ensure that the Ombudsman was notified of 2 residents (Resident (R)56 and R93) discharge to an acute care hospital out of a sample of 26 residents. This failure increased the risk for inappropriate transfer or discharge and increased the risk for the resident having access to an advocate who could inform them of their options and rights.Findings include:Review of the facility's policy and procedures titled, Admission, Discharge and Transfer - Code of Ethics revised on 10/23/19 indicated . The written notice of transfer or discharge includes: . The name, address, and telephone number of the State Ombudsman . The policy did not include Ombudsman notification of the transfer/discharge.Review of R56's Face Sheet in the Electronic Medical Record (EMR) under the Resident tab indicated he was initially admitted to the facility on [DATE].Review of R56's Notice of Transfer or discharge date d 07/31/25, provided by the facility, indicated that R56 required immediate care which could not be provided by the facility.Review of R93's Face Sheet in the EMR under the Resident tab indicated she was initially admitted to the facility on [DATE] with a primary diagnosis of chronic respiratory failure.Review of R93's Notice of Transfer or discharge date d 06/11/25, provided by the facility, indicated that R93 required immediate care which could not be provided by the facility.During an interview on 09/10/25 at 6:41 PM, the Administrator revealed that the previous Social Worker (SW) was employed by the facility up until August 2025 and that she had been responsible for notifying the Ombudsman of resident transfers/discharges. The Administrator stated no paper copy was kept, but she had an email that was sent to the Ombudsman's office on 09/09/25 requesting confirmation that the previous SW had provided monthly transfer/discharge notifications.During a follow up interview on 09/11/25 at 4:25 PM, the Administrator stated that when sending a resident to the hospital, the nurse was to complete a Notice of Transfer or Discharge and the Ombudsman's office was to be notified at the beginning of the month of any discharges for the prior month. The Administrator provided an email dated 09/09/25 that the Human Resources (HR) staff emailed the Ombudsman's office requesting confirmation from their office to determine if the previous SW had been sending monthly transfer/discharge notifications.During an interview on 09/11/25 at 10:33 AM, the Ombudsman Program Assistant reported that they had not received any transfer/discharge reports from the facility since March 2025.During an interview on 09/11/25 at 4:30 PM, the Business Office Manager (BOM) stated that she was to fill out the Notice of Transfer or Discharge form, send a copy of the forms with the resident to the hospital, and then send a copy to the Responsible Party. The Social Worker would then run a report at the beginning of the month for the month prior for all transfers/discharges. The SW was to send notification to the Ombudsman's office.

Based on record review and interview, the facility failed to ensure that assessments accurately reflected the medication status for 1 resident (Resident (R)7) in a sample of 26 residents. This had the potential to lead to inaccurate reimbursements and unmet care needs for the resident.Findings include:Review of R7's undated Face Sheet located in R7's electronic medical record (EMR) under the Face Sheet tab revealed R7 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included but was not limited to cerebral infarction (stroke).Review of R7's quarterly Minimum Data Set (MDS), located in the EMR under the MDS tab with an Assessment Reference Date (ARD) of 06/16/25, documented that R7 was receiving an anticoagulant (a medication that prevents or reduces blood clotting (coagulation).Review of R7s Physician Order located in the EMR under the Orders tab revealed R7 was taking Clopidogrel (Plavix) which is classified as an antiplatelet (medication that prevents platelets from clumping together to form a clot).During an interview on 09/10/25 at 7:25 PM, the MDS Coordinator (MDSC) stated, [R7] is taking an antiplatelet medication and not an anticoagulant. The MDS with an ARD of 06/16/25 was miscoded and needs to be corrected.

Based on observation, interview, record review, and review of facility policy, the facility failed to clean respiratory equipment for 3 of 4 residents (Resident (R)6, R87, and R68) reviewed for respiratory care in the sample of 26 residents. The failure to maintain a clean oxygen concentrator filter had the potential to increase the risk of infections for the residents.Findings include:Review of the facility's policy titled Equipment Rounds General dated 02/12/24 revealed, Policy: The facility shall identify a process to facilitate general equipment rounds. Purpose: . To perform routine preventive maintenance and track due dates for scheduled, comprehensive preventive maintenance . veinlet filters on oxygen concentrators shall be visually inspected and cleaned/replaced as necessary.Review of R6's undated Face Sheet located in R6's electronic medical record (EMR) under the Face Sheet tab revealed R6 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included but was not limited to chronic respiratory failure.Review of R6's Physician Order dated 04/21/24 located in the EMR under the Orders tab revealed, Shiley size 6IC75 [sic] cuffless trach 2 lpm [liters per minute] of O2 [oxygen] with humidity on trach collar continuous day, night.Review of R6's Physician Order dated 09/08/25 located in the EMR under the Orders tab revealed, clean and check concentrators/compressor filters weekly on Mondays and PRN [as needed].During an observation and interview on 09/10/25 at 6:00 PM, the Assistant Director of Nursing (ADON) confirmed R6's oxygen concentrator filter was coated with dirt and dust. The ADON stated, The filter should be cleaned weekly, this will improve air flow and decrease the risk of bacteria.Review of R87's undated Face Sheet located in R87's EMR under the Face Sheet tab revealed R87 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included but was not limited to asthma and chronic heart failure.Review of R87's Physician Order dated 06/27/25 located in the EMR under the Orders tab revealed, O2 - 2 lpm via nasal cannula every shift day, night.Further review of R87's Physician Order fails to reveal any orders for the cleaning of the concentrator filter.During an observation and interview on 09/10/25 at 6:05 PM, the ADON confirmed R87's oxygen concentrator was coated with dirt and dust. The ADON stated, The filter should be cleaned weekly, this will improve air flow and decrease the risk of bacteria.Review of R68's undated Face Sheet located in R68's EMR under the Face Sheet tab revealed R68 was admitted to the facility on [DATE] with diagnoses which included but was not limited to respiratory failure.Review of R68's Physician Order dated 06/27/25 located in the EMR under the Orders tab revealed, [NAME] & Paykel Healthcare my AIRVO 2Optiflow + Medium NC [high-flow nasal cannula (HFNC)] target flow 15 lpm temp 31c FIO2 [the fraction of inspired oxygen] 30-32 to maintain SPO > 92% 2 lpm O concentrator every shift day, night.Further review of R87's Physician Order failed to reveal any orders for the cleaning of the concentrator filter.During observation and interview on 09/10/25 at 6:10 PM, the ADON confirmed R68's oxygen concentrator was coated with dirt and dust. The ADON stated, The filter should be cleaned weekly, this will improve air flow and decrease the risk of bacteria.

Based on observation, interview, and facility policy review, the facility failed to ensure that 1 of 4 medication carts were properly secured. This had the potential for the medications to be accessed by staff, residents, or visitors with the potential for adverse effects.Findings include:Review of the facility's policy titled, Pharmacy Services Policies and Procedures: Medication Storage revised on 04/01/22 revealed, Policy: 1. Medications and biologicals are stored safely, securely . in accordance with State and Federal laws, the facility will store all drugs and biologicals in locked compartments . 2. The medication . is only accessible to licensed nursing personnel, pharmacy personnel or authorized staff members.During an observation and interview on 09/10/25 at 4:05 PM, Licensed Practical Nurse (LPN)1 was preparing medications to administer to a resident. Resident (R)46 was at the medication cart and asked LPN1 if she would take her blood glucose (accucheck). LPN1 said she would as soon as she was finished with the resident's medications. R46 said she would just wait by the medication cart until she was done. LPN1 left the medication cart unlocked and out of eyesight, in the hallway, and entered the other resident's room. At 4:23 PM LPN1 returned to the unlocked medication cart with R46 still sitting in front of the unlocked medication cart. LPN1 stated, I usually always lock my cart, but I was in a hurry and forgot this time.During an interview on 09/10/25 at 7:36 PM, the Administrator revealed it was not acceptable practice and staff must keep their med cart locked if they walk away from it for any period of time.

Based on observation, interview, and review of facility policy, the facility failed to ensure glucometers (machines to check blood glucose levels) were disinfected after use for 2 (Residents (R)96 and R46) out of 2 observed during glucose monitoring out of a total sample of 26 residents. This had the potential to cause the spread of infection.Findings include:Review of the facility's policy titled Infection Prevention and Control Policies and Procedures revised on 05/15/23 indicated, under the Policy section, Equipment will be maintained and kept sanitized or disinfected in accord with acceptable policies.During an observation and interview on 09/10/25 at 4:06 PM, revealed Licensed Practical Nurse (LPN)1 took a glucometer in R96's room to obtain his blood glucose level (Accu-Chek). After LPN1 completed the Accu-Chek, she put the glucometer device in the top right drawer of the med cart without sanitizing it. At 4:23 PM LPN1 was observed to complete an Accu-Chek on R46. After LPN1 completed the Accu-Chek, she put the glucometer device on the top of the med cart without it being cleaned. LPN1 confirmed she did not clean the glucometer between the two residents. She said she was in a hurry to get her medications administered and that sometimes it happens; we put them away without cleaning them. LPN1 confirmed she had been trained to clean the glucometer devices before and after each use and between residents with alcohol wipes by her agency.Review of the facility provided Matrix dated 09/08/25 revealed the facility currently had 13 diabetic residents that received accuchecks. None of the 13 residents had any bloodborne pathogens/diseases.During an interview on 09/11/25 at 11:48 AM, the Assistant Director of Nursing/Infection Preventionist (ADON/IP) stated, My expectation is that we clean patient care equipment before and after and in between use on residents. Staff are trained to use the bleach wipes inside their med carts. I do in-services as needed, every three months, and annually. We do skills checkoffs on the glucometer devices as well, so everyone is trained on how to properly clean them. The ADON/IP confirmed the 13 residents did not have any bloodborne pathogens/diseases.During an interview on 09/11/25 at 12:00 PM, the Administrator stated, Staff are trained during orientation, quarterly, annually during the skills checkoff competencies, and as needed. For agency staff, they're provided training prior to their first shift by the agency they contract through. For cleaning Accu-Chek devices, we use the purple top Sani-Cloths and let them air dry for two minutes. All the med carts have them and bleach wipes on their carts. Staff are trained to use them before and after use and in between residents.

Based on the facility policy, observations and interviews, the facility failed to ensure expired medications were removed and not stored with other medications in use for residents in 3 of 4 med carts and 2 of 2 medication rooms. The facility further failed to ensure medications that were discontinued, or the medications for discharged residents were not stored in a med room on the North Hall. The facility additionally failed to ensure personal snacks were not stored on the North Hall front med cart. Review of the facility policy titled, Section 5 - Medication Disposal and Returns, states under procedures: 1. When medication is discontinued or a resident is discharged , facility staff should refer to the LTC Provider Pharmacy policies regarding medication return eligibility and the process to be followed for returns. 2. Nursing staff shall dispose of any medication that has been discontinued, expired or that is not returnable to the pharmacy according to Facility Policy. 3. Facility should segregate and securely store the medications to be returned to pharmacy until they are picked up by pharmacy. Review of the facility policy titled, Section 8 - Medication Storage, states under policy: 1. Medications and biological's are stored safely, securely and properly following a manufacturer's recommendations or those of the supplier. 2. The medication and biological supply is only accessible to licensed nursing personnel, pharmacy personnel or authorized staff member. Procedures: 6. Once any medication or biological package is opened, the facility should follow manufacturer/supplier guidelines with respect to expiration dates of opened medications. 7. Once any multi-dose packaged medication or biological is opened, nursing will mark the multi-dose products (e.g. inhalers, insulin, ophthalmic, otics and the like) with the date opened and follow manufacturer's/supplier guidelines with respect to expiration dates. The findings include: An observation on 08/25/24 at 11:42 AM of the North Hall A medication cart revealed: A bottle of Levetiracetam 100 milligram/milliliter, Manufactured by APL Healthcare Limited was expired. A Basaglar Kwik Pen, Manufactured by Lilly with Lot #D667654C has no open date and no expiration date. A Lispro Kwik Pen, Manufactured by Lilly with Lot #D672155A opened on 07/23/24 with no expiration date had expired after being in use for over 28 days. During an interview with Licensed Practical Nurse (LPN)1 at 08/25/24 at 11:45 AM, she confirmed the findings and removed the expired medications from the medication cart. An observation on 08/25/24 at 12:28 PM of North Hall B medication cart revealed: One bottle of Geri Care Saline Nasal Spray 1.5 ounces, Lot #97051 was expired on 06/24. Also stored in the medication cart North B was an opened cherry coke and a pack of cheese Ritz crackers. During an interview at this time with LPN2 confirmed the expired nasal spray, the cherry coke and the cheese Ritz crackers and removed them from the medication cart. An observation on 08/27/24 at 10:32 AM of the North Medication Room revealed: The medication Lorazepam 1 milligram/milliliter, individual wrapped 25 packages with Lot #254510 was expired on 07/28/24. Lorazepam 1 milligram/milliliter, individual wrapped 2 packages with Lot #252609 was expired on 06/17/24. One bag of Vancomycin 250 milliliters for intravenous use with ID 32571 and RO #27805 contained a use by date of 08/19/24. The medications were confirmed as expired and removed from storage by the Assistant Director of Nursing (ADON). During the North Hall Medication Room observation, the cabinets contained 3 shelves high of medications that were either discontinued or the residents were no longer residing in the facility. The cabinet contained 3 shelves full of blister packs of medications. The cabinet was locked on one side and the other side was easily opened. During an interview with the ADON, she stated the medications are awaiting to be discontinued for 60 days before they can be returned to the pharmacy. She stated the pharmacy will not take them back until they have been in the facility storage for 60 days. This surveyor asked the ADON who was monitoring the meds for the 60 days and she stated she did not know if anyone was monitoring the medications. Review on 08/27/24 at 10:50 AM of the South Hall Medication Storage Room revealed: Expired medications in the Emergency Medication Box. The medication Fluconazole 50 milligrams, 5 pills with Lot #FL0823001A, Manufactured by NorthStar were expired on 07/31/24. Also in the emergency medication box were 6 tablets of Baclofen with Lot #07352 expired on 04/30/24. The South Medication Room expired medications were verified as expired by the ADON on 08/27/24 at 11:10 AM and removed from storage. During observations of med pass on 08/27/24 at 08:00 AM revealed LPN5 administering medications. LPN5 was in the process of pulling an inhaler from North Med Cart A, she removed the inhaler and handed it to this surveyor. The inhaler was for Symbicort and was opened on 05/25/24 and was only to be used for 3 months and then discarded. The inhaler was expired and LPN5 confirmed that it was expired and pulled a second inhaler for the resident from the med cart and administered it. During an interview on 08/28/24 at 10:05 AM with the Administrator, she stated that the pharmacy comes on Tuesdays, and will pick up the discontinued meds at that time. This surveyor informed her that the cabinet was overly full and the medications should not be stored in the med room for long periods of time. The medications were not controlled drugs but could easily be taken from the medication room.

Based on the facility policy, observations, record reviews and interviews, the facility failed to ensure Resident (R)20) was afforded and/or provided an ongoing program of activities designed to meet her interest and preferences for 1 of 2 residents reviewed for activities. Review of the facility policy titled, Activity/Recreation Programming, states as the policy, Based on a comprehensive assessment, individualized care plan and the preferences of each resident, the Activity/Recreation Director and staff shall provide an ongoing Activity/Recreation program to support resident's personal choice of activities, facility-sponsored group and individual activities, and independent activities designed to meet the interests of and support the physical, mental and psychosocial well-being of each resident, encouraging both independence and community interaction. Purpose: To implement an ongoing resident centered activities program that incorporated the resident's needs, interests, hobbies and cultural preferences which is integral to maintaining and/or improving physical, mental, psychosocial well-being and independence. To create opportunities for each resident to have a meaningful life by supporting the domains of wellness (security, autonomy, growth, connectedness, identity, joy and meaning). The findings include: The facility admitted R20 on 06/14/24 with diagnoses including, but not limited to, muscle wasting and atrophy, need for assistance with personal care, muscle weakness, end stage renal disease with need for Dialysis. Review of the Minimum Data Set Assessment (MDS) revealed a five day assessment dated [DATE] and the Brief Interview for Mental States (BIMS) is scored as a (0) indicated R20 is severely impaired cognition. Multiple observations on 08/25/24, 08/26/24, 08/27/24 and 08/28/24 at various times revealed R20 in bed, daily with no activities provided. During an interview on 08/25/24 at 06:30 PM with the personal representative for R20, she stated that R20 is always in the bed, never gotten up and activities are not provided for this resident. Review of the Comprehensive Care Plan for R20 states, Resident needs one to one visits such as listening to music, reading of the daily chronicles in an effort to meet her emotional, intellectual, physical and social needs. The goal states, she will benefit from one to one as evidenced to improve quality and effectiveness. The interventions listed are: Staff will read to resident during one to one visits. Activity staff will observe and document resident's response to the one to one visit. Staff will provide music of interest during one to one visits. Activity staff will provide one to one visits such as reading of the daily chronicles ad gospel music. Review of the documented activity sheets for 3 months which included June '24, July '24 and August '24 revealed, R20 was visited one time weekly in June '24 which included, 06/14/24, 06/21/24, 06/24/24 and 06/28/24 and the resident received reading of the current events and the radio was on during the visits. Nail care was provided only one time in the 3 months reviewed, which is documented on June 18th. Review of the activity attendance sheets for July '24 revealed, R20 received reading of cultural events on 7/01/24, 07/02/24 and 07/12/24. Current events news was provided on 07/31/24. During the one to one visits music was provided on 07/04/24 and 07/12/24. Reading was provided on 07/16/24 and 07/19/24 and 07/31/24. No documentation was for the time spent with the resident or if there was any type response from R20 during the activity. Review of the activity attendance sheet for August '24 revealed that 2 times weekly music and reading are provided at the same time. No current events are offered for August '24 and only 3 times for July '24. No documentation of the resident response if any or the amount of time spent with the resident was provided. During an interview on 08/27/24 at 11:14 AM with the Activity Director she stated, this resident needs in room activities. She stated, when asked, if R20 is able to get up or be gotten up into a geri chair and she stated she is able to get up into a geri chair and could possibly attend social activities with other resident's. This surveyor asked about the documented day of nail care on 06/18/24 since it was only documented as receiving one time, and she stated, if the aide has already provided nail care then she does not do it, but the resident likes to have manicures. R20, likes gospel music and religious services, but none were provided. No social interaction or group activities were offered to R20 for the 3 months of activity attendance reviewed.

Based on the facility policy, record reviews and interviews, the facility failed to ensure Resident (R)41) or her responsible party received a copy of the Bed Hold Policy, in a timely manner, for a discharge to the hospital from 07/22/24 through 07/31/24. Review of the facility policy titled, Facility's Policy and State Requirements for Temporary Leave Bed-Hold, states, If a resident leaves the facility for temporary hospitalization or therapeutic leave, the resident or his/her representative may ask the facility to hold the resident's bed until the resident is ready to return. The resident and/or his/her representative will be given an copy of the facility's bed-hold policy before the resident actually leaves for his/her temporary leave or hospitalization . In the case of an emergency, hospitalization , the bed hold policy may accompany the resident to the hospital or will be given to the resident or his/her legal representative within twenty-four (24) hours of the resident's hospitalization . The findings include: The facility admitted R41 on 04/18/24 with diagnoses including, but not limited to, severe sepsis with septic shock, Alzheimer's, dementia, acute respiratory failure and pneumonia. Review of the medical record on 08/27/24 at 09:03 AM for R41 revealed a discharge to the hospital on 07/22/24 through 07/31/24 for respiratory distress. There was no documentation to ensure the resident nor the resident received a copy of the facility bed hold policy in a timely manner. During an interview on 08/28/24 at 08:40 AM with the Administrator she provided a copy of the bed hold policy dated 07/22/24 which included the resident representative's name, and the date that R41 was transferred to the hospital but no documentation to ensure the resident or the representative received a copy of the bed hold policy within a timely manner of the discharge to the hospital.

Based on the facility policy, records reviews and interviews, the facility failed to ensure Resident (R)41 and her responsible party received notice of transfer, for a hospital stay, in writing and in a language they could understand of the reason for transfer for 1 of 2 residents reviewed for hospitalization . Review on 08/26/24 at 03:10 PM of the facility policy titled, Admission, Discharge and Transfer, states: 4. Facility staff provides, upon admission, at the time of transfer to a hospital, and before therapeutic leave begins, written information to the patient/resident and a family member or representative concerning the duration of the bed-hold policy under the state plan and under alternative payor plans. Facility staff documents in the medical record that written notice was provided. 21. The patient/resident/family member receives notice of transfer or discharge, as soon as practical depending on the reason for the discharge, in a language they can understand. A. Safety or health of the patient/resident or others is at stake. C. An immediate transfer or discharge is required by the patient/resident's urgent medical needs. 22. The written notice of transfer or discharge includes. A. The reason for discharge. B. The effective date of the transfer or discharge. C. The location to which the patient/resident will be transferred or discharged . 23. The reasons's for transfer or discharge are recorded in the patient/resident's clinical record. The findings include: The facility admitted R41 on 04/18/24 with diagnoses including, but not limited to, severe sepsis with septic shock, Alzheimer's, dementia, schizophrenia, atrial fibrillation, diabetes mellitus and hypertension. Review of the medical record on 08/27/24 at 09:03 AM for R41 revealed a discharge to the hospital on 07/22/24 for respiratory distress. There was no documentation to ensure the resident nor the resident received notification of transfer to the hospital to include the reason for transfer. The Administrator provided a from titled, SNF/NF to Hospital Transfer Form, the form included the resident's name, the date of birth and the date of transfer to the hospital. No other documentation was on the form. A second form was provided which states, Pursuant to Federal and State regulations, this Notice is being provided as a formal notification that this resident is transferred and or discharged from this facility on 07/22/24 for the following reason, no reason was documented. The facility social worker signed the document, but no documentation to ensure the resident nor the personal representative received a copy. During an interview on 08/28/24 at 08:40 AM with the Administrator, this surveyor brought to her attention that the transfer form contained the resident's name, date of birth, and the date transferred to the hospital and that no other documentation was on the form. The Administrator circled an area on the form, Additional Relevant Information, an acute care transfer list of relevant documentation sent to the resident/patient. The checklist was not provided for R41 nor her responsible party. During an interview on 08/28/24 at 09:20 AM with Registered Nurse (RN)1, she stated, when asked about the process for resident transfer to the hospital and she stated, First we assess the resident, get vitals, and notify the attending physician and the resident's personal representative. If we receive orders to send out to the hospital then we call 911. When asked about the notice of transfer to the hospital, she stated, it is filled out and a copy is presented to the resident and the personal representative along with the Bed Hold Policy. She also mentioned the check list that is completed and in the medical record. No completed checklist was provided for R41's discharge to the hospital.

Based on review of facility policy, interviews, and record review, the facility failed to ensure Resident (R)1 and R2 was free from electrical hazards. On 04/08/24 at 4:00 PM, the Administrator and Director of Nursing were notified that the failure to maintain all mechanical, electrical, and patient care equipment in safe operation constituted Immediate Jeopardy (IJ) at F908. On 04/08/24 at 4:00 PM, the survey team provided the Administrator with a copy of the CMS Immediate Jeopardy (IJ) Template and informed the facility IJ existed as of 12/15/23. The IJ was related to 42 CFR 483.90 - Physical Environment. On 04/08/24 at 6:18 PM, the facility presented an acceptable plan of removal of the IJ. On 04/08/24 at 6:18 PM, the survey team, validated the facility's corrective actions and removed the IJ. The facility remained out of compliance at F908 at a lower scope and severity of D following removal of the IJ. Findings include: Review of the facility's policy titled, Maintenance/Housekeeping Policies and Procedures dated email revision August 2019, indicated, 2). Observe bed operation 6). Check underside bed frame and mattress support platform 8). Check wiring for proper connections and damage (fraying, kinking, or deterioration). Bedframes, mattresses, bed rails (if applicable), inspect bed power cord, cord plug and wall plug for damage. Review of R1's Face Sheet revealed R1 was admitted to the facility on [DATE] with diagnoses including but not limited to: depression, heart failure, and cognitive communication deficit. Review of R1's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) date of 10/31/23 revealed a Brief Interview for Mental Status (BIMS) score of 12 out of 15, indicating R1 was moderately cognitively impaired. Review of R1's Physician Orders revealed R1 was ordered, Albuterol sulfate, HFA aerosol inhaler; 90 mcg/actuation; amt 2 puffs; inhalation and O2 supplies weekly on Sundays. Review of R1's Care Plan with a start date of 08/10/22, revealed, [R1] is at risk for respiratory complications . with an approach indicating, Keep room cool and free of irritants such as smoke, dust, cleaning agents. Review of R1's Progress Notes dated 12/15/23, revealed, Resident is received back to the facility at MHR with room change at change of shift (7pm). Resident vital signs taken and recorded- and are abnormal as follows T- 103.6, p 115, r- 24, bp- 100/68. Report and after visit summary (hospital paperwork) were provided to oncoming nurse. This nurse writer called the on call provider and received telephone orders which are being entered by department and these are for Tylenol 650mg every 6 hours as needed for fever and or pain, flu and covid swabs, chest x ray, vitals times two this shift, oxygen as needed- titrate oxygen to maintain o2 saturations greater than 92%, and provider notification- notify provider if o2 saturations fall less than 92%. These orders are conveyed in nurse report hand off. Review of R2's Face Sheet revealed R2 was admitted to the facility on [DATE] with diagnoses including but not limited to: anxiety disorder, absence of right leg below knee, and morbid obesity. Review of R2's Quarterly MDS with an ARD date of 11/03/24 revealed a BIMS score of 14 out of 15, indicating R2 was cognitively intact. Review of R2's Physician Orders revealed R2 was ordered, O2 4 liters per minute via nasal cannula. Review of a Five-Day Report dated 02/15/24 revealed, Certified Nursing Assistant (CNA) was sitting at the nursing station, when she overheard R2 calling out for assistance. When entering the room, R2 stated the bed was smoking. Staff reports sparks were observed. Review of a Work History Report revealed the following: Task Type Preventive Maintenance, Due Date 10/31/23, 11/30/23, and 12/31/23, Category Beds - Electric, Task Description Beds & Mattresses: Inspect Bed Rails. Review of the Work History Order revealed the tasks during the indicated days were completed. However further review of the Work History Report did not indicate that the electric system, (check wiring for proper connections and damage fraying, kinking, or deterioration) of the beds were inspected, only that the bed rails were inspected. Review of a Fire Report from the local fire department dated 12/15/23 revealed, Engine 32 investigated and found a damaged cord from a bed. There was no fire. Reports from staff members confirmed this cord was arcing [when electricity jumps from one connection to another. The discharge of electricity is produced during an electrical breakdown . This often causes a flash, sparks, and a sizzling or cracking sound]. Engine 32-1 unplugged the cord from the wall socket. There was no fire extension. Ladder 4 then ventilated the wing. Command was terminated and Engine 32 went back in service. The Maintenance Director was unavailable for interview. During an interview on 04/08/24 at 11:09 AM, R2 stated he looked over, heard zapping and heard R1 making non-coherent noises. R2 further stated he saw flames and the bed itself was on fire, so he pushed the call button and called for help. During an interview on 04/08/24 at 11:29 AM, RN1 stated she heard R2 calling for help. RN1 stated upon entering the room she saw sparks coming from under R1's bed. RN1 pulled the alarm, and everyone came in to assist with getting the residents out of the room. RN1 further stated R1 was in his bed at the time, and she could see the sparks and smoke coming from behind the bed. There was a moderate amount of smoke and you could see the smoke in the room. RN1 stated she utilized the fire extinguisher, aiming behind and on the bed, shortly thereafter the fire department was on the scene. RN1 concluded R1 is total care, g-tube and incontinent. During an interview on 04/08/24 at 11:38 AM, Certified Nursing Assistant (CNA)1 stated she heard R2 yelling out Fire. CNA1 stated upon entering the room she saw smoke and they moved R1 out of his bed first and then proceeded to move R2 out of his bed to safety. CNA1 further stated the fire department was called. CNA1 concluded that R1 and R2 are total care. During an interview on 04/08/24 at 1:09 PM, R1 stated he didn't see any fire, but he heard R2 calling for help. R1 concluded he was okay, but he needs a new bed. During an interview on 04/08/24 at approximately 2:40 PM, the Administrator stated the Work History Report does not indicate what maintenance checked. The Administrator further stated the facility does not have any written documentation of the routine preventive maintenance of electric beds. On 04/08/24 at 6:18 PM, the facility presented an acceptable plan of removal, which included the following: Resident #2 resides in the facility. On 12-15-2023, Resident #2 notified staff that that [sic] resident #1 bed was smoking. Staff members responded to the incident, Resident #1 and Resident #2 were relocated. The Fire Department responded and found a damaged cord from the bed- there was no actual fire. A complete audit of mechanical, electrical and patient care equipment was performed on 4-8-24 with no concerns at this time. The Medical Director was notified of the incident on 12-15-2023. Residents who reside in the facility have the potential to be affected by this alleged deficient practice. Administrator re-educated the Maintenance Supervisor via telephone on preventative maintenance for mechanical, electrical and patient care equipment on 4-8-2024. Additional education to be completed with Regional Maintenance. Director of Nursing/Designee will re-educate licensed nurses and unlicensed staff 4-8-24 to include the following: - Process of documenting maintenance concerns in the maintenance log. - RACE (Rescue, Alarm, Contain, Extinguish) is to be initiated. Staff members are required to be a part of an emergency. - Staff is required to remain in place until cleared. - Staff re-educated on power cord safety and non-battery operated equipment. Education focused on observation for function and deterioration of parts the equipment. Staff not receiving this re-education on 4-8-24 will receive prior to working the next scheduled shift. This will be presented in new hire orientation and for agency staff. The Maintenance Director will perform audits of ten resident's mechanical, electrical and patient care equipment Monday - Friday for four weeks and then ten weekly for additional months. Any concerns will be addressed at the time of discovery. The Medical Director was notified on 4-8-24 of the Immediate Jeopardy. An Ad-Hoc Quality Assurance Performance Improvement meeting was held on 4-8-2024 regarding the contents of this plan. The Facility Administrator will oversee compliance of this plan for three months.

Based on review of facility policy, record review, observations, and interviews, the facility failed to assist residents with Activities of Daily Living (ADL) care for 6 of 8 residents (R)13, R18, R25, R68, R74, and R78, who were dependent for ADL care in a total sample of 21 residents. Findings include: Review of the facility policy titled, Activities of Daily Living, Optimal Function, dated 08/30/17 revealed, The Facility provides necessary care to all residents that are unable to carry out activities of daily living on their own to ensure they maintain proper nutrition, grooming, and hygiene. 1. Review of R13's Face Sheet located in the electronic medical record (EMR) under the Resident tab, revealed an admitted [DATE] with medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R13's quarterly Minimum Data Set (MDS) located in the EMR under the RAI tab with an assessment reference date (ARD) of 06/22/22, revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating R13 was cognitively intact. The MDS revealed R13 required extensive physical assistance of one person for her personal hygiene needs. Review of R13's Care Plan located in the EMR under the RAI tab last updated 08/02/22 read, . is dependent with bathing, limited to extensive assist with bed mobility, dressing, toileting and hygiene, supervision for eating and dependent for transfer, and locomotion. One of the interventions included in the Care Plan was, Provide required assistance for self care [sic]. Review of R13's EMR revealed no documented refusals of ADL care in the past 30 days. During an observation on 09/26/22 at 11:22 AM, R13 was lying in bed and R13's hair appeared unwashed with white buildup throughout. R13's hair was pulled up into a bun hairstyle at the time of the observation. R13 stated it had been quite a while since she had her hair washed and would like for it to be washed as soon as possible. During an observation on 09/27/22 at 11:42 AM, R13 was lying in bed and her hair remained unwashed, with white buildup, pulled up into a bun hairstyle. R13 again stated she wanted her hair to be washed. R13 proceeded to loosen her hair from the bun. R13's hair was mid-back length, and the hair did not flow freely. R13's hair was severely tangled and matted with white buildup throughout entire length of hair. R13 stated her hair had not been washed since 07/13/22. R13 stated, I remember vividly because it was the day before my birthday. R13 stated she had never refused to have her hair washed. During an observation on 09/28/22 at 8:36 AM, R13's hair remained unwashed with white buildup. During an interview on 09/27/22 at 2:40 PM, Certified Nursing Assistant (CNA)3 stated she washed residents' hair when she gave them a bath or shower. CNA3 stated she was the primary caregiver for R13, had worked at the facility for approximately one month, and had never washed R13's hair. CNA3 stated R13 had never refused to have her hair washed. During an interview on 09/27/22 at 3:20 PM, CNA1 stated she has been assigned to R13 on the day and evening shift for the past month. CNA1 stated she had worked at the facility for approximately one month and had never washed R13's hair. CNA1 stated she had never known R13 to refuse to have her hair washed. 2. Review of R74's Face Sheet located in the EMR under the Resident tab, revealed an admitted [DATE] with medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R74's MDS located in the EMR under the RAI tab with an ARD of 09/07/22, revealed a BIMS score of 12 out of 15, indicating R74 was moderately cognitively impaired. The MDS revealed R74 required extensive physical assistance of one person for her personal hygiene needs. Review of R74's Care Plan located in the EMR under the RAI tab last updated 08/19/22 read, . requires assistance with adl's d/t [due to] recent compression fracture. One of the interventions included in the care plan was, Assist with personal hygiene as needed. Review of R74's EMR revealed no documented refusals of ADL care in the past 30 days. During an observation on 09/26/22 at 9:53 AM, R74 was lying in bed awake and R74 had excessive chin hair, gray in color, approximately 1.5 inches long. R74 stated she did not know the last time her chin hair had been groomed but she did not like long chin hair and would like for it to be removed. During an observation on 09/27/22 at 8:27 AM, R74 was sitting upright in bed eating breakfast. R74's chin hair remained unchanged from the observation on 09/26/22. During an observation on 09/28/22 at 8:37 AM, R74 was sitting in bed awake reading a magazine. R74's chin hair remained unchanged from previous two observations. During an interview on 09/27/22 at 2:40 PM, CNA3 stated she was assigned to R74 in early September 2022 and shaved her chin hairs at that time. CNA3 stated she had not been assigned to R74 since that time. During an interview on 09/27/22 at 3:20 PM, CNA1 stated she was the main caregiver for R74. CNA1 stated she shaved residents' chin hair as needed. CNA1 stated she had never shaved R74 and had not noticed R74's chin hair. 3. Review of R78's Face Sheet located in the EMR under the Resident tab, revealed an admitted [DATE] with medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R78's quarterly MDS located in the EMR under the RAI tab with an ARD of 08/30/22, revealed a BIMS score of 10 out of 15, indicating R78 was moderately cognitively impaired. The MDS revealed R78 required extensive physical assistance of one person for her personal hygiene needs. Review of R78's Care Plan, located in the EMR under the RAI tab last updated 06/14//22 read, . requires assistance with adl's d/t dx of TIA with right sided weakness, MS and recent decline related to hospital stay. One of the interventions included in the care plan was, Assist with personal hygiene as needed. Review of R78's EMR revealed no refusal of ADL care in the past 30 days. During an observation on 09/26/22 at 10:09 AM, R78's hair appeared to be greasy and disheveled. R78 stated, My hair has only been washed twice since I have been here. During an observation on 09/27/22 at 11:59 AM, R78's hair remained greasy and disheveled. R78 stated, I haven't gotten my hair washed yet. R78 further stated the last time her hair was washed was last month. During an observation on 09/28/22 at 8:38 AM, R78's hair remained greasy and disheveled. During an interview on 09/27/22 at 2:40 PM, CNA3 stated she was the primary caregiver for R78. CNA3 stated R78 had never refused ADL care until yesterday. CNA3 stated the last time she had washed R78's hair was the beginning of September. During an interview on 09/27/22 at 3:20 PM, CNA1 stated she has been assigned to R78 on the day and evening shift for the past month. CNA1 stated she had never washed R78's hair and she had never known R78 to refuse care. During an interview on 09/27/22 at 3:33 PM, the Director of Nursing (DON) stated, she expected all refusals of ADL care to be documented. The DON stated she expected the residents' hair to be washed with showers or bed baths. 4. Review of R68's EMR Face Sheet under the Resident tab revealed R68 admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R68's MDS with an ARD of 08/13/22 revealed a BIMS score of 12 out of 15 indicating the resident was moderately impaired cognitively and required extensive assistance from one person for personal hygiene. Review of R68's Care Plan located in the EMR under the Care Plan tab dated 08/18/22 revealed a problem, start date of 06/06/22 indicating R68, requires assistance with ADLs. with the goal resident will have a clean, neat appearance qd [everyday] and approaches to include assist with nail care as needed. Review of R68's Progress Notes under the Progress Notes tab in the EMR for August 2022 and September 2022 revealed one note regarding care refusals, on 08/07/2022 at 6:13 AM, Resident refused ADL care from staff times several attempts from different staff members. During an observation on 09/26/22 at 9:53 AM, R68 was sleeping, her toenails were observed to be long and jagged. During interview on 09/27/22 at 9:00 AM, R68 was difficult to understand at times and interview was limited. R68's toenails were not visible. During an observation on 09/27/22 at 11:55 AM, R68's toenails were observed to remain long and jagged. During an interview on 09/27/22 at 3:17 PM, Licensed Practical Nurse (LPN)4, stated she had noticed R68's toenails were very long and needed cut. LPN4 stated that R68 did refuse cares but if you butter her up maybe she'll let me cut the nails. LPN4 stated that when residents refused cares it should be documented on the Medication Administration Record (MAR) or in the Progress Notes. LPN4 opened R68's MAR in the EMR. LPN4 could not find were care refusals would be documented for R68. During an interview on 09/27/22 at 3:37 PM, the DON stated any direct care staff can provide nail cares; and only nursing staff or podiatry cut toenails. The DON stated refusals of care should be documented and care planned. The DON stated R68 did refuse some cares at times and that it should be documented. During an interview on 09/28/22 at 11:02 AM, the DON confirmed there were no additional refusals of care documented for R68 in August or September of 2022 and there was no documentation of staff offering to cut R68's toenails. The DON stated for toenails licensed nursing staff should offer to cut residents toenails unless the resident was diabetic and on the podiatry list. 5. Review of R25's Face Sheet under the Profile tab in the EMR revealed R25 was originally admitted to the facility on [DATE]. R25 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Quarterly MDS found under the MDS tab with an ARD of 07/12/22, revealed R25's cognition was intact with a BIMS score of 13 out of 15. R25 required extensive staff assistance with ADLs. Review of R25's Care Plan dated 08/07/22 located in the EMR under the RAI tab indicated he required supervision to total assistance with all ADLs. The Care Plan indicated a licensed nurse or podiatrist would clip and file toenails and (certified nurse aides) would clip and file fingernails. During an observation and interview on 09/26/22 at 9:31 AM, R25 said he thought he had a sore on his foot and he was concerned about his foot not being treated. On 09/27/22 at 9:21 AM, R25's feet was observed with the Assistant Director of Nursing (ADON). His toenails were an inch long and jagged. R25 said he wanted them treated as soon as possible. He said he believed they were starting to hurt, and he thought he had a sore on his feet. The ADON said she was unsure of the last time a podiatrist saw the resident. During an interview with CNA1 on 09/28/22 at 4:45 PM related to ADLs indicated the nurses or the podiatrist cut the resident's toenails. During an interview with CNA5 on 09/28/22 at 4:46 PM related to ADLs indicated only the nurses and podiatrist cut resident's toenails. On 09/28/22 at 4:53 PM, during an interview with the DON, she said her expectations were that residents requiring ADL assistance received the care and services, including toenails being trimmed and clean. 6. Review of R18's EMR revealed the undated Face Sheet under the Resident tab indicated R18 was admitted to the facility on [DATE] and readmitted on [DATE]. R18 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R18's quarterly MDS with ARD of 6/14/22 indicated that R18 had a BIMS score of 15 out of 15, which indicated R18 was cognitively intact. R18 was documented to require total assistance with ADLs, including hygiene and grooming. Review of R18's Care Plan located in the resident's EMR under the RAI tab indicated a problem with limited mobility, personal hygiene and bathing with interventions to assist with all ADL needs including routine nail care. During an observation and interview on 09/27/22 at 2:15 PM, R18 was observed to have approximately 1/2-inch hair growth on her chin and around her lip area. She said the staff were supposed to remove it and she did not want it on her face, but they did not take very good care of her and provide assistance as needed. During an interview on 09/28/22 at 5:05 PM, CNA1 said when they were shorthanded, so a lot of residents did not get showers or required assistance. CNA1 said she tells the DON and tries to make sure everyone gets what they need. She verified R18 should not have the facial hair. During an interview on 09/28/22 at 4:48 PM, the DON said her expectations were residents to be kept clean, she said showers were given three times a week, but sometimes they refuse. The DON said she required staff to ask the residents if they wanted facial hair removed at the time of their showers.

