Every finding on record at Mt Pleasant Healthcare and Rehabilitation

Based on policy review, review of facility documents and interview, the facility failed to provide a Dietary Manual (an officially recognized, evidence-based reference used by healthcare facilities to guide the preparation, ordering, and administration of patient diets) that was approved by the Registered Dietician and the Medical Director. The census was 54, with all residents receiving meals from the kitchen. The findings include: Based on the facility policy titled, Diet Manual, dated 10/2019, revealed .It is the center policy to use an approved diet manual for manual planning for regular and therapeutic diet plans .The medical director reviews and approves the diet manual annually .The Dining Service Director ensures that a copy of the Diet Manual will be available in the Dining Service Department and at other locations indicated . The Dining Service Director and Registered Dietitian or other clinically qualified professional, will ensure that the Diet Manual serves as a guide for ordering diets and that the menus served, will be consistent with the diet manual . The facility was unable to provide a Dietary Manual which included signatures of the Medical Director and Registered Dietitian. During an interview on 6/24/2026 at 3:10 PM, the Dietary Manager (DM) was asked if the kitchen had a manual with therapeutic diets with signatures of the Medical Director and the Registered Dietician. The DM stated, No. During an interview in the Administrator's office on 6/24/2026 at 3:12 PM, the Administrator (ADM) was asked should the facility have a dietary manual that is signed by the Medical Director and the Registered Dietician. The ADM stated, Do not think it is a requirement. The Administrator presented a [Named Food Service and Facility Management Company].Manual as the dietary manual. The ADM was asked if the manual had a signature by the Medical Director and the Registered Dietician. The ADM stated, No. The ADM was asked for a copy of the manual. The ADM stated, I have never given a whole manual. Review of the [Named company] .Dining Services Policy and Procedure Manual on 6/24/2026 at 3:59 PM, revealed the document was not signed by the Medical Director and the Registered Dietician. During an interview in the hallway, across from the ADM's office, on 6/24/2027 at 5:30 PM, the ADM approached the surveyors and stated, I gave the Dietary Manual. This surveyor and the team leader presented the [Named company] .Dining Services Policy and Procedure Manual to the ADM and asked if this was the dietary manual. The ADM stated, Yes. The facility failed to present an approved Diet Manual in accordance with the facility policy.

Based on facility policy review, medical record review, observation, and interview, the facility failed to ensure proper infection control practices were followed when 1 of 1 staff member (Certified Nurse Assistant (CNA) A) failed to properly handle soiled linens. The findings include: 1.Review of the facility policy titled, Infection Prevention and Control Program Policy, dated 4/2026, revealed .The facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable disease and infections.All staff shall assume that all residents are potentially infected or colonized with an organism that could be transmitted during the course of providing resident care services.Soiled linen shall be collected at the bedside and placed in a linen bag Soiled linen shall not be kept in the resident's room or bathroom . 2. Review of the medical record revealed Resident #40 was admitted to the facility on [DATE], with diagnoses including Alzheimer's, Dementia, Lack of Coordination, and Hypertension. Review of the quarterly Minimum Data Set assessment dated [DATE], revealed Resident #40 scored a 2 on the Brief Interview for Mental Status assessment, which indicated he was severely cognitively impaired. Resident #40 was always incontinent of bladder and bowel. During an observation and interview in Resident #40's room on 6/22/2026 at 3:58 PM, revealed bed linen with a large tan spot on the bed sheets on the floor. CNA A was asked if the bed linen on the floor was dirty. CNA A stated, I did a bed change and put them on the floor. CNA A was asked should the dirty bed linen be on the resident's floor. CNA A stated, No. CNA A was asked what should be done with dirty bed linen when changing a resident's bed. CNA A stated, I should put it in a plastic bag.should not have dirty linen on the floor. CNA A failed to handle soiled linens in a manner to prevent the potential spread of infection and in accordance with the facility policy. During an interview on 6/24/2026 at 3:02 PM, the Director of Nursing (DON) was asked how dirty, soiled linen should be handled. The DON stated, In general, dirty linen should be placed in a clear plastic bag, tied up, and taken into the utility room. The DON was asked should dirty, soiled linen be placed on the floor after a bed change. The DON stated, No.

Based on facility assessment review, medical record review, facility ADL (Activities of Daily Living) documentation review, facility staffing time punch review, observations, and interviews, the facility failed to maintain adequate staffing levels to meet the ADL needs (bathing/showers, grooming, and skin care) for 5 residents (Residents #7, #8, #13, #19, and #32) of 20 residents reviewed for ADL care. The findings include: 1. Review of the facility assessment dated [DATE], revealed . Average Daily Census (ADC) .50 .Registered Nurse Hours per Resident Day . 18.76 .Licensed Nurse Hours per Resident Day .55.20 .Nurse Aide Hours per Resident Day .55.01 .Total Nursing Hours per Resident Day .128.97 . 2. Review of the facility policy titled Nursing Services and Sufficient Staff, dated 1/23/2025, revealed .The facility will supply services by sufficient numbers of each of the following personnel types on a 24-hour basis to provide nursing care to all residents .nurse aides . Review of the facility policy titled, Facility Assessment, last revised on 1/25/2025, revealed .The facility conducts and documents a facility-wide assessment to determine what resources are necessary to care for our residents . The facility assessment will, at a minimum, address or include .the facility's resident population .The care required by the resident population .The facility will use the facility assessment to . Inform staffing decisions to ensure there are a sufficient number of staff .Consider specific staffing needs for each resident unit .each shift .and adjust as necessary based on any changes to its resident population .The facility assessment will be reviewed and updated as necessary and at least annually .based on changes to resident population . 3. Review of Licensure Staffing Requirements for 2/15/2025- 3/14/2025, revealed the facility census average for that period was 65. Review of Licensure Staffing Requirements for 2/15/2025- 3/14/2025, revealed on 2/15/2025, 2/22/2025, and 2/23/2025 the Aide hours were below the facility's assessment of 1.1 nurse aide hours per resident. Continued review revealed on 2/15/2025 nurse aide hours per resident were 0.73. Review revealed on 2/22/2025 nurse aide hours per resident were 1.08. Review revealed on 2/23/2025 nurse aide hours per resident were 1.04. Review of the Federal requirement for 483.35(b) Registered nurse, 483.35(b)(1), and 483.35(b)(3) for F727 revealed, . Except when waived under paragraph (e) or (f) of this section, the facility must use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week .483.35(b)(3) The director of nursing may serve as a charge nurse only when the facility has an average daily occupancy of 60 or fewer residents . 4. Review of the clock in and clock outs for 2/15/2025 from 7:32 AM until 6:51 PM (11 hours 19 minutes) [named Certified Nursing Assistant CNA #E] was the only CNA in the facility. Review of the clock in and clock outs for 3/15/2025 from 10:30 PM until 3/16/2025 at 7:06 AM (8 hours 36 minutes) revealed CNA #Q was the only CNA in the facility. 5. The facility failed to provide adequate personal hygiene and bathing Activities of Daily Living for Resident #8, #13, #19, and #32. 6. The facility failed to obtain timely skin treatment orders for Resident #8. 7. The facility failed to maintain Registered Nurse (RN) coverage for 8 consecutive hours a day 7 days a week. 8. During an interview on 3/19/25 at 11:11 AM, CNA A stated, .I am taking care of 20 residents today .the hospitality aides answer call lights, help with activities, pass ice, they cannot give any direct care because they are uncertified . During a telephone interview on 3/19/2025 at 6:03 PM, CNA B was asked about staffing for the facility. CNA B stated, .it is bad .I work night shift 7 PM to 7 AM, there have been numerous nights I have come in and meals are still not passed out and I have to feed residents on the hall .I know it's going to be a bad night if the trays are still on the hall .the nurses are having to work the floor as CNAs at times because we don't have enough help .baths are not getting done . CNA B was asked if she was able to complete incontinence care, turning and repositioning every 2 hours. CNA B stated, .when we come in and trays are still out it maybe 8:30 [8:30 PM] or 9:00 [9:00 PM] before we can ever start our turns by that time the residents are soaked .residents are left up in their chairs all day and when I go to get them out of the chair with the lift, the urine will get on me .I know of several days that only 1 CNA in the whole building .there are times I don't get to sit down to do any charting until 12:00 [12:00 AM] .I have expressed my concerns to nursing and they tell me just take a break for a little while .If you raise any concerns about the resident care the management staff will say your being aggressive .they want that point of care charting to be 100% .resident with skin issues, rashes, UTI's [Urinary Tract Infections] and it is because they are sitting in s . for hours .residents that really need 2 person assist you have to find help because they are so fragile I am afraid I might hurt them and that is hard when you are on the hall by yourself .there are 3 areas where you can chart showers either on paper or when you go in the computer you click on a link for ADLs and you either chart shower or bath . During an interview on 3/20/2025 at 9:08 AM, CNA N was asked why most CNA's have 20 residents a piece to care for CNA N stated, We have been short staffed this week. During an interview on 3/20/2025 at 8:20 AM, Licensed Practical Nurse (LPN) L confirmed she tries to assist staff with rounds when she can but her duties as a nurse often consume all her time. LPN L stated that there were 2 CNAs on her hall but now it is 1 and it is a lot for them to do. During an interview on 3/20/2025 at 8:27 AM, Registered Nurse (RN) J was asked how many CNAs usually work during the day. RN J stated, .We like to run 5-6, but we've had a lot of sickness over the last month. Most days we have had 4 people, this week has been harder, mostly 3 this week . During an interview on 3/20/2025 at 4:46 PM, the Director of Nursing (DON) was asked if a CNA could give adequate care to 20 residents. The DON stated that they could if they have support from the nurses, and that the nurses could assist with giving showers and doing ADLs between med passes. The DON confirmed the morning medication pass takes 2 to 3 hours and nurses give medications throughout the day, assist with meals, provide wound care, communicate with family and physicians, deal with events such as falls, and occasionally do lab draws. Refer to F677, F684, F727

Based on facility policy review, medical record review, observations and interviews the facility failed to provide adequate personal hygiene and bathing to 4 of 8 (Resident #8, #13, #19, and #32) sampled residents reviewed for Activities of Daily Living. The findings include: 1. Review of the facility policy titled, Activities of Daily Living (ADLs), revised 1/2025, revealed .Care and services will be provided for the following .Bathing, dressing, grooming .A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good .grooming, and personal and oral hygiene . Review of the facility policy titled Nursing Services and Sufficient Staff, dated 1/23/2025 revealed, .It is the policy of this facility to provide sufficient staff .to assure resident safety and attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident . 2. Review of the medical record revealed Resident #8 was admitted to the facility on [DATE], with diagnoses including Hemiplegia and Hemiparesis, Type 2 Diabetes, and Hypertensive Heart Disease. Review of the admission Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview of Mental Status (BIMS) score of 12, which indicated Resident #8 had moderate cognitive impairment and required substantial/maximal assistance with bathing. Review of the care plan revised 2/10/2025, revealed .Problem .has an ADL [Activities of Daily Living] self-care performance deficit r/t [regarding to] CVA [cerebrovascular accident] w/ [with] residual deficits, functional impairments .The resident will improve current level of function in ADL's through the review date .Approach .The resident requires substantial/maximal assistance by x1 [times 1] staff with bathing/showering . Review of Point of Care History dated 1/29/2025 - 3/18/2025, revealed .how did the resident bathe .activity did not occur . for dates 1/30/2025, 2/1/2025, 2/3/2025, 2/4/2025, 2/5/2025, 2/6/2025, 2/7/2025, 2/10/2025, 2/11/2025, 2/12/2025, 2/13/2025, 2/15/2025, 2/16/2025, 2/19/2025, 2/20/2025, 2/21/2025, 2/26/2025, 2/27/2025, 3/1/2025, 3/2/2025, 3/4/2025, 3/5/2025, 3/9/2025, 3/10/2025, 3/11/2025, 3/13/2025, 3/14/2025, 3/15/2025, 3/16/2025, 3/17/2025, and 3/18/2025. Resident #8 is documented to have received a shower on 2/18/2025 only. Review of Progress notes dated 1/30/2025-3/18/2025 does not reveal documentation of Resident refusing showers. During observation and interview in the resident's room on 3/17/2025 at 9:55 AM, revealed the resident sitting in her wheelchair at the sink brushing her hair and wearing a red and black plaid pajama top and bottom. Resident stated that it had been two weeks since she had a shower and asked to speak later. During an interview on 3/17/2025 at 11:14 AM, Resident #8 confirmed that the last time she had shower was on last Wednesday (3/12/2025) with therapy and that she was supposed to get a shower every Tuesday and Thursday. During observation and interview in the resident's room on 3/18/2025 at 8:11 AM, revealed the resident in lying in bed wearing a red and black plaid pajama shirt. Resident #8 confirmed she has not changed clothes and that she has been wearing the same socks for several days. During an interview on 3/18/2025 at 9:51 AM, Certified Nursing Assistant (CNA) NN confirmed there is a shower list that lists which rooms get showers on which days and they are to fill out a shower sheet and document the shower in the computer. CNA NN was asked where the shower sheets are kept. CNA NN stated, I believe we do have a book. CNA NN was asked to provide the book. CNA N stated, Give me just a second. Observation in the hallway on 3/18/2025 at 10:25 AM revealed Resident #8 was up in wheelchair wearing red and black plaid pajama top and bottoms. The resident confirmed she was going to ask staff if she could have a shower. 3/18/2025 11:00 AM facility unable to provide any shower sheets on Resident #8. Observation in the resident's room on 3/18/2025 at 3:33 PM, revealed the resident wearing red and black plaid pajama top and bottoms. Resident #8 confirmed she asked CNA EE if she could have a shower and was told staff would try to. During an interview on 3/18/2025 at 3:36 PM, the Assistant Director of Nursing (ADON) was asked who is responsible for showers on the hall, she stated, .the tech on this hall that is responsible for that room . During an interview on 3/19/2025 at 9:35 AM, CNA PP was asked if she knew when the residents she took care of received showers. CNA PP stated, I look in our book. Where do you chart that, CNA PP stated, .Matrix .I can put what kind of bath in here . CNA PP was asked if Resident #8 ever refuse. CNA PP responded, No. During an interview on 3/19/2025 at 10:53 AM, the ADON acknowledged the staff is expected to document showers in the computer and on the shower sheet. During an interview on 3/20/2025 at 4:44 PM, the DON was asked how often residents should get bathed, the DON stated, Depending on their preference but usually 2 to 3 times per week . 