Based on observations, interview, record review, and review of facility policy, the facility failed to ensure the environment remained as free from potential accident hazards as possible for 1 of 1 resident (R)23 reviewed for smoking. The facility failed to ensure R23 was effectively monitored to prevent smoking in non-smoking areas per facility policy. Findings include: Review of the facility provided Smoking Policy'' from the Admissions Handbook, signed by R23 on 07/22/22, revealed ''. this facility is a smoke-free environment and there are NO designated smoking areas inside the building or on its premises for its residents. Smoking in any areas of the facility or on its premises . is strictly prohibited and will not be tolerated. Violations of this policy endanger the health and safety of others and the facility and may be cause for progressive disciplines up to and including involuntary discharge. Review of R23's Care Plan located in the electronic medical record (EMR) under the Care Plan tab revealed problem, start date 08/24/22, for R23 is non-compliant with facility non-smoking policy as evidenced by his being found smoking in room and outside without supervision. The approaches included monitor resident and room for signs of symptoms of smoking. Request permission to search room when suspect of having smoking instruments on him.offer cessation programs . remind [R23] that this is a non-smoking facility as needed. Encourage him to consider the safety of others. review policy and procedures with resident in regards to smoking . Praise positive behaviors. Review of a R23's Safety Evaluation For Smoking/Care Plan dated 07/19/22, provided by the facility, revealed R23 could smoke safely without the use of safety devices. The form indicated the facility's non-smoking policy was reviewed by social services and the resident was able to verbalize the policy and restrictions. Review of R23's EMR Progress Notes under the Progress Notes tab revealed the following: On 06/02/22 at 4:45 PM, SSD [Social Services Director] informed by staff that [R23] was seen with tobacco products. SSD and nursing staff enter into resident room . observed smoke scent in room. SSD inquired about tobacco products [R23] became very hostile in tone, indicated that he will not give his tobacco products up unless they paid for them. [R23] was educated on safety and policy informed that he will have to discharge for not following policy. SSd [sic] informed that nursing staff will do 15 mins checks for safety . On 06/02/22 at 6:58 PM, [R23] outside on the porch smoking. Aide saw resident smoking and reported it. Aide watched resident and tried to tell him to give staff the cigarettes. Resident got verbally abusive and started getting physical. Staff backed away from resident and kept eye on resident to make sure he does not harm himself. Nurse charting contacted DON [Director of Nursing] and made aware of situation. Per DON and Doctor, an order was given to send resident out for combative behaviors. Resident has history of [CONDITION(S)]. Resident came from off porch and proceeded to go back into room when oncoming nurse asked him for the cigarettes. Resident stated he did not have any and continued to walk away. Resident has been on 15 [minute]checks since 515pm. On 06/03/22 at 3:48 PM, SSD reach out to [R23's family member] update on [R23] informed her of finding placing for [R23] non complaint with smoking polices [sic]. SSD send referral to [names of multiple alternative facilities]. SSD continue to search for placement nursing continue 15 mins checks. On 06/05/22 at 3:05 AM, [R23] WAS OBSERVED OUTSIDE ON PATIO AT 7:15 PM WITH CIGARETTE SMOKING I APPROACHED RESIDENT ASK HIM NOT TO SMOKE BECAUSE OF OUR NO SMOKING POLICY . HE BECAME VERBALLY LOUD FLINGING HANDS AND ARMS UP IN THE AIR STATING 'I'M NOT BOTHERING NO ONE IM OUTSIDE' HE CONTINUE TO SMOKE HIS CIGARETTE. DON WAS IMMEDIATELY NOTIFIED AND 911 [emergency services] CALLED. R23 did not leave with EMS and eventually gave cigarettes to nursing. On 06/06/22 12:16 PM, SSD met with [R23] in room observed laying [sic] in bed . still non compliant with smoking policy. SSD continues to educate on safety awareness. SSD continue to look for placement for. On 06/15/22 at 9:22 AM, SSD informed that [R23] continue to be no [sic] compliant with Smoking policies, educated by staff of policies. SSD continue to search for placement. On 06/17/22 at 1:25 PM, [R23] transferred out of facility due to noncompliance and believed to be a harm to himself and others. Resident . went on the sunporch where an aide caught the resident outside smoking. DON and other staff went to educate resident that he could not smoke, resident got upset and started using [sic] foul language towards staff. 911was called and residents room was searched and found a lighter in one of residents shirt pockets. Resident stayed in room until around lunch time and went outside. Aide came and got nurse and stated I think I know how he is getting stuff. Nurse went to the sunporch and saw a gentlemen walking up with a bag, nurse charting told staff to go get DON, DON came and talked with the gentlemen and handled the situation. EMS [Emergency Medical Services] was called and resident used very foul language with EMS. On 07/08/22 at 4:34 PM, SSD informed that [R23] is non compliance [sic] with smoking policies. SSD met with [R23] observed sitting in front of building. [Resident's Name] educated on safety and smoking policies; nonchalant mood stated ok. The note indicated the SSD was continuing to send referrals to alternate facilities. On 07/20/22 at 4:31 PM, [Recorded as Late Entry on 07/21/2022 04:31 AM] resident cont [continues] to not comply with facility rules with no smoking, seen smoking on back patio, inform resident he is not allowed to smoke started swearing and stated 'he is a grown man and he do what he want' he handed the cigarette over, I locked them up and notified np [nurse practitioner], order to DC [discontinue] nicotine patch On 07/22/22 at 1:12 PM, SSD observed resident being non compliance [sic] with smoking policy. SSD educated [R23] on smoking policy resident sign and verbalize understanding of smoking policy is aware of violations of policy. SSD continue to look for placement. On 07/26/22 at 4:52 PM, Resident found smoking in room, educated resident on the importance and safety issue on smoking in the facility resident stated that he understands, and he will not do it again. On 07/26/22 at 6:39 PM, STAFF REPORTS, RESIDENT NOT ADHERENT TO THE SMOKING POLICY PER FACILITY. WHEN ASKED, 'ARE YOU SMOKING IN THE ROOM?' RESIDENT LAUGHED AND STATED, 'I AIN'T SMOKING.' DON AND ADON [Assistant Director of Nursing] AT BEDSIDE, RESIDENT DECLINE ROOM CHECK, CIGARETTES NOT VISIBLE AT THE TIME OF OCCURRENCE HOWEVER NOTABLE SMELL PRESENT IN ROOM. POLICY REVIEWED WITH RESIDENT AS PREVIOUSLY OUTLINES BY SS [social services] DEPARTMENT. RESIDENT MAKE AWARE OF RIGHTS 'TO SIGN SELF OUT' PER CARE PLANNED INTERVENTIONS. RESIDENT ABLE TO VERBALIZE CARE PLAN AND DECLINED ANY CHANGES REQUESTED TO MET NEEDS AT THIS TIME. SAFETY RISK RT NONCOMPLIANCE REVIEWED RESIDENT ABLE TO VERBALIZE UNDERSTANDING AT THIS TIME. On 09/19/22 at 5:16 PM, SSD informed by NP that resident [sic] be smoking, SSD met with [R23] coming up the hallway asked if he has been smoking resident stated he was smoking outside. SSD inquired to see if he had any other tobacco items resident empty pockets and tote no observed tobacco products. SSD educated [R23] on smoking policies encourage him to consider the safety of others verbalize understanding. SSD offer cessation program and snacks denies at time. On 09/20/22 at 10:45 AM, SSD and Admin [Administrator] met with [R23] educating resident on the safety of not smoking in the building. [R23] verbally agreed that he understand the safety concerns. SSD will provide support and assistance as needed. During an interview on 09/26/22 at 11:06 AM, R10 stated he was concerned with another resident (R23) smoking in the facility and smelling cigarette smoke in the building. Review of R10's annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/04/22 located in the EMR revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating intact cognition. During an observation and interview on 09/27/22 at 4:53 PM, R23 was sitting in a chair located against the dining room wall on the concrete patio outside. The sliding door into the dining room was open approximately one foot, no smoke odor was noted in the dining room. R23 was observed to have a lit cigarette in his hand, upon the surveyor approaching the resident, R23 flicked the cigarette onto the concrete. The smoldering cigarette landed next to four other cigarette butts. When asked about smoking, R23 became defensive. R23 confirmed he was aware the facility was non-smoking. R23 stated we all smoke outside, when asked who we included R23 stated everybody. During an interview on 09/27/22 at 5:14 PM, Certified Nursing Assistant (CNA)4 stated R23 had been found in the building smoking in the past. CNA4 stated R23 had been informed he cannot smoke in the building, and he could sign himself out to go off property to smoke. During an interview on 09/27/22 at 5:18 PM, Licensed Practical Nurse (LPN)2 stated she did not know anything about R23's smoking and if she observed him smoking on the premises, she would report it to management and let them handle it. During an interview on 09/27/22 at 5:25 PM, CNA2 stated she has not observed R23 smoking. CNA2 stated R23 often smelled like smoke. CNA2 stated smoking was not allowed on property, so R23 typically went over to the property of the neighboring apartments to smoke. During an interview on 09/27/22 at 5:31 PM, the SSD stated R23 admitted to the facility prior to her starting in May 2022. The SSD stated to her knowledge if a resident who smokes admits to the facility nursing would complete a smoking assessment, offer cessation interventions, and review the non-smoking facility policy with him. The SSD stated if staff observed R23 smoking on the property he should be redirected. The SSD stated R23 would typically become very verbal when redirected by staff especially regarding smoking. The SSD stated R23 has been educated to go off property to smoke. During an interview on 09/27/22 at 5:38 PM, the Director of Nursing (DON) stated if a resident who smokes was admitted to the facility a smoking assessment would be completed and the resident would be informed of the facility policies and procedures. The DON stated she had received complaints related to R23's strong odor of cigarettes, and they have provided education, and he has the ability to sign himself out to go off premise. The DON stated if staff observe R23 smoking they should notify her or management and remove smoking paraphernalia if he is smoking on the property. During a follow up interview on 09/28/22 at 11:02 AM, the DON stated R23 only had one smoking assessment completed in July 2022 because R23 had not been smoking on admission to the facility. During an interview on 09/28/22 at 4:52 PM, when asked why R23's smoking assessment was completed on 07/19/22 when facility documentation showed he was observed smoking 06/02/22, the DON stated the facility had to consult with their legal team since this was a new situation for the facility, so the smoking assessment was provided by the legal team and that is why there was a delay.

Based on review of facility policy, record review, observation, and interviews, the facility failed to ensure that residents who required feeding assistance were able to dine with dignity. Two of 21 sampled residents (R)59 and R5, that were dependent on staff for feeding assistance, were observed to receive assistance from staff who were standing and not at eye level with the resident. Additionally, dining signage and Certified Nursing Assistant (CNA) staff did not use person-centered language and referred to residents who required assistance with dining as feeders. Findings include: 1. Review of the facility policy, revised 11/01/17, titled Leadership Policies and Procedures Section XI Resident Rights under the subject Environment that preserves dignity - Resident right for revealed The Facility staff will provide the patient/resident with the right to an environment that preserves dignity and contributes to a positive self-image. The Meal Service Times posted outside of the north and south hall's dining rooms for breakfast lunch and dinner on each hall revealed the second cart was labeled w/[with] feeders. 1. Review of R59's electronic medical record (EMR) quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/09/22 revealed: R59 originally admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During observation of lunch service in the South [NAME] dining room on 09/26/22 from 12:26 PM to 12:34 PM, CNA2 was feeding R59 her meal. R59 was seated in her geri chair. CNA2 was standing to the right of R59 while she fed R59 her entire meal over eight minutes. R59's eye level was approximately at CNA2's waist. At 12:34 PM, CNA2 prepared to assist another resident and another staff member brought CNA2 a chair from outside of the dining room. CNA2 commented that she couldn't find a chair earlier. During an interview on 09/26/22 at 12:40 PM, CNA2 stated she did not typically stand while assisting R59 with her meal. CNA2 stated at that time I didn't have a seat, but when I'm in there most of the time we don't have so many people in there and I have a chair. During an interview on 09/28/22 at 4:52 PM, the Director of Nursing (DON) stated she would expect staff to be at face level with the resident when assisting residents with meals. The DON stated that she had not observed staff standing above residents during dining but would reeducate staff if she observed this. The DON stated the appropriate terminology used by staff and on the dining posting should be resident requires assistance with feeding, and staff would be educated. 2. Review of R5's quarterly MDS located in the EMR under the RAI tab with an assessment reference date (ARD) of 08/30/22, BIMS score of 99, indicating R5 was unable to complete the interview. The MDS revealed R5 required total dependence for assistance with eating. During observation of lunch service in the South [NAME] dining room on 09/27/22 from 12:20 PM to 12:26 PM, CNA3 was feeding R5 her meal. R5 was seated in her geri chair. CNA3 was standing up while she fed R5 her lunch meal for over six minutes. R5's eye level was approximately at CNA3's waist. During an interview on 09/27/22 at 2:40 PM, CNA3 stated staff should sit when assisting residents with eating. CNA3 confirmed she was standing while feeding R5. During an interview on 09/27/22 at 5:35 PM with CNA1, when asked when the trays for the South [NAME] Hall would arrive, CNA1 stated, The trays are on the hall but the trays for the feeders are not here yet. Those will come after we finish passing the trays. This statement was made in the presence of one CNA, three nurses, and three residents. During a follow-up interview on 09/27/22 at 5:42 PM with CNA1, when asked to see if a certain resident that needed assistance with eating had received her tray, CNA1 stated, We are still passing trays to the feeders. CNA1 stated she was unaware the term feeder should not be used.

Based on interview, record review, and policy review, the facility failed to ensure a resident with a history of falls had Care Plan interventions implemented for one Resident (R)20 of two reviewed for falls. This had the potential for R20 to sustain a fall with injury. Findings include: Review of the paper Person-Centered Care Plan Process policy dated 07/01/16 provided by the facility, revealed The facility will develop and implement a baseline and comprehensive care plan that includes instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality of care. Review of R20's Face Sheet located in the electronic medical record (EMR) revealed R20 was originally admitted to the facility on [DATE]; his most recent readmission was on 09/06/22 from the hospital. R20 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the re-admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/28/22, revealed R20 was severely cognitively impaired with a Brief Interview for Mental Status (BIMS) score of 4 out of 15. R20 had walked during the assessment period. R20 was documented to be steady without staff assistance. Review of the Care Plan, dated 07/06/22 and located in the EMR under the Care Plan tab, revealed R20 was at risk for falls due to impaired safety awareness and increased need for assistance with Activities of Daily Living (ADLs). The goal was for the resident's needs to be met. The Care Plan included: remind him to stand up slowly, encourage him to use rails in the hall while ambulating, and ensure the environment was free of clutter. The Care Plan was updated on 08/31/22 to include placing a mat beside his bed and moving his bed against the wall. Observation on 09/27/22 at 3:20 PM revealed R20 was observed in his room, sitting on side of his bed. There was no fall mat in place and the bed was not against the wall. During an interview on 09/27/22 at 3:45 PM, the Assistant Director of Nursing (ADON) verified there was no mat on R20's floor and his bed was not against the wall as the Care Plan indicated.

Based on facility policy review, record reviews, observation, and interview, the facility failed to provide range of motion (ROM) services per the Care Plan for 1 of 1 Resident (R)25 reviewed for ROM in the total sample of 21. This had the potential for R25 to have a decline in functional status. Findings include: Review of the facility policy revised 05/01/22, provided by the Director of Nursing (DON) titled: Restorative Nursing Policies and Procedures, revealed Subject: Range of Motion exercises indicated: to review care plan to determine the type of ROM to be performed. The policy was a step-by-step instruction on how to perform ROM. Review of R25's electronic medical record (EMR) Face Sheet under the Profile tab revealed R25 was originally admitted to the facility on [DATE]. R25 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Quarterly Minimum Data Set (MDS) found under the MDS tab in the EMR with an Assessment Reference Date (ARD) of 07/12/22, revealed R25's cognition was intact with a Brief Interview for Mental Status (BIMS) score of 13 out of 15. The MDS assessment revealed R25 ROM limitations were on one side both her upper and lower extremities (shoulder, elbow, arms, hands, legs, feet). Review of the Care Plan last revised 08/07/22 located in the EMR under the Care Plan tab revealed R25 was to receive active/passive ROM during the AM and PM during care. During an observation and interview on 09/26/22 at 9:31 AM revealed R25 had a contracted right hand, He said he did not receive any exercises from staff to his hand. R25 said he cannot open and close his hand. He said he goes to therapy three times a week, but they do not stretch out his hand. R25 had his right hand clinched and attempted to open his hand but was unable. During an interview with the Physical Therapist Assistant (PTA) on 09/27/22 at 12:15 PM he said R25 received therapy three times a week, he said the therapy lasted between 15 minutes to an hour. He said he received some ROM on his hand at that time, however the staff should be doing the ROM on the other days when he did not attend therapy. The PTA said ROM was important to prevent further decline. On 09/27/22 at 2:50 PM during an observation and interview with the Assistant Director of Nursing (ADON) she attempted to open R25's right hand and said his hand was not contracted completely. The ADON could not fully open R25's right hand. During an interview with Certified Nursing Assistant (CNA)1 on 09/28/22 at 4:45 PM related to ROM every shift both AM and PM, she said she had not done any ROM on R25's hand, but the day shift could have been doing ROM, she did not know. During an interview with CNA5 on 09/28/22 at 4:46 PM related to ROM every shift both AM and PM. She said she had not done any ROM on R25's hand, but the day shift could have been doing ROM, she did not know. On 09/28/22 at 4:53 PM during an interview with the DON, she said her expectations were that residents requiring ROM received the care and services to prevent further decline in ROM.

Based on review of facility policy, record review, observation, and interviews, the facility failed to provide ordered supplements used to potentially prevent weight loss for 1 of 2 residents (R)59 reviewed for nutrition in a total sample of 21 residents. Findings include: Review of facility policy titled, Supplements, dated 08/01/20 revealed, Deliver labeled supplements to designated patients or residents. Review of facility policy titled, Therapeutic Diets, dated 08/01/20 revealed, Check all trays for accuracy before they are served to the patient/resident. Review of R59's Face Sheet located in the electronic medical record (EMR) under the Resident tab, revealed an admitted [DATE] with medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R59's quarterly Minimum Data Set (MDS) located in the EMR under the RAI tab with an assessment reference date (ARD) of 08/09/22, revealed a Brief Interview for Mental Status (BIMS) score was not completed by staff because R59 was rarely/never understood. The MDS revealed R59 required extensive physical assistance of one person for assistance with eating. Review of R59's Orders located in the EMR under the Resident tab revealed the following orders: 9/08/22 - frozen nutritional treat bid [twice a day] (lunch and dinner); and 08/05/22 -regular pureed diet with nectar thick liquids. Staff assistance with all meals. Review of R59's Vitals Report located in the EMR under the Resident tab revealed the following weights: 08/05/22 - 127.6 lbs [pounds] and 09/06/22 - 119.9 lbs. This indicated a weight loss of 6% in one month. Review of R59's lunch meal ticket dated 09/27/22 included the following items: pureed sweet and sour pork, pureed fluffy rice, pureed oriental vegetable blend, bread slurry, pureed frozen nutritional treat, nectar thickened iced tea, and nectar thickened water. During an observation on 09/27/22 at 12:29 PM, R59 was observed seated her geri chair being assisted with her lunch meal. R59 had eaten nearly 100% of her meal with only a small bit of pureed cake remained. R59's dinner tray did not include the pureed frozen nutritional treat, nor did it include the nectar thickened iced tea. Review of R59's dinner meal ticket dated 09/27/22 included the following items: pureed roast beef, pureed parsley buttered noodles, pureed vegetable blend, bread slurry, pureed frozen nutritional treat, nectar thickened iced tea and nectar thickened 2% milk. During an observation on 09/27/22 at 5:44 PM, R59 was observed seated in her bed being assisted to eat her dinner meal by Certified Nursing Assistant (CNA)4. R59's dinner tray did not include the pureed frozen nutritional treat, nor did it include the nectar thickened 2% milk. CNA4 confirmed the absence of these items. Review of R59's Care Plan located in the EMR under the RAI tab last updated 09/08/22 read, . has a weight loss of 6% in one month r/t [related to] [CONDITION(S)], hospitalization , AMS [altered mental status]. One of the interventions included in the care plan was, Supplements as ordered. Review of R59's EMR revealed no refusal of ordered supplements. During an interview on 09/28/22 at 11:54 AM, the Dietary Manager (DM) stated when plating meals, the cook puts the items on the plate but there are three dietary staff, the sender, the loader, and the runner that are responsible for ensuring the correct items on the meal tickets. The DM stated, The sender calls out the items on the meal ticket to the cook. The loader is last and is supposed to check the ticket and ensure all items on the ticket are put on the plate. If missing items, the loader notifies the runner, and they get the items. The DM further stated, My expectation is that these types are things [items left off the residents' meal tray] are not to happen and if the item is on the meal ticket, the resident should receive. During an interview with the Registered Dietitian (RD) and DM on 09/28/22 at 4:28 PM, the RD stated, On 9/8 [R59] had a weight loss of 6% in one month and then 4% in 6 months. She was in the hospital in late July with [CONDITION(S)] and [CONDITION(S)] [urinary tract infection]. That's when weight loss occurred between 8/5 and 9/6. I assessed her on 9/8 and I ordered frozen nutritional treat twice a day and house shake at breakfast. The frozen treat added an extra 600 calories and 19 grams of protein, and the house shake added an extra 200 calories and 6 grams of protein. The RD further stated, My expectation is for my orders to be carried out so she wouldn't have continued weight loss. The DM stated, The frozen nutritional treat was on recall, so I replaced it with a shake for some residents but not for [R59]. The RD, I didn't know that it was on recall. There are other brands that could have been used. I should have been told about the recall so that an appropriate substitution could have been made.

Based on review of the facility policy, record review, observations and interviews, the facility failed to provide adequate accommodations to Resident (R)13 related to bedding sheets. Additionally, staff were unaware that the Hoyer lift is able to meet R1's3 bariatric needs, 1 of 5 residents reviewed for Activities of Daily living (ADL). Findings include: Review of the facility policy last revised 11/01/17, titled Leadership Policies and Procedures Section XI Resident Rights under the subject Environment that preserves dignity - Resident right for revealed The Facility staff will provide the patient/resident with the right to an environment that preserves dignity and contributes to a positive self-image. An observation and interview on 12/06/22 at 1:26 PM with R13 in their room revealed R13 wrapped in a sheet with no bedding sheets on the bariatric mattress. R13 stated that they have not been able to have a shower in months due to the facility no longer renting a bariatric Hoyer lift that is able to meet their needs. R13 further stated that since the equipment is no longer available at the facility, they have no choice but to receive a bed bath even though that is not their preference for every day. Record review on 12/06/22 at 2:00 PM of R13's ADL Shower Documentation for October 2022 revealed completed bed baths for each day during 10/1/22-10/31/22 with no documentation of a completed shower. Record review on 12/06/22 at 2:03 PM of R13's ADL Shower Documentation for November 2022 revealed completed bed baths for each day during 11/1/22-11/30/22 with no documentation of a completed shower. Record review on 12/06/22 at 2:06 PM of R13's ADL Shower Documentation for December 2022 revealed completed bed baths for each day during 12/1/22- 12/6/22 (current date) with no documentation of a completed shower. An interview on 12/07/22 at 11:42 AM with Certified Nursing Assistant (CNA)1 revealed I've been working at the facility for a few months and I work with R13. Further stated that they are unsure if the facility has equipment for bariatric residents and she only gives the resident a bed bath. An interview on 12/07/22 at 11:47 AM with Licensed Practical Nurse (LPN)1 revealed I previously worked at this facility but now I am an agency nurse for the facility and has worked with the resident for several years. When I worked a few years ago, R13 was able to take showers and was able to transfer with a bariatric Hoyer lift. LPN1 further stated that they were unsure if the resident receives showers at this time or if the facility still has adequate bariatric equipment. An interview with the Director of Nursing (DON) on 12/07/22 at 2:30 PM revealed the Hoyer lift on the unit is able to accommodate for the resident's needs and is able to withstand 700 lbs. The DON further stated that they were unaware the resident would like to take a shower over a bed bath.

Based on review of the facility policy, record review, observations and interviews, the facility failed to provide adequate accommodations to Resident (R)13 related to bedding sheets. Additionally, staff were unaware that the Hoyer lift is able to meet R1's3 bariatric needs, 1 of 5 residents reviewed for Activities of Daily living (ADL). Findings include: Review of the facility policy last revised 11/01/17, titled Leadership Policies and Procedures Section XI Resident Rights under the subject Environment that preserves dignity - Resident right for revealed The Facility staff will provide the patient/resident with the right to an environment that preserves dignity and contributes to a positive self-image. An observation and interview on 12/06/22 at 1:26 PM with R13 in their room revealed R13 wrapped in a sheet with no bedding sheets on the bariatric mattress. R13 stated that they have not been able to have a shower in months due to the facility no longer renting a bariatric Hoyer lift that is able to meet their needs. R13 further stated that since the equipment is no longer available at the facility, they have no choice but to receive a bed bath even though that is not their preference for every day. Record review on 12/06/22 at 2:00 PM of R13's ADL Shower Documentation for October 2022 revealed completed bed baths for each day during 10/1/22-10/31/22 with no documentation of a completed shower. Record review on 12/06/22 at 2:03 PM of R13's ADL Shower Documentation for November 2022 revealed completed bed baths for each day during 11/1/22-11/30/22 with no documentation of a completed shower. Record review on 12/06/22 at 2:06 PM of R13's ADL Shower Documentation for December 2022 revealed completed bed baths for each day during 12/1/22- 12/6/22 (current date) with no documentation of a completed shower. An interview on 12/07/22 at 11:42 AM with Certified Nursing Assistant (CNA)1 revealed I've been working at the facility for a few months and I work with R13. Further stated that they are unsure if the facility has equipment for bariatric residents and she only gives the resident a bed bath. An interview on 12/07/22 at 11:47 AM with Licensed Practical Nurse (LPN)1 revealed I previously worked at this facility but now I am an agency nurse for the facility and has worked with the resident for several years. When I worked a few years ago, R13 was able to take showers and was able to transfer with a bariatric Hoyer lift. LPN1 further stated that they were unsure if the resident receives showers at this time or if the facility still has adequate bariatric equipment. An interview with the Director of Nursing (DON) on 12/07/22 at 2:30 PM revealed the Hoyer lift on the unit is able to accommodate for the resident's needs and is able to withstand 700 lbs. The DON further stated that they were unaware the resident would like to take a shower over a bed bath.

Based on observation, record review, staff interviews and review of facility documents and policies, the facility failed to 1) screen for COVID 19 signs/symptoms on outside visitors or vendors prior to entering the facility and ensure that outside visitors or vendors followed facility protocol for use of personal protective equipment (PPE) during observation of two of two residents (Resident #3 and Resident #4) transported in and out of facility by contract vendor, 2) failed to implement facility policies and procedures based on national standards related to COVID-19, 3) thoroughly complete documentation on respiratory signs and symptoms for monitoring of any potential COVID-19 infections for residents and 4) for one of five residents (Resident #1) observed for infection control practices related to sanitizing resident equipment Resident #1. The facility had one resident positive for COVID-19 (Resident #1) and two residents (Resident #4 and Resident #5) of five residents reviewed for infection control practices, who required [MEDICAL TREATMENT] treatments three times a week. These multiple failures had the potential for COVID-19 virus to go undetected in the facility. The facility Administrator was informed on 07/01/20 at 9:45 PM that Immediate Jeopardy existed on 06/22/20. The facility provided an Immediate Jeopardy Removal Plan that was accepted on 07/02/20 at 2:15 PM and the Immediate Jeopardy at F880 was removed with an effective completion date of 07/02/20 and lowered to a scope and severity of E. Findings included: 1. During the initial tour on 07/01/20 at 11:45 AM of the South Hall, all residents were noted to be on Droplet Precautions. During an observation on 07/01/20 at 12:05 PM the outside transport company staff were observed to enter the South hall exit door with Resident #3, who was returning from an appointment. The transport staff were not screened prior to entering the building and were observed wearing a mask only. They were instructed to put a gown on by Registered Nurse (RN) #10. During an interview with RN #10 on 07/01/20 at 12:15 PM, revealed all residents were on Droplet Precautions which meant anyone who had direct interactions with a resident were required to wear personal protective equipment (PPE) of a gown, mask and gloves. During an observation on 07/01/20 at 1:30 PM, two different transport company staff, were observed entering the South Hall exit door to pick up Resident #4, no screening was done prior to entering, they proceeded to Resident #4's room and placed the resident on the stretcher. The transport company staff did not have a gown on, and the resident did not have a mask on when leaving the facility. Resident #4 was in droplet precautions at the time due to outside [MEDICAL TREATMENT] treatments. During an interview with the Administrator on 07/01/20 at 2:00 PM, revealed the facility was no longer completing the screening on the transport company staff as it was being done .by the transport company owner . The Administrator was unable to state why the facility was no longer screening the transport staff and that the change occurred approximately a week and a half ago. When the Administrator was asked to provide any documentation, or communication from the transport company owner regarding the decision for the facility to no longer screen the transporters, the Administrator was unable to do so. During an interview on 07/01/20 at 3:00 PM with Central Supply clerk #3, who coordinates the resident's transportation with the transport company, confirmed what the Administrator had stated regarding the change with the process for the transport company owner to complete the screenings and the facility would not need to perform the screening. Central Supply clerk #3 further stated on days she was in the building she would complete a screening on them when they entered, but she did not screen all of them. During an interview on 07/02/20 at 12:00 PM with transport company owner #19, s/he stated on 6/22/20 that s/he made the change for the screening process to be completed by him/her each day with his/her staff and .was attempting to expedite the process when picking up a resident . 2. The facility admitted Resident #1 on 09/26/19 with [DIAGNOSES REDACTED]. Review of Resident #1's laboratory results, located in the medical record, Resident #1 had previous COVID-19 testing completed at the facility on 05/05/20 and 05/12/20 and was positive each time. Resident #1 was placed on droplet precautions when the first positive test results came back on 05/05/20 and remained in droplet precautions until her transfer to the hospital on [DATE]. Review of the Resident #1's medical record revealed on 06/21/20, Resident #1 was hospitalized for [REDACTED]. Resident #1 was tested at the hospital for COVID-19 and had a positive result dated 06/25/20. According to the hospital discharge summary dated 06/30/20 Resident #1's discharge [DIAGNOSES REDACTED]. The resident was treated with Remdesivir (a medication to treat COVID-19) while hospitalized . Observations of the room Resident #1 was in on 07/01/20 from 11:30 AM through 4:30 PM, revealed s/he was currently on Droplet Precautions, however it was noted that all residents on the South Hall, 41 total residents, had signs posted on their doors for Droplet Precautions The signs for Droplet Precautions instructed staff and visitors to wear a gown, mask and gloves when interacting directly with resident care. During an interview with the Interim Director of Nursing (DON) and Administrator on 07/01/20 at 4:30 PM, revealed Resident #1 was not considered to be .positive for COVID . but the facility was monitoring him/her for the 14 days after re-admission. The Administrator further stated the reason Resident #1 was placed in her current room, a private room, was based on the transport staff informing the facility the resident was COVID 19 positive. Prior to Resident #1's transfer on 06/21/20 the resident occupied a semi-private room, with a roommate who has tested negative for COVID. During the interview with the DON on 07/01/20 at 4:30 PM, the DON stated the residents on the South Hall were not .truly on Droplet Precautions . The DON stated Resident #1 was the only resident on Droplet Precautions and staff would be expected to follow the droplet precautions procedure. The DON further stated the Droplet Precautions signs for the other residents were in the process of being taken down. A review of the facility's undated, policy Accepting and Transferring Patients/Residents, revealed under Policy: Patients/Residents who have received a COVID-19 Positive Test while in Hospital. The following must be implemented: 1. The patient/resident must be placed on isolation for at least 14 days with transmission-based precautions (TBP) in place for care of a COVID-19 patient/resident. 2. Preferably place the patient/resident in a location designated to care for COVID-19 (identify a wing or unit and only house resident with COVID-19 or suspected to have COVID-19). 3. During a review on 07/01/20 on 12:30 PM of the facility COVID-19 documentation for June 2020, the monitoring for respiratory sign/symptoms on all residents, it was noted that there was a lack of documentation for several days/shifts. According to the form utilized by the facility for COVID-19 monitoring, the staff were instructed to record blood pressure, heart rate, respiratory rate, temperature, and oxygen saturations. During an interview on 07/01/20 at 12:45 PM with RN #10, revealed the respiratory monitoring documentation was only written on the handwritten sheets and if there was no documentation there it would not be found anywhere else. During an interview with the DON on 07/01/20 at 3:00 PM, revealed the facility had educated the nurses and certified nursing assistants (CNA) .recently . to complete the COVID-19 monitoring documentation for each shift/day on the separate shifts and was considered now to be a facility .standard of practice . and an order would no longer be placed on individual resident orders. The DON was unable to provide any documentation that showed the education to the nursing staff regarding the recent change. 4. On 07/01/20 between 6:35 PM and 6:44 PM, RN #10 was observed entering Resident #1's room to answer her call light and then provide personal care. RN #10 was observed donning a disposable plastic gown, gloves, and an N-95 disposable mask prior to entering the resident's room. RN #10 did not don a face shield. RN #10 removed all the above-mentioned PPE prior to exiting the resident's room. During an interview with RN #10 on 07/01/20 at 6:45 PM, stated s/he knew s/he was supposed to be wearing a face shield or goggles when entering Resident #1's room because the resident was on Droplet Precautions for COVID-19. S/he stated s/he did not have a face shield because the facility had run out of them. RN #10 stated s/he had been issued a pair of goggles, and that s/he was supposed to wear them at all times while working on the unit, but that s/he had not been wearing them because they were uncomfortable and they fogged up easily, making it hard to see. A review of the facility's policy Infection Prevention and Control Policies and Procedures - Isolation/Precautions including Standard/ Universal Precautions, dated 09/2011, revealed Masks, Respiratory Protection, Eye Protection, Face Shields (PPE, barrier equipment): l) Various types of masks, goggles, and face shields are worn alone or in combination to provide barrier protection. a) Masks that cover both the nose and the mouth, and goggles or a face shield are worn during procedures and patient/resident-care activities that are likely to generate splashes or sprays of blood, body fluids, secretions, or excretions. During an observation conducted on 07/01/20 between 2:55 PM and 3:10 PM, CNA #11 was observed entering Resident #1's room to obtain the resident's weight and provide personal care. CNA #11 was asked if the resident was on any special type of isolation prior to entering the resident's room, and s/he stated that the resident was on isolation, but s/he did not know why. A Droplet Precaution Sign was observed on the resident's door at the time of the observation. CNA #11 donned a disposable isolation gown prior to entering the resident's room, and then gloves after approaching the resident's bedside. CNA #11 wore his/her personal cloth mask into the resident's room and did not don a face shield or goggles while in Resident #1's room obtaining the resident's weight and providing personal care. Additionally, CNA #11 entered Resident #1's room with the facility's mechanical lift, on which the resident's weight was to be obtained. When CNA #11 exited the resident's room at 3:10 PM, s/he was observed doffing his/her disposable gown and gloves but did not remove his/her personal cloth mask. CNA #11 pushed the mechanical lift down the hallway and parked it in front of the nurse's station. During an interview on 07/01/20 at 3:15 PM with CNA #11, s/he stated Resident #1 was on isolation for COVID-19. CNA #11 stated staff was expected to don a disposable gown, gloves, an N-95 disposable mask, and either a face shield or goggles prior to entering the resident's room. S/he stated all Personal Protective Equipment (PPE) was to be doffed prior to exiting the resident's room. CNA #11 stated s/he had not worn an N-95 mask into the resident's room because there hadn't been one available in the PPE rack on the resident's doorway. CNA #11 stated s/he had a face shield that had been provided by the facility and did not know why she hadn't thought to put it on. When asked how the mechanical lift was to be sanitized after use for a resident in isolation for COVID 19? CNA #11 stated, I should have cleaned the Hoyer Lift (mechanical lift) with a Flex Wipe (disinfectant wipe) to sanitize it before taking it out of the resident's room. CNA #11 cleaned the mechanical lift with a disinfectant wipe and then put it into the unit shower room for storage. A review of the facility's policy Infection Prevention and Control Policies and Procedures - Isolation/Precautions including Standard/ Universal Precautions, dated 09/2011, revealed Patient/Resident-Care Equipment and Articles: Non-critical equipment a) Non-critical equipment (i.e., equipment that touches intact skin) contaminated with blood, body fluids, secretions, or excretions is cleaned after use, and b) Disinfect after use with a hospital grade disinfectant or bleach (l:10 dilution) if soiled with body fluids. During an interview on 07/01/20 at 11:50 AM with Housekeeping Manager #8 revealed the facility used Virex, or Flex Wipes (a bleach disinfectant wipe) which are Environmental Protection Agency (EPA) approved disinfectants against the COVID-19 virus. During an interview with the Director of Nursing/Infection Preventionist on 07/01/20 at 5:00 PM, s/he stated staff was to follow Droplet Precautions for anyone in the facility with suspected or confirmed COVID 19. She indicated this meant staff should be donning a disposable gown, gloves, an N-95 mask, and either a face shield or a pair of goggles prior to entering the resident's room. S/he indicated Resident #1 was on Droplet Precautions, and therefore staff should be donning all the above-mentioned PPE. During an interview with the Regional Nurse Consultant on 07/01/20 at 5:35 PM, s/he stated the expectation was that staff should be following Droplet Precautions for Resident #1. S/he stated Centers for Disease Control (CDC) Guidelines were to be followed, and indicated this meant staff was to be donning a disposable gown, gloves, an N-95 mask, and either a face shield or goggles prior to entering Resident #1's room. S/he stated all the stated PPE was provided by the facility. The Immediate Jeopardy Removal Plan included the following: Licensed Nurse identified not following droplet precautions for Resident #1 were reeducated by Director of Nursing. Director of Nursing observed return demonstration of donning appropriate PPE for droplet precautions completed on 07/02/20 at 9:30 AM. Certified Nursing Assistant was re-educated by Nurse Consultant via phone 07/02/20 at 10:10 AM on transmission-based precautions and equipment cleaning with return verbalization of correct PPE for droplet precautions and cleaning equipment, return demonstration will be completed prior to next shift. Signs posted on rooms not requiring droplet precautions have been removed by the Director of Nursing on 07/01/20 6:05 PM. Hoyer lifts (mechanical lift) have been disinfected by Housekeeping Director on 07/02/20 between 9:00 AM and 10:00 AM. Screening for COVID-19 symptoms was completed on all facility residents on 07/02/20 by 7:00 AM (end of 11-7 shift) by the nursing staff utilizing the resident screening form. Contracted transport company was re-educated on transmission-based precautions by the Administrator on 07/02/20 at 9:30 AM. The transport company was informed of the signage and the expectation of pickup and delivery at the main door and not to enter facility to retrieve or deliver [MEDICAL TREATMENT] residents. Clinical staff which includes licensed nurses, Certified Nursing Assistants were re-educated on transmission-based precautions, specifically donning personal protective equipment and screening for signs and symptoms of COVID-19, cleaning Hoyer lifts (mechanical lift) between residents and utilizing the resident screening form on 07/01/20 starting at 9:30 PM by the Director of Nursing and/or Nursing Management. Any clinical staff not receiving this education will receive prior to next scheduled shift. On 07/02/20, there was currently 79% of staff trained and in-serviced. Licensed nurses were re-educated by the Director of Nursing and/or Nursing Management on the requirement of delivering and retrieval of the resident needing non-emergency transport at the door when summonsed by the transport company, therefore eliminating the need for transporters to enter the facility, except for complicated transfers and bariatric transports, for this all transport will be screened and don appropriate PPE. Any licensed nurse not receiving this education will receive prior to next scheduled shift. As of 07/07/20, starting at 9:30 PM, 68% of staff was trained and in-serviced. ln addition to re-education, a sign is posted at alternative entrances Do not Enter- Must use Main entrance on 07/01/20 at 10:45 PM by Human Resources. Director or Nursing or Administrator will observe the transport company for proper screening and process of delivering and retrieving resident daily for two days, then five times a week for eight weeks. Director of Nursing or Administrator will validate personal protective equipment use on transmission based precaution rooms and observe Hoyer lift (mechanical lift) cleaning for two days, then five times a week for eight weeks. Director of Nursing will validate resident screening daily for two days, then five times a week for eight weeks. Medical Director was notified of the Immediate Jeopardy on 07/01/20 at 9:20 AM by the Administrator. Ad Hoc Quality Assurance Performance lmprovement Committee meeting was held on 07/02/2020 at 9:20 AM to review the contents of this plan. Results of observations will be presented to the Quality Assurance and Performance lmprovement Committee for recommendations for three months. Any concerns identified will be addressed at time of discovery.