3. Review of medical records revealed Resident #13 was admitted to the facility on [DATE], with diagnoses which include Secondary Malignant Neoplasm, Essential Hypertension and Chronic Atrial Fibrillation. Review of the Admission MDS assessment dated [DATE], revealed a score of 13, which indicated Resident #13 was cognitively intact. Observation on 3/18/2025 at 8:48 AM, revealed Resident #13, a female resident, had facial hair on top lip and chin. Observation on 3/18/2025 at 3:20 PM, revealed Resident #13 remained in bed with bed clothes on and facial hair continued to be present on top lip and chin. Observation and interview in Resident #13's room on 3/19/2025 at 9:42 AM, revealed Resident #13 continued to have facial hair on top lip and chin. Resident #19 was asked whether she liked the facial hair removed and she stated, I get it shaved when somebody does it for me and I need this hair done to. During an interview on 3/19/2025 at 11:06 AM, CNA E was asked how often the female residents have their facial hair trimmed. CNA E stated, I usually shave their face on shower day. 4. Review of the medical record revealed Resident #19 was admitted to the facility on [DATE], with diagnoses including Alzheimer's, Bipolar Disorder, Anxiety, and Major Depressive Disorder. Review of the annual MDS assessment dated [DATE], revealed a BIMS score of 13, which indicated Resident #19 was cognitively intact, uses wheelchair for mobility and required substantial to maximal assist for shower/bath and supervision or touching assist needed for personal hygiene. Review of the quarterly MDS assessment dated [DATE], revealed a BIMS score of 12, which indicated Resident #19 was moderately cognitively impaired, required substantial to maximal assist needed for shower/bath and transfers, and supervision or touching assist needed for personal hygiene. 47127 51365 51670

Based on facility policy review, medical record review and interview, the facility failed to report allegations of sexual abuse for 1 of 4 (Resident 165) residents reviewed. The findings include: 1. Review of the facility policy titled Compliance with Reporting Allegations of Abuse/Neglect Exploitation dated 2/19/2025, revealed It is the policy of this facility to report all allegations of abuse .are reported immediately to the Administrator of the facility and to other appropriate agencies in accordance with current state and federal regulations .Sexual Abuse is the non-consensual sexual contact of any type with a resident .the facility will report all alleged violations and all substantiated incidents to the state agency .Abuse: The willful infliction of injury .intimidation .It includes .sexual abuse .is the non-consensual sexual contact of any type with a resident .Alleged violation: A situation or occurrence that is observed or reported by staff, resident, relative, visitor or others but has not yet been investigated and, if verified, could be noncompliance with the Federal requirements related to mistreatment .Investigation: The facility will investigate all allegations and types of incidents .Reporting .The facility will report all alleged violations and all substantiated incidents to the state agency and to all other agencies required .The licensed/Registered Nurse will: Respond to the needs of the resident and protect him/her from further incident .Remove the accused employee from resident care areas .Notify the attending physician, resident's family/legal representative and Medical Director . Review of the Policy titled Abuse, Neglect and Exploitation, dated 2/19/2025 revealed .It is the policy of this facility to provide protection for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse .'Sexual Abuse' is non-consensual sexual contact of any type with a resident .Identification of Abuse, Neglect and Exploitation .Resident, staff or family report of abuse .The facility will make efforts to ensure all residents are protected from physical and psychological harm . 2. Review of medical records revealed Resident #165 was admitted to this facility on 10/6/2022, with diagnoses which include Type 2 Diabetes Mellitus, Major Depressive Disorder, and Bipolar Disorder. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 14, which indicated Resident #165 was cognitively intact. Review of the Care Plan revealed 3/25/2024 Resident #165 had .Behavioral Symptom r/t [related to] emotional outbursts .noted to place herself on the floor .history if telling stories that are not exactly accurate .history if making sexual inappropriate statements and making sexual advances towards staff . Review of Resident Progress Notes dated 4/10/2024 at 12:30 PM, revealed Social Service Director (SSD) documented Resident making false accusations about staff/care received. Review of Resident Progress Notes dated 4/12/2024 at 7:11 AM, SSD documented Resident #165 .Recently exhibited increase in socially inappropriate behaviors related to male staff members and making false allegations . Review of Progress Notes dated 4/14/2024, revealed Resident #165 was seen by the Medical Director. Review of TIBRS (Tennessee Incident Based Reporting System) Narrative dated 4/12/2024 at 10:28 AM, revealed The Director of Nursing (DON ) .stated the staff was made aware of the allegations by a resident of the facility [Named Resident #165] on Wednesday April 10, 2024, and began looking into the allegations .there was an allegation that [Named LPN H] had inappropriate sexual contact with [Named Resident #165] on Tuesday 4/9/2024 during an examination of her pelvic and buttocks region due to complaints of hurting in the area. The DON stated [Named Resident #165] had a growth on her pelvic region that requires them to have 2 staff with peri care. Law enforcement reported Resident #165 was confused and was on the phone when she was interviewed. [Named Resident #165] reported to law enforcement she had been raped by [Named LPN H]. [Named Resident #165] allegedly reported she was asleep and knew he had sex with her.After getting information for a report I left the facility. I was contacted a short time later by [Named DON] and advised that after I left Named Resident [Resident #165] requested to speak with her. [Named Resident #165] informed the [named DON] that what she told did not happen. She stated she lied about it because she was mad. Named DON stated [Named Resident #165] had called her friend [Named FM I] and told her it was all a lie. [Named FM I] also stated she was on the phone with [Named Resident #165] when I [law enforcement] was speaking with her and she told me something totally different than she told her. Due to [Named Resident #165] stating she lied about the allegations this report is closed as unfounded . The Administrator was asked on 3/19/2025 to supply a copy of the URIS report mentioning Resident #165 and was unable to provide. An email was sent to the Ombudsman on 3/19/2025 at 8:59 AM, asking whether she had been notified of the allegation of sexual abuse by Named Resident #165 and the Ombudsman stated, she had not been notified. During an interview on 3/20/2025 at 4:45 PM, the Director of Nursing (DON) was asked whether education was done after the allegation of abuse by Resident #165, and she responded No. The DON was asked when this incident was reported to the state agency and she stated, it was not reported to the state agency. During an interview in the Conference Room on 3/20/2025 at 5:15 PM, the Administrator was asked if she was the Abuse Coordinator, and she responded that she was, and the DON would fill in when she was absent. The Administrator was asked when should abuse be reported and the Administrator responded, immediately. The Administrator was asked whether she reported the incident between Resident #165 and LPN H to the State Agency and she responded, I did not because the investigation was completed with the 2-hour window. A follow up question was asked . The Administrator stated, [Named LPN H] was suspended pending investigation.