Based on observation, review of facility files, and interview, the facility failed to ensure that each resident received adequate supervision and assistance devices to prevent accidents. During an interview with the Director of Nursing (DON), Nurse Consultant, and the Administrator on 2/2/19 at approximately 11:54 AM, the Administrator was informed that Immediate Jeopardy and/or substandard quality of care was identified at a scope and severity of J as of 1/25/19 relating to Resident #17. Resident #17 obtained access to a medication cart taking 22 narcotic pills. Review of the facility Immediate Plan for Improvement (IPIP) and verification of the facility Immediate Plan for Improvement (IPIP) revealed that the Immediate Jeopardy was removed as of 1/27/19 but that deficient practice still exists for fall prevention measures that were not in place for Resident #40, and a 16-ounce screw-top pump bottle of Epi-Clenz containing 70% Ethyl Alcohol and [MEDICATION NAME] Nasal Spray left unattended intermittently throughout the medication pass, accessible to any cognitively impaired self-mobile residents (two of three residents reviewed for accidents and two of two units observed); therefore, the scope and severity was lowered to D. The findings included: Review of the facility five-day investigation report dated 2/1/19 revealed It was reported to the DON around 1-26-19 around 1:15 am that the Narcotic count was off and the medication specifically [MEDICATION NAME] 5/325 mg was missing, 22 pills. The nurse assigned to the cart and nurses on staff at the time of the incident did an audit and search through all medication carts, medication rooms, trash cans, etc. To locate the medication. Staff unable to locate medication and initial investigation started, reported misappropriation and suspended assigned nurse. Nurse assigned to medication cart was sent for a drug testing. Physician was notified, and medication replaced, resident (Resident #32) was observed for pain and or discomfort and did no exhibit any signs and symptoms of pain at time of observation. Resident (Resident #32) received all ordered medications as prescribe. Family and MD (Medical Doctor) were notified of occurrence. Drug screen from nurse was received and negative. The statement from the nurse reports that another resident (Resident #17) was at the medication cart when (s/he) was pulling medications and asking for a (drink) and (s/he) left to go get (him/her) a (drink). Staff interviews revealed no observations of anyone with unusual behavior or unlocked medication carts. Trash was searched with no pills located. 1-26-19 approx. 1:15 During lunch, aide observed resident (Resident #17) with a medication pack in (his/her) lap at lunch. Nursing notified, and resident reviewed and stated (s/he) took the pills from the trash and only took 4 pills, however account reflects 21 pills, (s/he) agreed to allow us to search room, no medication recovered. (S/He) was placed on 1 on 1 until transfer to ER (emergency room ). After notification of MD, etc. the resident was transported to ER for evaluation, however no abnormal observations noted, and vital signs stable. Local law enforcement notified; (case number), took police report and resident was not in the building at the time and assigned an investigator who called on 1-28-19 and request follow up after completed. Complete building sweep completed of all resident rooms, building for any additional pills, none located. Review of medication cart, all locks appropriately, no issues identified. Hospital notes reveal no acute changes, no signs of overdose. Resident stated at the hospital that (s/he) took the medications. (S/He) returned and was placed on q (every) 15 minute checks and subsequently sent out again. Resident (Resident #17) has a history of drug abuse and manipulative behaviors (review of care plan revealed s/he was care planed for manipulative behaviors). Resident self admits that (s/he) took medications and reportedly to relax per hospital notes. The facility investigation identifies no misappropriation by the nurse, however the medications was stolen, replaced by the facility and residents assessed with [REDACTED]. The number of narcotic's missing was verified as 22 pills with the DON during an interview on 2/2/19. Review of Resident #17 medical record revealed that the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #17's medical record revealed an Emergency Dept Final Report dated 1/26/19 under Chief complaint Pt states (s/he) took pack of [MEDICATION NAME] 5/325 from facility (s/he) lives in, and [MEDICATION NAME], Tylenol. Pt (patient) drowsy but alert and able to answer questions,. denies SI (suicidal ideation) or HI (homicidal ideation) under History of Present Illness .presents for evaluation following an intentional overdose. However, the patient stated that (s/he) had no intention of [MEDICAL CONDITION] at this, and stated that (s/he) took the pills to relax. Patient does endorse feeling sleepy and hungry, but denies dizziness. (S/He) denies any attempt to self-harm. During an interview on 2/2/19 the DON stated that Resident #17 came back from the hospital on [DATE] in the morning and when s/he went to talk with the resident on 1/27/19 in the afternoon he stated that he was suicidal. The DON immediately called to have the resident sent to the hospital for a psych evaluation. The resident is still currently at the hospital under evaluation. Review of Resident #17's medical record revealed that the resident returned to the facility from the hospital on [DATE] at 4:45 AM and 15 minute checks were documented until 1/27/19 12:45 PM. Further review of medical record revealed a nurses note dated 1/27/19 at 1:00 PM Resident sent to (name of hospital) for eval r/t (related to) suicidal though/attempt. Charge Nurse @ (name of hospital) given report. Resident stated to DON that the incident that occurred on yesterday with missing narcs that (s/he) was trying to kill (him/herself) and also stated that (s/he) took all 20 of the pills that were in question. EMS (emergency medical services) have @ facility with stricter (sic) @ this time. Resident alert and verbal, able to make needs known. No immediate danger noted @ this time. Review of Resident #17's medical record revealed psych evaluations dated: 11/26/18 No Behavioral problems are noted on exam or reported by staff at this time. Patient has NO homoicidal (sic) ideation. No signs or symptoms of anxiety. Patient has NO suicidal ideation. Currently patient is doing will off {name of medication) and eating well and sleeps well. No behaviors noted by staff and no complaints voiced today. 10/1/18 No Behavioral problems are noted on exam or reported by staff at this time. Patient has NO homoicidal (sic) ideation. No signs or symptoms of anxiety. Patient has NO suicidal ideation. Currently patient is doing well and reports fair sleep but helped by current psychiatric medications. Mood much better and no complaints voiced today. 7/30/18 revealed. No Behavioral problems are noted on exam or reported by staff at this time. Patient has NO homoicidal (sic) ideation. No adverse events or side effects to [MEDICAL CONDITION] medications are noted presently. Patient currently displays no signs or symptoms of anxiety. Patient has NO suicidal ideation. Currently patient is pleasant and friendly and no complaints voiced today. Review of Resident #17's physician progress notes [REDACTED]. 1/17/19 Psychologic: Oriented x 3, Normal Mood/Affect, cheerful mood. 1/16/19 Psychologic: Oriented x 3, Normal Mood/Affect, cheerful mood. 1/8/19 Psychologic: Oriented x 3, Normal Mood/Affect, cheerful mood During an interview on 2/11/19 at approximately 10:00 AM Registered Nurse (RN) #5 stated that on 1/25/19 at approximately 5:00 pm s/he was passing medication when Resident #17 asked him/her to get him/her a drink. RN #5 stated that s/he asked a CNA to get the resident a drink, but the CNA stated that s/he didn't want to so s/he (the RN) went and got the resident a drink. RN #5 stated that s/he could not remember if s/he locked the medication cart but knows that s/he is supposed to lock the cart whenever s/he steps away from it. RN #5 stated that Resident #17 was in a good mood and did not seem depressed and did not state that s/he was going to hurt him/herself. RN #5 stated that at change of shift is when they noticed the narcotics missing, it was during med count. RN #5 stated that s/he and other staff searched the facility for the missing medications and could not find them, they notified the DON. Review of the facility policy titled Pharmacy Services Policies and Procedures revealed under number 17 At the conclusion of the medication pass, the authorized staff member or licensed nurse will return the cart to the proper storage location and ensure that: H. Cart is locked. During an interview on 2/12/19 at approximately 12:56 pm the Social Service Director (SSD) stated that s/he talks with Resident #17 daily and the resident never expressed [MEDICAL CONDITION] or signs of depression. The SSD stated that they have talked about the residents past history with drug use, but the resident never expressed an current urges. During an interview with the DON, Nurse Consultant, and the Administrator on 2/2/19 at approximately 11:54 AM, the Administrator was informed that immediate jeopardy was identified as of 1/25/19 relating to Resident #17. Administrator stated that they have put a plan of correction in place. The DON stated that all carts were audited, and all medications were accounted for except the 22 narcotic pills. The DON stated that the narcotics belonged to Resident #32 and the s/he did not miss a dose of his/her prescribed medication, the narcotics were replaced on 1/26/19. The DON stated that staff searched the facility and all resident rooms with the resident's permission and could not find the pills. The DON stated that s/he audited the medication carts to make sure that all locks on the carts were working, and s/he put bright colored stickers on the top of medication carts to remind nurses to lock the cart. The Administrator stated that s/he has been checking the carts twice daily. The surveyor was given a Immediate Plan for Improvement (IPIP). Review of the facility Immediate Plan for Improvement (IPIP) revealed: Resident missing the medication was assessed with [REDACTED]. Resident whom the medication was located in his room was placed one on one 1-26-19 immediately at time of discovery, identified residents room was searched with permission, MD notified and resident sent to ER for evaluation. No acute distress noted at time, however sent for assessment as precautionary measures. RP notified, pharmacy notified. Resident placed on every 15 minute checks when he returned from hospital. Local Law Enforcement notified 1-26-19. Search was completed in attempt to locate medications. This was completed on 1-26-19. Audit of medication cart locks completed on 1-27-19 to verify in working condition. Small reminders will be placed on the medication cart Did you lock your cart. (use bright paper). In-servicing related to narcotic medication storage was started on 1-26-19 and completed on 1-28-19; any nurse not receiving the education by 2-1-19 will receive prior to the start of shift. Education includes, locking cart, double locks, maintaining keys, counting narcotics and reporting issues related to medication cart locks etc. Reported to all three State reporting agencies per requirements on 1-26-19. Observations of all residents was completed on 1-26-19, no issues identified. Audit of all narcotics was completed on 1-26-19 to verify all residents' medication in place. Nursing staff has been re-educated on the medication storage to include the following: Medication cart are to be locked at all times when away from cart. Medication counts should be completed every time the keys or cart is handed off. If you identify medication cart issues notify administrator immediately. Maintaining medication keys at all times. Double lock on Narcotics. This re-education was completed started on 1-26-19; This education will be presented in the new hire orientation. Any staff who did not receive this education will be re-educations before their next shift to work by the administrator, Director of Nursing/Nursing Management/CSD. Licensed nurses will be observed daily for 5 days on each shift then 5 times a week for 2 weeks by members of nursing management to validate that the transfer of learning regarding the expectation of medication cart not being left unlocked, any issues with locks are reported, medication count. The DON/ADON will randomly interview licensed nurses weekly for 3 months to validate that nurses understand the policy. Any issues identified will be corrected at the time of discovery. The medical Director was notified on this on 1-26-19 An Ad Hoc Quality Assurance Performance Improvement meeting is scheduled for 2-15-19 regarding the contents of this plan. The data received will be reviewed in the QAPI meeting monthly for 3 months for determination of compliance and further actions. Any concerns identified will be addressed at time of discovery. Review of Resident #32's MAR indicated [REDACTED]. Review of the pharmacy order form revealed that replacement narcotics were ordered and received on 1/26/19. Review of Resident #17's Medical record revealed documentation of 15-minute checks. Review of audits revealed that all resident rooms were searched. Interviews with residents revealed that staff did search rooms with the resident's permission. During the days of survey, medication carts on both units were checked and carts were locked. During the days of survey, it was verified that bright stickers were on the tops of very medication cart on both units with the reminder to lock cart. During the days of survey, interviews with staff verified training was completed and that staff were knowledgeable of the topics that were in serviced. During the days of survey, Narcotic Reconciliation on both units on all medication carts (4 total) were observed with no concerns. Audit for medication cart lock check was reviewed and verified that it was documented as being checked on 1-27-19. Audit for Narcotics count was reviewed and verified that it was documented as being checked on 1-26-19. Audit for room checks and resident checks were reviewed and verified that it was documented as being checked on 1-26-19. Audit for all medication accounted for reviewed and verified that it was documented as being checked on 1-27-19. Review on 2/2/19 of Administrators twice daily checks of medication carts verified that the Administrator checked the medication carts on both units twice daily starting on 1-29-19 through 2/2/19. Review on 2/2/19 of nursing observation audit verified that nurses were being observed daily on each unit every shift starting on 1/28/19 through 2/1/19. During observation of medication administration on 02/01/19 from 5:03 PM through approximately 5:40 PM, Licensed Practical Nurse (LPN) #1 had a 16 ounce screw-top pump bottle of Epi-Clenz containing 70% Ethyl Alcohol on top of the medication cart which s/he left unattended intermittently throughout the medication pass, accessible to any cognitively impaired self-mobile residents. Ambulatory Resident #4, identified as cognitively impaired by LPN #1, was observed in the hall near the cart. Observation on 02/02/19 at 8:45 AM revealed Registered Nurse (RN) #1 with a 16 ounce screw-top pump bottle of Epi-Clenz on top of her/his medication cart which s/he left unattended intermittently at the nursing station. During observation of medication administration on 02/02/19 at 10:08 AM, RN #1 left Resident #2's [MEDICATION NAME] Nasal Spray and the Epi-Clenz on top of the medication cart while s/he administered the resident's oral medication in his/her room. During observation of medication administration on 02/02/19 at 9:05 AM, LPN #2 was noted with a 16 ounce screw-top pump bottle of Epi-Clenz on top of the medication cart which s/he left unattended throughout the medication pass. The facility admitted Resident #40 with [DIAGNOSES REDACTED]. Review of Incident/Accident Investigation Worksheets on 1/31/19 at 2:35 PM revealed that the resident had sustained falls on 10/1/18, 10/6/18, 10/7/18, 10/13/18, 10/15/18, and 11/4/18. Each time the resident was found out of his/her low bed on the floor. Record review on 2/3/19 at 11:58 AM revealed an 8/15/18 Physician's 0rder for floor mats at bedside. Review of the Care Plan on 2/03/19 at 12:04 AM revealed that interventions/approaches for falls included floor mats and a scoop mattress. Observations on all four days of the survey revealed the resident in a low bed with only one fall mat on one side of the bed. No scoop mattress was noted on the bed. During an observation and interview on 02/03/19 at 12:13 PM, Certified Nursing Assistant #2 verified there was no scoop mattress and only one mat on one side of the bed. During an interview on 2/03/19 at 12:43 PM, RN #2 stated they spoke to the resident and asked if s/he was purposefully putting him/herself on the floor. After the resident responded affirmatively, they no longer considered it a fall if the resident was found on the floor, even though it was unwitnessed and, s/he agreed, met the definition of a fall. RN #2 verified the Care Plan for floor mats and a scoop mattress to prevent falls and minimize injury in the event of future falls. S/he stated, I guess I should have made sure the scoop mattress was put on.

Based on observation, interview, and record review, the facility failed to ensure three of 13 sampled residents reviewed were free from abuse by staff (Resident #66, #59 and #34). Certified Nursing Assistant (CNA) #9 threw a phone and hit Reisdent #66. CNA #10 punched Resident #34 in the left eye. Resident #59 reported to the Activity Director that an aide who had cared for him/her had used a bad choice of words during their conversation which upset him/her. The findings included: Review of the facility five-day report dated 8/10/18 revealed On 8/5/18, the resident (Resident #66) was reported to have had a behavioral outburst with the aide on duty (CNA #9) on the 3-11 shift. The resident was redirected. On 8/6/16 (8/6/18) at 9:00 am, the resident reported to staff that (s/he) had been hit by the aide with the telephone. A body audit was completed. No redness or irregularities were noted. The resident had no apparent injury. (S/he) did have c/o (complaints of) pain to (his/her) right arm. Review of Resident #66's medical record on 1/31/19 revealed s/he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. of Spine, C3-C7, [DIAGNOSES REDACTED], and [MEDICAL CONDITION]. During an interview on 01/31/19 at approximately 02:39 PM, Resident #66 stated that a staff member was rude to him/her, that s/he brought him/her two pieces of plain bread instead of a sandwich. When s/he went to the nurses station to address this, the staff member threw a phone at him/her. Resident #66 stated that the phone hit him/her but another staff member tried to stop it. Resident #66 stated that this took place on the night shift. Review of Resident #66's physician's Progress Notes on 1/31/19 revealed a note dated 8/6/19 Importantly over the weekend had an altercation with 1 of the staff members. A full specifics unknown. (S/He) reports that (s/he) somehow missed (his/her) dinner tray and was given a sandwich. (S/He) reports that someone had tampered with a sandwich therefore (s/he) got upset and the hospice (sic) sandwich back at the staff member. (S/He) then reports the staff member threw something at (him/her). (S/He) reports that this made contact with (his/her) right upper extremity. On exam today (s/he) is complaining of some pain to (his/her) right upper extremity. Review of CNA #9's employee file on 1/31/9 revealed that the CNA was suspended and terminated on 8/6/18. Her/his last day worked was 8/5/18. The termination was involuntary for violation of rules/policy. Review of the facility investigation for Resident #34 revealed At 8:00 am on 10/2/18 Resident reported to nurse physical abuse by staff member (CNA #10). DON and Administrator notified. Investigation initiated. Administrator interviewed (Resident #34) on 10/2/18 at approximately 10:25 am. (S/He) was noted to have a black bruise beneath (his/her) left eye. Upon closer observation, there was also a smaller, lighter area at the corner of (his/her) right eye. (Resident #34) said the night before (s/he) had put (him/herself) in bed. At approximately 11pm the CNA came into (his/her) room to change (his/her) clothes. (S/He) said the CNA was taking (his/her) pants off roughly and (s/he) called the CNA a (offensive name) and kicked her/him in the chest. In response (s/he) said the CNA punched (him/her) in the left eye. (S/He) said the CNA also tried to punch (him/her) in the right eye but (s/he) blocked most of it with (his/her) hand. Record review on 1/31/19 revealed Resident #34 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #34's medical record on 1/31/19 revealed a note dated 10/1/18 at 11:30 pm that stated: reddened abrasion noted to res (resident's) face @ l cheek area. Incident report received from 3-11 shift nurse r/t (related to) (his/her) skin abnormality. Review on 1/31/19 revealed a Social Services (SS) note dated 10/2/18 that stated: SSD (Social Services Director) spoke with resident in concern of incident on (MONTH) 1, (YEAR). Resident seems to be ok emotionally. (S/He) continues to have (his/her) daily stop and conversation with SSD. Writer has also made a psych eval referral. SSD will follow up as needed. Record review 1/31/19 revealed a Physician's Progress Note dated 10/2/18: .(S/He) was noted this morning to have bruising around (his/her) left eye as well as some associated swelling. On exam (s/he) states this somewhat tender. (S/He) denies any overt headache. (S/He) denies any change in (his/her) vision. Vital signs reviewed and are stable. (S/He) denies any other new complaints Review of CNA #10's employee file on 1/31/9 revealed that the CNA was suspended on 10/2/18 pending investigation. The CNA was terminated on 10/8/18. Her/his last day worked was 10/1/18. Terminated involuntary for unsatisfactory performance and violation of rules. During an interview on 01/31/19 at approximately 11:55 AM, Resident #34 stated that s/he called a staff member a name and the staff member hit him/her in the face. Resident #34 stated that s/he does not have issues with other staff, only that one. The facility's policy titled Abuse, Neglect, Exploitation, or Mistreatment states: 1. The facility's leadership prohibits neglect, mental, physical and/or verbal abuse, use of a physical and/or chemical restraint not required to treat a medical condition, involuntary seclusion, corporal punishment and misappropriation of a patients/resident's property and/or funds and ensures that alleged violations involving abuse, neglect, exploitation or misappropriation of property and/or funds and ensures that alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, and are reported immediately. Under the section titled III: Prevention, it states: 4. Adequate supervision of staff is maintained in order to identify and prevent inappropriate behaviors, such as: A. The use of derogatory/harassing language; B. Rough handling; and C. Ignoring the patient's/resident's needs requests, etc. The facility reported an allegation of verbal abuse of Resident #59 by Certified Nurse Aide (CNA) #8 to the State Agency on 1/24/19. Review of the Five-Day Follow-Up Report dated 1/30/19 indicated, based on investigation, that the facility was not able to substantiate the abuse. The resident would be followed up by Social Services to ensure psychosocial needs were met. The aide was terminated related to poor customer service skills. Resident #59 reported to the Activity Director that an aide who had cared for him/her had used a bad choice of words during their conversation. The Director Of Nursing (DON) and Administrator were both notified. CNA #8's Corrective Action Form dated 1/24/19 indicated that the CNA was suspended pending investigation. CNA #8's facility-obtained statement indicated Resident #59 liked to joke around with staff when working with them. Resident #59 made the comment to CNA #8 that s/he could be handled and dealt with. CNA #8 responded, What do you mean? Resident #59 repeated the comment. CNA #8 jokingly mentioned Resident #59 getting weights from therapy and taking care of boobs in front and back. Resident #59 laughed at that. CNA #8 asked why the woman that s/he talked about didn't come visit him/her or make sure s/he was okay. No more was said about this conversation. In an interview with the surveyor on 2/3/19 at approximately 11:40 AM, the Activities Director stated Resident #59 came to the activities room and told him/her that s/he wanted to talk to him/her about a CNA. S/he told him/her that CNA #8 came in the room and was working with his/her roommate. Resident #59 had his/her shirt off and was at the armoire getting a shirt out. CNA #8 walked behind him/her and said you have breasts on your back. Resident #59 said s/he did not say anything to CNA #8, just laughed it off, but that it did bother him/her. Resident #59 told the Activities Director about the incident the day after it occurred. Resident #59 said s/he was thinking about reporting it officially. Resident #59 stated s/he was not sure if CNA #8 was joking or not. The Activities Director stated Resident #59's roommate was interviewable and Resident #59 stated if the roommate needed to tell staff, s/he would since s/he was in the room. Resident #59 wrote what CNA #8 said because s/he did not want to say it out loud. There were other residents in the activity room at the time. The Social Services Director documented s/he spoke with Resident #59 regarding his/her complaint against the staff member in question. Resident #59 stated that CNA #8 made inappropriate comments about his/her weight stating s/he should take care of the titties on his/her back. The resident stated they normally had a good working relationship and had a tendency to joke around with one another, but s/he did not know why CNA #8 would say that. In an interview with the surveyor on 2/3/19 at approximately 11:30 AM, the Social Services Director stated the incident had been reported to the Activities Director and s/he reported it to him/her. The Social Services Director talked with Resident #58 and s/he said CNA #8 came in to provide care. CNA #8 made some statements about his/her size that day and s/he made a statement back about handling him/her. CNA #8 said 'how about you go to the gym and handle the breasts on your back?' The incident occurred in the resident's room. Resident #59 had a roommate, but s/he never made a statement about what happened. In an interview with the surveyor on 2/3/19 at approximately 1:00 PM, the Director of Nursing stated the Social Services Director told him/her Resident #8 had a grievance about how s/he was spoken to by CNA #8. The Director of Nursing went and talked with the resident and s/he stated CNA #8 had entered his/her room and had mentioned him/her having breasts. Resident #59 also stated s/he had a joking relationship with a lot of CNAs but that struck him/her the wrong way.

Based on review of facility files and interview, the facility failed to implement abuse policies for 3 of 13 sampled residents reviewed for abuse. Review of facility files revealed Certified Nursing Assistant (CNA) #8 verbally and mentally abused Resident #59. CNA #9 threw a phone and hit Reisdent #66. CNA #10 punched Resident #34 in the left eye. The findings included: The facility reported an allegation verbal abuse of Resident #59 by Certified Nurse Aide (CNA) #8 to the State Agency on 1/24/19. Review of the Five-Day Follow-Up Report dated 1/30/19 indicated, based on investigation, that the facility was not able to substantiate the abuse occurred. The aide was terminated related to poor customer service skills. CNA #8's facility-obtained statement indicated Resident #59 liked to joke around with staff when working with them. Resident #59 made the comment to CNA #8 that s/he could be handled and dealt with. CNA #8 responded, What do you mean? Resident #59 repeated the comment. CNA #8 jokingly mentioned Resident #59 getting weights from therapy and taking care of boobs in front and back. Resident #59 laughed at that. CNA #8 asked why the woman that s/he talked about didn't come visit him/her or make sure s/he was okay. No more was said concerning this conversation. In an interview with the surveyor on 2/3/19 at approximately 11:40 AM, the Activities Director stated Resident #59 came to the activities room and told him/her that s/he wanted to talk to him/her about a CNA. S/he told him/herthat CNA #8 came in the room and was working with his/her roommate. Resident #59 had his/her shirt off and was at the armoire getting a shirt out. CNA #8 walked behind him/her and said s/he had breasts on his/her back. Resident #59 said s/he did not say anything to CNA #8, just laughed it off, but that it did bother him/her. Resident #59 told the Activities Director about the incident the day after it occurred. Resident #59 said s/he was thinking about reporting it officially. Resident #59 stated s/he was not sure if CNA #8 was joking or not. The Social Services Director documented s/he spoke with Resident #59 regarding his/her complaint against the staff member in question. Resident #59 stated that CNA #8 made inappropriate comments about his/her weight stating s/he should take care of the titties on his/her back. In an interview with the surveyor on 2/3/19 at approximately 11:30 AM, the Social Services Director stated the incident had been reported to the Activities Director and s/he reported it to him/her. The Social Services Director talked with Resident #58 and s/he said CNA #8 came in to provide care. CNA #8 made some statements about his/her size that day and s/he made a statement back about handling him/her. CNA #8 said, How about you go to the gym and handle the breasts on your back? In an interview with the surveyor on 2/3/19 at approximately 1:00 PM, the Director of Nursing stated the Social Services Director told him/her Resident #8 had a grievance about how s/he was spoken to by CNA #8. The Director of Nursing went and talked with the resident and s/he stated CNA #8 had entered his/her room and had mentioned him/her having breasts. Resident #59 also stated s/he had a joking relationship with a lot of CNAs but that struck him/her the wrong way. Review of the facility's Abuse, Neglect, Exploitation, or Mistreatment policy revealed the facility prohibited mental and/or verbal abuse. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain, or mental anguish. Review of the facility five-day report dated 8/10/18 revealed On 8/5/18, the resident (Resident #66) was reported to have has a behavioral outburst with the aide on duty (CNA #9) on the 3-11 shift. The resident was redirected. On 8/6/16 (8/6/18) at 9:00 am, the resident reported to staff that (s/he) had been hit by the aide with the telephone. A body audit was completed. No redness or irregularities were noted. The resident had no apparent injury. (S/he) did have c/o (complaints of) pain to (his/her) right arm. Record review on 1/31/19 revealed Resident #66 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]., sequela, acute embolism and [MEDICAL CONDITION] of superficial veins of right upper extremity, acute embolism and [MEDICAL CONDITION] of unspecified deep vein of right lower extremity-RLE THROMBUS, unspecified [MEDICAL CONDITION], unspecified site-DJD, Fusion of spine, cervical region-C3-C-7, [DIAGNOSES REDACTED], [MEDICAL CONDITIONS] of native coronary artery without [MEDICAL CONDITION] pectoris-CAD. During an interview on 01/31/19 at approximately 02:39 PM Resident #66 stated that a staff member was rude to him/her. That s/he brought him/her two pieces of plain bread instead of a sandwich. When s/he went to the nurse's station to address this with the staff member, the staff member threw a phone at him/her. Resident #66 stated that the phone hit him/her but another staff member tried to stop it. Resident #66 stated that this took place on the night shift. Review of Resident #66's physicians notes on 1/31/19 revealed a note dated 8/6/19 Importantly over the weekend had an altercation with 1 of the staff members. A full specifics unknown. (S/He) reports that (s/he) somehow missed (his/her) dinner tray and was given a sandwich. (S/He) reports that someone had tampered with a sandwich therefore (s/he) got upset and the hospice (sic) sandwich back at the staff member. (S/He) then reports the staff member threw something at (him/her). (S/He) reports that this made contact with (his/her) right upper extremity. On exam today (s/he) is complaining of some pain to (his/her) right upper extremity. Review of CNA #9's employee file on 1/31/9 revealed that the CNA was suspended terminated on 8/6/18, last day worked was 8/5/18. Terminated involuntary for violation of rules/policy. Review of the facility investigation for Resident #34 revealed At 8:00 am on 10/2/18 Resident reported to nurse physical abuse by staff member (CNA #10). DON and Administrator notified. Investigation initiated. Administrator interviewed (Resident #34) on 10/2/18 at approximately 10:25 am. (S/He) was noted to have a black bruise beneath (his/her) left eye. Upon closer observation, there was also a smaller, lighter area at the corner of (his/her) right eye. (Resident #34) said the night before (s/he) had put (him/herself) in bed. At approximately 11pm the CNA came into (his/her) room to change (his/her) clothes. (S/He) said the CNA was taking (his/her) pants off roughly and (s/he) called the CNA a (offensive name) and kicked her/him in the chest. In response (s/he) said the CNA punched (him/her) in the left eye. (S/He) said the CNA also tried to punch (him/her) in the right eye but (s/he) blocked most of it with (his/her) hand. Review of Resident #34's medical record on 1/31/19 revealed s/he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #34's medical record on 1/31/19 revealed a note dated 10/1/18 at 11:30 pm reddened abrasion noted to res (resident) face @ l cheek area. Incident report received from 3-11 shift nurse r/t (related to) (his/her) skin abnormality. Review of Resident #34's Social Services (SS) note on 1/31/19 revealed a SS note dated 10/2/18 SSD (Social Services Director) spoke with resident in concern of incident on (MONTH) 1. (YEAR). Resident seems to be ok emotionally. (S/He) continues to have (his/her) daily stop and conversation with SSD. Writer has also made a psych eval referral. SSD will follow up as needed. Review of Resident #34's Physicians notes on 1/31/19 revealed a Physicians note dated 10/2/18 .(S/He) was noted this morning to have bruising around (his/her) left eye as well as some associated swelling. On exam (s/he) states this somewhat tender. (S/He) denies any overt headache. (S/He) denies any change in (his/her) vision. Vital signs reviewed and are stable. (S/He) denies any other new complaints Review of CNA #10's employee file on 1/31/9 revealed that the CNA was suspended on 10/2/18 pending investigation. The CNA was terminated on 10/8/18, last day worked 10/1/18. Terminated involuntary for unsatisfactory performance and violation of rules. During an interview with Resident #34 on 01/31/19 at approximately 11:55 AM Resident #34 stated that s/he called a staff member a name and the staff member hit him/her in the face. Resident #34 stated that s/he does not have issues with other staff only that one. Review of the facilities policy titled abuse, neglect, exploitation, or mistreatment revealed 1. The facilities leadership prohibits neglect, mental, physical and/or verbal abuse, use of a physical and/or chemical restraint not required to treat a medical condition, involuntary seclusion, corporal punishment and misappropriation of a patients/resident's Property and/or funds and ensures that alleged violations involving abuse, neglect, exploitation or misappropriation of property and/or funds and ensures that alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, and are reported immediately. Under the section titled III: Prevention 4. Adequate supervision of staff is maintained in order to identify and prevent inappropriate behaviors, such as: A. The use of derogatory/harassing language; beat. Rough handling; and B. Ignoring the patient's/residents needs requests, etc.

Based on review of facility files and interview, the facility failed to have evidence that two of thirteen residents reviewed for allegations of abuse were thoroughly investigated. An allegation of verbal/mental abuse by Resident #59 was not thoroughly investigated. The facility failed to obtain a witness statements from the resident and his/her roommate related to the incident. Resident #232's report of sexual assault was not thoroughly investigated. Resident #232 did not return to the facility after being sent to the emergency room and the facility failed obtain a copy of the results of the evaluation. The findings included: The facility reported an allegation of verbal abuse of Resident #59 by Certified Nurse Aide (CNA) #8 to the State Agency on 1/24/19. Review of the Five-Day Follow-Up Report dated 1/30/19 indicated that, based on investigation, the facility was not able to substantiate abuse occurred. The aide was terminated related to poor customer service skills. Resident #59 reported to the Activity Director that an aide who had cared for him/her had used a bad choice of words during their conversation. CNA #8's facility-obtained statement indicated Resident #59 liked to joke around with staff when working with them. Resident #59 made the comment to CNA #8 that s/he could be handled and dealt with. CNA #8 responded, What do you mean? Resident #59 repeated the comment. CNA #8 jokingly mentioned Resident #59 getting weights from therapy and taking care of boobs in front and back. Resident #59 laughed at that. CNA #8 asked why the woman that s/he talked about didn't come visit him/her or make sure s/he was okay. No more was said about this conversation. In an interview with the surveyor on 2/3/19 at approximately 11:40 AM, the Activities Director stated Resident #59 came to the activities room and told him/her that s/he wanted to talk to him/her about a CNA. S/he told him/her that CNA #8 came in the room and was working with his/her roommate. Resident #59 had his/her shirt off and was at the armoire getting a shirt out. CNA #8 walked behind him/her and said you have breast on your back. Resident #59 said s/he did not say anything to CNA #8, just laughed it off, but that it did bother him/her. Resident #59 told the Activities Director about the incident the day after it occurred. Resident #59 said s/he was thinking about reporting it officially. Resident #59 stated s/he was not sure if CNA #8 was joking or not. The Activities Director stated Resident #59's roommate was interviewable. Resident #59 stated if the roommate needed to tell staff s/he would since s/he was in the room. In an interview with the surveyor on 2/3/19 at approximately 11:30 AM, the Social Services Director stated the incident had been reported to the Activities Director and s/he reported it to him/her. The Social Services Director talked with Resident #58 and s/he said CNA #8 came in to provide care. CNA #8 made some statements about his/her size that day and s/he made a statement back about handling him/her. CNA #8 said, How about you go to the gym and handle the breasts on your back? The incident occurred in the resident's room. Resident #59 had a roommate, but s/he never made a statement about what happened. In an interview with the surveyor on 2/3/19 at approximately 1:00 PM, the Director of Nursing (DON) stated the Social Services Director told him/her Resident #8 had a grievance about how s/he had been spoken to by CNA #8. The Director of Nursing went and talked with the resident and s/he stated CNA #8 had entered his/her room and had mentioned him/her having breasts. The Director of Nursing provided a form that had a room number at the top but not the name of the resident it corresponded to. The form had two questions that staff asked the resident: Do you know CNA #8? and How is the care provided by (him/her)? This was the same form used to interview other residents on the unit. The facility had no documentation and were unable to verbalize to the surveyor that a staff member talked with Resident #59's roommate regarding the incident. Resident #59 indicated his/her roommate witnessed the incident and the facility failed to interview the resident to find out what the resident saw or heard. Review of the facility's Abuse, Neglect, and Misappropriation of Property policy revealed guidelines for investigation included to interview individuals having first-hand knowledge of the incident and to write summaries of the interviews. The facility reported an allegation of sexual abuse involving Resident #232 to the State Agency on 1/7/19. Resident #232 reported an allegation of sexual abuse by an unknown perpetrator. Review of the Five-Day Follow-Up Report dated 1/11/19 revealed the facility was not able to substantiate sexual abuse. The resident was admitted to the hospital related to other health issues. Review of the facility's investigation revealed there was no documentation from the hospital related to the results of the rape evaluation. Review of a 1/7/19 physician's orders [REDACTED]. During an interview with the surveyor on 2/2/19 at approximately 1:45 PM, the DON stated Resident #232's spouse came in and asked to speak to him/her. The resident's spouse said someone needed to come see his/her spouse. S/he said that s/he had been raped. The DON went to the room and s/he and the spouse talked to the resident. S/he repeated that s/he had been raped. The DON stated s/he talked with the nurse at the hospital who did the initial assessment and stated that s/he had concluded there was no suspicion that any sexual assault/rape had occurred. The nurse at the hospital stated s/he did a DNA swab and checked for [MEDICAL CONDITION]. The DON stated s/he had not talked with Resident #232's spouse since the initial report. On 2/3/19 at approximately 12:55 PM, the DON stated that, when contacted to request information, the hospital nurse stated s/he had nothing to do with medical records. The DON did not contact medical records about a report because Resident #232 had been expected to return to the facility. The DON stated s/he did not contact medical records at the hospital when it was getting close to the end of the resident's 10 day bed hold to obtain a copy of the results of the resident's sexual assault evaluation. The DON stated no staff were suspended during the investigation because s/he had no identity.

Based on observation, record review, and interview, the facility failed to develop and/or follow care plan interventions for 2 of 2 sampled residents reviewed for pressure ulcers, 1 of 3 sampled residents reviewed for accidents, 1 of 1 sampled residents reviewed for pain management, and 1 of 1 sampled resident reviewed for infection. Residents #32 and #54 were not turned and repositioned according to the care plan. Resident #40 did not have fall and injury prevention measures in place as per the care plan. The care plan for isolation was not followed for Resident #16. Resident #32 had no care plan for a pressure ulcer and his/her care plan to address pain/comfort was not followed. During wound care for Resident #32, the resident stated that s/he was in pain. The nurse completed wound care for Resident #32 without further addressing Resident #32's pain. Additionally, during an assessment of Resident #32's feet by a nurse the resident screamed in pain. The nurse continued to move Resident #32's feet as s/he screamed out in pain. The nurse did not address Resident #32's pain during or immediately after the assessment of the resident's feet. The findings included: The facility admitted Resident #40 with [DIAGNOSES REDACTED]. Review of Incident/Accident Investigation Worksheets on 1/31/19 at 2:35 PM revealed that Resident #40 had sustained falls on 10/1/18, 10/6/18, 10/7/18, 10/13/18, 10/15/18, and 11/4/18. Each time the resident was found out of his/her low bed on the floor. Review of Resident #40's Care Plan on 2/03/19 at 12:04 AM revealed that interventions/approaches for falls included floor mats and a scoop mattress. Observations on all four days of the survey revealed Resident #40 in a low bed with only one fall mat on one side of the bed. No scoop mattress was noted on the bed. During an observation and interview on 02/03/19 at 12:13 PM, Certified Nursing Assistant #2 verified there was no scoop mattress and only one mat on one side of the bed. During an interview on 2/03/19 at 12:43 PM, RN #2 verified Resident #40's Care Plan for floor mats and a scoop mattress to prevent falls and minimize injury in the event of future falls. S/he stated, I guess I should have made sure the scoop mattress was put on. The facility admitted Resident #54 with [DIAGNOSES REDACTED]. Review of Wound Physician's weekly Wound Evaluation and Management Summaries for 1/30/19 revealed that Resident #54 had a Stage 4 sacral pressure ulcer measuring 2.3 cm (centimeters) x 1.4 cm x .2 cm. Review of Resident #54's Care Plan on 2/03/19 at 12:18 AM revealed that interventions/approaches for the Stage 4 pressure ulcer included to Turn and reposition per facility protocol for comfort and circulation. Multiple observations on 1/31/19 (11:06 AM, 12:19 PM, 1:56 PM, 3:07 PM, and 4:22 PM) revealed Resident #54 positioned on his/her back with his/her head of bed elevated 30-45 degrees, generating additional pressure to the sacral area. There were no positioning pillows or devices in the bed to indicate any attempts had been made to turn and position the resident. During an interview on 2/3/19 at 7:45 AM, when asked about the facility protocol for turning and positioning, Registered Nurse (RN) #2 responded, Approximately every 2 hours and PRN (as needed). The facility admitted Resident #16 initially on 12/8/17 for rehabilitation for deconditioning following hospitalization . S/he remained long term care related to [MEDICAL CONDITIONS], Diabetes Mellitus , [MEDICAL CONDITION], Hypertension, and Chronic [MEDICAL CONDITION]. Observation on 1/31/19 at 12:51 PM revealed Resident #16 was on transmission-based precautions for possible [DIAGNOSES REDACTED] ([MEDICAL CONDITION]) as stated by LPN #5. Review of Resident #16's Care Plan on 2/2/19 at 10:53 PM revealed a [DIAGNOSES REDACTED] related problem with interventions including isolation per facility protocol. During an interview on 2/3/19 at 9:53 AM, when asked about the facility protocol for [DIAGNOSES REDACTED], the Unit Manager stated, Anyone entering the room should wear gown, mask, and gloves. There are containers in the bathroom for linen and trash. Staff should remove everything and wash hands before leaving the room. S/he further stated it was not acceptable to use hand sanitizer. You must wash hands in the room. On 1/31/19 at 3:14 PM. LPN #8 was observed entering the resident's room without donning any personal protective Equipment (PPE). S/he went to the resident's bedside, moved the over-bed table, and told the resident they would take his/her tray out in a bit. When the nurse left the room, s/he did not wash her/his hands. When asked what the resident was on precautions for, LPN #8 replied, [DIAGNOSES REDACTED]. On 2/01/19 at 9:41 AM, LPN #5 and the NP went in to see the resident. The NP had not applied her/his gown properly. It was not tied and kept falling down to her/his elbows. The NP kept pulling the gown back up, touching the shoulder area of her/his lab coat with gloved hands after touching the resident. The left side of the NP's lab coat also came into contact with the resident's over-bed table. When s/he left the room, s/he removed the PPE and used hand sanitizer from her/his pocket. S/he did not wash her/his hands upon exit from the room. After returning to the nursing station for a brief period and noting that the resident had 1 or 2 loose stools in the last day, the NP washed her/his hands in the bathroom at the nursing station. On 2/3/19 at approximately 1:19 PM, the Minimum Data Set (MDS) Coordinator was observed entering Resident #16's room without donning PPE. The MDS Coordinator stated, I am only going to give him (her) this bag from his (her) niece. I won't touch anything. Review of Resident #32's medical record on 1/31/19 revealed s/he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. During observation of a pressure ulcer treatment for [REDACTED].#3 and Certified Nursing Assistant (CNA) #4 positioned the resident onto his/her right side. The resident expressed pain during the repositioning but reached out, grabbed the siderail with his/her left hand, and assisted with the positioning. As the nurse removed the soiled dressing from the left buttock, Resident #32 stated, It hurts and pulled slightly away. The CNA comforted Resident #32. The surveyor asked the CNA to repeat what the resident said as the nurse failed to acknowledge the resident's expression of pain. To the surveyor, LPN #3 stated, He (She) gets Tylenol. To Resident #32, s/he stated, I'll give you pain medicine in a little bit. The nurse proceeded to cleanse Resident #32's unstageable pressure ulcer twice with 4x4s soaked with wound cleanser, then patted the area dry. During the procedure, Resident #32 again stated, It hurts back there. When the resident was not acknowledged, the surveyor asked CNA #4 to repeat what the resident had said. The nurse completed the procedure without further addressing Resident #32's pain. Review of Resident #32's Care Plan revealed a 2/16/18 problem related to alteration in comfort with need for pain medication though it was not specifically in reference to the pressure ulcer. Interventions included to Monitor resident for 5/5 Interventions included to Monitor resident for s/s (signs/symptoms) of pain/ discomfort . Administer medications per MD orders Interventions included to Monitor resident for s/s (signs/symptoms) of pain/ discomfort . Administer medications per MD orders. Evaluate/record/report effectiveness. Record review for Resident #32 on 2/3/19 revealed physician's orders [REDACTED]. Further review revealed no evidence of pain assessment or administration of PRN medication. During an interview on 2/3/19 at 1:45 PM with the Corporate Consultant present, the Director of Nurses stated, If the resident expressed pain, I would expect the nurse to stop the treatment, assess the resident, and give pain medication. If none was ordered, I would expect her to call the physician. Review of Resident #32's Care Plan on 1/31/19 revealed a problem with a start date of 2/16/18 (Resident #32) is at risk for skin breakdown related to impaired physical mobility, episodes of bladder and bowel incontinence, impaired cognitive function, self-care deficits and medical Dx (diagnosis) CVD (Cardiovascular disease), [MEDICAL CONDITIONS], DM (Diabetes Mellitus). BLE (Bilateral Lower Extremity) [MEDICAL CONDITION] is present. Pt (Patient) is obese and takes antidepressant medication. A cushion and mattress for pressure reduction is utilized. Resident is currently being treated for [REDACTED]. 10/19/18 blister to RLE (Right Lower Extremity). (S/He) was treated for [REDACTED]. Approaches included: assist with turning and repositioning every two hours and PRN (as needed) if indicated. During the days of survey several observations were made of Resident #32 in the supine position (on 01/31/19 at approximately 11:30 AM, 2:20 PM; on 2/1/19 at approximately 8:24 AM, 10:20 AM, 5:10 PM; on 2/2/19 at approximately 7:15 AM and 3:30 PM). During an interview on 2/2/19 at approximately 3:30 PM, Resident #32 stated that s/he had not had assistance with turning all day and wanted to get out of bed, but no one would get him/her up. During an interview on 2/2/19 at approximately 8:30 AM, the Director of Nursing (DON) stated that if a resident is care planned to be positioned every 2 hours, s/he expects staff to ask the resident if s/he needs help repositioning every 2 hours. The DON stated that CNAs do not document when they reposition residents. The DON stated that there is no way of tracking if a resident is repositioned every 2 hours. Review of the Wound Treatment & Progress Record dated 1/16/19 revealed that Resident #32 had a pressure ulcer on the left buttocks measuring 7.7 x 7.7 centimeters, depth not measurable. Further review of the resident's Care Plan revealed that it did not include the pressure ulcer to the left buttocks. Review of Resident #32's Care Plan on 1/31/19 revealed a problem with a start date of 2/16/18 for potential for alteration in comfort with need for pain medication r/t (related to) dx. of gout, DM, [MEDICAL CONDITION], diverticulitis, OA, cervical spondylitis, diverticulitis. (Resident #32) has altered level of comfort S/P fall(s) at times. Approaches included administer medications per MD (Medical Doctor) orders. Evaluate/record/report effectiveness and any adverse side effects. During an observation on 2/1/19 at approximately 8:24 AM the Licensed Practical Nurse (LPN) #5 assessed Resident #32's feet. During the assessment, Resident #32 screamed in pain. LPN #5 stated I'm sorry but continued to move the resident as s/he screamed out in pain. During an interview on 2/1/19 at approximately 10:20 AM (almost 2 hours later), LPN #5 stated that s/he had not given Resident #32 pain medication that morning but was going to give it to him/her in a few. During an interview on 2/2/19 at approximately 8:30 AM, the Director of Nursing (DON) stated that when a resident screams out in pain, s/he expected staff to stop and report to a nurse, check for PRNs, contact a doctor for pain if needed, and for the nurse to administer medications per MD orders.

Based on observation, record review, and interview, the facility failed to identify and provide treatment for [REDACTED]. Resident #32 expressed pain during positioning and during a pressure ulcer treatment that was not addressed. The finding included: The facility admitted Resident #32 with [DIAGNOSES REDACTED]. During observation of a pressure ulcer treatment for [REDACTED].#3 and Certified Nursing Assistant (CNA) #4 positioned the resident onto his/her right side. The resident expressed pain during the repositioning but reached out, grabbed the siderail with his/her left hand, and assisted with the positioning. As the nurse removed the soiled dressing from the left buttock, Resident #32 stated, It hurts and pulled slightly away. The CNA comforted the resident. The surveyor asked the CNA to repeat what the resident said as the nurse failed to acknowledge the resident's expression of pain. To the surveyor, LPN #3 stated, He (She) gets Tylenol. To the resident, s/he stated, I'll give you pain medicine in a little bit. The nurse proceeded to cleanse the unstageable pressure ulcer twice with 4x4s soaked with wound cleanser, then patted the area dry. During the procedure, Resident #32 again stated, It hurts back there. When the resident was not acknowledged, the surveyor asked CNA #4 to repeat what the resident had said. The nurse completed the procedure without further addressing the resident's pain. Record review on 2/3/19 revealed physician's orders [REDACTED]. Further review revealed no evidence of pain assessment or administration of PRN medication. Review of the Care Plan revealed a 2/16/18 problem related to alteration in comfort with need for pain medication though it was not specifically in reference to the pressure ulcer. Interventions included to Monitor resident for 5/5Interventions included to Monitor resident for s/s (signs/symptoms) of pain/ discomfort . Administer medications per MD (Medical Doctor) orders. Interventions included to Monitor resident for s/s (signs/symptoms) of pain/ discomfort . Administer medications per MD orders. Evaluate/record/report effectiveness. During an interview on 2/3/19 at 1:45 PM with the Corporate Consultant present, the Director of Nurses (DON) stated, If the resident expressed pain, I would expect the nurse to stop the treatment, assess the resident, and give pain medication. If none was ordered, I would expect her to call the physician. Review of Resident #32's care plan on 1/31/19 revealed a problem with a start date of 2/16/18 potential for alteration in comfort with need for pain medication r/t (related to) dx. (diagnoses) of gout, DM, [MEDICAL CONDITION], diverticulitis, OA ([MEDICAL CONDITION]), cervical spondylitis, diverticulitis. (Resident #32) has altered level of comfort S/P (status/post) fall(s) at times. Approaches included administer medications per MD orders. Evaluate/record/report effectiveness and any adverse side effects. During an observation on 2/1/19 at approximately 8:24 AM, LPN #5 assessed Resident #32's feet. During the assessment, Resident #32 screamed in pain. LPN #5 stated I'm sorry but continued to move the resident as s/he screamed out in pain. During an interview on 2/1/19 at approximately 10:20 AM LPN #5 stated that s/he had not given Resident #32 pain medication that morning but was going to give it to him/her in a few. During an interview on 2/2/19 at approximately 8:30 AM, the Director of Nurses stated that when a resident screams out in pain, s/he expected the staff to stop and report to a nurse, check for PRNs (as needed medication), contact a doctor for pain medication if needed, and for the nurse to administer medications per MD orders.

Based on review of facility files and interview, the facility failed to ensure each resident received services in accordance with the written plan of care. Certified Nurse Aide (CNA) #1 did not follow Resident #1's care plan and provided the resident with food that was not the appropriate consistency. Resident #1 choked on the food and became unresponsive. Resident #1 was sent out to the hospital and expired. One of four residents reviewed for care plans. The findings included: The facility reported an allegation of neglect for Resident #1 by CNA #1 on [DATE]. The description of the reportable incident indicated Resident #1 choked and was transferred to the emergency room by E[CONDITION]. Review of the facility's Five-Day Follow-Up Report dated [DATE] indicated at approximately 9:30 PM, CNA #1 was with Resident #1 in the north day room. CNA #1 brought a pimento cheese sandwich to the north day room. When CNA #1 left the room to obtain a thickened drink and a cloth cover for Resident #1, s/he placed the sandwich out of reach; however, Resident #1 was able to obtain the sandwich while CNA #1 was out of the room. Resident #1 had orders for a mechanical soft diet with pureed bread. When reentering the room, CNA #1 saw Resident #1 choking and called to the nurse for help. The nurse immediately entered the room and performed the [MEDICATION NAME] maneuver. E[CONDITION] arrived and Resident #1 was transported to the hospital. After review of the incident, it was determined that neglect was substantiated. Further review of the medical record revealed the Annual Minimum Data Set ((MDS) dated [DATE] coded Resident #1 as having a Brief Interview for Mental Status (BI[CONDITION]) score of 4. The Quarterly MDS dated [DATE] coded Resident #1 as having a BI[CONDITION] score of 5. The Annual MDS coded Resident #1 as independent with setup help only for eating. Review of the care plan revealed at risk for altered nutrition related to consuming a mechanically altered diet related to dysphagia was identified as a problem area. Interventions and approaches to this problem area were documented on the care plan and included to provide diet as ordered with resident food preferences as feasible and offer snacks per protocol. Review of Resident #1's [DATE] Physician order [REDACTED]. Review of the Diet Order and Communication form dated [DATE] revealed Resident #1's diet order was changed to mechanical soft, puree bread with nectar thick liquids related to chewing/swallowing problems. Review of the Nurses' Note dated [DATE] at 9:50 PM indicated the CNA summoned the nurse into the dayroom at 9:40 PM. Noted resident with food coming out of his/her mouth. No pulse or respirations noted. Writer cleaned out resident's mouth and removed a chunk of mashed up food. Abdominal thrust performed with pulse noted. Repositioned resident on right side and removed remainder of visible obstruction. Respirations shallow, MD in facility and at resident side. 911 called. Review of the Physician Telephone Orders revealed an order dated [DATE] to transfer the resident to the hospital for evaluation related to choking and change in level of consciousness. Licensed Practical Nurse (LPN) #1's facility-obtained statement indicated s/he was at the nurses' station charting and was called to come quick. Resident #1 was sitting in the geri chair. LPN #1 repositioned him/her to do abdominal thrust and sweep his/her mouth. Resident #1 was unresponsive and a code blue was called. In an interview with the surveyor on [DATE] at approximately 6:35 PM, LPN #1 stated that s/he was sitting at the desk charting. S/he heard someone yell out oh my God. There were two CNAs in the doorway of the dayroom when the LPN first looked up. CNA #1 said all s/he did was give the resident a sandwich. The resident's gerichair was in the center of the room when LPN #1 entered the dayroom, not close enough to the table for the resident to reach. LPN #1 went in and Resident #1 had some chewed up food coming out of his/her mouth. The resident looked ashen. LPN #1 went over and called the resident's name. S/he checked him/her for a pulse and s/he didn't feel a pulse. LPN #1 tried to sweep the resident's mouth out. Resident #1 was in the gerichair, LPN #1 did a couple of chest thrusts and they turned him/her over and did some thrusts in the back. S/he turned the resident back over and the resident groaned. LPN #1 felt a pulse. They placed the resident in the floor, other staff and the facility physician were in the room. LPN #1 had told a CNA to call 911. There were 3 other nurses and the physician in the dayroom. LPN #1 stepped out of the room to give 911 the information they requested. LPN #2 took over and was in the floor with the resident when LPN #1 went to talk with 911. LPN #1 went back in the dayroom at one point and they had a non-rebreather on the resident. LPN #1 stated Resident #1 was not able to get around with the gerichair. The resident was able to feed him/herself during mealtimes and snacks. CNA #1's facility-obtained statement indicated when snacks came out Resident #1 had a banana on the snack tray. The banana was too hard to chew. CNA #1 got the resident a pimento sandwich and removed the crust. CNA #1 went to get a nectar thick liquid and when s/he came back s/he noticed the resident was unresponsive. CNA #1 called LPN #1 and told him/her Resident #1 was choking. Review of the facility's investigation revealed a typed statement that indicated it was a phone interview with CNA #1 on [DATE]. CNA #1 said s/he was in the day room with Resident #1 and asked if s/he wanted a snack and s/he said that s/he did. They were in the day room alone. CNA #1 went to the nourishment room and got Resident #1 a banana. Resident #1 said the banana was too hard for him/her to chew. CNA #1 then got up and pushed the resident back from the table. CNA #1 took the banana and went to the nourishment room and picked a pimento cheese sandwich as an alternative for Resident #1. CNA #1 unwrapped the sandwich and removed the crust. S/he added thickened liquid to the sandwich to mash it because the resident needed it to be mechanical soft. CNA #1 returned to the day room with the sandwich and placed it on the table in front of Resident #1. CNA #1 walked to the nourishment room to get a thickened drink for the resident and a cloth to cover him/her because s/he spilled food when s/he ate. CNA #1 said s/he was walking back to the dayroom and saw Resident #1 choking. S/he yelled to LPN #1 for help and went to help Resident #1. CNA #1 was asked if the resident ever grabbed food and s/he said yes. CNA #1 was asked how much of the sandwich Resident #1 had eaten and s/he said a little more than half. CNA #1 asked how Resident #1 was doing and was informed the resident had passed. In a telephone interview with the surveyor on [DATE] at approximately 1:45 PM, CNA #1 stated Resident #1 had a banana for a snack and s/he complained it was too hard. CNA #1 went and got the resident a pimento cheese sandwich and s/he softened it with nectar thick liquid and took the crust off and mashed it up. CNA #1 put it on the table and moved Resident #1 from the table to go get him/her a drink from the nourishment kitchen. When CNA #1 got back to the dayroom the resident had moved him/herself to the table and gotten the sandwich. CNA #1 stated the resident could move the chair as far as s/he wanted. CNA #1 stated s/he was assigned to the resident the majority of the time. CNA #1 stated s/he had not given the resident a sandwich with thickened liquids before. There were no other staff or residents in the dayroom when CNA #1 left the resident there. CNA #1 stated s/he knew the resident was on a mechanical soft diet but didn't know s/he needed pureed bread. CNA #1 stated they probably have that information in the chart, s/he stated s/he doesn't look at the resident's chart because of HIPPA. CNA #1 stated s/he thinks there is a book at the nurses' station that has information on resident care. CNA #1 stated s/he looks at those sometime, like if s/he has a new admission. CNA #1 stated s/he worked at the facility for ,[DATE] years prior to the incident. Plan of Correction: Allegation of Compliance [DATE] On [DATE] at 9:40 PM, Resident #1 was noted by assigned Licensed Nurse to have food visibly coming out of mouth and was without pulse or respirations. Immediate treatment of [REDACTED]. The physician of record was present in the facility at the time of incident and ordered oxygen to be administered via non-rebreather mask and immediate transport to Providence Northeast Hospital for evaluation and treatment. Emergency medical services initiated immediately and resident exited facility at 9:48 PM. Facility Licensed Nurse notified resident's responsible party via telephone on [DATE] at 9:55 PM. An immediate investigation of the incident was initiated by the facility leadership. The identified employee that was determined to have provided the food product was suspended on [DATE] and subsequently terminated from the facility on [DATE]. Residents in the facility with mechanically altered diets have the potential to be affected by this alleged deficient practice. The facility contracted Registered Dietitian has reviewed facility residents with orders for mechanically altered diets to validate accuracy with corresponding tray card. This was completed on [DATE]. All concerns were addressed at time of discovery. The facility Director of Nursing has re-educated the facility nursing department staff on following mechanically altered diets. The facility Speech Therapist has re-educated facility nursing department staff on utilizing the Matrix system to identify resident diets, confirming resident diets with tray cards during meal service and the specific textures of mechanically altered diets in relation to snacks. This re-education included specific information on consistency of solids and thickness of the different liquids, as well as the clinical reasons for mechanically altered diets and snacks such as inability to chew and/or safely swallow different consistencies. This re-education also included the process on how to verify the ordered diet prior to providing any resident a meal or snack and to inform a Licensed Nurse should staff observe any signs of aspiration, such as runny nose, watery eyes or cough during the consumption of a food product or if a resident is refusing the provided food item of their specific mechanically altered diet, to validate with a Licensed Nurse, Speech Therapist or Dietary Manager that any substituted item is safe for consumption under that resident's ordered mechanically altered diet. This re-education was completed on [DATE]. Any facility nursing department staff not receiving this re-education on this date will receive prior to next scheduled shift. This information will be present in new hire orientation. The facility Director of Nursing will monitor residents with mechanically altered diets for accuracy of tray cards and provided snacks 5 times per week for 2 weeks, 3 times per week for 2 weeks, then weekly for 2 months. Results of the monitoring will be presented to the Quality Assurance Performance Improvement (QAPI) Committee for a period of 3 months or until substantial compliance is achieved and maintained. Any areas of concern identified will be addressed at time of discovery. Observations, interviews, and review of policies revealed the plan of correction developed by the facility on [DATE] had been implemented and was in practice removing the deficient practice. Facility nursing staff had been educated and was knowledgeable of the policy. The Administrator was informed of this on [DATE]. The Immediate Jeopardy at Past Noncompliance at F-282 was corrected as of [DATE].

Based on review of facility files and interview, the facility failed to ensure the facility was administered in a manner that enabled it to use its resources effectively to maintain the highest practicable physical well-being of each resident. Certified Nurse Aide (CNA) #1 did not follow Resident #1's diet order and provided the resident with food that was not the appropriate consistency. Resident #1 choked on the food and became unresponsive when CNA #1 left the room to obtain a thickened drink and a cloth cover. Resident #1 was sent out to the hospital and expired. One of four residents reviewed for administration. The findings included: Cross refer to F224, F282, F323, and F365 as they relate to an incident that occurred on [DATE] when Resident #1 was left unattended and obtained food that was not the appropriate consistency. S/he choked and was sent out to the hospital. The facility reported an allegation of neglect for Resident #1 by CNA #1 on [DATE]. The description of the reportable incident indicated Resident #1 choked and was transferred to the emergency room by E[CONDITION]. Review of the facility's Five-Day Follow-Up Report dated [DATE] indicated at approximately 9:30 PM, CNA #1 was with Resident #1 in the north day room. CNA #1 brought a pimento cheese sandwich to the north day room. When CNA #1 left the room to obtain a thickened drink and a cloth cover for Resident #1, s/he placed the sandwich out of reach; however, Resident #1 was able to obtain the sandwich while CNA #1 was out of the room. Resident #1 had orders for a mechanical soft diet with pureed bread. When reentering the room, CNA #1 saw Resident #1 choking and called to the nurse for help. The nurse immediately entered the room and performed the [MEDICATION NAME] maneuver. E[CONDITION] arrived and Resident #1 was transported to the hospital. After review of the incident, it was determined that neglect was substantiated. Review of the Nurses' Note dated [DATE] at 9:50 PM indicated the CNA summoned the nurse into the dayroom at 9:40 PM. Noted resident with food coming out of his/her mouth. No pulse or respirations noted. Writer cleaned out resident's mouth and removed a chunk of mashed up food. Abdominal thrust performed with pulse noted. Repositioned resident on right side and removed remainder of visible obstruction. Respirations shallow, MD in facility and at resident side. 911 called. In an interview with the surveyor on [DATE] at approximately 6:35 PM, Licensed Practical Nurse (LPN) #1 stated that s/he was sitting at the desk charting. S/he heard someone yell out oh my God. There were two CNAs in the doorway of the dayroom when the LPN first looked up. CNA #1 said all s/he did was give the resident a sandwich. The resident's gerichair was in the center of the room when LPN #1 entered the dayroom, not close enough to the table for the resident to reach. LPN #1 went in and Resident #1 had some chewed up food coming out of his/her mouth. The resident looked ashen. LPN #1 went over and called the resident's name. S/he checked him/her for a pulse and s/he didn't feel a pulse. LPN #1 tried to sweep the resident's mouth out. Resident #1 was in the gerichair, LPN #1 did a couple of chest thrusts and they turned him/her over and did some thrusts in the back. S/he turned the resident back over and the resident groaned. LPN #1 felt a pulse. They placed the resident in the floor, other staff and the facility physician were in the room. LPN #1 had told a CNA to call 911. There were 3 other nurses and the physician in the dayroom. LPN #1 stepped out of the room to give 911 the information they requested. LPN #2 took over and was in the floor with the resident when LPN #1 went to talk with 911. LPN #1 went back in the dayroom at one point and they had a non-rebreather on the resident. LPN #1 stated Resident #1 was not able to get around with the gerichair. The resident was able to feed him/herself during mealtimes and snacks. In an interview with the surveyor on [DATE] at approximately 7:15 PM, the Director of Nursing (DON) stated s/he was not at the facility when the incident occurred. CNA #1 was going to give the resident a banana, but it was too hard. So s/he gave him/her a pimento cheese sandwich. CNA #1 said s/he removed the crust and was going to soak the sandwich in thickened liquids. CNA #1 went to the nutrition room. When s/he returned to the dayroom the resident already had the sandwich. The sandwich was left on the table. The CNA had already put the thickener on the bread, but s/he went to get the resident something to drink. The resident was on a mechanical soft diet with pureed bread. The DON stated it was not acceptable practice to put thickener on the bread to puree it. In an interview with the surveyor on [DATE] at approximately 2:15 PM, the administrator stated around 9:30 PM CNA #1 had the resident in the dayroom on the North Unit, s/he got him/her a banana and the resident said it was too hard. CNA #1 went and got the resident a pimento cheese sandwich and said s/he put nectar thick liquid on the sandwich to soften it up. CNA #1 put the sandwich on the table in the dayroom and went to get the resident a drink and a covering. CNA #1 stated the resident was not near the table. When s/he returned the resident had scooted to the table and got the sandwich. Resident #1 had eaten about half the sandwich and was choking when s/he returned. The CNA #1 called the nurse and they called a code blue. The resident had his/her mouth full. Plan of Correction: Allegation of Compliance [DATE] On [DATE] at 9:40 PM, Resident #1 was noted by assigned Licensed Nurse to have food visibly coming out of mouth and was without pulse or respirations. Immediate treatment of [REDACTED]. The physician of record was present in the facility at the time of incident and ordered oxygen to be administered via non-rebreather mask and immediate transport to Providence Northeast Hospital for evaluation and treatment. Emergency medical services initiated immediately and resident exited facility at 9:48 PM. Facility Licensed Nurse notified resident's responsible party via telephone on [DATE] at 9:55 PM. An immediate investigation of the incident was initiated by the facility leadership. The identified employee that was determined to have provided the food product was suspended on [DATE] and subsequently terminated from the facility on [DATE]. Residents in the facility with mechanically altered diets have the potential to be affected by this alleged deficient practice. The facility contracted Registered Dietitian has reviewed facility residents with orders for mechanically altered diets to validate accuracy with corresponding tray card. This was completed on [DATE]. All concerns were addressed at time of discovery. The facility Director of Nursing has re-educated the facility nursing department staff on following mechanically altered diets. The facility Speech Therapist has re-educated facility nursing department staff on utilizing the Matrix system to identify resident diets, confirming resident diets with tray cards during meal service and the specific textures of mechanically altered diets in relation to snacks. This re-education included specific information on consistency of solids and thickness of the different liquids, as well as the clinical reasons for mechanically altered diets and snacks such as inability to chew and/or safely swallow different consistencies. This re-education also included the process on how to verify the ordered diet prior to providing any resident a meal or snack and to inform a Licensed Nurse should staff observe any signs of aspiration, such as runny nose, watery eyes or cough during the consumption of a food product or if a resident is refusing the provided food item of their specific mechanically altered diet, to validate with a Licensed Nurse, Speech Therapist or Dietary Manager that any substituted item is safe for consumption under that resident's ordered mechanically altered diet. This re-education was completed on [DATE]. Any facility nursing department staff not receiving this re-education on this date will receive prior to next scheduled shift. This information will be present in new hire orientation. The facility Director of Nursing will monitor residents with mechanically altered diets for accuracy of tray cards and provided snacks 5 times per week for 2 weeks, 3 times per week for 2 weeks, then weekly for 2 months. Results of the monitoring will be presented to the Quality Assurance Performance Improvement (QAPI) Committee for a period of 3 months or until substantial compliance is achieved and maintained. Any areas of concern identified will be addressed at time of discovery. Observations, interviews, and review of policies revealed the plan of correction developed by the facility on [DATE] had been implemented and was in practice removing the deficient practice. Facility nursing staff had been educated and was knowledgeable of the policy. The Administrator was informed of this on [DATE]. The Immediate Jeopardy at Past Noncompliance F-490 were corrected as of [DATE].

Based on review of facility files and interview, the facility failed to ensure each resident received food prepared in a form designed to meet individual needs. Certified Nurse Aide (CNA) #1 did not follow Resident #1's diet order and provided the resident with food that was not the appropriate consistency. Resident #1 choked on the food and became unresponsive. Resident #1 was sent out to the hospital and expired. One of three residents reviewed for mechanically altered diet. The findings included: The facility reported an allegation of neglect for Resident #1 by CNA #1 on 5/31/17. The description of the reportable incident indicated Resident #1 choked and was transferred to the emergency room by E[CONDITION]. Review of the facility's Five-Day Follow-Up Report dated 6/5/17 indicated at approximately 9:30 PM, CNA #1 was with Resident #1 in the north day room. CNA #1 brought a pimento cheese sandwich to the north day room. When CNA #1 left the room to obtain a thickened drink and a cloth cover for Resident #1, s/he placed the sandwich out of reach; however, Resident #1 was able to obtain the sandwich while CNA #1 was out of the room. Resident #1 had orders for a mechanical soft diet with pureed bread. When reentering the room, CNA #1 saw Resident #1 choking and called to the nurse for help. The nurse immediately entered the room and performed the [MEDICATION NAME] maneuver. E[CONDITION] arrived and Resident #1 was transported to the hospital. After review of the incident, it was determined that neglect was substantiated. Further review of the medical record revealed the Annual Minimum Data Set ((MDS) dated [DATE] coded Resident #1 as having a Brief Interview for Mental Status (BI[CONDITION]) score of 4. The Quarterly MDS dated [DATE] coded Resident #1 as having a BI[CONDITION] score of 5. The Annual MDS coded Resident #1 as independent with setup help only for eating. Review of the care plan revealed at risk for altered nutrition related to consuming a mechanically altered diet related to dysphagia was identified as a problem area. Interventions and approaches to this problem area were documented on the care plan and included to provide diet as ordered with resident food preferences as feasible and offer snacks per protocol. Review of Resident #1's May 2017 Physician order [REDACTED]. Review of the Diet Order and Communication form dated 7/14/16 revealed Resident #1's diet order was changed to mechanical soft, puree bread with nectar thick liquids related to chewing/swallowing problems. Review of the Nurses' Note dated 5/30/17 at 9:50 PM indicated the CNA summoned the nurse into the dayroom at 9:40 PM. Noted resident with food coming out of his/her mouth. No pulse or respirations noted. Writer cleaned out resident's mouth and removed a chunk of mashed up food. Abdominal thrust performed with pulse noted. Repositioned resident on right side and removed remainder of visible obstruction. Respirations shallow, MD in facility and at resident side. 911 called. Review of the Physician Telephone Orders revealed an order dated 5/30/17 to transfer the resident to the hospital for evaluation related to choking and change in level of consciousness. Licensed Practical Nurse (LPN) #1's facility-obtained statement indicated s/he was at the nurses' station charting and was called to come quick. Resident #1 was sitting in the geri chair. LPN #1 repositioned him/her to do abdominal thrust and sweep his/her mouth. Resident #1 was unresponsive and a code blue was called. In an interview with the surveyor on 6/12/17 at approximately 6:35 PM, LPN #1 stated that s/he was sitting at the desk charting. S/he heard someone yell out oh my God. There were two CNAs in the doorway of the dayroom when the LPN first looked up. CNA #1 said all s/he did was give the resident a sandwich. The resident's gerichair was in the center of the room when LPN #1 entered the dayroom, not close enough to the table for the resident to reach. LPN #1 went in and Resident #1 had some chewed up food coming out of his/her mouth. The resident looked ashen. LPN #1 went over and called the resident's name. S/he checked him/her for a pulse and s/he didn't feel a pulse. LPN #1 tried to sweep the resident's mouth out. Resident #1 was in the gerichair, LPN #1 did a couple of chest thrusts and they turned him/her over and did some thrusts in the back. S/he turned the resident back over and the resident groaned. LPN #1 felt a pulse. They placed the resident in the floor, other staff and the facility physician were in the room. LPN #1 had told a CNA to call 911. There were 3 other nurses and the physician in the dayroom. LPN #1 stepped out of the room to give 911 the information they requested. LPN #2 took over and was in the floor with the resident when LPN #1 went to talk with 911. LPN #1 went back in the dayroom at one point and they had a non-rebreather on the resident. LPN #1 stated Resident #1 was not able to get around with the gerichair. The resident was able to feed him/herself during mealtimes and snacks. In an interview with the surveyor on 6/12/17 at approximately 7:15 PM, the Director of Nursing (DON) stated s/he was not at the facility when the incident occurred. CNA #1 was going to give the resident a banana, but it was too hard. So s/he gave him/her a pimento cheese sandwich. CNA #1 said s/he removed the crust and was going to soak the sandwich in thickened liquids. CNA #1 went to the nutrition room. When s/he returned to the dayroom the resident already had the sandwich. The sandwich was left on the table. The CNA had already put the thickener on the bread, but s/he went to get the resident something to drink. The resident was on a mechanical soft diet with pureed bread. The DON stated it was not acceptable practice to put thickener on the bread to puree it. In an interview with the surveyor on 6/13/17 at approximately 1:25 PM, the speech therapist stated s/he never picked up Resident #1 for therapy because s/he wasn't appropriate for therapy because of his/her dementia and not being able to follow through with strategies or safety precautions him/herself. The speech therapist was walking by and Resident #1 was eating in the dayroom. The speech therapist noticed the resident was having trouble especially with the bread products on his/her tray. The speech therapist observed the resident for a few minutes and decided to downgrade his/her diet to mechanical soft with puree bread and nectar thick liquids. Previously the resident was on a mechanical soft diet with thin liquids. Resident #1 was coughing and clearing his/her throat a lot while the speech therapist observed him/her. The speech therapist observed Resident #1 during meals after changing the resident's diet and s/he was doing great with the diet change. The speech therapist stated adding thickened liquids to a sandwich would make the sandwich soggy and gummy. The speech therapist would not recommend that. CNA #1's facility-obtained statement indicated when snacks came out Resident #1 had a banana on the snack tray. The banana was too hard to chew. CNA #1 got the resident a pimento sandwich and removed the crust. CNA #1 went to get a nectar thick liquid and when s/he came back s/he noticed the resident was unresponsive. CNA #1 called LPN #1 and told him/her Resident #1 was choking. Review of the facility's investigation revealed a typed statement that indicated it was a phone interview with CNA #1 on 6/3/17. CNA #1 said s/he was in the day room with Resident #1 and asked if s/he wanted a snack and s/he said that s/he did. They were in the day room alone. CNA #1 went to the nourishment room and got Resident #1 a banana. Resident #1 said the banana was too hard for him/her to chew. CNA #1 then got up and pushed the resident back from the table. CNA #1 took the banana and went to the nourishment room and picked a pimento cheese sandwich as an alternative for Resident #1. CNA #1 unwrapped the sandwich and removed the crust. S/he added thickened liquid to the sandwich to mash it because the resident needed it to be mechanical soft. CNA #1 returned to the day room with the sandwich and placed it on the table in front of Resident #1. CNA #1 walked to the nourishment room to get a thickened drink for the resident and a cloth to cover him/her because s/he spilled food when s/he ate. CNA #1 said s/he was walking back to the dayroom and saw Resident #1 choking. S/he yelled to LPN #1 for help and went to help Resident #1. CNA #1 was asked if the resident ever grabbed food and s/he said yes. CNA #1 was asked how much of the sandwich Resident #1 had eaten and s/he said a little more than half. CNA #1 asked how Resident #1 was doing and was informed the resident had passed. In a telephone interview with the surveyor on 6/13/17 at approximately 1:45 PM, CNA #1 stated Resident #1 had a banana for a snack and s/he complained it was too hard. CNA #1 went and got the resident a pimento cheese sandwich and s/he softened it with nectar thick liquid and took the crust off and mashed it up. CNA #1 put it on the table and moved Resident #1 from the table to go get him/her a drink from the nourishment kitchen. When CNA #1 got back to the dayroom the resident had moved him/herself to the table and gotten the sandwich. CNA #1 stated the resident could move the chair as far as s/he wanted. CNA #1 stated s/he was assigned to the resident the majority of the time. CNA #1 stated s/he had not given the resident a sandwich with thickened liquids before. There were no other staff or residents in the dayroom when CNA #1 left the resident there. CNA #1 stated s/he knew the resident was on a mechanical soft diet but didn't know s/he needed pureed bread. CNA #1 stated they probably have that information in the chart, s/he stated s/he doesn't look at the resident's chart because of HIPPA. CNA #1 stated s/he thinks there is a book at the nurses' station that has information on resident care. CNA #1 stated s/he looks at those sometime, like if s/he has a new admission. CNA #1 stated s/he worked at the facility for 4-5 years prior to the incident. Review of the facility's Aspiration Precautions Guidelines revealed choking precautions are interventions to reduce the risk of aspirating on food, liquids, and/or secretions during the swallowing process into the trachea and lungs. Every precaution should be communicated to all staff, including follow prescribed diet including correct texture and liquids. Review of the facility's Diet and Nutrition Care Manual revealed pureed foods are generally cohesive, moist mashed potato or pudding-like consistency for people who cannot tolerate regular or mechanical soft foods. Food is pureed in a food processor to achieve a consistent smooth and easy-to-swallow product. Plan of Correction: Allegation of Compliance 6/2/2017 On 5/30/17 at 9:40 PM, Resident #1 was noted by assigned Licensed Nurse to have food visibly coming out of mouth and was without pulse or respirations. Immediate treatment of [REDACTED]. The physician of record was present in the facility at the time of incident and ordered oxygen to be administered via non-rebreather mask and immediate transport to Providence Northeast Hospital for evaluation and treatment. Emergency medical services initiated immediately and resident exited facility at 9:48 PM. Facility Licensed Nurse notified resident's responsible party via telephone on 5/30/17 at 9:55 PM. An immediate investigation of the incident was initiated by the facility leadership. The identified employee that was determined to have provided the food product was suspended on 5/31/17 and subsequently terminated from the facility on 6/7/17. Residents in the facility with mechanically altered diets have the potential to be affected by this alleged deficient practice. The facility contracted Registered Dietitian has reviewed facility residents with orders for mechanically altered diets to validate accuracy with corresponding tray card. This was completed on 5/31/17. All concerns were addressed at time of discovery. The facility Director of Nursing has re-educated the facility nursing department staff on following mechanically altered diets. The facility Speech Therapist has re-educated facility nursing department staff on utilizing the Matrix system to identify resident diets, confirming resident diets with tray cards during meal service and the specific textures of mechanically altered diets in relation to snacks. This re-education included specific information on consistency of solids and thickness of the different liquids, as well as the clinical reasons for mechanically altered diets and snacks such as inability to chew and/or safely swallow different consistencies. This re-education also included the process on how to verify the ordered diet prior to providing any resident a meal or snack and to inform a Licensed Nurse should staff observe any signs of aspiration, such as runny nose, watery eyes or cough during the consumption of a food product or if a resident is refusing the provided food item of their specific mechanically altered diet, to validate with a Licensed Nurse, Speech Therapist or Dietary Manager that any substituted item is safe for consumption under that resident's ordered mechanically altered diet. This re-education was completed on 6/2/17. Any facility nursing department staff not receiving this re-education on this date will receive prior to next scheduled shift. This information will be present in new hire orientation. The facility Director of Nursing will monitor residents with mechanically altered diets for accuracy of tray cards and provided snacks 5 times per week for 2 weeks, 3 times per week for 2 weeks, then weekly for 2 months. Results of the monitoring will be presented to the Quality Assurance Performance Improvement (QAPI) Committee for a period of 3 months or until substantial compliance is achieved and maintained. Any areas of concern identified will be addressed at time of discovery. Observations, interviews, and review of policies revealed the plan of correction developed by the facility on 5/31/2017 had been implemented and was in practice removing the deficient practice. Facility nursing staff had been educated and was knowledgeable of the policy. The Administrator was informed of this on 6/14/2017. The Immediate Jeopardy at Past Noncompliance at F-365 was corrected as of 6/2/2017.

Based on review of facility files and interview, the facility failed to ensure each resident's environment remained as free from accident hazards as possible. Certified Nurse Aide (CNA) #1 did not follow Resident #1's diet order and provided the resident with food that was not the appropriate consistency. Resident #1 was left unattended, choked on the food and became unresponsive. Resident #1 was sent out to the hospital and expired. One of one residents reviewed for accidents/hazards. The findings included: The facility reported an allegation of neglect for Resident #1 by CNA #1 on [DATE]. The description of the reportable incident indicated Resident #1 choked and was transferred to the emergency room by E[CONDITION]. Review of the facility's Five-Day Follow-Up Report dated [DATE] indicated at approximately 9:30 PM, CNA #1 was with Resident #1 in the north day room. CNA #1 brought a pimento cheese sandwich to the north day room. When CNA #1 left the room to obtain a thickened drink and a cloth cover for Resident #1, s/he placed the sandwich out of reach; however, Resident #1 was able to obtain the sandwich while CNA #1 was out of the room. Resident #1 had orders for a mechanical soft diet with pureed bread. When reentering the room, CNA #1 saw Resident #1 choking and called to the nurse for help. The nurse immediately entered the room and performed the Heimlich maneuver. E[CONDITION] arrived and Resident #1 was transported to the hospital. After review of the incident, it was determined that neglect was substantiated. Further review of the medical record revealed the Annual Minimum Data Set ((MDS) dated [DATE] coded Resident #1 as having a Brief Interview for Mental Status (BI[CONDITION]) score of 4. The Quarterly MDS dated [DATE] coded Resident #1 as having a BI[CONDITION] score of 5. The Annual MDS coded Resident #1 as independent with setup help only for eating. Review of the care plan revealed at risk for altered nutrition related to consuming a mechanically altered diet related to dysphagia was identified as a problem area. Interventions and approaches to this problem area were documented on the care plan and included to provide diet as ordered with resident food preferences as feasible and offer snacks per protocol. Review of Resident #1's [DATE] Physician order [REDACTED]. Review of the Diet Order and Communication form dated [DATE] revealed Resident #1's diet order was changed to mechanical soft, puree bread with nectar thick liquids related to chewing/swallowing problems. Review of the Nurses' Note dated [DATE] at 9:50 PM indicated the CNA summoned the nurse into the dayroom at 9:40 PM. Noted resident with food coming out of his/her mouth. No pulse or respirations noted. Writer cleaned out resident's mouth and removed a chunk of mashed up food. Abdominal thrust performed with pulse noted. Repositioned resident on right side and removed remainder of visible obstruction. Respirations shallow, MD in facility and at resident side. 911 called. Review of the Physician Telephone Orders revealed an order dated [DATE] to transfer the resident to the hospital for evaluation related to choking and change in level of consciousness. Licensed Practical Nurse (LPN) #1's facility-obtained statement indicated s/he was at the nurses' station charting and was called to come quick. Resident #1 was sitting in the geri chair. LPN #1 repositioned him/her to do abdominal thrust and sweep his/her mouth. Resident #1 was unresponsive and a code blue was called. In an interview with the surveyor on [DATE] at approximately 6:35 PM, LPN #1 stated that s/he was sitting at the desk charting. S/he heard someone yell out oh my God. There were two CNAs in the doorway of the dayroom when the LPN first looked up. CNA #1 said all s/he did was give the resident a sandwich. The resident's gerichair was in the center of the room when LPN #1 entered the dayroom, not close enough to the table for the resident to reach. LPN #1 went in and Resident #1 had some chewed up food coming out of his/her mouth. The resident looked ashen. LPN #1 went over and called the resident's name. S/he checked him/her for a pulse and s/he didn't feel a pulse. LPN #1 tried to sweep the resident's mouth out. Resident #1 was in the gerichair, LPN #1 did a couple of chest thrusts and they turned him/her over and did some thrusts in the back. S/he turned the resident back over and the resident groaned. LPN #1 felt a pulse. They placed the resident in the floor, other staff and the facility physician were in the room. LPN #1 had told a CNA to call 911. There were 3 other nurses and the physician in the dayroom. LPN #1 stepped out of the room to give 911 the information they requested. LPN #2 took over and was in the floor with the resident when LPN #1 went to talk with 911. LPN #1 went back in the dayroom at one point and they had a non-rebreather on the resident. LPN #1 stated Resident #1 was not able to get around with the gerichair. The resident was able to feed him/herself during mealtimes and snacks. In an interview with the surveyor on [DATE] at approximately 6:50 PM, LPN #2 stated s/he went into the room and asked LPN #1 if Resident #1 was breathing. LPN #1 said yes, they put him/her on the floor. Another nurse came down and put a rebreathing mask on the resident. The physician came down to the dayroom. LPN #1 had left to talk to 911. E[CONDITION] came and took the resident out. In an interview with the surveyor on [DATE] at approximately 7:15 PM, the Director of Nursing (DON) stated s/he was not at the facility when the incident occurred. CNA #1 was going to give the resident a banana, but it was too hard. So s/he gave him/her a pimento cheese sandwich. CNA #1 said s/he removed the crust and was going to soak the sandwich in thickened liquids. CNA #1 went to the nutrition room. When s/he returned to the dayroom the resident already had the sandwich. The sandwich was left on the table. The CNA had already put the thickener on the bread, but s/he went to get the resident something to drink. The resident was on a mechanical soft diet with pureed bread. The DON stated it was not acceptable practice to put thickener on the bread to puree it. In an interview with the surveyor on [DATE] at approximately 1:25 PM, the speech therapist stated s/he never picked up Resident #1 for therapy because s/he wasn't appropriate for therapy because of his/her dementia and not being able to follow through with strategies or safety precautions him/herself. The speech therapist was walking by and Resident #1 was eating in the dayroom. The speech therapist noticed the resident was having trouble especially with the bread products on his/her tray. The speech therapist observed the resident for a few minutes and decided to downgrade his/her diet to mechanical soft with puree bread and nectar thick liquids. Previously the resident was on a mechanical soft diet with thin liquids. Resident #1 was coughing and clearing his/her throat a lot while the speech therapist observed him/her. The speech therapist observed Resident #1 during meals after changing the resident's diet and s/he was doing great with the diet change. The speech therapist stated adding thickened liquids to a sandwich would make the sandwich soggy and gummy. The speech therapist would not recommend that. CNA #1's facility-obtained statement indicated when snacks came out Resident #1 had a banana on the snack tray. The banana was too hard to chew. CNA #1 got the resident a pimento sandwich and removed the crust. CNA #1 went to get a nectar thick liquid and when s/he came back s/he noticed the resident was unresponsive. CNA #1 called LPN #1 and told him/her Resident #1 was choking. Review of the facility's investigation revealed a typed statement that indicated it was a phone interview with CNA #1 on [DATE]. CNA #1 said s/he was in the day room with Resident #1 and asked if s/he wanted a snack and s/he said that s/he did. They were in the day room alone. CNA #1 went to the nourishment room and got Resident #1 a banana. Resident #1 said the banana was too hard for him/her to chew. CNA #1 then got up and pushed the resident back from the table. CNA #1 took the banana and went to the nourishment room and picked a pimento cheese sandwich as an alternative for Resident #1. CNA #1 unwrapped the sandwich and removed the crust. S/he added thickened liquid to the sandwich to mash it because the resident needed it to be mechanical soft. CNA #1 returned to the day room with the sandwich and placed it on the table in front of Resident #1. CNA #1 walked to the nourishment room to get a thickened drink for the resident and a cloth to cover him/her because s/he spilled food when s/he ate. CNA #1 said s/he was walking back to the dayroom and saw Resident #1 choking. S/he yelled to LPN #1 for help and went to help Resident #1. CNA #1 was asked if the resident ever grabbed food and s/he said yes. CNA #1 was asked how much of the sandwich Resident #1 had eaten and s/he said a little more than half. CNA #1 asked how Resident #1 was doing and was informed the resident had passed. In a telephone interview with the surveyor on [DATE] at approximately 1:45 PM, CNA #1 stated Resident #1 had a banana for a snack and s/he complained it was too hard. CNA #1 went and got the resident a pimento cheese sandwich and s/he softened it with nectar thick liquid and took the crust off and mashed it up. CNA #1 put it on the table and moved Resident #1 from the table to go get him/her a drink from the nourishment kitchen. When CNA #1 got back to the dayroom the resident had moved him/herself to the table and gotten the sandwich. CNA #1 stated the resident could move the chair as far as s/he wanted. CNA #1 stated s/he was assigned to the resident the majority of the time. CNA #1 stated s/he had not given the resident a sandwich with thickened liquids before. There were no other staff or residents in the dayroom when CNA #1 left the resident there. CNA #1 stated s/he knew the resident was on a mechanical soft diet but didn't know s/he needed pureed bread. CNA #1 stated they probably have that information in the chart, s/he stated s/he doesn't look at the resident's chart because of HIPPA. CNA #1 stated s/he thinks there is a book at the nurses' station that has information on resident care. CNA #1 stated s/he looks at those sometime, like if s/he has a new admission. CNA #1 stated s/he worked at the facility for ,[DATE] years prior to the incident. In an interview with the surveyor on [DATE] at approximately 2:15 PM, the administrator stated around 9:30 PM CNA #1 had the resident in the dayroom on the North Unit, s/he got him/her a banana and the resident said it was too hard. CNA #1 went and got the resident a pimento cheese sandwich and said s/he put nectar thick liquid on the sandwich to soften it up. CNA #1 put the sandwich on the table in the dayroom and went to get the resident a drink and a covering. CNA #1 stated the resident was not near the table. When s/he returned the resident had scooted to the table and got the sandwich. Resident #1 had eaten about half the sandwich and was choking when s/he returned. The CNA #1 called the nurse and they called a code blue. The resident had his/her mouth full. Review of the facility's Aspiration Precautions Guidelines revealed choking precautions are interventions to reduce the risk of aspirating on food, liquids, and/or secretions during the swallowing process into the trachea and lungs. Every precaution should be communicated to all staff, including follow prescribed diet including correct texture and liquids. Review of the facility's Diet and Nutrition Care Manual revealed pureed foods are generally cohesive, moist mashed potato or pudding-like consistency for people who cannot tolerate regular or mechanical soft foods. Food is pureed in a food processor to achieve a consistent smooth and easy-to-swallow product. Review of the facility's Abuse, Neglect and Misappropriation of Property policy revealed the facility prohibits neglect. Neglect is the failure of the facility, its 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. The policy also indicated in the event an employee is accused of abuse/neglect, that employee will be suspended during the investigation process. Review of CNA #1's Timecard revealed s/he worked [DATE] from 2:58 PM until 11:03 PM. CNA #1 was suspended [DATE], did not return to the facility and was terminated [DATE]. Plan of Correction: Allegation of Compliance [DATE] On [DATE] at 9:40 PM, Resident #1 was noted by assigned Licensed Nurse to have food visibly coming out of mouth and was without pulse or respirations. Immediate treatment of [REDACTED]. The physician of record was present in the facility at the time of incident and ordered oxygen to be administered via non-rebreather mask and immediate transport to Providence Northeast Hospital for evaluation and treatment. Emergency medical services initiated immediately and resident exited facility at 9:48 PM. Facility Licensed Nurse notified resident's responsible party via telephone on [DATE] at 9:55 PM. An immediate investigation of the incident was initiated by the facility leadership. The identified employee that was determined to have provided the food product was suspended on [DATE] and subsequently terminated from the facility on [DATE]. Residents in the facility with mechanically altered diets have the potential to be affected by this alleged deficient practice. The facility contracted Registered Dietitian has reviewed facility residents with orders for mechanically altered diets to validate accuracy with corresponding tray card. This was completed on [DATE]. All concerns were addressed at time of discovery. The facility Director of Nursing has re-educated the facility nursing department staff on following mechanically altered diets. The facility Speech Therapist has re-educated facility nursing department staff on utilizing the Matrix system to identify resident diets, confirming resident diets with tray cards during meal service and the specific textures of mechanically altered diets in relation to snacks. This re-education included specific information on consistency of solids and thickness of the different liquids, as well as the clinical reasons for mechanically altered diets and snacks such as inability to chew and/or safely swallow different consistencies. This re-education also included the process on how to verify the ordered diet prior to providing any resident a meal or snack and to inform a Licensed Nurse should staff observe any signs of aspiration, such as runny nose, watery eyes or cough during the consumption of a food product or if a resident is refusing the provided food item of their specific mechanically altered diet, to validate with a Licensed Nurse, Speech Therapist or Dietary Manager that any substituted item is safe for consumption under that resident's ordered mechanically altered diet. This re-education was completed on [DATE]. Any facility nursing department staff not receiving this re-education on this date will receive prior to next scheduled shift. This information will be present in new hire orientation. The facility Director of Nursing will monitor residents with mechanically altered diets for accuracy of tray cards and provided snacks 5 times per week for 2 weeks, 3 times per week for 2 weeks, then weekly for 2 months. Results of the monitoring will be presented to the Quality Assurance Performance Improvement (QAPI) Committee for a period of 3 months or until substantial compliance is achieved and maintained. Any areas of concern identified will be addressed at time of discovery. Observations, interviews, and review of policies revealed the plan of correction developed by the facility on [DATE] had been implemented and was in practice removing the deficient practice. Facility nursing staff had been educated and was knowledgeable of the policy. The Administrator was informed of this on [DATE]. The Immediate Jeopardy and/or Substandard Quality of Care at Past Noncompliance at F-323 was corrected as of [DATE].