Based on facility policy, observation and interview the facility failed to store all drugs in accordance with currently accepted professional principles for 1 of 4 medication storage areas. The findings include: 1. Review of the facility policy titled, Medication Storage, with revision date 9/2024 revealed, .It is the policy to this facility to ensure all medications housed on our premises will be stored in accordance to .External Products .drugs for external use are stored separately from internal .medications .Internal Products: Medications to be administered by mouth are stored separately from other formulations ( .eye drops .). 2. During an observation and interview on 3/19/2025 at 10:56 AM, Registered Nurse (RN) L was working on the [NAME] medication cart. RN L was asked to open the medication cart so surveyor could review the storage of medications. Continued observation revealed a bottle of antacid chewable tablets stored with eye drops and an ear wax removal bottle stored with the topical Lidocaine (topical pain medication) and Nicotine (transdermal patch used to quit smoking) patches. RN L was asked if these medications should be stored together and she stated, No. During an interview on 3/20/2025 at 4:45 PM, the Director of Nursing (DON) was asked if oral medications should be stored with the eye drops; she stated, No. The DON was asked should an ear wax removal kit be stored with topical patches and she stated, No.

Based on facility policy review, record review, and interviews, the facility failed to maintain Registered Nurse (RN) coverage for 8 consecutive hours a day 7 days a week. The findings included: 1. Review of the facility policy titled Nursing Services and Sufficient Staff, dated 1/23/2025 revealed, .It is the policy of this facility to provide sufficient staff with appropriate competencies and skill sets to assure resident safety and attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident. The facility's census, acuity and diagnoses of the resident population will be considered based on the facility assessment .The facility must ensure that licensed nurses have the specific competencies and skill sets necessary to care for resident's needs as identified through resident assessments and described in the plan of care .Except when waived, the facility must use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week .The Director of Nursing [DON] may serve as a charge nurse only when the facility has an average daily occupancy of 60 or fewer residents . 2. Review of the facility's licensure information revealed the facility has 4 RNs. Review of the staffing clock in and out punches for 2/15/2025, and 2/22/2025 revealed no RN coverage for 8 consecutive hours. Review of the staffing clock in and out punches for 3/6/2025, revealed no RN coverage for 8 consecutive hours. Director of Nursing (DON) worked 8.5 hours; facility census was 64. Review of the facility's Daily Nurse Staffing Form dated 3/6/2025, revealed there were no RNs scheduled that date. 3. During an interview on 3/20/2025 at 4:46 PM, the DON confirmed there must be RN coverage for 8 consecutive hours every day and that the DON cannot serve as a charge nurse if the facility's average daily occupancy is greater than 60.

Based on the facility policy, Facility Assessment review, Chapter 1000-02 Rules and Regulation of the Licensed Practical Nurses Rules and Regulations review, employee file review, medical record review, observation and interview, the facility failed to ensure all nursing staff possessed the competencies and skill sets necessary to provide nursing and related services to meet the residents' needs safely for 2 of 2 (Resident #50 and Resident #63) sampled residents with PICC lines (Peripherally Inserted Central Catheter inserted into the arm and threaded into a large vein near the heart). The findings include: 1. Review of the facility policy titled, Nursing Services and Sufficient Staff, dated 1/23/2025 revealed, .It is the policy of this facility to provide sufficient staff with appropriate competencies and skill sets to assure resident safety and attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident .The facility must ensure that licensed nurses have the specific competencies and skill sets necessary to care for resident's needs as identified through resident assessments and described in the plan of care . 2. Review of the facility policy titled, Facility Assessment, revised 1/25/2025 revealed, .The facility assessment will, at a minimum, address or include .care required by the resident population, using evidence-based, data-driven methods .staff competencies and skill sets that are necessary to provide the level and types of care needed . 3. Review of CHAPTER 1000-02 RULES AND REGULATIONS OF LICENSED PRACTICAL NURSES dated 10/2024, revealed 1000-02-.02 (3), .Licensed Practical Nurses shall not administer the following fluids/medication/agents or drug classifications in the context of intravenous therapy .Titrated medication and dosages calculated and adjusted by the nurse based on patient assessment and/or interpretation of lab values . and 1000-02-.02 (4) (a) 1.The Licensed Practical Nurse administers IV [Intravenous] push medications in peripheral lines [flexible tube inserted into a vein in the arm, hand, leg, or foot] only . 4. Review of the medical record revealed Resident #50 admitted on [DATE] and readmitted on [DATE] with diagnoses which included Osteomyelitis of Vertebra (bone infection of the spinal column), lumbar region. Review of the Admission Minimum Data Set (MDS) dated [DATE], revealed Resident #50 was receiving IV medications over the last 7 days. Review of the Physician Order Report dated 2/20/2025-3/20/2025 revealed an order for PICC line for Antibiotic (ATB) infusion with start date 3/12/2025. Continued review revealed an order for Vancomycin (Antibiotic given that may require blood levels to monitor dosage) 1,250 mg (milligram) intravenous with start date of 1/28/2025 and Ceftriaxone (antibiotic) 2 gm (gram) intravenous with start date of 2/27/2025. Review Hospital #1's Discharge Instructions dated 2/27/2025 for Resident #50 revealed, .You [Resident #50] are going home with a peripherally inserted central catheter (PICC) . Review of the Medication Administration History dated 3/1/2025-3/20/2025 revealed Daptomycin (Vancomycin) and Ceftriaxone (Rocephin) 2 gm was administered intravenously via PICC line by Licensed Practical Nurse (LPN) LPN L on 3/7/2025, 3/13/2025, 3/15/2025 and LPN M administered Daptomycin and Ceftriaxone intravenously via the PICC line on 3/15/2025 and 3/19/2025. 5. Review of the medical record revealed Resident #65 was admitted to the facility on [DATE], with diagnoses which included Osteomyelitis, unspecified and Charcot's (a progressive condition causing the bones and joints in the foot to degenerate) joint, right ankle and foot. Review of the MDS dated [DATE] revealed Resident #65 had an IV access over the last 7 days. Review of the Physician Order Report dated 2/20/2025 - 3/20/2025 revealed an order for PICC line dressing change per RN (Registered Nurse) every 3 days. Continued review revealed and order for Vancomycin 750 mg intravenous per venous catheter every 12 hours with start date of 3/15/2025. Review of the Medication Administration History dated 3/1/2025-3/20/2025 revealed Vancomycin 750 mg was administered intravenously through PICC line by LPN L on 3/17/2025 and 3/18/2025 and LPN M administered Vancomycin via the PICC line on 3/19/2025 and 3/20/2025. During an observation and interview on 3/19/2025 at 8:45 AM LPN M stated, .[Named Resident #50] has a PICC line and receiving Rocephin 2 gm, she has been here for 3 weeks, she is receiving the medication for Osteomyelitis of her Spine post her surgery . During the interview a lab tech informed LPN M she was unable to obtain the Vancomycin trough (lowest level of the drug in the resident's body to monitor the antibiotic) on Resident #65, the nurse informed the lab tech to let the Director of Nursing (DON) know on her way out so the DON could try and draw the lab from her PICC line. The LPN stated, .the lab comes every Wednesday to draw troughs . The LPN was asked if she could access a PICC line and she stated, .Yes I can hang the IV, but I can't draw blood from the port . The nurse put on her protective gown prior to going into the room to hang the Rocephin, she prepared the IV medication to hang on IV pole, flushes the tubing line and uses a dial a flow to set the rate, the nurse flushed the PICC line port with 10 ml [milliliters] of normal saline flush per a 10 ml syringe, hung the Rocephin, verified the IV antibiotic was dripping and the resident was ok. During an interview on 3/20/2025 at 8:52 AM, LPN L was asked if she had administered Vancomycin through [Named Resident #50 and Resident #65]'s PICC line. LPN L confirmed she had accessed the PICC line and ?performed the Vancomycin ?for [Named Resident #50 and Resident #65]. LPN L was asked if she had been through an IV certification course. LPN L stated, .I haven't gone anywhere for that. I don't remember any extra training I received here at the facility? .? During an interview on 3/20/2025 at 5:00 PM, the DON was asked if LPNs could access PICC lines and hang IV antibiotics. The DON stated, .LPNs can do anything but hang blood products or push medications. They can and have been trained. I have skill check offs; we provide training and skill check offs . 6. Review of Licensed Practical Nurse (LPN) M's employee file revealed training for Peripheral IV Insertion dated 7/19/2024 with the observer's signature of Registered Nurse (RN) C. No specialized IV (intravenous) training for PICC lines [thin tube inserted into a vein in the arm and threaded to a large vein near the heart] was found in the employee file. Review of LPN L's employee file revealed training for Peripheral IV Insertion dated 8/8/2024, with the observer's signature as LPN O. LPN L's employee file revealed no specialized IV training. 7. The Regional Nurse came to the conference room on 3/20/2025 at 6:07 PM and presented a copy of Chapter 1000-02 Rules and Regulation of Licensed Practical Nurses and stated, .Nothing says they cannot . referring to accessing a PICC line.

Based on facility policy review, medical records review, observations, and interviews the facility failed to follow physician orders and failed to obtain timely skin treatment orders for 2 of 20 (Resident #7 and #8) sampled residents. The findings include: 1. Review of the facility policy titled, Medication Orders, revised 2/2025, revealed .Medications should be administered only upon the signed order of a person lawfully authorized to prescribe .The charge nurse on duty at the time the order is received should note the order and enter it on the physician order sheet or electronic format . Review of the facility policy titled, Oxygen Administration, revised 1/23/2025, revealed .Oxygen is administered to residents who need it, consistent with professional standards of practice . Review of the facility policy titled, Wound Treatment Management, revised 3/2024, revealed .Wound treatments will be provided in accordance with physician orders .Treatments will be documented on the Treatment Administration Record . 2. Review of the medical record revealed Resident #7 was admitted to the facility on [DATE], with diagnoses including Chronic Respiratory Failure, Depression, Anxiety, and Chronic Pain Syndrome. Review of the quarterly MDS dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 13, which indicated she had no cognitive impairment, was dependent on staff for all care, always incontinent. Resident received Antianxiety, Antidepressants, Anticoagulants, and Anticonvulsants, and received Oxygen. Review of the significant change Minimum Data Set (MDS) dated [DATE], revealed a BIMS score of 12, which indicated she had moderate cognitive impairment. Resident was dependent on staff for all care and was always incontinent. Resident received Antianxiety, Antidepressants, and Anticonvulsants, and received Oxygen and Hospice care. Review of the care plan dated 10/9/2024, revealed .has altered respiratory status/difficulty breathing related to chronic respiratory failure .elevate head of bed .O2 per MD orders . Physician's Orders dated 10/22/2024 revealed .O2 [Oxygen] at 4 LPM [liters per minute] BNC [binasal cannula-a medical device to deliver supplemental oxygen through the nostrils] PRN [as needed] SOB [shortness of breath . Observation in the resident's room on 3/17/2024 at 9:56 AM and at 03/18/25 09:14 AM, revealed the resident's oxygen set to 2 liters. During an interview on 3/18/2025 at 9:22 AM, LPN F Confirmed that Resident #7's oxygen order was for 4 liters, and stated, .I will change that right now . During an interview on 3/20/25 at 4:44 PM, the Director of Nursing confirmed that physician's orders be followed regarding oxygen settings. 3. Review of the medical record revealed Resident #8 was admitted to the facility on [DATE], with diagnoses including Hemiplegia and Hemiparesis, Diabetes, and Hypertensive Heart Disease. Review of the admission Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview of Mental Status (BIMS) score of 12, which indicated Resident #8 had moderate cognitive impairment and is at risk for pressure ulcers/injuries. Review of the care plan revised 2/10/2025, revealed .Resident will not exhibit skin breakdown .Apply moisture barrier to skin .Report any signs of skin breakdown . Review of the facility's form titled, Skin Integrity Events, dated 3/14/2025, revealed .MASD [Moisture-Associated Skin Damage] to right and left buttock .zinc cream [used to protect skin from being irritated and wet] twice a day . Review of the Physicians Orders dated 3/14/2025- 3/18/2025, revealed no order for zinc cream. Review of the Progress Notes dated 3/14/2025 - 3/18/2025, revealed no documentation regarding the resident's skin condition. Review of the Physicians Orders dated 3/19/2025, revealed .Zinc to bil. bouttucks [bilateral buttocks] BID [twice a day] . Review of the progress note dated 3/19/2025 at 1:49 PM, the Advanced Practice registered Nurse Practitioner (APRN NP) documented, .Seen today for evaluation of MASD. The resident has skin irritation, redness to b/l [bilateral] buttocks .consult wound care. cleanse area with wound cleanser, apply zinc oxide to affected area BID until healed . During an interview in the resident's room on 3/17/2025 at 11:47 AM, the resident confirmed she has an open spot on her bottom and the staff is aware. During an interview on 3/19/2025 at 10:53 AM, the ADON was asked what the process is when a resident has a new skin condition, she stated, .document in progress note .who we contacted .implement those verbal orders .enter the order in the computer . The ADON acknowledged there was not a physician's order from 3/14/2025 - 3/19/2025 for treatment of the MASD. The ADON was asked if any treatments were provided from 3/14/2025-3/19/2025, she stated, .I do know she was getting the zinc applied . Observation in the resident's room on 3/19/2025 at 3:09 PM with the ADON revealed MASD to buttocks as described in event note. During an interview on 3/20/2025, at 4:44 PM, the DON was asked what should be done when a skin issue is identified, she stated, .notify the md [Medical Doctor] .look at it .do an event .notify family .get an order for treatment . The DON acknowledged that an identified skin issue should be documented in the medical record, should receive an order on the day a skin issue is identified, and that nursing staff cannot treat a skin issue without an order. 51670

Based on policy review, record review, and interview, the facility failed to implement interventions to ensure a resident's environment remained free of accident hazards for 1 of 3 (Resident #2) sampled residents reviewed for accidents. This failure contributed to resident falls with injury. Findings included: 1. A review of the facility policy titled Accidents and Supervision, revised 03/23/2022, indicated, The resident environment will remain as free of accident hazards as is possible. Each resident will receive adequate supervision and assistive devices to prevent accidents. This includes: Identifying hazard(s) and risk(s). Evaluating and analyzing hazards(s) and risk(s). Implementing interventions to reduce hazards(s) and risk(s). Monitoring for effectiveness and modifying interventions when necessary. Additionally, the policy specified, The facility should make a reasonable effort to identify the hazards and risk factors for each resident. 