Based on review of facility files and interview, the facility failed to ensure each resident was free from neglect. Certified Nurse Aide (CNA) #1 did not follow Resident #1's diet order and provided the resident with food that was not the appropriate consistency. Resident #1 choked on the food and became unresponsive. Resident #1 was sent out to the hospital and expired. One of three residents reviewed for abuse/ neglect. The findings included: The facility reported an allegation of neglect for Resident #1 by CNA #1 on [DATE]. The description of the reportable incident indicated Resident #1 choked and was transferred to the emergency room by E[CONDITION] (emergency medical service). Review of the facility's Five-Day Follow-Up Report dated [DATE] indicated at approximately 9:30 PM, CNA #1 was with Resident #1 in the north day room. CNA #1 brought a pimento cheese sandwich to the north day room. When CNA #1 left the room to obtain a thickened drink and a cloth cover for Resident #1, s/he placed the sandwich out of reach; however, Resident #1 was able to obtain the sandwich while CNA #1 was out of the room. Resident #1 had orders for a mechanical soft diet with pureed bread. When reentering the room, CNA #1 saw Resident #1 choking and called to the nurse for help. The nurse immediately entered the room and performed the [MEDICATION NAME] maneuver. E[CONDITION] arrived and Resident #1 was transported to the hospital. After review of the incident, it was determined that neglect was substantiated. Further review of the medical record revealed the Annual Minimum Data Set ((MDS) dated [DATE] coded Resident #1 as having a Brief Interview for Mental Status (BI[CONDITION]) score of 4. The Quarterly MDS dated [DATE] coded Resident #1 as having a BI[CONDITION] score of 5. The Annual MDS coded Resident #1 as independent with setup help only for eating. Review of the care plan revealed at risk for altered nutrition related to consuming a mechanically altered diet related to dysphagia was identified as a problem area. Interventions and approaches to this problem area were documented on the care plan and included to provide diet as ordered with resident food preferences as feasible and offer snacks per protocol. Review of Resident #1's [DATE] Physician order [REDACTED]. Review of the Diet Order and Communication form dated [DATE] revealed Resident #1's diet order was changed to mechanical soft, puree bread with nectar thick liquids related to chewing/swallowing problems. Review of the Psychiatrist Progress Note for visit on [DATE] revealed the resident was currently stable and calm without overt [MEDICAL CONDITION] and no behaviors noted by staff. Review of the Nurses' Note dated [DATE] at 9:50 PM indicated CNA#1 summoned the nurse into the dayroom at 9:40 PM. Noted resident with food coming out of his/her mouth. No pulse or respirations noted. Writer cleaned out resident's mouth and removed a chunk of mashed up food. Abdominal thrust performed with pulse noted. Repositioned resident on right side and removed remainder of visible obstruction. Respirations shallow, MD in facility and at resident side. 911 called. Review of the Physician Telephone Orders revealed an order dated [DATE] to transfer the resident to the hospital for evaluation related to choking and change in level of consciousness. LPN #1's facility-obtained statement indicated s/he was at the nurses' station charting and was called to come quick. Resident #1 was sitting in the geri chair. LPN #1 repositioned him/her to do abdominal thrust and sweep his/her mouth. Resident #1 was unresponsive and a code blue was called. In an interview with the surveyor on [DATE] at approximately 6:35 PM, LPN #1 stated that s/he was sitting at the desk charting. S/he heard someone yell out oh my God. There were two CNAs in the doorway of the dayroom when the LPN first looked up. CNA #1 said all s/he did was give the resident a sandwich. The resident's gerichair was in the center of the room when LPN #1 entered the dayroom, not close enough to the table for the resident to reach. LPN #1 went in and Resident #1 had some chewed up food coming out of his/her mouth. The resident looked ashen. LPN #1 went over and called the resident's name. S/he checked him/her for a pulse and s/he didn't feel a pulse. LPN #1 tried to sweep the resident's mouth out. Resident #1 was in the gerichair, LPN #1 did a couple of chest thrusts and they turned him/her over and did some thrusts in the back. S/he turned the resident back over and the resident groaned. LPN #1 felt a pulse. They placed the resident in the floor, other staff and the facility physician were in the room. LPN #1 told a CNA to call 911. There were 3 other nurses and the physician in the dayroom. LPN #1 stepped out of the room to give 911 the information they requested. LPN #2 took over and was in the floor with the resident when LPN #1 went to talk with 911. LPN #1 went back in the dayroom at one point and they had a non-rebreather on the resident. LPN #1 stated Resident #1 was not able to get around with the gerichair. The resident was able to feed him/herself during mealtimes and snacks. In an interview with the surveyor on [DATE] at approximately 6:50 PM, LPN #2 stated s/he went into the room and asked LPN #1 if Resident #1 was breathing. LPN #1 said yes, they put him/her on the floor. Another nurse came down and put a rebreathing mask on the resident. The physician came down to the dayroom. LPN #1 had left to talk to 911. E[CONDITION] came and took the resident out. In an interview with the surveyor on [DATE] at approximately 7:15 PM, the Director of Nursing (DON) stated s/he was not at the facility when the incident occurred. CNA #1 was going to give the resident a banana, but it was too hard. So s/he gave him/her a pimento cheese sandwich. CNA #1 said s/he removed the crust and was going to soak the sandwich in thickened liquids. CNA #1 went to the nutrition room. When s/he returned to the dayroom the resident already had the sandwich. The sandwich was left on the table. The CNA had already put the thickener on the bread, but s/he went to get the resident something to drink. The resident was on a mechanical soft diet with pureed bread. The DON stated it was not acceptable practice to put thickener on the bread to puree it. In an interview with the surveyor on [DATE] at approximately 1:25 PM, the speech therapist stated s/he never picked up Resident #1 for therapy because s/he wasn't appropriate for therapy because of his/her dementia and not being able to follow through with strategies or safety precautions him/herself. The speech therapist was walking by and Resident #1 was eating in the dayroom. The speech therapist noticed the resident was having trouble especially with the bread products on his/her tray. The speech therapist observed the resident for a few minutes and decided to downgrade his/her diet to mechanical soft with puree bread and nectar thick liquids. Previously the resident was on a mechanical soft diet with thin liquids. Resident #1 was coughing and clearing his/her throat a lot while the speech therapist observed him/her. The speech therapist observed Resident #1 during meals after changing the resident's diet and s/he was doing great with the diet change. The speech therapist stated adding thickened liquids to a sandwich would make the sandwich soggy and gummy. The speech therapist would not recommend that. CNA #1's facility-obtained statement indicated when snacks came out Resident #1 had a banana on the snack tray. The banana was too hard to chew. CNA #1 got the resident a pimento sandwich and removed the crust. CNA #1 went to get a nectar thick liquid and when s/he came back s/he noticed the resident was unresponsive. CNA #1 called LPN #1 and told him/her Resident #1 was choking. Review of the facility's investigation revealed a typed statement that indicated it was a phone interview with CNA #1 on [DATE]. CNA #1 said s/he was in the day room with Resident #1 and asked if s/he wanted a snack and s/he said that s/he did. They were in the day room alone. CNA #1 went to the nourishment room and got Resident #1 a banana. Resident #1 said the banana was too hard for him/her to chew. CNA #1 then got up and pushed the resident back from the table. CNA #1 took the banana and went to the nourishment room and picked a pimento cheese sandwich as an alternative for Resident #1. CNA #1 unwrapped the sandwich and removed the crust. S/he added thickened liquid to the sandwich to mash it because the resident needed it to be mechanical soft. CNA #1 returned to the day room with the sandwich and placed it on the table in front of Resident #1. CNA #1 walked to the nourishment room to get a thickened drink for the resident and a cloth to cover him/her because s/he spilled food when s/he ate. CNA #1 said s/he was walking back to the dayroom and saw Resident #1 choking. S/he yelled to LPN #1 for help and went to help Resident #1. CNA #1 was asked if the resident ever grabbed food and s/he said yes. CNA #1 was asked how much of the sandwich Resident #1 had eaten and s/he said a little more than half. CNA #1 asked how Resident #1 was doing and was informed the resident had passed. In a telephone interview with the surveyor on [DATE] at approximately 1:45 PM, CNA #1 stated Resident #1 had a banana for a snack and s/he complained it was too hard. CNA #1 went and got the resident a pimento cheese sandwich and s/he softened it with nectar thick liquid and took the crust off and mashed it up. CNA #1 put it on the table and moved Resident #1 from the table to go get him/her a drink from the nourishment kitchen. When CNA #1 got back to the dayroom the resident had moved him/herself to the table and gotten the sandwich. CNA #1 stated the resident could move the chair as far as s/he wanted. CNA #1 stated s/he was assigned to the resident the majority of the time. CNA #1 stated s/he had not given the resident a sandwich with thickened liquids before. There were no other staff or residents in the dayroom when CNA #1 left the resident there. CNA #1 stated s/he knew the resident was on a mechanical soft diet but didn't know s/he needed pureed bread. CNA #1 stated they probably have that information in the chart, s/he stated s/he doesn't look at the resident's chart because of HIPPA. CNA #1 stated s/he thinks there is a book at the nurses' station that has information on resident care. CNA #1 stated s/he looks at those sometime, like if s/he has a new admission. CNA #1 stated s/he worked at the facility for ,[DATE] years prior to the incident. In an interview with the surveyor on [DATE] at approximately 2:15 PM, the administrator stated around 9:30 PM CNA #1 had the resident in the dayroom on the North Unit, s/he got him/her a banana and the resident said it was too hard. CNA #1 went and got the resident a pimento cheese sandwich and said s/he put nectar thick liquid on the sandwich to soften it up. CNA #1 put the sandwich on the table in the dayroom and went to get the resident a drink and a covering. CNA #1 stated the resident was not near the table. When s/he returned the resident had scooted to the table and got the sandwich. Resident #1 had eaten about half the sandwich and was choking when s/he returned. The CNA #1 called the nurse and they called a code blue. The resident had his/her mouth full. Review of the facility's Aspiration Precautions Guidelines revealed choking precautions are interventions to reduce the risk of aspirating on food, liquids, and/or secretions during the swallowing process into the trachea and lungs. Every precaution should be communicated to all staff, including follow prescribed diet including correct texture and liquids. Review of the facility's Diet and Nutrition Care Manual revealed pureed foods are generally cohesive, moist mashed potato or pudding-like consistency for people who cannot tolerate regular or mechanical soft foods. Food is pureed in a food processor to achieve a consistent smooth and easy-to-swallow product. Review of the facility's Abuse, Neglect and Misappropriation of Property policy revealed the facility prohibits neglect. Neglect is the failure of the facility, its 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. The policy also indicated in the event an employee is accused of abuse/neglect, that employee will be suspended during the investigation process. Review of CNA #1's Timecard revealed s/he worked [DATE] from 2:58 PM until 11:03 PM. CNA #1 was suspended on [DATE] and did not return to work; s/he was terminated [DATE]. Plan of Correction: Allegation of Compliance [DATE] On [DATE] at 9:40 PM, Resident #1 was noted by assigned Licensed Nurse to have food visibly coming out of mouth and was without pulse or respirations. Immediate treatment of [REDACTED]. The physician of record was present in the facility at the time of incident and ordered oxygen to be administered via non-rebreather mask and immediate transport to Providence Northeast Hospital for evaluation and treatment. Emergency medical services initiated immediately and resident exited facility at 9:48 PM. Facility Licensed Nurse notified resident's responsible party via telephone on [DATE] at 9:55 PM. An immediate investigation of the incident was initiated by the facility leadership. The identified employee that was determined to have provided the food product was suspended on [DATE] and subsequently terminated from the facility on [DATE]. Residents in the facility with mechanically altered diets have the potential to be affected by this alleged deficient practice. The facility contracted Registered Dietitian has reviewed facility residents with orders for mechanically altered diets to validate accuracy with corresponding tray card. This was completed on [DATE]. All concerns were addressed at time of discovery. The facility Director of Nursing has re-educated the facility nursing department staff on following mechanically altered diets. The facility Speech Therapist has re-educated facility nursing department staff on utilizing the Matrix system to identify resident diets, confirming resident diets with tray cards during meal service and the specific textures of mechanically altered diets in relation to snacks. This re-education included specific information on consistency of solids and thickness of the different liquids, as well as the clinical reasons for mechanically altered diets and snacks such as inability to chew and/or safely swallow different consistencies. This re-education also included the process on how to verify the ordered diet prior to providing any resident a meal or snack and to inform a Licensed Nurse should staff observe any signs of aspiration, such as runny nose, watery eyes or cough during the consumption of a food product or if a resident is refusing the provided food item of their specific mechanically altered diet, to validate with a Licensed Nurse, Speech Therapist or Dietary Manager that any substituted item is safe for consumption under that resident's ordered mechanically altered diet. This re-education was completed on [DATE]. Any facility nursing department staff not receiving this re-education on this date will receive prior to next scheduled shift. This information will be present in new hire orientation. The facility Director of Nursing will monitor residents with mechanically altered diets for accuracy of tray cards and provided snacks 5 times per week for 2 weeks, 3 times per week for 2 weeks, then weekly for 2 months. Results of the monitoring will be presented to the Quality Assurance Performance Improvement (QAPI) Committee for a period of 3 months or until substantial compliance is achieved and maintained. Any areas of concern identified will be addressed at time of discovery. Observations, interviews, and review of policies revealed the plan of correction developed by the facility on [DATE] had been implemented and was in practice removing the deficient practice. Facility nursing staff had been educated and was knowledgeable of the policy. The Administrator was informed of this on [DATE]. The Immediate Jeopardy and/or Substandard Quality of Care at Past Noncompliance at F-224 was corrected as of [DATE].

On the days of the complaint inspection, based on record reviews, observation, and interview the facility staff (Licensed Practical Nurse (LPN) #2 and #3 failed to inform the resident's physicians of the families concern that Resident #2's right leg was swollen and they were concern that the resident had a [MEDICAL CONDITION]; failed to notify the resident/ resident's physician that Resident #3 had an open area on her/his sacral area, 2 of 5 resident's reviewed for notification. The findings included: Resident #2 was sampled as a result of a facility reported incident that stated, the resident .has a history of [MEDICAL CONDITION] ([MEDICAL CONDITION]. Daughter reported to a Charge Nurse that s/he felt her/his mother was developing another [MEDICAL CONDITION]. The Charge Nurse stated s/he would inform the Dr., but forgot to do so. One week later Dr. was notified and Doppler Study confirmed a [MEDICAL CONDITION]. Resident has suffered no ill effects and is currently being treated for [REDACTED]. Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the facility investigation indicated that Licensed Practical Nurse (LPN) #3 was given a warning and inserviced about not calling the doctor immediately when the family reported a possible [MEDICAL CONDITIONS]. No other staff was identified in the incident report. Review of the Daily Skilled Nurse's Notes from 02/03 - 03/06/2017 revealed a note dated 02/24/2017 that stated, Alert oriented to name surroundings. Blood sugar 4:30 PM 245 and 209 @ 9:00 PM - skin warm and dry. New order to increase [MEDICATION NAME] to 48 units @ HS (hour of sleep) noted and administered. Attempt to call dtr (daughter) - phone not working. Niece in and updated on new order. I'll tell my mom. Family concerned with pedal [MEDICAL CONDITION] and request need for TED hose. Message left for M.D. There was no assessments noted regarding the resident's [MEDICAL CONDITION] The note was signed by LPN #2. On 02/28/2017 at 6:25 PM the next note regarding the families concerns stated, spoke with RP. regarding concerns r/t (related to) res (residents) RLE (right lower extremity) [MEDICAL CONDITION]. NP (nurse practitioner) in facility and made aware. NP assessed res with NO (new order) written: RLE swelling and pain please get Doppler Study (venous). Review of the Physician's Problem Log dated 02/24/2017 stated Family wants order for TED hose. Review of the physician's orders [REDACTED]. On 02/28/2017 an order was written that stated, RLE (right lower extremity) swelling and pain please get doppler study. Review of the Ultrasound Report dated 03/01/2017 stated, Ven Doppler Extrem/LIM, right. Impression: [MEDICAL CONDITION] involving the common femoral, profundus, superficial femoral, and popliteal veins. In an interview with the surveyor on 06/13/2017 at 10:45 AM Licensed Practical Nurse #1 stated that s/he was not sure when the family member told him/her about their concern that Resident #3 had a blood clot. S/he stated, I saw Resident #2's leg, it was swollen. I told the family I would forward to the doctor. I would put in doctor's book. LPN #3 confirmed that s/he forgot to let the doctor know about the families concerns and failed to chart the families concerns. Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set ((MDS) dated [DATE] indicated the resident had a brief interview of mental status (BI[CONDITION]) of 15; her/his speech was clear, understood and understandable. S/he required a two person assist for transfer/mobility. S/he used a wheelchair to ambulate. S/he was occasionally incontinent of bowel/bladder. S/he was care planned for being at risk to develop a pressure ulcer. Review of the Nursing Data Collection Tool (Admission Collection Tool) dated 03/03/2017 revealed no problems with the resident's skin; it was noted as warm and dry. Review of the Braden Scale For Predicting Pressure Sore Risk dated 03/08/2017 scored the resident at 16 indicating s/he was at risk. Review of the Interim Plan of Care dated 03/08/2017 indicated the resident was at risk for pressure ulcers with interventions that included turn and reposition, inspect skin according to facility protocol, and incontinent care. Review of the first shift (7 AM-3 PM) CNA (certified nurse aide) Daily Skin Inspection Record for March 2017 indicated that on March 14 and 18, 2017 the resident had an open area on her sacrum. The inspection for March 15, 16, and 17, 2017 were initialed as done but no information related to the site (redness, rash, bruise, open area, dressing) was provided. A skin diagram showed an open area on the resident sacrum. Review of the Daily Skilled Nurse's Notes from 03/03 thru 03/18/2017 revealed a noted dated 03/15/2017 at 1045 PM that stated, Resident c/o (complained of) pain near rectum. Resident has quarter size open area to gluteal cleft. Base is pink, surrounding skin is normal. Barrier cream applied and resident positioned to (R) (right) side for comfort. This is not new wound care nurse was notified when area was new. Review of physician's orders [REDACTED]. Review of Resident #3 Discharge Summary dated 03/18/2017 revealed no information about a pressure ulcer, the wound care/treatments orders had no treatments. The physician's discharge summary noted the resident's skin had no rashes or skin breakdown. In an interview with the surveyor on 06/13/2017 at approximately 11:45 AM the wound nurse stated after reviewing the chart that s/he was not the wound nurse when this happened. S/he confirmed that the documentation indicated that the resident had something going on with her/his skin and s/he didn't see any notes from the wound nurse. In an interview with the surveyor on 06/13/2017 at 1:05 PM the Director of Medical Records stated there were no other notes related to the resident's skin care.

Based on record reviews, interview, and review of the professional resource, Perry/Potter Clinical Nursing Skills and Techniques 8th Edition, chapter 26, Documentation and Informatics, the facility nursing staff (Licensed Practical Nurse #2 and #3) failed to follow professional standards of nursing practice related to the assessment of Resident #2 swollen right leg and the families concern that resident had a [MEDICAL CONDITION]; documentation of the date the pressure sore dressings for Residents #4 and #5 (3 of 5 residents sampled for professional standards). The findings included: Resident #2 was sampled as a result of a facility reported incident that stated, the resident .has a history of [MEDICAL CONDITION] ([MEDICAL CONDITION]. Daughter reported to a Charge Nurse that s/he felt her/his mother was developing another [MEDICAL CONDITION]. The Charge Nurse stated s/he would inform the Dr., but forgot to do so. One week later Dr. was notified and Doppler Study confirmed a [MEDICAL CONDITION]. Resident has suffered no ill effects and is currently being treated for [REDACTED]. Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the facility investigation indicated that Licensed Practical Nurse (LPN) #3 was given a warning and inserviced about not calling the doctor immediately when the family reported a possible [MEDICAL CONDITIONS]. No other staff was identified in the incident report. Review of the Daily Skilled Nurse's Notes from 02/03 - 03/06/2017 revealed a note dated 02/24/2017 that stated, Alert oriented to name surroundings. Blood sugar 4:30 PM 245 and 209 @ 9:00 PM - skin warm and dry. New order to increase [MEDICATION NAME] to 48 units @ HS (hour of sleep) noted and administered. Attempt to call dtr (daughter) - phone not working. Niece in and updated on new order. I'll tell my mom. Family concerned with pedal [MEDICAL CONDITION] and request need for TED hose. Message left for M.D. There was no assessments noted regarding the resident's [MEDICAL CONDITION] The note was signed by LPN #2. On 02/28/2017 at 6:25 PM the next note regarding the families concerns stated, spoke with RP. regarding concerns r/t (related to) res (residents) RLE (right lower extremity) [MEDICAL CONDITION]. NP (nurse practitioner) in facility and made aware. NP assessed res with NO (new order) written: RLE swelling and pain please get Doppler Study (venous). Review of the Physician's Problem Log dated 02/24/2017 stated Family wants order for TED hose. Review of the physician's orders [REDACTED]. On 02/28/2017 an order was written that stated, RLE (right lower extremity) swelling and pain please get doppler study. Review of the Ultrasound Report dated 03/01/2017 stated, Ven Doppler Extrem/LIM, right. Impression: [MEDICAL CONDITION] involving the common femoral, profundus, superficial femoral, and popliteal veins. In an interview with the surveyor on 06/13/2017 at 10:45 AM Licensed Practical Nurse #3 stated that s/he was not sure when the family member told him/her about their concern that Resident #3 had a blood clot. S/he stated, I saw Resident #2's leg, it was swollen. I told the family I would forward to the doctor. I would put in doctor's book. LPN #3 confirmed that s/he forgot to let the doctor know about the families concerns and failed to chart the families concerns or document information regarding his/her assessment. Resident #4 was admitted to the facility with [DIAGNOSES REDACTED]. review of the resident's medical record revealed [REDACTED]. Review of the wound care specialist evaluation date 05/31/2017 and observation at the time of the survey revealed the wound was healing. Resident #5 was admitted to the facility with [DIAGNOSES REDACTED]. review of the resident's medical record revealed [REDACTED]. Review of the initial wound care specialist evaluation was dated 05/31/2017; the resident refused observation by the surveyor. In an interview with the surveyor on 06/13/2017 at approximately 11:45 AM s/he stated that s/he had noticed that the charting was not done but that the dressings were dated correctly when she would take them off. I do the dressings Monday thru Friday, when I come in on Monday they are dated and changed like they're supposed to be.

Based on record reviews, interview and observations the facility failed to ensure that Resident #3 received care consistent with professional standards of practice, to treat pressure ulcers to promote healing and prevent new ulcers from developing. Resident #3 developed a pressure ulcer while at the facility and was not assessed or treated for [REDACTED].#4 and #5 (3 of 5 residents sampled for pressure ulcers) failed to have documentation that their pressure ulcer dressings were changed. The findings included: Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set ((MDS) dated [DATE] indicated the resident had a brief interview of mental status (BI[CONDITION]) of 15; her/his speech was clear, understood and understandable. S/he required a two person assist for transfer/mobility. S/he used a wheelchair to ambulate. S/he was occasionally incontinent of bowel/bladder. S/he was care planned for being at risk to develop a pressure ulcer. Review of the Nursing Data Collection Tool (Admission Collection Tool) dated 03/03/2017 revealed no problems with the resident's skin; it was noted as warm and dry. Review of the Braden Scale For Predicting Pressure Sore Risk dated 03/08/2017 scored the resident at 16 indicating s/he was at risk. Review of the Interim Plan of Care dated 03/08/2017 indicated the resident was at risk for pressure ulcers with interventions that included turn and reposition, inspect skin according to facility protocol, and incontinent care. Review of the first shift (7 AM-3 PM) CNA (certified nurse aide) Daily Skin Inspection Record for March 2017 indicated that on March 14 and 18, 2017 the resident had an open area on her sacrum. The inspection for March 15, 16, and 17, 2017 were initialed as done but no information related to the site (redness, rash, bruise, open area, dressing) was provided. A skin diagram showed an open area on the resident sacrum. Review of the Daily Skilled Nurse's Notes from 03/03 thru 03/18/2017 revealed a noted dated 03/15/2017 at 1045 PM that stated, Resident c/o (complained of) pain near rectum. Resident has quarter size open area to gluteal cleft. Base is pink, surrounding skin is normal. Barrier cream applied and resident positioned to (R) (right) side for comfort. This is not new wound care nurse was notified when area was new. Review of physician's orders [REDACTED]. Review of Resident #3 Discharge Summary dated 03/18/2017 revealed no information about a pressure ulcer, the wound care/treatments orders had no treatments . The physician's discharge summary noted the resident's skin had no rashes or skin breakdown. In an interview with the surveyor on 06/13/2017 at approximately 11:45 AM the wound nurse stated after reviewing the chart that s/he was not the wound nurse when this happened. S/he confirmed that the documentation indicated that the resident had something going on with her/his skin and s/he didn't see any notes from the wound nurse. In an interview with the surveyor on 06/13/2017 at 1:05 PM the Director of Medical Records stated there were no other notes related to the resident's skin care. Resident #4 was admitted to the facility with [DIAGNOSES REDACTED]. review of the resident's medical record revealed [REDACTED]. Review of the wound care specialist evaluation date 05/31/2017 and observation at the time of the survey revealed the wound was healing. Resident #5 was admitted to the facility with [DIAGNOSES REDACTED]. review of the resident's medical record revealed [REDACTED]. Review of the initial wound care specialist evaluation was dated 05/31/2017; the resident refused observation by the surveyor. In an interview with the surveyor on 06/13/2017 at approximately 11:45 AM the wound nurse stated that s/he had noticed that the charting was not done but that the dressings were dated correctly when she would take them off. I do the dressings Monday thru Friday, when I come in on Monday they are dated and changed like they're supposed to be, but not initialed as done.

On the days of the survey, based on record review, interview, and review of Perry and Potters Clinical Nursing Skill &Techniques, the facility nursing staff failed to adhere to accepted professional standards of practice for 3 of 13 sampled residents reviewed for professional standards for medication administration. Nursing staff failed to clarify orders and/or accurately transcribe Physician orders [REDACTED].#8. Nursing failed to follow acceptable standards of practice related to the application of [MEDICATION NAME] medication patches for Resident #3. The findings included: The facility readmitted Resident #4 with [DIAGNOSES REDACTED]. Record review on 2/12/13 of the 11/13/12 facility Admission physician's orders [REDACTED]. Review on 2/11/13 of the cumulative Admission physician's orders [REDACTED]. A diagonal line had been drawn through the entries for several of the medications on the list including the [MEDICATION NAME] and [MEDICATION NAME] with no indication/documentation of what this meant. Record review on 2/12/13 of the "Active...Discontinued" medication list with a "Run Date/Time 11/13/12 0908" which (per interview) came from the hospital (Initialed by the facility physician on 11/14/12), revealed that the resident's discharge medications did not include [MEDICATION NAME], but [MEDICATION NAME] 40 mg daily. The "Active" medication list also indicated the resident was to take [MEDICATION NAME] HCL 0.3 mg twice daily, and that the [MEDICATION NAME] 0.2 mg twice daily had been stopped 11/12/12 (in the hospital) per Dr. order. The "Active" medication list did not include the medications [MEDICATION NAME] and [MEDICATION NAME], and it was documented that both of these medications had been stopped on 11/12/12 (in the hospital) per Dr. order. There was no indication that the resident's transfer medications included Folic Acid 0.4 mg, but this had been listed on the facility's Admission cumulative orders. A [MEDICATION NAME]-M Advanced Formula/[MEDICATION NAME] was included on the "Active" medication list; however, this medication was not included on the facility's 11/13/12 cumulative admission orders [REDACTED] During an interview on 2/13/13, the resident's Physician and the Director of Nursing (DON) both agreed that the lined through entries and documentation on the facility's 11/13/12 Admission Physician order [REDACTED]. The Physician stated that a new telephone order should have been written to clarify any medication discrepancies or medications discontinued. When asked, the Physician stated that the discharge summary and the hospital medication list are usually faxed to him/her or telephoned to him/her (if he/she were not in the building). An order is then given over the phone or the orders signed and faxed back to indicate which orders were to be continued on admission. When asked to see documentation that this had been done on 11/13/12 (the day of admission), the DON was unable to provide this. The Nursing Notes dated 11/13/12 did not indicate that the nurse had called the Physician to receive an order to continue all the medications as listed on the admission orders [REDACTED]. The Physician verified he/she had initialed the hospital's "Active...Discontinued" medication list 11/14/12 (with no changes indicated) and had signed the Admission cumulative orders on 11/14/12. During an interview on 2/12/13, the DON stated that the nurse transcribing the admission orders [REDACTED]. The DON verified one dose of [MEDICATION NAME] 20 mg had been documented on the November 2012 Documentation Record as having been given (in error) on 11/14/12 at 9:00 AM. Record review on 2/12/13 revealed there was no telephone order noted in the chart to discontinue the [MEDICATION NAME] 20 mg daily. Review on 2/11/13 of the typed computer generated monthly Physician order [REDACTED]. Review of the facility's medication administration documentation for November/December 2012 and January/February 2013 revealed the medication [MEDICATION NAME] had not been documented as having been given from 11/15/12 through 2/11/13. The above documentation was verified by Licensed Practical Nurse (LPN) #4 on 2/11/13 at 1:15 PM after reviewing the record with the surveyor. During an interview on 2/13/13, the resident's Physician stated that the resident was not supposed to receive the [MEDICATION NAME] since the medication had been added in error onto the 11/13/12 admission orders [REDACTED]'s discharge "Active" medication list. The physician/DON verified there was no order on the chart to discontinue the [MEDICATION NAME]. The DON acknowledged that the orders for the [MEDICATION NAME] daily had been carried over incorrectly onto the cumulative Physician monthly order sheets. Record review on 2/11/13 revealed a Physician's Telephone Order dated 11/14/12 for "[MEDICATION NAME] 20 mg 2 tabs (40 mg) PO daily...". Further review revealed that the medication [MEDICATION NAME] 40 mg once daily had never been started and had not been administered as ordered from 11/15/12 through 2/11/13. The order for the [MEDICATION NAME] once daily had been continued on the computer generated monthly cumulative orders (signed by the Physician) for December 2012 and January/February 2013. Review of the Medications Flowsheet for November 2012 revealed the medication had not been added to the flowsheet. Review of the Medications Flowsheets for December 2012 and January/February 2013 revealed the medication [MEDICATION NAME] had been added as an entry, but had been yellowed out with no initials to indicate the medication had been administered. The above documentation was verified with LPN #4 on 2/11/13 at 1:15 PM. Record review revealed that the medication [MEDICATION NAME] 15 mg once daily had not been given as ordered from 12/1/12 through 1/13/13. A Physician's Telephone order was written 11/14/12 (signed 11/18/12 by the Physician) to restart the medication after it had been discontinued earlier that day. The medication [MEDICATION NAME] 15 mg at bedtime had been initialed as having been given on the November 2012 Medication Administration Records from November 13th (Admission) through the 30th. The orders for [MEDICATION NAME] 15 mg at bedtime had been carried over onto the December 2012 and January 2013 cumulative orders, but was not continued onto the December and January Medication Administration Records. [MEDICATION NAME] 15 mg at bedtime had been documented as "DC'd 11/14/12" and yellowed out on the December 2012 and January 2013 Medications Flowsheets with no initials to indicate the medication had been given in December or from January 1st-13th as ordered. The resident did not receive the ordered [MEDICATION NAME] 15 mg at bedtime from 12/1/12 through 1/13/13. The above documentation was verified with LPN #4 on 2/11/13 at 1:15 PM. During an interview on 2/13/13, the Physician verified he/she had re-ordered the [MEDICATION NAME] 15 mg daily on 11/14/12 due to the resident's depression/lack of appetite and had wanted the medication continued. A Physician's Telephone order dated 11/14/12 stated, "...D/C Folic Acid 0.4 mg daily". There was no telephone order noted in the chart related to restarting or changing the dosage after the D/C order had been written. A typed computer generated Physician order [REDACTED]. When asked during an interview on 2/13/13, about how the order had been changed and if the intent had been to continue the medication at the 1 mg dosage, the Physician stated that one dosage was for over the counter administration and the other was prescription strength which the pharmacy would provide. The Physician stated he/she believed this was discussed with the nurse and an order should have been written for the Folic Acid 1 mg dose. Review of the cumulative monthly orders revealed the order for Folic Acid 1 mg was carried over onto the December 2012 and January/February 2013 cumulative monthly orders indicating the resident was to receive this medication. However, review of the November/December 2012 Medications Flowsheets revealed that Folic Acid 1 mg daily had been discontinued 11/14/12 with the entries yellowed out with no initials to indicate the resident had received Folic Acid from 11/15/12 through 12/31/12. Review of the January/February 2013 Medications Flowsheet revealed Folic Acid 1 mg had been administered from 1/1/13 through 2/11/13. The above documentation was verified by LPN #4 on 2/11/13 at 1:15 PM. During an interview on 2/13/13, when asked about the discrepancy between the [MEDICATION NAME] doses between the facility's admission orders hospital discharge medication list, the Physician stated that possibly the resident's blood pressure on admission led to a change in dosage. However, there was no documentation of a reason for the change in the record or a telephone order clarifying what should be given. When asked if the [MEDICATION NAME]-M should have been continued, the Physician stated that he/she had thought that he/she had discontinued this medication. During an interview on 2/12/13 at 9:10 AM, the DON was asked about the process of how Physician orders [REDACTED]. New admission orders [REDACTED]. The discharge summary is faxed to the Physician. The Physician will fax a signed copy back with medications to be continued and/or any changes to the medications. If the Physician or Nurse Practitioner were in the building, one of them could sign the orders. These signed orders are then faxed to the pharmacy. As physician orders [REDACTED]. These cumulative orders are then printed out near the end of the month (the 25th). A first check of these orders is usually done by the Unit Manager. This is a check comparing written orders to the Physician order [REDACTED]. The nurses compare the new Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Corrections are made to the new Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. When asked (on 2/13/13) to review the facility's policy related to the transcription of the monthly orders, the DON stated the facility had no specific policy that outlined this information and stated she/he had typed up the information for review and provided the surveyor with a copy. During an interview on 2/12/13 at 3:30 PM, the DON and Unit Manager were present. After reviewing the monthly cumulative orders, they both verified that nursing staff had failed to sign the monthly cumulative orders indicating that the 2 checks had been completed for Resident #4 for the months of November 2012, December 2012, January 2013, and February 2013. Review of Perry and Potter's Clinical Nursing Skills & Techniques, 7th Edition, Copyright 2010, page 515, states under Safe Medication Administration (Right Medication) that..."...Regardless of how you receive the order, you compare the prescriber's written orders with the MAR indicated . It went on to state on page 518 that "Transcription errors are one of the most common sources of medication errors." Resident #8 was admitted on [DATE] with a [DIAGNOSES REDACTED]. During the record review on 2/11/13 at 12:40 PM, it was noted on the physicians orders for November, December, January and February that the resident was to receive [MEDICATION NAME] and Tylenol Extra Strength by mouth. According to the physicians orders for the same months listed, the resident was to receive nothing by mouth. The physicians orders had been signed each month by the physician as accurate, but not any of the above listed months had been signed by nursing as reviewed. The medication administration record(MAR) for February, which was in use, continued to have [MEDICATION NAME] and Tylenol Extra Strength listed as being administered by mouth and was signed as given. Also, the January MAR indicated [REDACTED]. Continued review of the MAR indicated [REDACTED]. An interview with Licensed Practical Nurse(LPN) #2 on 2/12/13 at 11:00 am, revealed that he/she did see that the medications listed above were to be given to the resident by mouth and that if the order was followed as written there would be a concern. LPN#2 stated that Resident #8 did not receive any medications by mouth, that all medications were given through the [MEDICAL CONDITION] tube. Resident #3 was readmitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Hand written under the row to document the administration of the patch was the word "site" and beginning on 02-09-13 entries had been made. Some entries were numbers and some were letters. No entries had been made to indicate site rotation had been made from 02-01 to 02-08-13. Review of the December 2012 and January 2013 MARs revealed a handwritten entry row for documenting patch site rotation. These were complete except for 01-01-13. Interview with LPN #4 confirmed the missing entries for February 2013. S/he stated she "always rotates the patch and that s/he works Monday through Friday." Review of the facility's 'procedure': "Instructions for use of the [MEDICATION NAME] Patch Grid stated "use all sites (13-28) before repeating numbers." It also stated in bold print "***No one site should be reused within 14 days!!" It also stated "Please use these codes to document the site of patch on the MAR indicated This is followed by number (13 through 28) and description ( such as 17: left upper chest) of the site and included a body graph showing the numbered sites. Review of Manufacturer's instructions for [MEDICATION NAME] revealed the need to "rotate the placement of the patch to a new site daily and not to repeat a placement site more often than every 14 days and it is to be placed on intact skin'. Failure to rotate placement site may cause skin irritation and effect absorption of the medication."

On the days of the survey, based on record review and interview, the facility failed to ensure that 2 of 10 sampled residents reviewed for medication administration remained free of three significant medication errors. Resident #4 did not receive ordered [MEDICATION NAME] (a medication for high blood pressure) from 11/15/12 through 2/11/12. During this time frame, the resident was started on another medication, [MEDICATION NAME], due to elevated blood pressures. Resident #4 did not receive ordered [MEDICATION NAME] (an Anti-depressant) from 12/1/12 through 1/13/13 as ordered. The resident experienced symptoms of depression during this time frame and the [MEDICATION NAME] dosage was increased. Resident # 5 did not receive [MEDICATION NAME] as ordered by the physician. The findings included: The facility readmitted Resident #4 with [DIAGNOSES REDACTED]. Record review on 2/11/13 revealed a Physician's Telephone Order dated 11/14/12 for "[MEDICATION NAME] 20 mg 2 tabs (40 mg) PO daily...". Further review revealed that the medication [MEDICATION NAME] 40 mg once daily had never been started and had not been administered as ordered from 11/15/12 through 2/11/13. The order for the [MEDICATION NAME] once daily had been carried over onto the computer generated monthly cumulative orders (signed by the Physician) for December 2012 and January/February 2013. However, a review of the Medications Flowsheet for November 2012 revealed the medication had not been added to the flowsheet and there was no indication the medication had been given. Review of the Medications Flowsheets for December 2012 and January/February 2013 revealed the medication [MEDICATION NAME] had been added as an entry, but had been yellowed out with no initials to indicate the medication had been administered. The above findings were verified with LPN #4 on 2/11/13 at 1:15 PM. Review of the Nurse Practitioner's Progress Note dated 1/1/13 revealed Resident #4 was seen for Chest Pain and elevated blood pressure. According to the note, "...(Resident #4's) BP (blood pressure) has been persistently elevated over the past few weeks. (She/he) is on several beta-blockers and her HR (heart rate) remains fairly constant at approximately 60 bpm (beats per minute). S/he was started [MEDICATION NAME] week. ... BP medications have not been adjusted in the past several weeks...". The plan was to start [MEDICATION NAME] 10 mg once daily. The medication was started on 1/2/13. Record review on 2/11/13 revealed that the medication [MEDICATION NAME] 15 mg once daily had not been continued as ordered from 12/1/12 through 1/13/13. A Physician's Telephone order was written 11/14/12 to restart the medication after it had been discontinued earlier that day. The medication [MEDICATION NAME] 15 mg at bedtime had been initialed as having been given on the November 2012 Medication Administration Records from November 13th through the 30th. The orders for [MEDICATION NAME] 15 mg had been carried over onto the December 2012 and January 2013 cumulative orders; however, the medication had been documented as having been "DC'd 11/14/12" and yellowed out on the December 2012 and January 2013 Medications Flowsheets with no initials to indicate the medication had been given. The resident did not receive the ordered [MEDICATION NAME] 15 mg at bedtime from 12/1/12 through 1/13/13. The above finding were verified with LPN #4 on 2/11/13 at 1:15 PM. During an interview on 2/13/13, the Physician verified he/she had re-ordered the [MEDICATION NAME] 15 mg daily on 11/14/12 due to the resident's depression/poor appetite and wanted that continued. A Psychiatry consult note dated 1/14/13 documented the resident was currently sad and experiencing problems with sleep, irritability, poor concentration, poor appetite, decreased energy, feelings of guilt, anhedonia, and sad affect. The psychiatrist's recommendation to increase the [MEDICATION NAME] to 30 mg at bedtime was implemented 1/15/13. The facility admitted Resident #5 with [DIAGNOSES REDACTED]. [MEDICATION NAME] was not administered as ordered on 4 days. Subsequently, the [MEDICATION NAME] dosage had to be increased due to subtherapeutic levels. Record review on 2/11/13 revealed a Physician's Telephone Order dated 1/9/13 which stated, "...Cont(inue) [MEDICATION NAME] 2.5 mg (milligrams) on T (Tuesday), Th (Thursday), Sat (Saturday), Sun (Sunday), 3 mg M (Monday), W (Wednesday), F (Friday) + Repeat INR (International Normalization Ratio) on 1/14/13". Review of the January 2013 Lab Flowsheet revealed the entry was incorrectly transcribed and showed that [MEDICATION NAME] 2.5 mg was only to be given on Tuesdays, Thursdays, and Saturdays, (omitting the Sunday dose). The [MEDICATION NAME] had been documented as having been given as ordered from 1/9/13 through 1/12/13. However, there was no indication that [MEDICATION NAME] had been given on 1/13/13 (Sunday) or 1/14/13 (the day the PT/INR had been ordered). Review of lab results revealed a PT ([MEDICATION NAME]) INR had been collected on 1/14/13 and reported on 1/15/13. The INR was 1.8 (L) Low with the reference range being 2.0-3.5. A note on the bottom of the lab sheet documented that on 1/15/13 at 12:35 AM, the Physician had been notified of the lab results and ordered the [MEDICATION NAME] continued at the same dosage as ordered previously. A PT/INR was to be repeated on 1/17/13. Further review revealed a Physician's Telephone Order had been written for this on 1/15/13. Review of the Documentation Record for January 2013 revealed no indication that the order 1/15/13 to continue the [MEDICATION NAME] 2.5 mg on T, Th, Sat, Sun; and [MEDICATION NAME] 3 mg on M, W, and F had been done. There was no documentation of a new entry or continued documentation on the previous entry to show the [MEDICATION NAME] had been administered as ordered on [DATE] and 1/16/13. Review of lab results on 1/17/13 revealed an INR of 1.3 (L) Low. A Physician's Telephone Order had been written on 1/17/13 to "Start 3 mg [MEDICATION NAME] PO (By Mouth) QD (daily) + re(check) PT/INR on 1/21/13...". The above documentation was verified with Licensed Practical Nurse #2 on 2/12/13 at 10:50 AM.

On the days of the complaint and extended survey based on record review and interviews, the facility failed to implement procedures to ensure 3 of 5 residents reviewed with tracheostomies and 1 of 1 residents reviewed with dehydration were not neglected. Resident #6 did not receive the necessary emergency care at the time she was found with [MEDICAL CONDITION] her hand. Resident's #7 and #8 identified with tracheostomies failed to have necessary [MEDICAL CONDITION] at the bedside or readily available and the staff acknowledged a lack of training related to [MEDICAL CONDITION]. The facility failed to ensure Resident #9, admitted with a [MEDICAL CONDITION] and a [DIAGNOSES REDACTED]. The findings included: The facility admitted Resident #6 on [DATE] and readmitted on [DATE], with [DIAGNOSES REDACTED]. Record review on [DATE] revealed Resident #6 was sent to the emergency roiagnom on [DATE] for "status [REDACTED]." Review of the Physician's orders revealed the following: "[MEDICAL CONDITION] every 3 days and PRN (as needed), clean inner cannula once a day, suction as needed date time and initial,[MEDICAL CONDITION] every shift, and O2 2 l/[MEDICAL CONDITION] maintain sats @ 90% [MEDICAL CONDITION]." There was no physician's order for the type and size of Resident #6's trach. There was no documentation in the nurse's notes or assessments of the type and size of Resident #6's trach. Record review revealed Resident #6 was transferred to the emergency roiagnom on [DATE] for "trach to be replaced." Review of the Nurse's Notes revealed on [DATE] at 1:35 AM, "writer (LPN #1) noted resident (Resident #6) [MEDICAL CONDITION] hand, South Wing nurse called for backup kept airway open attempted to [MEDICAL CONDITION] in, unsuccessful 911 called gave report. MD called, order to send resident to hospital to replace trach. Resident alert and breathing through mouth, EMS arrived attempted to [MEDICAL CONDITION] no avail, Resident transported to (hospital)." At 3:05 AM, "(hospital) called to report Resident had expired." Review of the Medication Administration for [DATE] revealed no documentation that Resident #6 was suctioned. During an interview on [DATE] at 1:35 PM, Licensed Practical Nurse (LPN) #1 stated that she was assigned to Resident #6 on [DATE] during the night shift. She stated that she walked into the resident's room and saw the "[MEDICAL CONDITION] out". LPN #1 told the Certified Nursing Assistant (CNA) to call 911. LPN #1 stated that the other nurse (LPN #2) came into the room and she (LPN #1) then left the room to call the doctor. LPN #1 stated that she "freaked out" and "didn't know what to do" and "had never been through this before." LPN #1 stated that she had never received training or inservices regarding emergency care of tracheostomies or how to replace a decannulated trach. LPN #1 stated that there was not a [MEDICAL CONDITION] emergency supplies in Resident #6's room. Review of the facility obtained statement of LPN #2 dated [DATE] revealed, at "1:,[DATE]:45 AM, I got called to go to the other side. I ran to the other side, when I got to the unit, the nurse yelled 'Oh my god! She's blue y'all, she's blue!' I went in the room, she was blue, her fingertips and hands were blue. We had to find out if she's a full code. She was not breathing, she did not have a pulse. There was no ambu bag. Instructed the other nurse to call 911. I tried to reinsert [MEDICAL CONDITION] came out. I extended her neck and started compressions. She started breathing. She (LPN #1) found the ambu bag. The nurse was frantic and freaking out. I told her to call (Physician). She (Resident #6) started mouth breathing. (LPN #1) was trying to hook the ambu bag to the concentrator. When (Resident #6) left she was breathing. The nurse told me she received a phone call saying she (resident #6) had expired." "The [MEDICAL CONDITION] there, but there was no arbitrator (sic)." Multiple attempts were made by telephone to contact LPN #2 on [DATE] and [DATE]. During an interview on [DATE] at 1:45 PM, the Attending Physician/Medical Director stated she was notified on [DATE] that Resident #1 had decannulated. The Physician stated that Resident #6 had a history of [REDACTED]. The Physician was asked what emergency supplies should be available at a trached resident's bedside. She stated that no supplies were needed at the bedside, the supplies only needed to be available in the building. She further stated that there was no policy that spoke to having emergency supplies. The Physician was informed of the facility's policy on [MEDICAL CONDITION] Care and emergency supplies. She then stated that it "wouldn't be a bad idea" to have the supplies at the bedside. The facility admitted Resident #7 on [DATE] with [DIAGNOSES REDACTED]. Observation of Resident #7's room on [DATE] revealed an ambu bag hanging on the wall above the bed. LPN #4 was asked how she would respond if Resident #7 was decannulated. She stated that she would try to replace [MEDICAL CONDITION]. LPN #4 was asked to locate the emergency supplies. She confirmed that there was no obturator in the resident's room. After approximately 5 minutes of searching through the resident's drawers and bins she located [MEDICAL CONDITION] out kit. LPN #4 confirmed that she did not know what all the contents were for in the kit. The facility admitted Resident #8 on [DATE] with [DIAGNOSES REDACTED]. Review of the Nurse's Notes revealed on [DATE] "[MEDICAL CONDITION] writer (LPN #3) found out that inner cannula is absent." Review of the Physician's orders revealed an order written [REDACTED]. During an interview on [DATE] at 10:30 AM, LPN #3 confirmed Resident #8 had a size 6 trach. LPN #3 was asked where the emergency supplies for the resident were located. LPN #3 located the disposable inner cannulas in her med cart. She also located two boxes of a size 8 [MEDICAL CONDITION] out kits. One box had been opened and was missing part of the contents. LPN #3 confirmed the supplies at the bedside were not the appropriate supplies. LPN #3 then stated that Resident #8 had pulled his inner cannula out again this morning and that was the reason that there were no disposable cannulas in the resident's room. LPN #3 confirmed that Resident #8 had pulled out his inner cannula on previous occasions. Further review revealed no interventions had been initiated related to Resident #8 partially decannulation. Observation of the unit supply rooms and the central supply room on [DATE] revealed no size 6 Shiley [MEDICAL CONDITION]. During an interview on [DATE] at 12:00 PM, the Nurse Consultant and the Director of Nurses confirmed there were no size 6 [MEDICAL CONDITION] house and confirmed the necessary emergency supplies were not at the residents' bedsides. The facility admitted Resident #10 on [DATE] with [DIAGNOSES REDACTED]. Resident #10 was discharged to the hospital on [DATE] related to acute respiratory distress. Record review revealed no documentation of the type and size [MEDICAL CONDITION] for Resident #10. During an interview on [DATE] at 12:20 PM, the Nurse Consultant confirmed that there was no documentation of the type and [MEDICAL CONDITION] for Resident #10. She stated that she would not know how staff would know what emergency supplies were necessary for Resident #10. Four nurses were interviewed (LPN #3, #4, #5, #6). All four stated that they check for [MEDICAL CONDITION] at the beginning of their shifts. All four stated that each resident with [MEDICAL CONDITION] have a replacement kit at the bedside. During an interview on [DATE] at 3:15 PM, the Director of Nurses (DON) stated that nurses should check at the beginning of their shifts for the necessary emergency supplies. The DON confirmed that if the nurses were checking each shift for the necessary emergency supplies then they would have noticed the supplies were not present at the bedside. The DON also stated that there were no inservices conducted related to emergency management of tracheostomies,[MEDICAL CONDITION] outs or the necessary emergency supplies at the bedside. The DON confirmed no interventions were put in place related to Resident #8 pulling at [MEDICAL CONDITION] partial decannulations. Review of the [DATE] General Spending Ledger revealed no Size 6 Shiley Tracheostomies were ordered. Review of the Policy on [MEDICAL CONDITION] Care stated, "... If [MEDICAL CONDITION] outer cannula is accidentally extubated, attempt to insert [MEDICAL CONDITION](same type and [MEDICAL CONDITION] obturator should always be kept at bedside for such emergencies)." The facility admitted Resident #9 on [DATE] with [DIAGNOSES REDACTED]. Record review revealed Resident #9 was alert and had confusion at times. Further review revealed a dietary assessment dated [DATE] that indicated Resident #9 required ,[DATE] milliliters of fluid a day and required 2300 calories per day. Resident #9 was ordered [MEDICATION NAME] 1.5, 1 can every 4 hours and 150 ml water flushes every 4 hours. Resident #9's weight was noted to be stable at 175 pounds for the month of [DATE]. On [DATE] an order was written for [MEDICATION NAME] 1.5 at 110 ml/hr from 7 PM-5 AM, 8 AM-10 AM, 1 PM-3 PM and 5 PM-6 PM with water flushes every 4 hours. On [DATE], Resident #9's weight decreased to 159.2 pounds. A significant loss of 9% in approximately 2 weeks. The Registered Dietitian saw Resident #9 on [DATE] and did not note the significant weight loss. Furthermore the tube feeds were decreased to 80 ml/hr for 12 hours with 150 ml water flushes every 4 hours. The new order provided Resident #9 with 900 ml of water and 960 ml of formula (significantly less than the required amount). Resident #9's weight on [DATE] was 154.6, another 3 % loss in one week. On [DATE] Resident #9 weighed 147, a 5 % loss on one week. Resident #9 sustained a 19% weight loss in less than 4 weeks. Review of Resident #9's physician's orders from admission through discharge included an order for [REDACTED]. Review of the Nurse's Notes from [DATE] through [DATE] revealed multiple entries that indicated Resident #9 would disconnect his tube feeds and saturate the bed with formula. Review of the ADL Tracking Log for [DATE] revealed Resident #9 refused all meals. Further record review revealed no documentation of intake and output for Resident #9. No behavior monitoring or interventions were put in place related to the resident's behavior of disconnecting his tube feeding. Resident #9 was noted to be able to self propel himself in the wheelchair. Resident #9 was also noted to be alert and oriented times three on admission. However, he had increasing confusion during the month of [DATE]. Review of the Neurological Flowsheet dated ,[DATE] through ,[DATE] revealed Resident #9 was confused at all times. Review of the Nurse's Notes revealed on [DATE] the resident's son reported the resident was dehydrated. Yogurt was offered and the resident declined water. His tube was flushed with 90 ml of water. The resident was noted to have confusion at times. On ,[DATE] the resident was noted down the service hallway by the exit door. On [DATE] at 7:30 PM, "resident decided to go sit outside for awhile and removed shirt exposing self, gentle encouragement to come back into building." On ,[DATE] at 11:45 AM, "Res alert and oriented x 2 with confusion noted. Resident's son found resident in hall near front entrance without pants on and with a brief and shirt." On [DATE] at 5:30 PM a late entry documented "upon entry to the building noted resident sitting halfway undressed on the front porch. Was hot and slightly lethargic. Asked resident to come inside and he stated no. Expressed to him that he needed to come in or he would get heat exhaustion. He then agreed to come in. Assisted back to the room and turned on AC (airconditioning) unit. Placed cool towels and washcloths to help cool him. Offered fluids and he declined. Would not allow staff to provide any fluids via tube." On [DATE] at 5:30 PM, "summoned to North Wing by resident's family member. Noted resident sitting up in wheelchair with signs and symptoms of lethargy. O2 sat fluctuating, 911 called... " Review of the Emergency Department's record from the Hospital dated [DATE] revealed Resident #9's admitting [DIAGNOSES REDACTED]. Acute Dehydration 2. [MEDICAL CONDITION]." Resident #9's labs were as follows: Sodium 162 (high), Chloride 117 (high), Glucose 198 (high), BUN 48 (high). Resident #9 received one liter of IV fluids in the ER prior to admission to the hospital. During an interview on [DATE] at 2:15 PM, the Registered Dietitian stated that Resident #9 did not tolerate the [MEDICATION NAME] tube feeds because he felt too full. She also stated that he would disconnect his continuous tube feeds. The RD stated that she was trying to find a way to provide Resident #9 his required nutrition but stated that she "didn't know what else to do." The RD stated that she saw the resident on [DATE] and confirmed that she did not address the significant weight loss. Also, she confirmed, that the order was changed to decrease the amount of formula. She stated that the Attending Physician changed the order and she was not aware of the change until after the resident was discharged . The RD stated that she was in the building on ,[DATE] but did not see Resident #9. She stated that the facility staff did not inform her of the continued significant weight loss. The RD stated that she did not contact the Attending Physician for further interventions and confirmed that no interventions were put in place to address the resident's significant weight loss. The RD confirmed that Resident #9 was not provided adequate hydration. During an interview on [DATE] at 3 PM, the Assistant Director of Nurses (ADON) confirmed the significant weight loss of Resident #9, confirmed the RD and the doctor were not notified of the loss. She also confirmed no interventions were put in place related to the weight loss. The ADON confirmed an elopement assessment was not completed. She confirmed Resident #9 had increasing confusion. The ADON also confirmed that no interventions were put in place related to Resident #9's known wandering and exit seeking. The ADON confirmed that Resident #9 was outside for an undetermined amount of time and was not provided adequate hydration. The ADON confirmed there was no documentation that the physician was notified of the resident going outside and subsequent heat exhaustion. The ADON confirmed that Resident #9 was sent to the hospital for dehydration. Resident #9 expired on [DATE]. Review of the facility's policy on Elopement Risk Assessment revealed: "all residents are assessed on admission by a licensed nurse for elopement risk utilizing an elopement risk assessment form. All residents are re-assessed for elopement potential by the MDS nurse/Social Service or designee periodically throughout the patients stay." Review of the facility's policy on Extreme Heat revealed the symptoms of heat stroke/exhaustion included "... headache, dizziness, weakness, the person may be confused and may find it difficult to coordinate body movements. Treatment should include removing person to cool environment and encouraging increased consumption of fluids. The physician should be notified promptly to obtain specific directions for care. Depending on the time and exposure this event may require a self report to the state agency per regulations. " On [DATE] at 6:15 PM the Administrator and a Corporate Consultant were notified that Substandard Quality of Care and/or Immediate Jeopardy was identified at F-157, F-225, F-226, F-250, F-279, F-309, and F-490 at a scope and severity of "J". The Substandard Quality of Care and/or Immediate Jeopardy existed in the facility on [DATE] when property not belonging to Resident #2 was found in his room, law enforcement became involved, and an investigation was started that was found to be incomplete and not done timely leaving residents potentially vulnerable and at risk until interventions were implemented [DATE] for their protection. Additional allegations of sexual abuse of Resident #1 by Resident #2 made on [DATE] were not addressed until [DATE] and again an incomplete and delayed investigation was conducted and interventions that were implemented to protect the residents did not address care and/or social needs of Residents involved in the allegations. (Residents #1, #2, and #3) On [DATE] at 2:30 PM the Administrator and a Corporate Consultant were notified that Substandard Quality of Care and/or Immediate Jeopardy was identified at the additional areas of F-224, F-280, F-281, F-328, F-501, and F-520 at a scope and severity of "J". The citation at F-490, cited on [DATE], was also included in this Immediate Jeopardy and the scope and severity was elevated to a "K". The Substandard Quality of Care and/or Immediate Jeopardy existed in the facility as of [DATE] when Resident #6 decannulated and the necessary emergency care was not provided to the resident and the facility became aware that emergency supplies were not available for [MEDICAL CONDITION] in the building and facility staff were not adequately trained to provide all aspects of care required [MEDICAL CONDITION]. The Immediate Jeopardy was not removed upon exit from the facility on [DATE] and remains ongoing.

On the days of the complaint and extended survey, based on record review, the facility failed to provide medically related social services to Residents #1, #2, and #3 to attain or maintain their highest level of well-being for 3 of 3 residents involved in allegations of abuse or misappropriation of property. The findings included: Resident #1 with [DIAGNOSES REDACTED]. The resident was severely cognitively impaired and required total care from the staff. She had a history of [REDACTED]. On 7/7/2011, members of the resident's family alleged to staff that their sister had been sexually abused. Resident #1 named the alleged perpetrator during an interview with the Director of Nurses (DON) on 7/8/11. Review of the Social Service Progress Notes showed the resident's allegation was not addressed, nor was there any follow-up by Social Services concerning the allegation and the resident's room change (that occurred 7/9/2011) until 7/12/2011. The 7/12/2011 progress note said, "This writer was informed by Administrator to document on Resident daily re: following up on allegation which was reported on 07/08/2011. ..." No negative behaviors were noted. One more progress note was done on 7/13/2011, and again, no negative behaviors were noted. An interview with the Administrator on 7/19/2011 revealed the Social Worker was on vacation during the time period of the alleged abuse of the resident. The Administrator, whose background is Social Work, checked on the resident and found no negative outcomes but failed to document her visits or findings. Resident #3 with [DIAGNOSES REDACTED]. Her rings had been found in Resident #2's room on 6/20/2011. Resident #3 pressed charges against Resident #2 and her case was still pending as of 7/26/2011. A witness statement was dated 7/7/2011 and documented that the Administrator was notified 7/7/2011 that Resident #3 reported missing rings. The Administrator interviewed Resident #3 on 7/8/2011 at 10 AM and documented that the resident did identify 4 of the rings that were found in the room of Resident #2. Resident #3 asked where her rings were found and the Administrator declined to give that information stating she would let the law enforcement investigators speak with her. Resident #3 asked at that time "Is it... (Resident #2)?" and when asked by the Administrator why she thought that, Resident #3 commented "He is always lookin'-always lookin' around to see what we have." Review of the Social Services Progress Notes showed no documentation of any counseling or emotional support provided to the resident related to the incident. Resident #2 with [DIAGNOSES REDACTED]. He was the alleged perpetrator in the sexual abuse allegation and in the misappropriation of resident property allegation. Review of the Social Services Progress Notes from 4/5/2011 through 6/20/2011 showed an entry date 6/9/2011 that stated, "...Resident displays being very demanding, cursing and yelling at times re: staff related to ADL (activities of daily living) care. Resident #2 states that he has a poor appetite and has little interest and little pleasure in doing things due to back pain, during this assessment period. Resident was last seen by the Psychiatrist on 5/16/2011, and by physician on 5/8/2011 and 5/25/2011, per physicians progress notes. Resident had order written to D/C (discontinue) Tylenol #3 and give Tylox for pain... The last entry described the events of 6/20/2011 when Resident #2's room was searched by the Administrator due to the smell of a strong drug substance in his room. There was no further documentation concerning any counseling of the resident, assisting the resident in managing the new 1:1 supervision, or preparing him for possible legal action. On 7/25/2011 at 6:15 PM the Administrator and a Corporate Consultant were notified that Substandard Quality of Care and/or Immediate Jeopardy was identified at F-157, F-225, F-226, F-250, F-279, F-309, and F-490 at a scope and severity of "J". The Substandard Quality of Care and/or Immediate Jeopardy existed in the facility on 6/20/2011 when property not belonging to Resident #2 was found in his room, law enforcement became involved, and an investigation was started that was found to be incomplete and not done timely leaving residents potentially vulnerable and at risk until interventions were implemented 7/8/2011 for their protection. Additional allegations of sexual abuse of Resident #1 by Resident #2 made on 7/7/2011 were not addressed until 7/8/2011 and again an incomplete and delayed investigation was conducted and interventions that were implemented to protect the residents did not address care and/or social needs of Residents involved in the allegations. (Residents #1, #2, and #3) On 8/1/2011 at 2:30 PM the Administrator and a Corporate Consultant were notified that Substandard Quality of Care and/or Immediate Jeopardy was identified at the additional areas of F-224, F-280, F-281, F-328, F-501, and F-520 at a scope and severity of "J". The citation at F-490, cited on 7/25/2011, was also included in this Immediate Jeopardy and the scope and severity was elevated to a "K". The Substandard Quality of Care and/or Immediate Jeopardy existed in the facility as of 7/21/2011 when Resident #6 decannulated and the necessary emergency care was not provided to the resident and the facility became aware that emergency supplies were not available for the trach residents in the building and facility staff were not adequately trained to provide all aspects of care required with trach residents. The Immediate Jeopardy was not removed upon exit from the facility on 8/2/2011 and remains ongoing.

On the days of the complaint and extended survey, based on record review, the facility failed to develop a comprehensive plan of care describing the services to be provided to one resident for his protection and the protection of other residents for 1 of 1 resident with a history of being a registered sex offender ( Resident #2). The findings included: Resident #2 with [DIAGNOSES REDACTED]. Review of the resident assessments of 10/13/2010 and 4/8/2011 showed the resident was cognitively intact with no communication impairment. The resident needed extensive to total assistance with transfer and dressing. Limited assistance was needed for hygiene but the resident was independent for bathing and eating. Review of the medical record showed the resident used an electric wheelchair for mobility. He came and left the facility at will. Review of the medical record revealed the resident was a registered sex offender. He was convicted in 1992 of Criminal Sexual Conduct. The facility assisted the resident to register with the county bi-annually. Review of the resident's care plan showed no problem addressing his status as a registered sex offender. There were no measures put in place to protect the community of vulnerable adults he lived with at the facility from potential harm. There also was no plan to assist the resident in protecting himself from potential harm from others who might take advantage of his history. On 7/25/2011 at 6:15 PM the Administrator and a Corporate Consultant were notified that Substandard Quality of Care and/or Immediate Jeopardy was identified at F-157, F-225, F-226, F-250, F-279, F-309, and F-490 at a scope and severity of "J". The Substandard Quality of Care and/or Immediate Jeopardy existed in the facility on 6/20/2011 when property not belonging to Resident #2 was found in his room, law enforcement became involved, and an investigation was started that was found to be incomplete and not done timely leaving residents potentially vulnerable and at risk until interventions were implemented 7/8/2011 for their protection. Additional allegations of sexual abuse of Resident #1 by Resident #2 made on 7/7/2011 were not addressed until 7/8/2011 and again an incomplete and delayed investigation was conducted and interventions that were implemented to protect the residents did not address care and/or social needs of Residents involved in the allegations. (Residents #1, #2, and #3) On 8/1/2011 at 2:30 PM the Administrator and a Corporate Consultant were notified that Substandard Quality of Care and/or Immediate Jeopardy was identified at the additional areas of F-224, F-280, F-281, F-328, F-501, and F-520 at a scope and severity of "J". The citation at F-490, cited on 7/25/2011, was also included in this Immediate Jeopardy and the scope and severity was elevated to a "K". The Substandard Quality of Care and/or Immediate Jeopardy existed in the facility as of 7/21/2011 when Resident #6 decannulated and the necessary emergency care was not provided to the resident and the facility became aware that emergency supplies were not available for [MEDICAL CONDITION] in the building and facility staff were not adequately trained to provide all aspects of care required [MEDICAL CONDITION]. The Immediate Jeopardy was not removed upon exit from the facility on 8/2/2011 and remains ongoing.

NOT CORRECTED On the days of the follow up visit, based on observations, interviews and record reviews the deficiency was not corrected. The facility failed to ensure 1 of 2 resident's (having a [MEDICAL CONDITION]) care plans were reviewed and revised with adequate interventions to ensure the safety of Resident #8's [MEDICAL CONDITION] and failed to assure the resident was care planned with appropriate interventions related to capping [MEDICAL CONDITION] discharge teaching. The findings included: Review of the Plan of Correction with a completion date of 8/13/2011 revealed the facility was to review all resident care plans during the morning stand up meeting Monday thru Friday. The care plans were to be reviewed for accuracy and updated with any acute care concerns. The Director of Nursing was to monitor the process and report to the Quality Assurance Committee any areas of concern. The facility failed to assure all residents' care plans were accurately reviewed and revised per their plan of correction. The findings are as follows: The facility admitted Resident #8 on 7/1/2011 with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. A [MEDICATION NAME] was performed with the following results: "[MEDICATION NAME] revealed subtotal occlusion of the trachea. Therefore,[MEDICAL CONDITION] could not be removed but was downsized to #4 cannuli." Resident #8 was sent back to the VA on 9/16 related to an accidental decannulation. Further review of the physician's orders [REDACTED]. The resident was receiving speech therapy until 9/21/11 when services were discontinued. SLP was not assisting the resident in capping trials and no documentation was located related to capping. Review of the Re-Admit note dated 9/22 but the encounter date was 9/17 documented: "sent out to VAH to be evaluated for possible removal of [MEDICAL CONDITION]. Underwent [MEDICATION NAME] and pt's (patients)[MEDICAL CONDITION] decreased to #4 from #6. Pt returns for continued teaching on care of his trach..." Record review on 10/3/2011 revealed a Nurse's Note dated 8/23/2011 at 7:45 PM that documented: "Summoned to room and resident put call light on upon, upon entering room sitting on side of bed holding cannula. Resident stated "I coughed and it came out"...New inner cannula inserted without difficulty." On 9/16/2011 at 10:20 AM, "this writer was summoned in the room by (Certified Nursing Assistant). Upon entering resident sitting on the side of the bed with the [MEDICAL CONDITION] and inner cannula in the left hand. Right side was loosed (sic). "Resident said: "when I sat, it fell out."[MEDICAL CONDITION] was insert (sic) by this writer without difficulty...Resident placed on 1:1 observation." At 10:35 AM, (Attending Physician) was notified and orders obtained to send to the hospital. The resident returned on 9/17 at 2 AM with two #4 [MEDICAL CONDITION] kits. The 1:1 observations were not continued and no other interventions were put in place related to [MEDICAL CONDITION]. On 9/21, discharge teaching began for Resident #8's care of his [MEDICAL CONDITION]. The nurses notes documented that the resident was able to perform his [MEDICAL CONDITION] successfully. On 9/28/2011 at 2:36 AM, "(Certified Nursing Assistant) reported [MEDICAL CONDITION]. On arrival to room, resident sitting on the side of the bed c (with)[MEDICAL CONDITION] and in lock position, stated he was coughing earlier." There was no documentation located related to the capping of the trach. Review of the Care Plan dated 8/1 and reviewed on 9/21 revealed a problem area of "resident has hx (history) of dislodging [MEDICAL CONDITION], unclear if it was intentional, resident denies, stated he was fidgeting [MEDICAL CONDITION] it became dislodged." Approaches included "encourage resident to not dislodge trach, explain importance of [MEDICAL CONDITION] to resident, ensure [MEDICAL CONDITION] remains at head of resident's bed, inservice staff on [MEDICAL CONDITION] and encourage CNAs to report [MEDICAL CONDITION]." 1:1 observations was listed on the care plan, however it had been crossed off. The care plan had not been updated with the dislodgements on 8/23, 9/16 or 9/28. No other interventions were put in place related to the dislodgements. The care plan was not updated to include any interventions related to weaning, capping or the use of a speaking valve. The care plan was not updated related to any [MEDICAL CONDITION] teaching. During an interview on 10/3/2011 at 4:37 PM, the Administrator and the Director of Nursing stated that Resident #8's 1:1 monitoring was discontinued on 8/22/2011. The DON stated that there were no other interventions put in place related to the decannulations. She stated that the resident was not intentionally pulling the [MEDICAL CONDITION] out and it was not a behavior concern. She stated that the resident was sent to the hospital on 9/16 related to the decannulation. The DON stated that the resident decannulated at the hospital. The DON stated that the VA sent Resident #8 back to the facility and [MEDICAL CONDITION] safe. Both the DON and the Administrator confirmed that when the resident returned to the facility, no interventions were initiated related to the resident's decannulations. During an interview on 10/13/2011 at 5:20 PM, Resident #8 was asked if he had problems with [MEDICAL CONDITION] out. He stated "yes." The resident reported all three incidents of [MEDICAL CONDITION]. Resident #8 then stated "last Tuesday it came out." Resident #8 stated that he sat up in bed and was coughing and [MEDICAL CONDITION] out. Resident #8 was asked specifically what came out and he stated his trach. Resident #8 was asked again if the entire device came out or only the inner part. Resident #8 stated again that the whole then came out and "shot across the room." Resident #8 then stated that he "put it back in." Resident #8 then stated that he reported the incident to the nurse. Resident #8 was asked about his hospitalization . He stated that while he was there he received a "cap." He stated that "someone" told him to cap [MEDICAL CONDITION] night while he was sleeping. Resident #8 stated that he tried to cap [MEDICAL CONDITION] he woke up in the middle of the night and couldn't breath. Resident #8 again stated that he reported this to the nurse. Resident #8 was asked if he was still capping [MEDICAL CONDITION] he stated "No, the nurses lost it." During an interview on 10/3/2011 at 5:25 PM, Licensed Practical Nurse (LPN) #3 stated that Resident #8 returned from the VA Hospital with a cap and he was capping his trach. LPN #3 stated that there were no orders for the capping and that none were needed. LPN #3 also stated that the resident lost the cap. During an interview on 10/3/2011 at 5:30 PM, Speech Language Pathologist #1 stated that she was aware Resident #8 was capping his trach. She stated that she was not assisting the resident with the capping trials. SLP #1 stated that there were no orders and no monitoring was in place related to Resident #8's capping. During the Exit Conference on 10/3/2011 at 6:30 PM, the DON, the Administrator and the Nurse Consultant all confirmed there were no orders for a cap. All also confirmed that a new cap had been ordered for Resident #8. The Nurse Consultant stated that the cap was being replaced because the resident had returned from the hospital with one and a new cap was going to be placed in his emergency kit. The DON was asked what interventions had been initiated by the facility to protect the resident's airway. The DON could not provide any interventions that were implemented.

On the days of the complaint and expanded survey based on record reviews, interviews, observations, the South Carolina Nursing Standard of Practice SECTION [DATE], the South Carolina Nurse Practice Act Laws and Policies, Chapter 33 Section [DATE], the Nursing Code of Ethics Provision 4.3, and the South Carolina LLR Advisory Opinion #37 the facility failed to ensure that 4 of 5 residents reviewed with tracheostomies and 1 of 1 resident reviewed for dehydration received services that meet professional standards of quality. The facility failed to provide necessary emergency care on [DATE] when Resident #6 was found holding [MEDICAL CONDITION] her hand; Residents #7 and #8 were observed without the necessary emergency supplies at their bedside or supplies were not readily available; Resident #10 was not adequately care planned regarding [MEDICAL CONDITION] care. Resident #9 not adequately assessed regarding enteral (tube fed) and oral intake of fluids/nutrition became dehydrated resulting in hospitalization on [DATE]. The findings included: The facility admitted Resident #6 on [DATE] and readmitted on [DATE], with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. There was no documentation in the nurse's notes or assessments of the type and size of [MEDICAL CONDITION] for Resident #6's. Review of the Nurse's Notes revealed on [DATE] at 1:35 AM, "writer (LPN #1) noted resident [MEDICAL CONDITION] hand, South Wing nurse called for backup kept airway open attempted to [MEDICAL CONDITION] in, unsuccessful 911 called gave report. MD called, order to send resident to hospital to replace trach. Resident alert and breathing through mouth, EMS arrived attempted to [MEDICAL CONDITION] no avail, Resident transported to (hospital). " At 3:05 AM, "(hospital) called to report Resident had expired. " Review of the Medication Administration for [DATE] revealed no documentation that Resident #6 was suctioned. During an interview on [DATE] at 1:35 PM, Licensed Practical Nurse (LPN) #1 stated that she was assigned to Resident #6 on [DATE] during the night shift. She stated that she walked into the resident's room and saw the "[MEDICAL CONDITION] out." LPN #1 stated that she "freaked out " and "didn't know what to do" and "had never been through this before." LPN #1 stated that she had never received training or inservices regarding emergency care of tracheostomies or how to replace a decannulated trach. LPN #1 stated that there was not a [MEDICAL CONDITION] emergency supplies in Resident #6's room. Review of the facility obtained statement of LPN #2 dated [DATE] revealed, at "1:,[DATE]:45 AM, I got called to go to the other side. I ran to the other side, when I got to the unit, the nurse yelled, 'Oh my god! She's blue y'all, she's blue!' I went in the room, she was blue, her fingertips and hands were blue. We had to find out if she's a full code. She was not breathing, she did not have a pulse. There was no ambu bag... The nurse was frantic and freaking out." Multiple attempts were made to contact LPN #2 on [DATE] and [DATE]. The facility admitted Resident #7 on [DATE] with [DIAGNOSES REDACTED]. Observation of Resident #7's room revealed an ambu bag hanging on the wall above the bed. LPN #4 was asked how she would respond if Resident #7 was decannulated. She stated that she would try to replace [MEDICAL CONDITION]. LPN #4 was asked to locate the emergency supplies. She confirmed that there was no obturator in the resident's room. After approximately 5 minutes of searching through the resident's drawers and bins she located [MEDICAL CONDITION] out kit. LPN #4 confirmed that she did not know what all the contents were for in the kit. The facility admitted Resident #8 on [DATE] with [DIAGNOSES REDACTED]. During an interview on [DATE] at 10:30 AM, LPN #3 confirmed Resident #8 had a size 6 trach. LPN #3 was asked where the emergency supplies for the resident were located. LPN #3 located the disposable inner cannulas in her med cart. She also located two boxes of a size 8 [MEDICAL CONDITION] out kits. One box had been opened and missing part of the contents. LPN #3 confirmed the supplies at the bedside were not the appropriate supplies. The facility admitted Resident #10 on [DATE] with [DIAGNOSES REDACTED]. Resident #10 was discharged to the hospital on [DATE] related to acute respiratory distress. Record review revealed the Interim Plan of Care did not address the resident's respiratory status, [MEDICAL CONDITION] or history of [MEDICAL CONDITION] hemorrhage. Further record review revealed no documentation of what type and size [MEDICAL CONDITION] ordered for Resident #10. During an interview on [DATE] at 12:20 PM, the Nurse Consultant confirmed the Interim Care Plan did not address the resident's needs. She confirmed that the resident'[MEDICAL CONDITIONS] history was not included and should have been. She also confirmed there was no documentation of what type and [MEDICAL CONDITION] #10 had. She stated that she would not know how staff would know what emergency supplies were necessary for Resident #10. Four nurses interviewed (LPN #3, #4, #5, #6) stated that they checked for [MEDICAL CONDITION] daily, at the beginning of their shifts. All four stated that each resident with [MEDICAL CONDITION] have a replacement kit at the bedside. During an interview on [DATE] at 3:15 PM, the Director of Nurses (DON) stated that nurses should check at the beginning of their shifts for the necessary emergency supplies. The DON confirmed that if the nurses were checking for the necessary emergency supplies then they would have noticed the supplies were not present at the bedside. Review of the policy on [MEDICAL CONDITION] Care stated, "... If [MEDICAL CONDITION] outer cannula is accidentally extubated, attempt to insert [MEDICAL CONDITION](same type and [MEDICAL CONDITION] obturator should always be kept at bedside for such emergencies). " The facility admitted Resident #9 on [DATE] with [DIAGNOSES REDACTED]. Record review revealed Resident #9 sustained a 19% weight loss in less than 4 weeks. Review of the Nurse's Notes revealed multiple entries indicated Resident #9 would disconnect his tube feeds and saturate the bed with formula. Further review revealed on [DATE] the resident's family member reported the resident was dehydrated. On ,[DATE] the resident was noted down the service hallway by the exit door. On ,[DATE] at 11:45 AM, "Res alert and oriented x 2 with confusion noted. Resident's son found resident in hall near front entrance without pants on and with a brief and shirt. On [DATE] at 5:30 PM a late entry documented "upon entry to the building noted resident sitting halfway undressed on the front porch. Was hot and slightly lethargic... Assisted back to the room and turned on AC unit. Placed cool towels and washcloths to help cool him..." Further record review revealed no documentation of intake and output for Resident #9. No behavior monitoring or interventions were put in place related to the resident's behavior of disconnecting his tube feeding or exit seeking behavior. There were no interventions put in place to address the resident's weight loss or refusal of meals/hydration. Record review revealed no Elopement Assessment was completed during the resident's admission to the facility. During an interview on [DATE] at 2:15 PM, the Registered Dietitian (RD) stated that she was trying to find a way to provide Resident #9 his required nutrition but stated that she "didn't know what else to do." The RD stated that she saw the resident on [DATE] and confirmed that she did not address the significant weight loss. The RD stated that she was in the building on ,[DATE] but did not see Resident #9. The RD stated that she did not contact the Attending Physician for further interventions and confirmed that no interventions were put in place to address the resident's significant weight loss. The RD confirmed that Resident #9 was not provided adequate hydration. During an interview on [DATE] at 3 PM, the Assistant Director of Nurses (ADON) confirmed an elopement assessment was not completed. The ADON also confirmed that no interventions were put in place related to Resident #9's known wandering and exit seeking. The ADON confirmed that Resident #9 was outside for an undetermined amount of time and was not provided adequate hydration. Review of the South Carolina Nursing Standard of Practice SECTION [DATE]. (23) stated, "... grounds for disciplinary action: assigned unqualified persons to perform nursing care functions, tasks, or responsibilities or failed to effectively supervise persons to whom nursing functions are delegated or assigned. " Review of the South Carolina Nurse Practice Act Laws and Policies, Chapter 33 Section [DATE](62) stated, "... 'Unprofessional conduct' means acts or behavior that fail to meet the minimally acceptable standard expected of similarly situated professionals including, but not limited to, conduct that may be harmful to the health, safety, and welfare of the public, conduct that may reflect negatively on one's fitness to practice nursing, or conduct that may violate any provision of the code of ethics adopted by the board or a specialty." Review of the Nursing Code of Ethics Provision 4.3 stated, "... nurses accept or reject specific roles based upon their education, knowledge, competence and extent of experience." Review of South Carolina LLR Advisory Opinion #37 stated, "... The Board of Nursing for South Carolina acknowledges that it is within the role and scope of practice of a RN (registered nurse) and LPN to temporarily remove, reposition or reinsert [MEDICAL CONDITION] in children and adults with well established stomas in the home or school setting providing the environment is supportive to emergency medical care. This responsibility is an expanded role for the RN and LPN. Appropriate written policies and procedures should be developed which specify required special education and training. This special education and training should include documented safety practices and other didactic material as well as clinical skill competency components. The agency policies and procedures should address how the agency will assure a physician or Advanced Practice Registered Nurse (APRN) authorizes removal, repositioning or reinsertion of [MEDICAL CONDITION]. This can be defined in the written policies, procedures, and protocols. Annual updates/reviews need to be documented." On [DATE] at 6:15 PM the Administrator and a Corporate Consultant were notified that Substandard Quality of Care and/or Immediate Jeopardy was identified at F-157, F-225, F-226, F-250, F-279, F-309, and F-490 at a scope and severity of "J". The Substandard Quality of Care and/or Immediate Jeopardy existed in the facility on [DATE] when property not belonging to Resident #2 was found in his room, law enforcement became involved, and an investigation was started that was found to be incomplete and not done timely leaving residents potentially vulnerable and at risk until interventions were implemented [DATE] for their protection. Additional allegations of sexual abuse of Resident #1 by Resident #2 made on [DATE] were not addressed until [DATE] and again an incomplete and delayed investigation was conducted and interventions that were implemented to protect the residents did not address care and/or social needs of Residents involved in the allegations. (Residents #1, #2, and #3) On [DATE] at 2:30 PM the Administrator and a Corporate Consultant were notified that Substandard Quality of Care and/or Immediate Jeopardy was identified at the additional areas of F-224, F-280, F-281, F-328, F-501, and F-520 at a scope and severity of "J". The citation at F-490, cited on [DATE], was also included in this Immediate Jeopardy and the scope and severity was elevated to a "K". The Substandard Quality of Care and/or Immediate Jeopardy existed in the facility as of [DATE] when Resident #6 decannulated and the necessary emergency care was not provided to the resident and the facility became aware that emergency supplies were not available for [MEDICAL CONDITION] in the building and facility staff were not adequately trained to provide all aspects of care required [MEDICAL CONDITION]. The Immediate Jeopardy was not removed upon exit from the facility on [DATE] and remains ongoing.