2. Review of the medical record for Resident #2 revealed the facility admitted the resident on 09/05/2022 with diagnoses that included Parkinson's disease, Alzheimer's disease, age-related Osteoporosis, and Anxiety Disorder. Review of the Event Report dated 03/01/2023 at 5:00 PM, revealed Resident #2 reported they fell reaching for something that had had fallen off their bedside table on to the floor. The immediate intervention was to declutter the resident's bedside table. The Event Report revealed the resident sustained redness to their left elbow. The facility updated the resident's care plan to include, bedside table decluttered, with a start date of 03/01/2023. However, the resident's care plan at the time of the fall already had an intervention directing staff to provide an environment free of clutter. Review of Resident #2's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/15/2023, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 7, which indicated the resident had severe cognitive impairment. Further review of the MDS revealed the resident required supervision with most activities of daily living, except the resident was totally dependent on staff for bathing, required extensive assistance with dressing, and limited assistance with toilet use. The MDS revealed Resident #2 was frequently incontinent of urine and occasionally incontinent of bowel. A review of the Event Report dated 04/09/2023, revealed Resident #2 was found on the floor on their left side. The Event Report revealed Resident #2 complained of left hip pain with movement and had a red knot noted on the resident's left hip. The Event Report revealed the resident was sent to the emergency room (ER) after a mobile x-ray confirmed the resident had sustained a left hip fracture. Per the Event Report, the root cause of the fall was that the resident had on fuzzy socks and the immediate intervention put in place was to remove the fuzzy socks from the resident's room. However, the resident's Care Plan in place at the time of the fall directed staff to provide proper, well-maintained footwear. Review of Resident #2's Resident Progress Notes, dated 04/10/2023 at 4:23 AM, revealed the resident's x-ray results were received and revealed, Osteoporosis. High suspicion of an impacted left-sided subcapital fracture. A review of the ED [Emergency Department] Note Physician, dated 04/10/2023, revealed Resident #2 presented to the ED post fall, mobile x-ray results showed a possible left hip fracture. The ED Physician's Note revealed a computed tomography (CT)) scan of the pelvis and hip was performed and revealed a fracture of the greater trochanter. Review of Resident #2's Resident Progress Notes, dated 04/19/2023 at 8:15 PM, revealed Resident #2 was found on the floor in the hallway beside their bedroom door. The Resident Progress Notes revealed the handrail on the wall was noted to be on the floor and Resident #2 was unable to explain what happened. Further review revealed the resident sustained two skin abrasions to the right arm and complained of bilateral hip pain due to their recent hip fracture. The intervention implemented as the result of this fall was for a medication review due to a recent change in the resident's medication regimen. A review of an Event Report dated 04/23/2023, revealed an unknown person placed a riser seat on Resident #2's toilet and when the certified nursing assistant (CNA) left the resident alone in the bathroom, the resident fell off the toilet onto their left side. Further review revealed Resident #2 complained of left knee pain and was not able to bear weight on their left leg. The Event Report revealed the probable root cause of the resident's fall was the riser on toilet and the resident being left alone in the bathroom. The immediate intervention was to remove the riser per the Event Report. Review of the Event Report dated 07/24/2023, revealed Resident #2 was found on the floor on their left side in the doorway to the bathroom. The Event Report revealed an applicable care plan intervention was not in place at the time of the resident's fall. Per the Event Report, Resident #2 attempted to go to the bathroom and their wheelchair and rollator were not present in the resident's room. The Event Report revealed the staff were educated to ensure the resident's wheelchair was in their room when the resident was in their bed. Review of the Event Report dated 07/28/2023, revealed Resident #2 was found on the floor beside their bed. The Event Report revealed there was no care plan interventions in place for a fall at bedside. Further review of the Event Report revealed the intervention for this fall was to place mats to the resident's bedside. Review of Resident #2's Care Plan, initiated on 09/06/2022, indicated the resident was at risk for falls related to weakness, Parkinson's disease, dementia, poor safety awareness and memory recall, and the inability to be educated. Interventions directed the staff to encourage the use of environmental devices such as handrails, keep personal items and frequently used items within reach, provide an environment free of clutter, and provide proper, well-maintained footwear. During an interview on 09/20/2023 at 12:42 PM, the Maintenance Director reported the handrail had been ripped out of the wall when the resident pulled on it on the way down to the floor. According to the Maintenance Director, he determined the screws that had been used to initially install the handrails were too short. During an interview on 09/20/2023 at 3:25 PM, LPN #9 stated there was a toilet riser in Resident #2's bathroom that was not a facility toilet riser. LPN #9 stated she did not know how the riser got into the facility because it was not the type of riser they used in the facility. LPN #9 stated the facility toilet risers had clamps that affixed to the toilet seat, whereas the rise that on Resident #2's toilet at the time of the fall was not affixed. LPN #9 stated she believed Resident #2 may have moved while sitting on the riser and then fell along with the riser. During an interview on 09/20/2023 at 3:35 PM, LPN #10 (who was called to Resident #2's room when Resident #2 was found on the floor beside the bed on 07/28/2023), stated there was only one mat in the room when she arrived in Resident #2's room to respond to the fall. LPN #10 stated the one mat that was at the resident's bedside was on the opposite side of the bed, and Resident #2 was found on the side of the bed without a fall mat in place.