On the days of the complaint and extended survey, based on record review, interviews, and review of facility files, the facility failed to ensure residents received necessary care and services of prompt assessment, interventions, monitoring, and continued assessment for 1 of 1 resident who was the alleged victim of sexual assault (Resident #1). The findings included: Resident #1, a [AGE] year old female with [DIAGNOSES REDACTED]. Review of the resident assessments of 8/25/2010 and 5/1/2011 showed the resident was severely cognitively impaired and she required total assistance from the staff for all her activities of daily living. On 7/7/2011, family members alleged that the resident was being sexually abused due to a new onset of vaginal bleeding. Review of the medical record showed no evidence the family made this complaint. The physician was not notified. An interview with LPN #7 on 7/19/2011 revealed she assessed the resident immediately after the family made their allegation, but her findings were not documented. The facility began an investigation on 7/8/11 after the resident named a male resident as the alleged perpetrator during an interview with the Director of Nurses (DON). The physician was notified and the resident was sent to the hospital for a rape kit on the afternoon of 7/8/11. She returned to the facility on [DATE] at 5:06 AM. No pelvic exam had been done or evidence recovered. Review of the medical record showed no physician's examination of the resident. An interview with the Medical Director on 7/19/11 revealed she did an external examination of the resident on 7/9/11 but was called away on an emergency before documenting in her progress notes. Review of the Nurse's Notes showed an entry on 7/9/11 at 6:50 PM saying the resident was in bed and adjusting to her new environment (her room was changed). It did not show any assessment of the resident related to vaginal bleeding, any developing physical signs of trauma, or signs of emotional distress. There were no further Nurse's Notes until 7/13/11. On 7/25/2011 at 6:15 PM the Administrator and a Corporate Consultant were notified that Substandard Quality of Care and/or Immediate Jeopardy was identified at F-157, F-225, F-226, F-250, F-279, F-309, and F-490 at a scope and severity of "J". The Substandard Quality of Care and/or Immediate Jeopardy existed in the facility on 6/20/2011 when property not belonging to Resident #2 was found in his room, law enforcement became involved, and an investigation was started that was found to be incomplete and not done timely leaving residents potentially vulnerable and at risk until interventions were implemented 7/8/2011 for their protection. Additional allegations of sexual abuse of Resident #1 by Resident #2 made on 7/7/2011 were not addressed until 7/8/2011 and again an incomplete and delayed investigation was conducted and interventions that were implemented to protect the residents did not address care and/or social needs of Residents involved in the allegations. (Residents #1, #2, and #3) On 8/1/2011 at 2:30 PM the Administrator and a Corporate Consultant were notified that Substandard Quality of Care and/or Immediate Jeopardy was identified at the additional areas of F-224, F-280, F-281, F-328, F-501, and F-520 at a scope and severity of "J". The citation at F-490, cited on 7/25/2011, was also included in this Immediate Jeopardy and the scope and severity was elevated to a "K". The Substandard Quality of Care and/or Immediate Jeopardy existed in the facility as of 7/21/2011 when Resident #6 decannulated and the necessary emergency care was not provided to the resident and the facility became aware that emergency supplies were not available for [MEDICAL CONDITION] in the building and facility staff were not adequately trained to provide all aspects of care required [MEDICAL CONDITION]. The Immediate Jeopardy was not removed upon exit from the facility on 8/2/2011 and remains ongoing.

On the days of the complaint and extended survey based on observations, record review and interviews the facility failed to ensure that residents receiving [MEDICAL CONDITION] care received proper treatment. The facility failed to provide necessary emergency care on [DATE] when Resident #6 was found holding [MEDICAL CONDITION] her hand; Residents #7 and #8 observed without the necessary emergency supplies at their bedside or readily available; Resident #10 was not adequately care planned regarding [MEDICAL CONDITION] care. The findings included: The facility admitted Resident #6 on [DATE] and readmitted on [DATE], with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum (MDS) data set [DATE] revealed Resident #6 had severely impaired decision making abilities. Resident #6 was not coded as having any behaviors. Review of the care plan revealed a problem area identified as "[MEDICAL CONDITION] and is at risk for increased secretion/congestion and infections..." Approaches included: "... Monitor for needed suctioning, provide support to prevent anxiety if episodes of sob (shortness of breath)." The care plan did not address the resident's respiratory arrest or history of mucous plugging. Record review on [DATE] revealed Resident #6 was sent to the emergency roiagnom on [DATE] for "status [REDACTED]." Review of the physician's orders [REDACTED].@ 90% [MEDICAL CONDITION]." There was no order for the type and size of Resident #6's trach. There was no documentation in the nurse's notes or assessments of the type and size of Resident #6's trach. Further review of the record revealed Resident #6 was ordered [MEDICATION NAME] nebulizers from ,[DATE] to [DATE]. The [MEDICATION NAME] was discontinued on [DATE] due to "unavailability." Staff interviews during the survey did not reveal what was meant by "unavailability". Review of the Davis Drug Guide revealed [MEDICATION NAME] is indicated for "patients with abnormal, [MEDICATION NAME], or inspissated mucous secretions in such conditions as [MEDICAL CONDITION] care for tracheostomies... atelectasis due to mucous obstruction." Review of the Physician's Progress Notes revealed on [DATE] a re-admit H&P (History and Physical), "... [AGE] year old who developed acute respiratory distress and required resuscitation for a short period secondary to being pulseless. Work up at hospital negative for PE (Pulmonary Embolism) or MI ([MEDICAL CONDITION] Infarction). It was felt patient probably developed mucous plugging and arrested..." Further review revealed Resident #6 was transferred to the emergency roiagnom on [DATE] for "trach to be replaced." Review of the Nurse's Notes revealed on [DATE] "(Attending Physician) called and notified of unavailability of [MEDICATION NAME]." On [DATE] at 1:35 AM, "writer (LPN #1) noted resident [MEDICAL CONDITION] hand, South Wing nurse called for backup kept airway open attempted to [MEDICAL CONDITION] in, unsuccessful 911 called gave report. MD called, order to send resident to hospital to replace trach. Resident alert and breathing through mouth, EMS arrived attempted to [MEDICAL CONDITION] no avail, Resident transported to (hospital). " At 3:05 AM, "(hospital) called to report Resident had expired. " Review of the Medication Administration for [DATE] revealed no documentation that Resident #6 was suctioned. During an interview on [DATE] at 1:35 PM, Licensed Practical Nurse (LPN) #1 stated that she was assigned to Resident #6 on [DATE] during the night shift. She stated that she walked into the resident's room and saw the "[MEDICAL CONDITION] out." LPN #1 told the Certified Nursing Assistant (CNA) to call 911. LPN #1 stated that the other nurse (LPN #2) came into the room and she (LPN #1) then left the room to call the doctor. LPN #1 stated that she "freaked out" and "didn't know what to do" and "had never been through this before." LPN #1 stated that she had never received training or inservices regarding emergency care of tracheostomies or how to replace a decannulated trach. LPN #1 stated that there was not a [MEDICAL CONDITION] emergency supplies in Resident #6's room. Review of the facility obtained statement of LPN #2 dated [DATE] revealed, at "1:,[DATE]:45 AM, I got called to go to the other side. I ran to the other side, when I got to the unit, the nurse yelled, 'Oh my god! She's blue y'all, she's blue!' I went in the room, she was blue, her fingertips and hands were blue. We had to find out if she's a full code. She was not breathing, she did not have a pulse. There was no ambu bag. Instructed the other nurse to call 911. I tried to reinsert [MEDICAL CONDITION] came out. I extended her neck and started compressions. She started breathing. She (LPN #1) found the ambu bag. The nurse was frantic and freaking out. I told her to call (Physician). She (Resident #6) started mouth breathing. (LPN #1) was trying to hook the ambu bag to the concentrator. When (Resident #6) left she was breathing. The nurse told me she received a phone call saying she (Resident #6) had expired." "The [MEDICAL CONDITION] there, but there was no arbitrator (sic)." Multiple attempts were made to contact LPN #2 on [DATE] and [DATE]. During an interview on [DATE] at 1:45 PM, the Attending Physician/Medical Director stated she was notified on [DATE] that Resident #6 had decannulated. The Physician stated that Resident #6 had a history of [REDACTED]. The Physician further stated that [MEDICATION NAME] was ordered to loosen secretions and prevent mucous plugging. She stated that the [MEDICATION NAME] was discontinued on [DATE] because the resident was not having any mucous plugs and therefore did not need the medication. The physician stated that she was not aware that [MEDICATION NAME] was unavailable. The Physician was asked what emergency supplies should be available at a trached resident's bedside. She stated that no supplies were needed at the bedside, the supplies only needed to be available in the building. She further stated that there was no policy that spoke to having emergency supplies. The Physician was informed of the facility's policy on [MEDICAL CONDITION] Care and emergency supplies. She then stated that it "wouldn't be a bad idea" to have the supplies at the bedside. The facility admitted Resident #7 on [DATE] with [DIAGNOSES REDACTED]. Observation during the survey of Resident #7's room revealed an ambu bag hanging on the wall above the bed. LPN #4 was asked how she would respond if Resident #7 was decannulated. She stated that she would try to replace [MEDICAL CONDITION]. LPN #4 was asked to locate the emergency supplies. She confirmed that there was no obturator in the resident's room. After approximately 5 minutes of searching through the resident's drawers and bins she located [MEDICAL CONDITION] out kit. LPN #4 confirmed that she did not know what all the contents were for in the kit. Observation during the survey of the unit supply rooms and the central supply room revealed no size 6 Shiley [MEDICAL CONDITION]. During an interview on [DATE] at 12:00 PM, the Nurse Consultant and the Director of Nurses confirmed there were no size 6 Shiley trachs in house and confirmed the necessary emergency supplies were not at the residents' bedsides. The facility admitted Resident #8 on [DATE] with [DIAGNOSES REDACTED]. Review of the Nurse's Notes revealed on [DATE] "[MEDICAL CONDITION] writer (LPN #3) found out that inner cannula is absent." Review of the physician's orders [REDACTED]. During an interview on [DATE] at 10:30 AM, LPN #3 confirmed that Resident #8 had a size 6 trach. LPN #3 was asked where the emergency supplies for the resident were located. LPN #3 located the disposable inner cannulas in her med cart. She also located two boxes of a size 8 [MEDICAL CONDITION] out kits. One box had been opened and missing part of the contents. LPN #3 confirmed the supplies at the bedside were not the appropriate supplies. LPN #3 then stated that Resident #8 had pulled his inner cannula out again this morning and that was the reason there was not disposable cannulas in the resident's room. LPN #3 confirmed that Resident #8 had pulled out his inner cannula on previous occasions. Review of the initial care plan revealed it had not been updated to reflect the partial decannulations or the resident's behavior of pulling at the trach. Further record review revealed no behavior monitoring or supervision for Resident #8. Also, there were no interventions put in place to prevent Resident #8 from pulling at [MEDICAL CONDITION] attempting to decannulate. The facility admitted Resident #10 on [DATE] with [DIAGNOSES REDACTED]. Resident #10 was discharged to the hospital on [DATE] related to acute respiratory distress. Record review revealed the interim plan of care did not address the resident's respiratory status, [MEDICAL CONDITION] or history of [MEDICAL CONDITION] hemorrhage. Further record review revealed no documentation of what type and size [MEDICAL CONDITION] ordered for Resident #10. During an interview on [DATE] at 12:20 PM, the Nurse Consultant confirmed the Interim Care Plan did not address the resident's needs. She confirmed that the resident'[MEDICAL CONDITIONS] history was not included and should have been. She also confirmed there was no documentation of what type and [MEDICAL CONDITION] #10 had. She stated that she would not know how staff would know what emergency supplies were necessary for Resident #10. Four nurses (LPN #3, #4 #5, #6) interviewed stated that they checked for [MEDICAL CONDITION] daily, at the beginning of their shifts. All four stated that each resident with [MEDICAL CONDITION] have a replacement kit at the bedside. During an interview on [DATE] at 3:15 PM, the Director of Nurses (DON) stated that nurses should check at the beginning of their shifts for the necessary emergency supplies. The DON confirmed that if the nurses were checking for the necessary emergency supplies then they would have noticed the supplies were not present at the bedside. The DON also stated that there were no inservices conducted related to emergency management of tracheostomies,[MEDICAL CONDITION] outs or emergency supplies at the bedside. The DON also confirmed the care plans were not updated and did not reflect each resident's current status. She confirmed no interventions were put in place related to Resident #8 pulling at [MEDICAL CONDITION] partial decannulations. Review of the [DATE] General Spending Ledger revealed no Size 6 Shiley tracheostomies were ordered. During an interview on [DATE] at 9:45 AM, the Nurse Consultant stated that the DON and another Nurse Consultant were suspended pending an investigation. She stated that a report was made to the State Certification Agency regarding the potential neglect of Resident #6's death. She stated that both the DON and the Nurse Consultant were aware the [MEDICAL CONDITION] were not in the facility. The Nurse Consultant stated that an ACLS (Advanced Cardiac Life Support) nurse had arrived at the facility on [DATE] to perform the inservices to the nurses regarding the emergency management of trachs and replacing a decannulated trach. During an observation on [DATE] at 11 AM, the ACLS Nurse was observed providing one to one training. The training only [MEDICAL CONDITION]. The training did not include replacing a decannulated trach, emergency management or competency checks. During an interview on [DATE] at 3 PM, the Assistant Director of Nurses (ADON) stated that she reported to the Nurse Consultant that the necessary emergency supplies were not at the residents' bedside. The ADON stated that she was told the nurse consultant would "take care of it." She also stated that all supplies were ordered through central supply. However, the central supply aid has been on suspension for 3 weeks. The ADON stated that she was not sure who was responsible for the procurement of the supplies. Review of the policy on [MEDICAL CONDITION] Care stated, "... If [MEDICAL CONDITION] outer cannula is accidentally extubated, attempt to insert [MEDICAL CONDITION](same type and [MEDICAL CONDITION] obturator should always be kept at bedside for such emergencies)... " On [DATE] at 6:15 PM the Administrator and a Corporate Consultant were notified that Substandard Quality of Care and/or Immediate Jeopardy was identified at F-157, F-225, F-226, F-250, F-279, F-309, and F-490 at a scope and severity of "J". The Substandard Quality of Care and/or Immediate Jeopardy existed in the facility on [DATE] when property not belonging to Resident #2 was found in his room, law enforcement became involved, and an investigation was started that was found to be incomplete and not done timely leaving residents potentially vulnerable and at risk until interventions were implemented [DATE] for their protection. Additional allegations of sexual abuse of Resident #1 by Resident #2 made on [DATE] were not addressed until [DATE] and again an incomplete and delayed investigation was conducted and interventions that were implemented to protect the residents did not address care and/or social needs of Residents involved in the allegations. (Residents #1, #2, and #3) On [DATE] at 2:30 PM the Administrator and a Corporate Consultant were notified that Substandard Quality of Care and/or Immediate Jeopardy was identified at the additional areas of F-224, F-280, F-281, F-328, F-501, and F-520 at a scope and severity of "J". The citation at F-490, cited on [DATE], was also included in this Immediate Jeopardy and the scope and severity was elevated to a "K". The Substandard Quality of Care and/or Immediate Jeopardy existed in the facility as of [DATE] when Resident #6 decannulated and the necessary emergency care was not provided to the resident and the facility became aware that emergency supplies were not available for [MEDICAL CONDITION] in the building and facility staff were not adequately trained to provide all aspects of care required [MEDICAL CONDITION]. The Immediate Jeopardy was not removed upon exit from the facility on [DATE] and remains ongoing.

NOT CORRECTED On the days of the follow up visit based on record review, observation and interview the deficiency was not corrected. The facility failed to assure one of two residents sampled with tracheostomies received the necessary care and services related to the tracheostomies. Resident #8, who had a history of [REDACTED]. The facility also failed to assure Resident #8 had orders and the appropriate monitoring in place related to the capping of his [MEDICAL CONDITION]. The findings included: The facility admitted Resident #8 on 7/1/2011 with [DIAGNOSES REDACTED]. Resident #8 was alert and oriented x3 per the Nurses Notes, Progress Notes, Social Notes and the BIMS Score of 15 on the Minimum Data Set (MDS). Resident #8 was placed on 1:1 monitoring for dislodgement of his [MEDICAL CONDITION] beginning 8/1/2011. The 1:1 monitoring was discontinued on 8/22/2011. The Psychiatrist evaluated Resident #8 on 8/1 with no recommendations. He was evaluated again on 8/18 and on 8/22 with no recommendations. Resident #8 was evaluated by the Attending Physician on 8/23/11 with no reference to the dislodgement on 8/23. The physician documented "referral to VAH about consideration [MEDICAL CONDITION]-pending." Review of the Re-Admit note dated 9/22 but the encounter date was 9/17 documented: "sent out to VAH to be evaluated for possible removal of [MEDICAL CONDITION]. Underwent [MEDICATION NAME] and pt's (patients)[MEDICAL CONDITION] decreased to #4 from #6. Pt returns for continued teaching on care of his trach..." Review of the physician's orders [REDACTED]. A [MEDICATION NAME] was performed with the following results: "[MEDICATION NAME] revealed subtotal occlusion of the trachea. Therefore,[MEDICAL CONDITION] could not be removed but was downsized to #4 cannuli." An order was written on 9/15/11 that changed the resident'[MEDICAL CONDITION] from a #6 to a #4. Resident #8 was sent back to the VA on 9/16 related to decannulation. Further review of the physician's orders [REDACTED]. The resident was receiving speech therapy until 9/21/11 when services were discontinued. SLP was not assisting the resident in capping trials and no documentation was located related to capping. Record review on 10/3/2011 revealed a Nurse's Note dated 8/23/2011 at 7:45 PM that documented: "Summoned to room and resident put call light on upon, upon entering room sitting on side of bed holding cannula. Resident stated "I coughed and it came out"...New inner cannula inserted without difficulty." There was no evidence the physician or the responsible party was notified related to the incident. On 9/16/2011 at 10:20 AM, "this writer was summoned in the room by (Certified Nursing Assistant). Upon entering resident sitting on the side of the bed with the [MEDICAL CONDITION] and inner cannula in the left hand. Right side was loosed (sic). "Resident said: "when I sat, it fell out."[MEDICAL CONDITION] was insert (sic) by this writer without difficulty...Resident placed on 1:1 observation." At 10:35 AM, (Attending Physician) was notified and orders obtained to send to the hospital. The resident returned on 9/17 at 2 AM with two #4 [MEDICAL CONDITION] kits. The 1:1 observations were not continued and no other interventions were put in place related to [MEDICAL CONDITION]. On 9/21, discharge teaching began for Resident #8's care of his [MEDICAL CONDITION]. The nurses notes documented that the resident was able to perform his [MEDICAL CONDITION] successfully. On 9/28/2011 at 2:36 AM, "(Certified Nursing Assistant) reported [MEDICAL CONDITION]. On arrival to room, resident sitting on the side of the bed c (with)[MEDICAL CONDITION] and in lock position, stated he was coughing earlier." There was no documentation that the physician or the responsible party was notified of the incident. There was no documentation located related to the capping of the trach. Review of the VA Hospital Discharge Summary dated 9/15 and signed 9/16 revealed no indication for any decannulation/capping trials. The Discharge Summary reported the [MEDICATION NAME] that indicate the [MEDICAL CONDITION] could not be removed due to an occlusion of the trachea. No orders were received related to capping of the trach. Review of the Care Plan dated 8/1 and reviewed on 9/21 revealed no interventions were put in place related to the dislodgements. The care plan was not updated to include any interventions related to weaning, capping or the use of a speaking valve. The care plan was not updated related to any [MEDICAL CONDITION] teaching. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Observation of Resident #8's emergency kit on 10/3/2011 at 4:00 PM revealed the above items as well as a speaking valve. During an interview on 10/3/2011 at 4:37 PM, the Administrator and the Director of Nursing stated that Resident #8's 1:1 monitoring was discontinued on 8/22/2011. They both were aware of Resident #8's decannulation on 9/16, however neither were aware of the dislodgements on 8/23 or 9/28 initially. The DON stated that there were no other interventions put in place. She stated that the resident was not intentionally pulling the [MEDICAL CONDITION] out and it was not a behavior concern. She stated that the resident was sent to the hospital on 9/16 related to the decannulation. The DON stated that the resident decannulated at the hospital. She stated that multiple tests and consults were made. The DON stated that the VA sent Resident #8 back to the facility and [MEDICAL CONDITION] safe. Both the DON and the Administrator confirmed that when the resident returned to the facility, no interventions were initiated related to the resident's decannulations. The DON then reviewed the nurses notes and stated that she did recall the 9/28 incident and had discussed the incident in the morning meeting. She stated that she spoke with the nurse and the nurse indicated that the incident did not occur. The DON stated that she did not have any documentation that the incident was discussed in the morning meeting and did not have any documentation/evidence of her investigation. During an interview on 10/13/2011 at 5:20 PM, Resident #8 was asked if he had problems with [MEDICAL CONDITION] out. He stated "yes." The resident reported all three incidents of [MEDICAL CONDITION]. Resident #8 then stated "last Tuesday it came out." Resident #8 stated that he sat up in bed and was coughing and [MEDICAL CONDITION] out. Resident #8 was asked specifically what came out and he stated his trach. Resident #8 was asked again if the entire device came out or only the inner part. Resident #8 stated again that the whole then came out and "shot across the room." Resident #8 then stated that he "put it back in." Resident #8 then stated that he reported the incident to the nurse. Resident #8 was asked about his hospitalization . He stated that while he was there he received a "cap." He stated that "someone" told him to cap [MEDICAL CONDITION] night while he was sleeping. Resident #8 stated that he tried to cap [MEDICAL CONDITION] he woke up in the middle of the night and couldn't breath. Resident #8 again stated that he reported this to the nurse. Resident #8 was asked if he was still capping [MEDICAL CONDITION] he stated "No, the nurses lost it." During an interview on 10/3/2011 at 5:25 PM, Licensed Practical Nurse (LPN) #3 stated that Resident #8 returned from the VA Hospital with a cap and he was capping his trach. LPN #3 stated that there were no orders for the capping and that none were needed. LPN #3 also stated that the resident lost the cap. During an interview on 10/3/2011 at 5:30 PM, Speech Language Pathologist #1 stated that she was aware Resident #8 was capping his trach. She stated that she was not assisting the resident with the capping trials. SLP #1 stated that there were no orders and no monitoring was in place related to Resident #8's capping. The Director of Nurses was asked if there was a policy related [MEDICAL CONDITION] and/or capping. No policy was produced. The policy on Tracheostomies was reviewed. Review of the Purchase Order dated 9/26/2011 revealed a "Speaking Valve" was ordered for Resident #8. The Administrator, the DON and the Supply Clerk stated that the "cap" was on back order and had not arrived. During the Exit Conference on 10/3/2011 at 6:30 PM, the DON, the Administrator and the Nurse Consultant all confirmed there were no orders for a cap. All also confirmed that a new cap had been ordered for Resident #8. The Nurse Consultant stated that the cap was being replaced because the resident had returned from the hospital with one and a new cap was going to be placed in his emergency kit. The Nurse Consultant confirmed that a cap was not an emergency supply device. The DON again stated that the resident's decannulation/dislodgements were not a behavior concern. The DON was asked what interventions had been initiated by the facility to protect the resident's airway. The DON could not provide any interventions that were implemented.

On the days of the Complaint and Extended survey the facility's Administration failed to put interventions in place to protect Resident #1 whose family alleged sexual abuse occurred on 7/7/2011 and Resident #3 whose rings were found in Resident #2's room on 6/20/2011. The facility failed to follow accepted procedures for the investigation of incidents involving alleged sexual abuse and misappropriation of property. The facility failed to identify timely the owner (s) of 6 rings found in Resident #2's room during a search on 6/20/2011; failed to provide medical social support to Resident's #1, #2, and #3; and failed to educate all facility staff regarding the allegations and the interventions necessary to protect all residents at risk of becoming victims. The facility's administration failed to ensure residents with tracheostomies (Resident's #6, #7, #8, #10) had the necessary emergency supplies at the bedside and failed to ensure staff members were adequately trained to handle emergency situations related to residents with tracheostomies. The findings included: Resident #1, a [AGE] year old female with [DIAGNOSES REDACTED]. Family members made their allegation on 7/7/2011. The facility delayed beginning the investigation into the allegation of Resident #1's possible sexual abuse until 7/8/2011. During an interview with the Administrator and the DON on 7/19/2011, the DON stated the resident's family reported their sister told them she had been abused. The investigation did not include a statement from the nurse on duty at the time the allegation was made. Resident #1 was not examined at the facility or the physician notified until 7/8/2011 and the resident was sent to the emergency roiagnom on that day. Resident #2 with [DIAGNOSES REDACTED]. The resident was alert and oriented. He propelled himself about the facility and into the community with an electric wheelchair. Review of the medical record and facility files revealed the resident was a registered sex offender. No care plan was in place to address the residents known behavior. Resident #3 with [DIAGNOSES REDACTED]. Review of the investigative materials for the allegation of misappropriation revealed that after six ladies rings and a facility central supply key were found on 6/20/2011 in Resident #2's room, the facility did not put into place any interventions until 7/8/2011 to protect residents from further potential misappropriation of property. In an interview on 7/18/11 with the Administrator and Director of Nursing (DON) the Administrator and DON stated that 5 rings and a key with "CS" (central supply) on it was found during the search. The search was halted when the items were found and the police called. The resident was left alone during the call to the police and was seen leaving the facility with items from his room. The search of Resident #2's room was not completed until the police conducted a search and after the resident had been seen leaving the building. During the interview with the Administrator and DON, they stated that after finding the jewelry in the resident's room, they checked with residents and/or family members who had reported missing rings in the past months with no results. There was no evidence of any other investigation and no interventions put in place until a resident came forward 2 weeks later to report missing rings. No measures were put in place to protect residents from further potential misappropriation of property. The facility admitted Resident #6 on 12/10/2009 and readmitted on [DATE], with [DIAGNOSES REDACTED]. Record review on 8/1/2011 revealed Resident #6 was sent to the emergency roiagnom on [DATE] following decannulation. The facility staff neglected to provide necessary emergency care to Resident #6, a [MEDICAL CONDITION] resident, when the resident decannulated. The facility admitted Resident #7 on 8/3/2010 with [DIAGNOSES REDACTED]. The facility admitted Resident #8 on 7/1/2011 with [DIAGNOSES REDACTED]. The facility admitted Resident #10 on 7/6/2011 with [DIAGNOSES REDACTED]. Resident #10 was discharged to the hospital on [DATE] related to acute respiratory distress. Observation of Resident #7 and #8's room revealed Resident #8 did not have a 6 Shiley at the bedside. Resident #7 did not have the emergency supplies readily available. Resident #10 was not adequately care planned regarding [MEDICAL CONDITION] care. During an observation of the unit supply rooms and the central supply room revealed no size 6 Shiley [MEDICAL CONDITION]. During an interview on 8/1/2011 at 12:00 PM, the Nurse Consultant and the Director of Nurses confirmed there were no size 6 [MEDICAL CONDITION] house and confirmed the necessary emergency supplies were not at the residents' bedsides. Review of the July 2011 General Spending Ledger revealed no Size 6 Shiley tracheostomies were ordered. During an interview on 8/1/2011 at 3:15 PM, the Director of Nurses (DON) confirmed that she was aware of LPN #1's statement of "freaking out" and the lack of knowledge regarding emergency management of tracheostomies when Resident #6 was found with [MEDICAL CONDITION] her hand. The DON also stated that there were no inservices conducted related to emergency management of tracheostomies,[MEDICAL CONDITION] outs or the need for emergency supplies at the bedside. During an interview on 8/2/2011 at 9:45 AM, the Administrator stated that both the DON and the Nurse Consultant working at the facility during the time the incident was investigated were aware the [MEDICAL CONDITION] were not available in the facility. During an interview on 8/2/2011 at 3 PM, the Assistant Director of Nurses (ADON) stated that she reported to the Nurse Consultant that the necessary emergency supplies were not at the resident's bedside. The ADON stated that she was told the nurse consultant would "take care of it." She also stated that all supplies were ordered through central supply. However, the central supply aid has been on suspension for 3 weeks. The ADON stated that she was not sure who was responsible for the procurement of the supplies. Cross Refers to F-224, F-225, and F-226 as it relates to the failure of the facility Administration to ensure residents are free from Neglect, Abuse, and Misappropriation, any alleged incidents are investigated timely, and interventions are in place to ensure residents are protected during an investigation. In addition failure of the facility to ensure emergency supplies are available as needed for resident care and staff is sufficiently trained to provide care for all residents in the building. On 7/25/2011 at 6:15 PM the Administrator and a Corporate Consultant were notified that Substandard Quality of Care and/or Immediate Jeopardy was identified at F-157, F-225, F-226, F-250, F-279, F-309, and F-490 at a scope and severity of "J". The Substandard Quality of Care and/or Immediate Jeopardy existed in the facility on 6/20/2011 when property not belonging to Resident #2 was found in his room, law enforcement became involved, and an investigation was started that was found to be incomplete and not done timely leaving residents potentially vulnerable and at risk until interventions were implemented 7/8/2011 for their protection. Additional allegations of sexual abuse of Resident #1 by Resident #2 made on 7/7/2011 were not addressed until 7/8/2011 and again an incomplete and delayed investigation was conducted and interventions that were implemented to protect the residents did not address care and/or social needs of Residents involved in the allegations. (Residents #1, #2, and #3) On 8/1/2011 at 2:30 PM the Administrator and a Corporate Consultant were notified that Substandard Quality of Care and/or Immediate Jeopardy was identified at the additional areas of F-224, F-280, F-281, F-328, F-501, and F-520 at a scope and severity of "J". The citation at F-490, cited on 7/25/2011, was also included in this Immediate Jeopardy and the scope and severity was elevated to a "K". The Substandard Quality of Care and/or Immediate Jeopardy existed in the facility as of 7/21/2011 when Resident #6 decannulated and the necessary emergency care was not provided to the resident and the facility became aware that emergency supplies were not available for [MEDICAL CONDITION] in the building and facility staff were not adequately trained to provide all aspects of care required [MEDICAL CONDITION]. The Immediate Jeopardy was not removed upon exit from the facility on 8/2/2011 and remains ongoing.

On the days of the Complaint and Extended survey based on interviews, observations, review of the facility's policy [MEDICAL CONDITION] Care, and record reviews, the facility Medical Director failed to ensure the facility's policies and procedures were implemented. Residents with tracheostomies did not have the necessary emergency supplies at the bedside, nor were the necessary emergency supplies ordered and in the facility's supply rooms. The findings included: Observation of Resident #7 and #8's room revealed Resident #8 did not have the appropriate [MEDICAL CONDITION] supplies at the bedside. Resident #7 did not have the emergency supplies readily available. During an observation of the unit supply rooms and the central supply room revealed no size 6 Shiley [MEDICAL CONDITION]. During an interview on 8/1/2011 at 12:00 PM, the Nurse Consultant and the Director of Nurses confirmed there were no size 6 [MEDICAL CONDITION] house and confirmed the necessary emergency supplies were not at the residents' bedsides. During an interview on 8/1/2011 at 1:45 PM, the Attending Physician/Medical Director was asked what emergency supplies should be available at a trached resident's bedside. The Medical Director stated that no supplies were needed at the bedside, the supplies only needed to be available in the building. She further stated that there was no policy that spoke to having emergency supplies. The Physician was informed of the facility's policy on [MEDICAL CONDITION] Care and emergency supplies. She then stated that it "wouldn't be a bad idea " to have the supplies at the bedside. On 7/25/2011 at 6:15 PM the Administrator and a Corporate Consultant were notified that Substandard Quality of Care and/or Immediate Jeopardy was identified at F-157, F-225, F-226, F-250, F-279, F-309, and F-490 at a scope and severity of "J". The Substandard Quality of Care and/or Immediate Jeopardy existed in the facility on 6/20/2011 when property not belonging to Resident #2 was found in his room, law enforcement became involved, and an investigation was started that was found to be incomplete and not done timely leaving residents potentially vulnerable and at risk until interventions were implemented 7/8/2011 for their protection. Additional allegations of sexual abuse of Resident #1 by Resident #2 made on 7/7/2011 were not addressed until 7/8/2011 and again an incomplete and delayed investigation was conducted and interventions that were implemented to protect the residents did not address care and/or social needs of Residents involved in the allegations. (Residents #1, #2, and #3) On 8/1/2011 at 2:30 PM the Administrator and a Corporate Consultant were notified that Substandard Quality of Care and/or Immediate Jeopardy was identified at the additional areas of F-224, F-280, F-281, F-328, F-501, and F-520 at a scope and severity of "J". The citation at F-490, cited on 7/25/2011, was also included in this Immediate Jeopardy and the scope and severity was elevated to a "K". The Substandard Quality of Care and/or Immediate Jeopardy existed in the facility as of 7/21/2011 when Resident #6 decannulated and the necessary emergency care was not provided to the resident and the facility became aware that emergency supplies were not available for [MEDICAL CONDITION] in the building and facility staff were not adequately trained to provide all aspects of care required [MEDICAL CONDITION]. The Immediate Jeopardy was not removed upon exit from the facility on 8/2/2011 and remains ongoing.

On the days of the complaint and extended survey, based on record reviews, observations, interviews, and review of facility files, the facility failed to ensure that all allegations of abuse were reported immediately to the State survey and certification agency and thoroughly investigated for 1 of 1 allegation of sexual abuse (Residents #1 and #2); and failed to ensure residents were protected from further potential misappropriation of property for 1 of 1 allegation of misappropriation of resident property reported (Resident #2 and #3). The facility delayed beginning the investigation into the allegation of Resident #1's possible sexual abuse. Family members made their allegation on 7/7/2011. The facility did not show evidence of an investigation until 7/8/2011. Review of their investigation revealed the allegation was not addressed till the next day and not all staff members working on the resident's unit were interviewed for possible pertinent information. Review of the investigative materials for the allegation of misappropriation revealed that after six ladies rings and a facility central supply key were found on 6/20/2011 in Resident #2's room, the facility did not aggressively investigate to identify any resident with missing items and did not put into place any interventions until 7/8/2011 to protect residents from further potential misappropriation of property. The findings included: Resident #1, a [AGE] year old female with [DIAGNOSES REDACTED]. Review of the resident assessments of 8/25/2010 and 5/1/2011 showed the resident was severely cognitively impaired. The 5/11/2011 assessment showed a score of 3 on the resident's BIMs (Brief Interview for Mental Status). Based on the assessment information, the resident sometimes understood communication and sometimes could be understood. She required total care from the staff for activities of daily living. Review of the facility's initial 24-Hour Report, stated under Brief Description of Reportable Incident: "Reported to facility on 7-7-11 at 3 PM Family reported concerning that they feel their loved one was sexually abused because she has had new incidence of vaginal bleeding..." On 7/8/2011, the Director of Nurses (DON) interviewed Resident #1. Review of her statement dated 7/8/2011 revealed the resident was asked if any men came in to her room or bothered her. She responded "(Resident #2) comes in has sex with me." The resident denied any sexual abuse from the staff. As the DON began opening the resident's incontinent brief for a physical examination, the resident said "That's what he does, (Resident #2), he tries to get in there." The DON noted some vaginal bleeding but no signs of obvious trauma. Review of the Nurse's Notes showed an entry on 7/8/2011 at 12:30 PM stating no vaginal bleeding was noted, and there had been no signs of vaginal bleeding for months. A note at 3:20 PM on 7/8/11 documented the allegation of abuse: "... Resident expressed that a male peer (resident) had come in to her room and touched her. Unable to express when this occurred but did identify a male resident by name (Resident #2). Call placed to Dr. George & the law enforcement division. Police came out and investigated. Instructed to send to ... Hospital for Eval (evaluation) & tx (treatment) & rape kit. ..." A grievance form documenting the family's allegation, completed by the DON, showed a communicated date of 7-8-11 with the 8 overwritten by a 7. The DON signed the document and dated it 7/7/11 at 3 PM. The State survey and certification agency was notified of the alleged abuse on 7/8/2011. The facility's initial report noted the incident was reported to the facility on [DATE] with the 8 overwritten by a 7. Resident #2 was placed under 1:1 supervision on 7/8/2011. Resident #1 returned to the facility from the hospital on [DATE] at 5:06 AM. She was placed in a different room, on the opposite side of the building. On 7/8/2011, the DON conducted interviews with the resident's past and current roommates and with the alert and oriented residents on her unit. None of the alert and oriented residents on this unit complained of inappropriate touching by male residents. Resident #2, the alleged perpetrator was independently mobile with no restrictions on his movements both in and out of the facility. There was no evidence other residents in the facility off of Resident #1's unit were interviewed. Resident #1's past roommate and her current roommate had some cognitive impairment and could not provide any useful information. Staff interview notes written by the DON, some undated and some dated 7/13/2011, revealed nine caregivers were interviewed. None of the staff members reported seeing Resident #2 go into Resident #1's room. Two of the nine staff members stated the resident had had occasional episodes of vaginal bleeding or spotting in the past months. Further review of the facility's investigation revealed an unsigned and undated statement identified by the DON as hers. The statement chronicled a number of complaints from the family, including that they noted Resident #1 was "all bruised up ... bruises on her legs resemble hand prints (right leg). She is very upset and having vaginal bleeding every so often. Resident #1 had stopped having periods. ... Her roommate states that a man comes in all the time" The facility's investigative report failed to include or address the family's observation of bruises on the resident's legs, and that one bruise resembled a hand print on the right leg. During an interview with the Administrator and the DON on 7/19/2011, the DON stated the resident's family reported their sister told them she had been abused. The investigation did not include a statement from the nurse on duty at the time the allegation was made. LPN #7, who was on duty for the 7-3 shift on 7/7/2011, was interviewed on 7/19/2011. She stated that when she came on duty that day, the resident was up in her chair because she had been restless all night. The resident continued to be restless. She was dressed in a gown and had her lap covered with a sheet. After breakfast, the resident was in the day room on the South Wing. Some yogurt had spilled on the sheet covering her legs. The resident's family members asked what the stain was from, and a CNA (Certified Nursing Assistant) answered that she did not know but it could be blood and the resident could be on her period again. Resident #1's family became upset. The CNA reported the incident to LPN #7. LPN #7 explained to the family that she had not noticed any vaginal bleeding for the past few months, and that the resident was in the day room under supervision for safety as she was so restless. The family complained that there were bruises on the resident's legs and one looked like a hand print. They claimed there was something going on and the facility was covering it up. LPN #7, the CNA, and the ADON immediately examined the resident. There was no vaginal bleeding and no suspicious markings on the resident's inner thighs or perineal area. A bruise was present on the right outer thigh, just above the knee, on the right shin and on the right wrist where the resident often banged her hand when agitated. The thigh bruise did not resemble a hand print. The leg bruises were attributed to the resident's recent falls. (Record review showed falls on 7/1/2011 and 7/5/2011.) LPN #7 described these events as occurring after breakfast. The DON documented she received the allegation at 3 PM on 7/7/2011. There was no explanation in the investigative notes for the discrepancy in times. Resident #1 was observed on 7/19/2011 at 10:55 AM. She was seated in a reclining chair by the nurse's station. She was clean, well groomed, dressed appropriately, and odor free. The resident sat forward in the chair and moved her legs to dangle on each side of the leg rest and then back up to the chair repeatedly. Her inner and outer thighs, just above the knees, made contact with the chair as she moved. Her right hand was contracted. Statements taken from the staff and residents by the DON during the facility's investigation failed to provide identifying information such as a room number for residents or the title of a staff member. First initials and last names only were provided. The DON signed the statements, but the person identified as providing the statement did not verify the information by their signature. Review of the Daily Staffing sheets from 7/4/2011 to 7/7/2011 revealed five nurses were assigned to South Unit on those days over all three shifts. LPN #7 was one of the five nurses and there was no statement from her in the facility's investigation. Possibly one nurse provided a statement. A particular last name was on one statement, and two nurses with that same last name were noted on the schedules, but the first initial on the statement did not match either first initial of the nurses. For that time period, 14 CNAs were assigned to South Unit on all three shifts. The facility obtained 5 statements from South Unit assigned CNAs. In addition, the Medical Records LPN, a North Unit LPN, and a North Unit CNA gave a statement to the DON. All of the staff members interviewed by the DON stated they had never seen Resident #2 go into Resident #1's room and/or said Resident #1 had not made a complaint of sexual abuse to them. The facility failed to interview the remainder of the South Unit staff to determine if there might be more information available. Resident #2 was interviewed at the facility on 7/18/2011. He denied any sexual contact with Resident #1 and denied any inappropriate touching of Resident #1. Resident #2 with [DIAGNOSES REDACTED]. The resident was alert and oriented and made his own healthcare decisions. His Quarterly Minimum Data Sets (MDS) with ARD dates of 4/1/2011 and 7/1/2011, coded the resident as he requiring extensive assistance with bed mobility, transfer, and toilet use. During an interview with the Director of Nursing (DON), on 7/26/2011 at 8:00 AM, she stated the resident was independent with transfers and only required assistance with putting on his pants. The amount of assistance that he needed depended on the staff that worked with him. A Physician's Progress Note dated 7/25/2011, stated, "...he has been very independent, able to come and go from facility at will without difficulties... he is able to transfer from bed to chair, dress himself, bathe himself and mostly continent..." Resident #2 propelled himself about the facility and into the community with an electric wheelchair. Review of the medical record and facility files revealed the resident was a registered sex offender. He also had a history of [REDACTED]. Review of the DON's interviews with staff revealed one staff member who stated other residents had accused the resident of theft back in 2008 and 2009. Documentation in the Social Services Progress Notes revealed multiple attempts by the facility to find alternate placement for the resident over the years. Review of the Nurse's Notes dated 6/20/2011 at 5:00 PM stated, "At 3:45 PM resident noted by charge nurse to smell of Marijuana. Reported to this nurse the Administrator and Social Services director. Call placed to the legal dept (department) and gave instructions to question resident, notify the MD and ask resident if he agreed to have the staff search his room and agreed to a drug test. He agreed to Both as he stated he has not do any drugs nor has he been around anybody who has. These three writers (Administrator, DON, and SS) began room search and after several minutes noted a Black Change type purse with 6 rings inside Similar to the ones that have been missing for several residents over the past month or So. Asked Resident #2 where these items came from and he where these items came from and he said Oh No, you're not gonna put that on me. At this point the search was stopped (by the Administrator) and call placed to the police. At this point we instructed the resident not to leave the building until the police arrives. This resident agreed and then quickly exited the building out the back door of South hall. Myself (DON) and the Administrator escorted resident back into the building and assigned a staff member to one on one." A Nurse's Note for 6:00 PM stated, "Police officers interviewing the resident as well as the other residents with missing items; 6:20 PM Police finished investigation and no arrests made at this time. Resident met with this writer and the Social Worker and stated that he did not want to stay here tonight because he does not trust anybody at this facility. Stated to him that if he was to leave that he should find a safe, secure place and not be in the streets. He appeared to listen but did not respond to us. He then left and went back to his room to make some phone calls. At this time physician was notified and gave order to obtain a urine drug screen. Sent male nurse to obtain the specimen as he verbalized to others that this writer 'planted the rings in his room'. Resident was unable to urinate at this time and that he will give the specimen later." The Nurse's Notes dated 6/22/2011 indicated urine obtained on that day was mislabeled and not processed, Resident #2 declined to give another urine specimen. In an interview on 7/18/2011 with the Administrator and Director of Nursing (DON) they stated that 5 rings and a key with "CS" (central supply) on it was found during the search. The "CS" was later identified as the Central Supply key. The search was halted when the items were found and the police called. Resident #2 left the facility by the back door during the time the police were called and after the resident was asked not to leave the building. Unknown staff members reported to the police that they saw the resident hand something in 2 bags off to two men out in back of the facility. During the search of Resident #2's room by the police officers nothing further was found. During the interview with the Administrator and DON, they stated that after finding the jewelry in the resident's room, they checked with residents and/or family members who had reported missing rings in the past months with no results. There was no evidence of any other investigation. No measures were put in place to protect residents from further potential misappropriation of property. The Administrator and DON stated the key was to the facility's central supply room. It was kept behind the South Wing nurses' station. It had been missing for about one month. On 7/7/2011, Resident #3 reported to her nurse that she had not seen her rings for over a month. The Administrator was notified and interviewed the resident on 7/8/2011. Resident #3 described the missing rings and the Administrator realized the descriptions matched 4 of the 6 rings that were found in Resident #2's room. A picture of the found rings was shown to the resident and she identified her rings. When the Administrator asked if she was interested in pressing charges against the person who stole them, the resident said: "I want to say yes." The police were notified. Resident #3 with [DIAGNOSES REDACTED]. Review of her medical record revealed she was alert and oriented with occasional periods of confusion. When the Administrator on 7/8/2011 interviewed Resident #3, the resident asked who took her rings. Then said, "Is it (Resident #2)?" When the Administrator asked her why she thought it was him, Resident #3 stated, "He is always lookin' - always lookin' around to see what we have." The resident reported to the DON on 7/13/2011, that Resident #2 had been to see her a day or two earlier and he inquired about how much her rings cost. She explained they were gifts and she did not know the cost. Resident #3 gave Resident #2 her sister's phone number. Resident #2 was interviewed on 7/18/2011, with the Ombudsman present at his request. The resident said he did sometimes go into Resident #3's room and she would ask him to go get a soda or snack from the machines for her, which he gladly did. Resident #2 denied taking the rings or the key. He stated, "The DON planted the items in his room, possibly." As of 7/19/11, no further information was forthcoming from the police about the status of the case. On 7/25/2011 at 6:15 PM the Administrator and a Corporate Consultant were notified that Substandard Quality of Care and/or Immediate Jeopardy was identified at F-157, F-225, F-226, F-250, F-279, F-309, and F-490 at a scope and severity of "J". The Substandard Quality of Care and/or Immediate Jeopardy existed in the facility on 6/20/2011 when property not belonging to Resident #2 was found in his room, law enforcement became involved, and an investigation was started that was found to be incomplete and not done timely leaving residents potentially vulnerable and at risk until interventions were implemented 7/8/2011 for their protection. Additional allegations of sexual abuse of Resident #1 by Resident #2 made on 7/7/2011 were not addressed until 7/8/2011 and again an incomplete and delayed investigation was conducted and interventions that were implemented to protect the residents did not address care and/or social needs of Residents involved in the allegations. (Residents #1, #2, and #3) On 8/1/2011 at 2:30 PM the Administrator and a Corporate Consultant were notified that Substandard Quality of Care and/or Immediate Jeopardy was identified at the additional areas of F-224, F-280, F-281, F-328, F-501, and F-520 at a scope and severity of "J". The citation at F-490, cited on 7/25/2011, was also included in this Immediate Jeopardy and the scope and severity was elevated to a "K". The Substandard Quality of Care and/or Immediate Jeopardy existed in the facility as of 7/21/2011 when Resident #6 decannulated and the necessary emergency care was not provided to the resident and the facility became aware that emergency supplies were not available for [MEDICAL CONDITION] in the building and facility staff were not adequately trained to provide all aspects of care required [MEDICAL CONDITION]. The Immediate Jeopardy was not removed upon exit from the facility on 8/2/2011 and remains ongoing.

On the days of the complaint and extended survey, based on review of the facility's investigative file for an allegation of sexual abuse, and based on review of the facility's policy and procedure for Abuse, Neglect, and Misappropriation of Property, the facility failed to follow it's procedure for allegations of physical/sexual assault, rape, molestation or coercion for 1 of 1 allegation of sexual abuse (Resident #1) and 1 of 1 allegation of Misappropriation of Property (Resident #3). Failure to investigate timely and thoroughly put all residents at risk for further abuse/misappropriation. In addition the facility failed to conduct pre-employment reference checks from on 14 of 24 newly hired employees as part of their screening policy. The findings included: Resident #1 with [DIAGNOSES REDACTED]. On 7/7/11, three of the resident's family members reported to the staff that they thought the resident had been sexually abused. The physician was not notified until 7/8/11 and ordered a transfer to the hospital for evaluation. The police, the State survey and certification agency, and the Ombudsman were also notified on 7/8/11. Resident #3 with [DIAGNOSES REDACTED]. Review of her medical record revealed she was alert and oriented with occasional periods of confusion. In an interview on 7/25/2011 at 4:00 PM, Licensed Practical Nurse (LPN) #7 stated, "It was the day after her birthday (6/25/11). She, (Resident #3) said she thought her rings were missing, she had not seen them for over a month. I told her I would report it to the Administrator. The Administrator went down and talked with Ms. ___ about her rings." Review of the Facility Five-Day Follow-Up Report dated 7/15/11 stated, "...On 7/7/11 Resident #3 reported 4 missing rings. Upon review she described the rings in detail and it became clear to the staff that these were the rings that had been given to the police on 6/20/11 regarding an investigation with Resident #2. At this time law enforcement was called and investigators came out. Resident #3 requested to press charges..." The facility failed to timely and thoroughly investigate the suspected theft resulting in an 18 day delay identifying an owner (Resident #3) of 4 of the rings and a delay in protection of other residents at risk of becoming a victim. Review of the facility's Abuse, Neglect, and Misappropriation of Property policy and procedures showed the following information under Component V: Reporting/Response "1. All alleged violations concerning abuse, neglect, or misappropriation of property are reported verbally immediately to the Administrator/Designee and other enforcement agencies, according to state law including the State Survey and Certification Agency (nurse aide registry or licensing authorities)." Review of the facility's Abuse, Neglect, and Misappropriation of Property policy and procedure showed the following information under Component VI: Investigation, section 7 Guidelines for Investigation on page SS - Section II - 9: "...C. Maintain resident's/patient's protection during the investigation. D. Notify the attending physician and resident's/patient's legally responsible party... F. Conduct/make arrangements for physical/mental examination. DO NOT CLEAN, SHOWER OR BATHE RESIDENT in allegations of physical/sexual assault, rape, molestation or coercion prior to any such examination." During review of employee files on 7/26/11 at 11:00 AM, 14 of 24 records reviewed did not have pre-employment references from previous employers. The HR (Human Resources) Director was interviewed on 7/26/2011. She stated that references were done prior to hire, sometimes she checked the references, sometimes the Director of Nurses checked them. Two of the employee files were shown to the HR Director that did not have reference checks. The HR Director stated that she would look for them. No employer references were provided by the facility. During an interview with the Administrator on 7/26/2011, she stated it was not the facility policy to conduct employment references. Review of the policy entitled "Employment Process", #4 stated, "References are checked including OIG exclusion check and abuse registry." As part of the screening process for new employees, the facility did not attempt to obtain information from previous employers for each new hire. On 7/25/2011 at 6:15 PM the Administrator and a Corporate Consultant were notified that Substandard Quality of Care and/or Immediate Jeopardy was identified at F-157, F-225, F-226, F-250, F-279, F-309, and F-490 at a scope and severity of "J". The Substandard Quality of Care and/or Immediate Jeopardy existed in the facility on 6/20/2011 when property not belonging to Resident #2 was found in his room, law enforcement became involved, and an investigation was started that was found to be incomplete and not done timely leaving residents potentially vulnerable and at risk until interventions were implemented 7/8/2011 for their protection. Additional allegations of sexual abuse of Resident #1 by Resident #2 made on 7/7/2011 were not addressed until 7/8/2011 and again an incomplete and delayed investigation was conducted and interventions that were implemented to protect the residents did not address care and/or social needs of Residents involved in the allegations. (Residents #1, #2, and #3) On 8/1/2011 at 2:30 PM the Administrator and a Corporate Consultant were notified that Substandard Quality of Care and/or Immediate Jeopardy was identified at the additional areas of F-224, F-280, F-281, F-328, F-501, and F-520 at a scope and severity of "J". The citation at F-490, cited on 7/25/2011, was also included in this Immediate Jeopardy and the scope and severity was elevated to a "K". The Substandard Quality of Care and/or Immediate Jeopardy existed in the facility as of 7/21/2011 when Resident #6 decannulated and the necessary emergency care was not provided to the resident and the facility became aware that emergency supplies were not available for [MEDICAL CONDITION] in the building and facility staff were not adequately trained to provide all aspects of care required [MEDICAL CONDITION]. The Immediate Jeopardy was not removed upon exit from the facility on 8/2/2011 and remains ongoing.

On the days of the complaint and extended survey, based on record review, interviews, review of the facility's policy on Extreme Heat, and review of the facility's investigative files, the facility failed to ensure the physician was immediately notified of 1 of 1 allegation of sexual abuse and 1 of 1 sampled resident with weight loss and possible heat related illness. The family of Resident #1 voiced concerns to a staff member on 7/7/2011 that Resident #1 may have been sexually abused. The Registered Dietitian (RD) was not notified when Resident #9 experienced a significant weight loss and the physician was not notified when the Resident #9 was found outside in the heat, lethargic and experiencing symptoms of possible heat exhaustion. The findings included: Resident #1, a fifty year old female, with [DIAGNOSES REDACTED]. On 7/7/11, the resident's family members alleged to staff that Resident #1 had been sexually abused. A review of the facility Complaint/Grievance Report signed 7/7/2011 at 3 PM revealed the statement "Family Expressed concern that they feel that Ms... has been sexually abused because she is having new onset bleeding". Review of an Incident Report by local law enforcement documented "...When the deputy arrived, he spoke with Ms...(Administrator). Ms... (Administrator).stated that Ms... (Resident #1) sister approached her yesterday (7/7/2011) and stated that her sister (Victim) was bleeding from her vagina. Ms...(Administrator) stated an investigation was started and the Director of Nursing was notified..." Review of the Nurses Notes found no documentation of an allegation or investigation until 7/8/2011 at 3:20 PM when it was noted "F/U (Follow-up) c (with) resident regarding family concerns about vaginal bleeding. Resident (#1) expressed that a male peer (resident #2) had come in to her room and touched her. Unable to express when this occurred but did identify a male resident by name. Call placed to Dr. ... & the Law enforcement division. Police came out and investigated. Instructed to send to ... for Eval (evaluation) & rape kit. Calls placed to Family & unable to be reached..." Review of the facility records revealed the concern of suspected sexual abuse was reported to the facility on [DATE] at 3 PM and not addressed until 7/8/2011 at 3:20 PM when a facility staff member examined Resident #1. At that time Resident #2 was identified as a possible perpetrator. Resident #1's physician and Law Enforcement were not notified until 24 hours after the initial allegation of suspected abuse. The date of physician notification of the allegation was confirmed during an interview with the physician on 7/19/11 at 2:45 PM. The facility admitted Resident #9 on 4/28/2011 with [DIAGNOSES REDACTED]. Record review revealed Resident #9 sustained a 19% weight loss in less than 4 weeks. Review of the Nurses Notes revealed on 6/4/2011 the resident's family member reported the resident was dehydrated. On 6/7 the resident was noted down the service hallway by the exit door. On 6/19 at 11:45 AM, "Res alert and oriented x 2 with confusion noted. Resident's son found resident in hall near front entrance without pants on and with a brief and shirt." On 6/19/2011 at 5:30 PM a late entry documented "upon entry to the building noted resident sitting halfway undressed on the front porch. Was hot and slightly lethargic... Assisted back to the room and turned on AC unit. Placed cool towels and washcloths to help cool him..." There was no documentation that the Attending Physician was notified of the incident. During an interview on 8/2/2011 at 12:35 PM, the Food Service Director stated that if a significant weight loss was detected then the Registered Dietitian would be notified as well as the doctor. During an interview on 8/2/2011 at 2:15 PM, the Registered Dietitian stated that she saw the resident on 6/2/2011 and confirmed that she did not address the significant weight loss. The RD stated that she was in the building on 6/12 but did not see Resident #9. She stated that the facility staff did not inform her of the continued significant weight loss. The RD stated that she did not contact the Attending Physician for further interventions and confirmed that no interventions were put in place to address the resident's significant weight loss. The RD confirmed that Resident #9 was not provided adequate hydration. During an interview on 8/2/2011 at 3 PM, the Assistant Director of Nurses (ADON) confirmed the RD and the doctor were not notified of the loss. The ADON confirmed there was no documentation that the physician was notified of the resident going outside and subsequent heat exhaustion. Review of the facility's policy on Extreme Heat revealed, "the physician should be notified promptly to obtain specific directions for care. Depending on the time and exposure this event may require a self report to the state agency per regulations. " On 7/25/2011 at 6:15 PM the Administrator and a Corporate Consultant were notified that Substandard Quality of Care and/or Immediate Jeopardy was identified at F-157, F-225, F-226, F-250, F-279, F-309, and F-490 at a scope and severity of "J". The Substandard Quality of Care and/or Immediate Jeopardy existed in the facility on 6/20/2011 when property not belonging to Resident #2 was found in his room, law enforcement became involved, and an investigation was started that was found to be incomplete and not done timely leaving residents potentially vulnerable and at risk until interventions were implemented 7/8/2011 for their protection. Additional allegations of sexual abuse of Resident #1 by Resident #2 made on 7/7/2011 were not addressed until 7/8/2011 and again an incomplete and delayed investigation was conducted and interventions that were implemented to protect the residents did not address care and/or social needs of Residents involved in the allegations. (Residents #1, #2, and #3) On 8/1/2011 at 2:30 PM the Administrator and a Corporate Consultant were notified that Substandard Quality of Care and/or Immediate Jeopardy was identified at the additional areas of F-224, F-280, F-281, F-328, F-501, and F-520 at a scope and severity of "J". The citation at F-490, cited on 7/25/2011, was also included in this Immediate Jeopardy and the scope and severity was elevated to a "K". The Substandard Quality of Care and/or Immediate Jeopardy existed in the facility as of 7/21/2011 when Resident #6 decannulated and the necessary emergency care was not provided to the resident and the facility became aware that emergency supplies were not available for [MEDICAL CONDITION] in the building and facility staff were not adequately trained to provide all aspects of care required [MEDICAL CONDITION]. The Immediate Jeopardy was not removed upon exit from the facility on 8/2/2011 and remains ongoing.

On the days of the Complaint and Extended survey based on observations, record review and interviews the facility failed to identify a concern and develop a plan of action for residents with tracheostomies. Residents #6, #7 and #8 failed to have the necessary and appropriate supplies at the bedside. (2 of 2 residents with tracheostomies reviewed and 1 of 3 closed records of residents with tracheostomies.) The findings included: Observation of Resident #7 and #8's room revealed Resident #8 did not have the appropriate supplies at the bedside. Resident #7 failed to have the necessary emergency supplies readily available. Observation during the survey of the unit supply rooms and the central supply room revealed no size 6 Shiley [MEDICAL CONDITION]. During an interview on 8/1/2011 at 12:00 PM, the Nurse Consultant and the Director of Nurses confirmed there were no size 6 [MEDICAL CONDITION] house and confirmed the necessary emergency supplies were not at the residents' bedsides. Review of the July 2011 General Spending Ledger revealed no Size 6 Shiley tracheostomies were ordered. During an interview on 8/1/2011 at 3:15 PM, the Director of Nurses (DON) confirmed she was aware of LPN #1's statement related to Resident #6, found with [MEDICAL CONDITION] her hand, of "freaking out" and the lack of knowledge regarding emergency management of tracheostomies. The DON also stated that there were no inservices conducted related to emergency management of tracheostomies,[MEDICAL CONDITION] outs or emergency supplies at the bedside. During an interview on 8/2/2011 at 9:45 AM, the Nurse Consultant stated that both the DON and the Nurse Consultant that was present during investigation of the incident with Resident #6 were aware the [MEDICAL CONDITION] were not in the facility. The Nurse Consultant stated that an ACLS (Advanced Cardiac Life Support) nurse had arrived at the facility on 8/2/2011 to perform the inservices to the nurses regarding the emergency management of trachs and replacing a decannulated trach. During an observation on 8/2/2011 at 11 AM, the ACLS Nurse was observed providing one to one training. The training only [MEDICAL CONDITION]. The training did not include replacing a decannulated trach, emergency management or competency checks. During an interview on 8/2/2011 at 3 PM, the Assistant Director of Nurses (ADON) stated that she reported to the Nurse Consultant that there were not the necessary emergency supplies at the resident's bedside. The ADON stated that she was told the nurse consultant would "take care of it." She also stated that all supplies were ordered through central supply. However, the central supply aid has been on suspension for 3 weeks. The ADON stated that she was not sure who was responsible for the procurement of the supplies. On 7/25/2011 at 6:15 PM the Administrator and a Corporate Consultant were notified that Substandard Quality of Care and/or Immediate Jeopardy was identified at F-157, F-225, F-226, F-250, F-279, F-309, and F-490 at a scope and severity of "J". The Substandard Quality of Care and/or Immediate Jeopardy existed in the facility on 6/20/2011 when property not belonging to Resident #2 was found in his room, law enforcement became involved, and an investigation was started that was found to be incomplete and not done timely leaving residents potentially vulnerable and at risk until interventions were implemented 7/8/2011 for their protection. Additional allegations of sexual abuse of Resident #1 by Resident #2 made on 7/7/2011 were not addressed until 7/8/2011 and again an incomplete and delayed investigation was conducted and interventions that were implemented to protect the residents did not address care and/or social needs of Residents involved in the allegations. (Residents #1, #2, and #3) On 8/1/2011 at 2:30 PM the Administrator and a Corporate Consultant were notified that Substandard Quality of Care and/or Immediate Jeopardy was identified at the additional areas of F-224, F-280, F-281, F-328, F-501, and F-520 at a scope and severity of "J". The citation at F-490, cited on 7/25/2011, was also included in this Immediate Jeopardy and the scope and severity was elevated to a "K". The Substandard Quality of Care and/or Immediate Jeopardy existed in the facility as of 7/21/2011 when Resident #6 decannulated and the necessary emergency care was not provided to the resident and the facility became aware that emergency supplies were not available for [MEDICAL CONDITION] in the building and facility staff were not adequately trained to provide all aspects of care required [MEDICAL CONDITION]. The Immediate Jeopardy was not removed upon exit from the facility on 8/2/2011 and remains ongoing.

On the days of the complaint and extended survey based on record review the facility failed to ensure that appropriated psychosocial services were provided for 1 of 5 residents reviewed with tracheostomies. Resident #8 had no behavior monitoring/supervision or interventions in place to address his know behavior of pulling at [MEDICAL CONDITION] attempting to decannulate. One of 1 resident reviewed with dehydration. Resident #9's with known wandering and exit seeking behaviors; and resisting nourishment had not interventions in place to address these behaviors. Resident #9 admitted to the hospital with [REDACTED]. The findings included: The facility admitted Resident #8 on 7/1/2011 with [DIAGNOSES REDACTED]. Review of the Nurse's Notes revealed on 7/23/2011 "[MEDICAL CONDITION] writer (LPN #3)found out that inner cannula is absent. " During an interview on 8/1/2011 at 10:30 AM, LPN #3 stated that Resident #8 had pulled his inner cannula out again this morning. LPN #3 confirmed that Resident #8 had pulled out his inner cannula on previous occasions. Record review revealed no behavior monitoring or supervision for Resident #8. Also, there were no interventions in place to prevent Resident #8 from pulling at [MEDICAL CONDITION] attempting to decannulate. The facility admitted Resident #9 on 4/28/2011 with [DIAGNOSES REDACTED]. Record review revealed Resident #9 sustained a 19% weight loss in less than 4 weeks. Review of the Nurse's Notes revealed multiple entries that indicated Resident #9 would disconnect his tube feeds and saturate the bed with formula. Further review revealed on 6/4/2011 the resident's family member reported the resident was dehydrated. On 6/7/2011 the resident was noted down the service hallway by the exit door. On 6/19/2011 at 11:45 AM, "Res alert and oriented x 2 with confusion noted. Resident's son found resident in hall near front entrance without pants on and with a brief and shirt." On 6/19/2011 at 5:30 PM a late entry documented, "upon entry to the building noted resident sitting halfway undressed on the front porch. Was hot and slightly lethargic... Assisted back to the room and turned on AC unit. Placed cool towels and washcloths to help cool him..." Review of the ADL Tracking Log for June 2011 revealed Resident #9 refused all meals. Resident #9 was noted to self propel himself in the wheelchair. Resident #9 was also noted to be alert and oriented times three on admission. However, he had increasing confusion during the month of June 2011. Review of the Neurological Flowsheet dated 6/17 through 6/20/2011 revealed Resident #9 was confused at all times. Further record review revealed no behavior monitoring or interventions in place related to the resident's behavior of disconnecting his tube feeding or his increased confusion with exit seeking behavior. During an interview on 8/2/2011 at 3 PM, the Assistant Director of Nurses (ADON) confirmed Resident #9 had increasing confusion. The ADON also confirmed that no interventions were put in place related to Resident #9's known wandering and exit seeking. The ADON confirmed that Resident #9 was outside for an undetermined amount of time and was not provided adequate hydration.

On the days of the complaint and extended survey based on record review and interview the facility failed to assure 1 of 1 residents maintained acceptable parameters of nutrition and body weight. Resident #9 sustained a 19% weight loss in less than 4 weeks. The findings included: The facility admitted Resident #9 on 4/28/2011 with [DIAGNOSES REDACTED]. Record review revealed a dietary assessment dated [DATE] that indicated Resident #9 required 2300-2400 milliliters of fluid a day and required 2300 calories per day. Resident #9 was ordered [MEDICATION NAME] 1.5, 1 can every 4 hours and 150 ml water flushes every 4 hours. Resident #9's weight was noted to be stable at 175 pounds for the month of May 2011. On 5/24/2011 an order was written for [MEDICATION NAME] 1.5 at 110 ml/hr from 7PM-5AM, 8AM-10 AM, 1PM-3PM and 5PM-6PM with water flushes every 4 hours. On 6/1/2011, Resident #9's weight decreased to 159.2 pounds. A significant loss of 9% in approximately 2 weeks. The Registered Dietitian saw Resident #9 on 6/2/2011 and did not note the significant weight loss. Furthermore the tube feeds were decreased to 80 ml/hr for 12 hours with 150 ml water flushes every 4 hours. The new order provided Resident #9 with 900 ml of water and 960 ml of formula (significantly less than the required amount). Resident #9's weight on 6/9/2011 was 154.6, another 3 % loss in one week. On 6/13/2011 Resident #9 weighed 147, a 5 % loss on one week. Resident #9 sustained a 19% weight loss in less than 4 weeks. Review of the physician's orders [REDACTED]. Review of the Nurse's Notes revealed multiple entries indicated Resident #9 would disconnect his tube feeds and saturate the bed with formula. Review of the ADL Tracking Log for June 2011 revealed Resident #9 refused all meals. Further record review revealed no documentation of intake and output for Resident #9. No behavior monitoring or interventions were put in place related to the resident's behavior of disconnecting his tube feeding. During an interview on 8/2/2011 at 2:15 PM, the Registered Dietitian stated that Resident #9 did not tolerate the [MEDICATION NAME] tube feeds because he felt too full. She also stated that he would disconnect his continuous tube feeds. The RD stated that she was trying to find a way to provide Resident #9 his required nutrition but stated that she "didn't know what else to do." The RD stated that she saw the resident on 6/2/2011 and confirmed that she did not address the significant weight loss. Also, she confirmed, that the order was changed to decrease the amount of formula. She stated that the Attending Physician changed the order and she was not aware of the change until after the resident was discharged . The RD stated that she was in the building on 6/12 but did not see Resident #4. She stated that the facility staff did not inform her of the continued significant weight loss. The RD stated that she did not contact the Attending Physician for further interventions and confirmed that no interventions were put in place to address the resident's significant weight loss. During an interview on 8/2/2011 at 3 PM, the Assistant Director of Nurses (ADON) confirmed the significant weight loss of Resident #9, confirmed the RD and the doctor were not notified of the loss. She also confirmed no interventions were put in place related to the weight loss.

On the days of the complaint and extended survey based on record review, interview and review of the facility's policy on Extreme Heat, the facility failed to assure one of one residents reviewed for hydration received adequate fluid intake to prevent dehydration. Resident #9 not adequately assessed regarding enteral and oral intake of fluids/nourishment became dehydrated resulting in hospitalization on [DATE]. The findings included: The facility admitted Resident #9 on [DATE] with [DIAGNOSES REDACTED]. Record review revealed Resident #9 sustained a 19% weight loss in less than 4 weeks. Review of the Nurses Notes revealed multiple entries indicated Resident #9 would disconnect his tube feeds and saturate the bed with formula. Further record review revealed no documentation of intake and output for Resident #9. Review of the Nurse's Notes revealed on [DATE] the resident's family member reported the resident was dehydrated. Yogurt was offered and the resident declined water. His tube was flushed with 90 ml of water. The resident was noted with confusion at times. On [DATE] at 7:30 PM, "resident decided to go sit outside for awhile and removed shirt exposing self, gentle encouragement to come back into building." On ,[DATE] at 11:45 AM, "Res alert and oriented x 2 with confusion noted. Resident's son found resident in hall near front entrance without pants on and with a brief and shirt." On [DATE] at 5:30 PM a late entry documented "upon entry to the building noted resident sitting halfway undressed on the front porch. Was hot and slightly lethargic. Asked resident to come inside and he stated no. Expressed to him that he needed to come in or he would get heat exhaustion. He then agreed to come in. Assisted back to the room and turned on AC unit. Placed cool towels and washcloths to help cool him. Offered fluids and he declined. Would not allow staff to provide any fluids via tube. " On [DATE] at 5:30 PM, "summoned to North Wing by resident's family member. Noted resident sitting up in wheelchair with signs and symptoms of lethargy. O2 sat fluctuating, 911 called..." Review of the Emergency Department's record from the Hospital dated [DATE] revealed Resident #9's [DIAGNOSES REDACTED]. Acute Dehydration 2. [MEDICAL CONDITION]. " Resident #9's labs were as follows: Sodium 162 (high), Chloride 117 (high), Glucose 198 (high), BUN 48 (high). Resident #9 received one liter of IV fluids in the ER. During an interview on [DATE] at 2:15 PM, the Registered Dietitian stated that Resident #9 was not provided adequate hydration. During an interview on [DATE] at 3 PM, the Assistant Director of Nurses (ADON) confirmed that Resident #9 was outside for an undetermined amount of time and was not provided adequate hydration. The ADON confirmed there was no documentation that the physician was notified of the resident going outside and subsequent heat exhaustion. The ADON confirmed that Resident #9 was sent to the hospital for dehydration. Resident #9 expired on [DATE]. Review of the facility's policy on Extreme Heat revealed the symptoms of heat stroke/exhaustion included "headache, dizziness, weakness, the person may be confused and may find it difficult to coordinate body movements. Treatment should include removing person to cool environment and encouraging increased consumption of fluids. The physician should be notified promptly to obtain specific directions for care. Depending on the time and exposure this event may require a self report to the state agency per regulations."

On the days of the complaint inspection, based on record reviews, observations, interviews, and review of the facility's investigative materials related to a resident's fall from bed and an injury of unknown origin, the facility failed to ensure the residents received adequate supervision and assistance devices to prevent accidents, and failed to properly supervise staff to ensure compliance with safety measures for 1 of 1 resident reviewed who sustained a serious injury from a fall (#1) and for 1 of 1 resident reviewed for a fracture of unknown origin (#3). On the night of 4/27-28/11, the staff failed to ensure Resident #1 had both side rails raised on her bed, and failed to ensure the bed was in the lowest position. At approximately 1:45 AM, the resident fell from the bed and sustained an abrasion to the forehead, and hematomas to the forehead, and upper lips and philtrum. There was also a questionable fracture at the base on the left hand fifth digit. Certified Nursing Assistant (CNA) #1 saw the side rails down when she began her shift and "assumed" the order for them had been changed. On 5/10/11, Resident #3 was found to have right ankle swelling and discoloration. An x-ray showed a fractured distal fibula. The facility's investigation revealed CNA #2 transferred the resident on 5/8/11 without using the required sit to stand lift and without the assistance of a second person. The resident's ankle became twisted in the CNA's legs during the transfer. CNA #2 acknowledged knowing he was supposed to use the lift but did not use it with the resident on 5/8/11. The findings included: Resident #1 with [DIAGNOSES REDACTED]. Review of the resident Minimum Data Sets for 4/19/10 and 4/7/11 showed the resident had short and long term memory problems with severely impaired decision making ability. The resident rarely understood communication, and others rarely understood the resident. She required total care from the staff for all activities of daily living. Neither assessment showed any falls. Review of the Nurse's Notes on 5/2/11 showed an entry for 4/28/11 at 1:45 AM saying: "resident noted on floor (with) tube feeding connected but beeping flow error noted lying on her back (with) head tilted back blood noted to forehead and floor swelling noted to (R) eyebrow redness and swelling noted to (L) forearm bed noted in mid air and side rails on each side of the bed noted to be down after assisting resident (with) the assist of the CNA resident transferred to bed cleaned resident's forehead (with) NS (normal saline) to assess where bleeding was coming from slit noted to forehead actively bleeding ask other nurse to get me a gauze and some tap (sic) and placed a dressing on forehead left other nurse and CNA (with) resident notified MD (medical doctor) of resident's condition and what occurred and received order to send resident to ER (emergency room ) call 911 to transport resident to ... and started neurocheck notified family of occurrence and order to send resident to ER for evaluation of condition." Nurse's Notes for 4/28/11, other than the late entry above, began at 3 PM and noted swelling and discoloration to the resident's forehead and eyes. Edema and discoloration was also noted to the left forearm. The 10 PM nurse's note included: " ... Side rails are up on both side and bed in low position. ..." Resident #1's physician examined her on 4/28/11 and noted "Pt (patient) fell out of bed last (Wed) nite suffered hematoma to forehead & upper lips & philtrum. X-rays of (L) hand -? fx (fracture) at base of 5th digit. ... Swelling & discoloration to forehead (with) central abrasion. ... upper lip & philtrum (with) bluish discoloration & swelling. ... (increase) pain meds to Tylenol #3 cool compress applied x24 (hours)" The resident was observed on all days of the complaint inspection to have both side rails raised when she was in bed. Her bed was kept in a mid-height position, not at the lowest position. Review of the resident's care plan dated 7/20/10 showed a problem of potential for falls and injuries related to impaired mobility, total care, and seizure disorder. "Has side rails (up times) 2 for bed parameters & safety (secondary to) seizures." The approaches to this problem included having the side rails up on each side of the bed. On 4/14/11, the care plan was reviewed and revised. It continued to show the problem of potential for falls and injuries. Approaches to this problem included the Falling Star Program and both side rails raised on the bed. Review of a Physical Restraint assessment dated [DATE] showed the resident required the use of bilateral bed rails due to seizure precautions, and because the resident fidgeted, was restless, and leaned while in bed. Review of the resident's cumulative physician's orders [REDACTED]. (diagnosis) seizures." Review of the Assignment sheets used by the CNAs at the time of the resident's fall showed the resident was to have side rails up on both side of the bed. At the bottom of the assignment sheets was the message: "ALL BEDS MUST BE IN LOWEST POSITION!" Review of the facility's investigation showed the following information: CNA #2, who was assigned to the resident on the 3-11 shift, stated he made last rounds on the resident at approximately 10:15 PM and side rails were "completely up." CNA #2 continued to say that both side rails were up at all times when he was on duty. CNA#1, who was assigned to the resident on the 11-7 shift said she saw the resident at approximately 11:15 PM and both side rails were down. She checked on the resident again at 12:45 PM and the resident appeared "OK." CNA #1 heard the tube feeding pump alarm and entered the room to see the resident on the floor. She summoned the nurse. CNA #1 reported in her interview with the Social Worker, "... that she was unaware of resident required to have side rails up, and could not find it in the book." LPN #6 responded to CNA #1's call and found the resident lying on the floor face down. There was blood on the floor. The resident was turned to her back, examined, and then lifted back to bed. According to the statement written by the Social Worker who interviewed LPN #6: "Nurse asked CNA if the side rails were down, and CNA stated 'yes.' The CNA stated the side rails were down when she completed her rounds, and assumed it was an order in place to have the side rails down." LPN #1 went to the resident with LPN #6 and noted the resident in the same condition. The ADON (Assistant Director of Nurses) wrote in her interview notes: "... Mr. (NAME REDACTED) stated he talked to (CNA #1) shortly after the incident & she stated that she noticed (resident's) side rails to be down but did not think much of it & thought that maybe there had been a change." LPN #2, who wrote the late entry nurse's note, said in her interview with the Social Worker that the resident was on her back by the time she entered the room. "... Transferred Resident to bed (with) CNA's and nurse, side rails noted to be already down when Resident found (with) air mattress inflated and bed in mid air." Interviews conducted during the complaint inspection revealed the following information: LPN #1, the 11-7 nurse, said he had not done rounds on the resident before being summoned to the resident's room. He confirmed that the bed was not in the lowest position. When asked about the side rails, he thought one was not up, on the side where the resident fell from the bed. LPN #1 thought CNA #1 knew the side rails were down but she thought they were discontinued so she did not say anything to the nurses. LPN #2 stated when she entered the room both side rails were down. She acknowledged the side rails were supposed to be raised on both sides of the bed. CNA #1, who was employed with the facility since 2005,stated in her interview that she found the side rails down on first rounds and the resident was "fine." The resident continued to be "fine" on second rounds. CNA #1 checked the book for a side rail order and did not find a paper for 11-7 (the assignment sheet). Because both side rails were down, she thought it could not be that a CNA forgot to raise them but the order for the side rails must have changed. She acknowledged that she did not check any of the other shift assignment sheets to see what devices the resident might need. When asked if she consulted the nurses about the side rails, CNA #1 stated she did not. CNA #1 stated the bed was not in its lowest position but was at "standard" height. She said the bed was always supposed to be in the lowest position but it was never kept in the lowest position. CNA #1 said she used "poor judgment" that night. Resident #3 with [DIAGNOSES REDACTED]. Review of the resident assessment Minimum Data Sets of 8/31/10 and 5/20/11 showed the resident required extensive assist of two people for transfer with a mechanical lift on the earlier assessment, and was noted to require the total assist of two people for transfer on the later assessment. Review of the Nurse's Notes showed an entry on 5/10/11 at 12:30 PM saying the resident complained of pain in her right ankle. The ankle had swelling, and was warm and painful to touch. When asked what happened, the resident stated her bed fell on her foot. The resident's roommate reported that Resident #3 hit her foot when being put to bed "last night." An X-ray showed a fractured distal fibula. The facility's investigation revealed Resident #3 was transferred to bed on 5/8/11 by CNA #2, without the sit to stand lift and without the assistance of a second person. CNA #2 reported to the Administrator on 5/10/11 that: "when putting her to bed me & (resident) got twisted up. Her ankle got wrapped around my leg. I didn't use a lift. I know I was supposed to use a lift, but sometimes she won't let me use it on her. No, I never told a nurse I just put her to bed. I wasn't thinking. ..." When asked if he checked the assignment sheet to see that she required a lift, CNA #2 responded: "I only look @ the names of the people I have. I never look @ that stuff. ..." CNA #2 worked at the facility since 1/17/11. Review of the resident's care plan dated 9/8/10 showed the resident required assistance with transfer. On 5/26/11, a notation was added to the problem of Falls/Injuries that said "sit to stand lift for transfers." Review of the Assignments 200-223 sheets used by the CNAs at the time of the incident, revealed the resident required "stand lift" for transfers from bed to chair.