Based on policy review, document review, record review, and interview, the facility failed to ensure staff reported an incident of alleged abuse to administrative staff and to the state survey agency for 1 of 3 (Resident #7) residents reviewed for abuse. Findings included: 1. Review of the facility policy titled, Abuse, Neglect, and Exploitation, with a revision date of 08/30/2022, revealed It is the policy of this facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property. Further review revealed, VII. Reporting/Response A. The facility will have written procedures that include: 1. Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes: a. Immediately, but no later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury. 2. Review of Resident Progress Notes, dated 01/27/2023, revealed Resident #7 was initially admitted to the facility. Review of the Resident Progress Notes, dated 01/29/2023 at 5:12 PM, revealed Resident #7 was sent to the hospital emergency room (ER) for evaluation. Review of Resident #7's Resident Face Sheet revealed the resident was readmitted to the facility on [DATE] with diagnoses that included Urinary Tract Infection and Unspecified Dementia. Further review of the Resident Face Sheet indicated the facility discharged the resident on 02/12/2023 and the resident did not return to the facility. A review of the admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/10/2023, revealed Resident #7 had a Brief Interview for Mental Status (BIMS) score of 9, which indicated the resident was moderately cognitively impaired. The MDS indicated Resident #7 exhibited other behavioral symptoms not directed toward others four to six days during the seven-day review period. The MDS indicated the resident required extensive assistance from staff for toilet use and personal hygiene and was always incontinent of urine and bowel. A review of Resident #7's Care Plan History, dated 02/06/2023 that indicated the resident had cognitive loss/dementia. Another problem statement, with a start date of 02/06/2023, indicated the resident used psychotropic medication. Approaches directed staff to assess if the resident's behavioral symptoms presented a danger to the resident and/or others. A third problem statement, dated 02/06/2023, indicated the resident was at risk for developing pressure ulcers related to incontinence. Approaches directed staff to provide incontinence care after each episode of incontinence. Review of a nursing Progress Note, dated 01/29/2023 at 5:12 PM, indicated that while incontinence care was being provided Resident #7 hit one certified nursing assistant (CNA) across the face and struck another CNA in the chest. After care was provided, Resident #7 got out of bed and struck their roommate in the shoulder with their fist. The Progress Note indicated the resident was placed in a wheelchair in the line of sight of staff and was later sent to the emergency room (ER) for evaluation. Review of a nursing Progress Note, dated 02/02/2023 and written by the DON, indicated the resident was admitted to the hospital on 01/29/2023 and was diagnosed with a urinary tract infection and pneumonia. The Progress Note indicated, that during an interview with staff members working at the time of the incident on 01/29/2023, Resident #7 thought a staff member was a man that rubbed their [genitalia] too hard during care. Review of a nursing Progress Note, dated 02/03/2023 at 6:20 PM, indicated the resident was transferred back to the facility from the hospital. The Progress Note indicated Resident #7 had redness and irritation in the genital area and was scratching the area and causing it to worsen. Review of a file provided by the Administrator on 09/20/2023, revealed that an investigation was conducted following the incidents that occurred on 01/29/2023 (the allegation by Resident #7 that a male staff member touched them roughly during care and the resident-to resident altercation between Resident #7 and their roommate). The file included statements dated 01/30/2023 from CNA #7 and Licensed Practical Nurse (LPN) #9, resident interviews, and a Care Management Progress Note from the hospital for Resident #7 (dated 01/29/2023 with a print date of 01/31/2023). Further review of documentation in the file indicated that staff in-servicing was provided on 01/30/2023 that included Abuse Investigating and Reporting, Signs of Abuse, Behavior Monitoring and the facility's policy related to behavior management plans and the Behavior Management Program Flowchart. Review of the phone interview statement made by CNA #7 and dated 01/30/2023 at 12:15 PM, indicated Resident #7 was assisted to use the toilet by two female CNAs (CNA #7 and CNA #8) on 01/29/2023. When CNA #8 wiped the resident's perineal area the resident hit CNA #8; CNA #7 said to the resident, Please don't hit us, and then Resident #7 struck CNA #7. According to the phone interview statement, Resident #7 later pointed at CNA #7 and stated, She's a part of the issue and that man that rubbed my [genital area] too hard, and pointed at CNA #8. The statement indicated that the CNAs noted Resident #7's perineal area was red, and that the area hurt when they touched the resident during perineal care. The statement also indicated that CNA #7 stated the CNAs did not report the incident to the nurse before Resident #7 hit their roommate but would be sure to report any similar incident next time. In an interview on 09/20/2023 at 12:24 PM, CNA #7 stated Resident #7 thought a man was rough with them during perineal care. CNA #7 stated there were no male staff working the night of 01/29/2023 and only she and CNA #8 were providing care for Resident #7. CNA #7 recalled that the Administrator and DON interviewed other residents on the hall where Resident #7 resided the next day to ask them about abuse and care. CNA #7 said she did not report Resident #7 stating that a man rubbed them too hard, to the DON until the next day. She stated she did not consider it abuse because they were trying to clean Resident #7 and change their brief when the resident made the comment. In an interview on 09/20/2023 at 1:30 PM, the Administrator stated the facility did not report the allegation made by Resident #7 to the state survey agency. He stated they did not report the allegation as abuse because it was determined to be a care issue since the resident was referring to the female CNA and stating she was a man, and staff had been conducting an adult brief change at the time. The Administrator stated there were no male staff members working during that shift. The Administrator stated the staff were in-serviced on abuse reporting in response to the allegation because the staff involved did not inform anyone about the allegation until the DON collected witness statements related to the resident becoming combative. The Administrator stated the facility had not reported the resident-to-resident altercation to the state survey agency either because when there was a resident-to-resident altercation, the facility reviewed whether the altercation was willfully intended toward the resident. He said in this case, Resident #7 was unaware of what they were doing, was sent to the hospital, and was diagnosed with a urinary tract infection that was likely associated with the combativeness. In an interview on 09/21/2023 at 12:00 PM, the Administrator reiterated that the allegation had not been reported because he knew from family conversations that Resident #7 had a history of making similar false allegations and the CNA that Resident #7 was referring to as a man was a female CNA who was trying to provide perineal care at the time the allegation was made. The Administrator stated he also took into account the fact that Resident #7 likely had pain in the perineal area due to being excoriated and had a chronic urinary tract infection.

Based on facility policy review, observation, and interview, the facility failed properly prevent and contain COVID-19 when the Maintenance Assistant was observed without a mask on, and COVID-19 screening logs for 10 of 10 sampled staff (Director of Nursing (DON), Infection Control Preventionist (ICP), Licensed Practical Nurse (LPN) #1, #2, #3 and Certified Nursing Assistant (CNA) #1, #2, #3, #4, and #5) were incomplete or missing during shifts worked in a 14 day review period. The findings include: Review of the (Named State) Department of Health, resource booklet for long-term care facilities, dated 8/28/2020, Page 8, showed, .Keep COVID-19 from Entering Your Facility .have all individuals wear a mask before entering the facility .HCP (Healthcare Personnel) should wear a facemask at all times while they are in the facility . Review of the facility's policy titled, Infection Prevention and Control Program, dated 9/2/2020, showed, .4. Standard Precautions .c. all staff shall use personal proactive equipment (PPE) . Observation in the facility's front hall on 12/1/2020 at 12:25 PM, showed the Maintenance Assistant without a face mask on. During an interview conducted on 12/1/2020 at 12:26 PM, the Maintenance Assistant confirmed he left his mask in the Maintenance Office. The Maintenance Assistant was asked if he should have his mask on. The Maintenance Assistant stated, Yes. During an interview conducted on 12/1/2020 at 12:27 PM, the Front Desk Receptionist, confirmed she did see the Maintenance Assistant enter the front door without a mask on, did not check his temperature or ask him to stop before entering. During an interview conducted on 12/1/2020 at 12:29 PM, the Infection Control Preventionist was asked if all staff should have a mask on when entering the building. The Infection Control Preventionist stated, Yes, the Front Desk Receptionist should have told him to put a mask on . During an interview conducted on 12/1/2020 at 12:55 PM, the Administrator confirmed it is mandatory for all staff to wear a mask. Review of the facility's policy titled, Coronavirus 2019 (COVID-19) Visitor Screening Toolkit, dated March 2020, showed, .The most effective way to protect your residents from coronavirus disease .is to prevent the disease form entering your nursing center. Through screening of staff .can help prevent [MEDICAL CONDITION] transmission to your residents and is essential . Review of the facility's policy titled, COVID-19 SOP (Standard of Practice), revised 4/3/2020, showed, .Complete infection control education and screening questionnaires for all employees .who attempt to enter facility. The screening will include temperature. Have designated facility employee at main entrance providing screening and offering education handouts .All employees should be screened, which includes a temperature . Review of the facility's undated policy titled, SCREENING TABLE FOR THE CORONAVIRUS, showed, Everyone that comes in the building must be screened no matter what .Document the correct temperature .fill out the remaining screening questions until the sheet is complete . Review of the facility's Individual Employee Time card and Employee Screening Tool from 11/10/2020 through 11/23/2020, showed 9 random employee screening logs were reviewed. The logs were incomplete or missing for the employees on the following dates: On 11/10/2020, of the 9 sampled employees, 5 worked, and the facility failed to provide a screening log for 1 of 5 employees (CNA #2). On 11/10/2020, 2 of 4 employees (DON and CNA #3) failed to answer the screening question Have you traveled by plane or cruise ship within and/or outside the United States ., 2 of 4 employees (DON and CNA #3) failed to answer the screening question .Fever (> (symbol for greater than) 99.6 (symbol for degrees F (Fahrenheit)) or history of fever ., 1 of 4 employees (CNA #4) failed to answer the screening question Please Indicate temperature ., 2 of 4 scheduled employees (DON and CNA #3) failed to answer the screening question Exposure to individuals with cold or flu-like symptoms ., 4 of 4 (DON, CNA #2, #3, and #4) scheduled employees failed to answer the screening question Education and/or Materials Provided?, 3 of 4 (CNA #2, #3, and #4) scheduled employees failed to answer the screening question .Printed materials, and 3 of 4 (CNA #2, #3, and #4) scheduled employees failed to answer the screening question, .Hand hygiene, including return demonstration. On 11/11/2020, of the 9 sampled employees, 6 worked, and the facility failed to provide a screening log for 1 of the 6 employees (CNA #2). On 11/11/2020, 2 of 5 employees (DON and LPN #1) failed to answer the screening question Have you traveled by plane or cruise ship within and/or outside the United States ., 2 of 5 employees (DON and LPN #1) failed to answer the screening question .Fever (> 99.6 degrees F) or history of fever ., 3 of 5 scheduled employees (DON, CNA #1, and #3) failed to answer the screening question Exposure to individuals with cold or flu-like symptoms ., 1 of 5 scheduled employees (ICP) answered yes to the screening question If YES, please indicate details: The ICP failed to provide details, 2 of 5 scheduled employees (DON and CNA #4) failed to answer the screening question Education and/or Materials Provided?, 2 of 5 scheduled employees (CNA #1 and #4) failed to answer the screening question .Printed materials, 2 of 5 (CNA #1 and #4) scheduled employees failed to answer the screening question, .Hand hygiene, including return demonstration. On 11/12/2020, of the 9 sampled employees, 7 worked, and the facility failed to provide a screening log for 2 of the 7 employees (LPN #2 and #3). On 11/12/2020, 1 of 5 employees (DON) failed to answer the screening question Have you traveled by plane or cruise ship within and/or outside the United States ., 1 of 5 employees (DON) failed to answer the screening question .Fever (> 99.6 degrees F) or history of fever ., 2 of 5 scheduled employees (DON and CNA #3) failed to answer the screening question Exposure to individuals with cold or flu-like symptoms ., 3 of 5 scheduled employees (DON, CNA #2, and #4) failed to answer the screening question Education and/or Materials Provided?, 2 of 5 scheduled employees (CNA # 2 and #4) failed to answer the screening question .Printed materials, 2 of 5 scheduled employees (CNA #2 and #4) failed to answer the screening question .Hand hygiene, including return demonstration. On 11/13/2020, of the 9 sampled employees, 7 worked, and the facility failed to provide a screening log for 4 of the 7 the employees (DON, CNA #2, #4, and LPN #3). On 11/13/2020, 1 of 3 employees (LPN #1) failed to answer the screening question Have you traveled by plane or cruise ship within and/or outside the United States ., 1 of 3 employees (ICP) failed to answer Please Indicate temperature . 1 of 3 scheduled employees (ICP) answered yes to the screening question If YES, please indicate details:, the ICP failed to provide details. On 11/14/2020, of the 9 sampled employees, 6 worked, and the facility failed to provide a screening log for 5 of the 6 employees (CNA #2, #3, #4, #5, LPN #3). 11/14/2020, 1 of 1 scheduled employee (CNA #1) failed to answer the screening question Exposure to individuals with cold or flu-like symptoms ., 1 of 1 scheduled employee (CNA #1) failed to answer the screening question Education and/or Materials Provided?, 1 of 1 scheduled employee (CNA #1) failed to answer the screening question, .Printed materials, 1 of 1 scheduled employee (CNA #1) failed to answer the screening question, .Hand hygiene, including return demonstration. On 11/15/2020, of the 9 sampled employees, 7 worked, and the facility failed to provide a screening log for 4 of the 7 employees (CNA #2, #3, #4, and LPN #3). On 11/15/2020, 1 of 3 scheduled employees (CNA #1) failed to answer the screening question Exposure to individuals with cold or flu-like symptoms ., 1 of 3 scheduled employees (CNA #1) failed to answer the screening question Education and/or Materials Provided?, 2 of 3 scheduled employees (ICP and CNA #1) failed to answer the screening question, .Printed materials, 2 of 3 scheduled employees (ICP and CNA #1) failed to answer the screening question, .Hand hygiene, including return demonstration. On 11/16/2020, of the 9 sampled employees, 7 worked, and the facility failed to provide a screening log for 3 of the 7 employees (ICP, CNA #3, and #4). On 11/16/2020, 2 of 4 employees (DON and LPN #1) failed to answer the screening question Have you traveled by plane or cruise ship within and/or outside the United States ., 2 of 4 employees (DON and LPN #1) failed to answer the screening question Sore throat ., 2 of 4 employees (LPN #1 and CNA #1) failed to answer the screening question Cough ., 2 of 4 employees (LPN #1 and CNA #1) failed to answer the screening question Runny nose ., 2 of 4 scheduled employees (LPN #1 and CNA #1) failed to answer the screening question Shortness of breath ., 2 of 4 scheduled employees (LPN #1 and CNA #1) failed to answer the screening question Diarrhea ., 3 of 4 scheduled employees (DON, LPN #1 and CNA #1) failed to answer the screening question Exposure to individuals with cold or flu-like symptoms ., 4 of 4 scheduled employees (DON, LPN #1, CNA #1, and #2) failed to answer the screening question Education and/or Materials Provided?, 3 of 4 scheduled employees (LPN #1, CNA #1, and #2) failed to answer the screening question, .Printed materials, 3 of 4 scheduled employees (LPN #1, CNA #1, and #2) failed to answer the screening question, .Hand hygiene, including return demonstration On 11/17/2020, of the 9 sampled employees, 6 worked, and the facility failed to provide a screening log for 2 of the 6 employees (CNA #3 and #4). On 11/17/2020, 2 of 4 employees (DON and LPN #1) failed to answer the screening question Have you traveled by plane or cruise ship within and/or outside the United States ., 2 of 4 employees (DON, LPN #1) failed to answer the screening question .Fever (>99.6 degrees F) or history of fever ., 1 of 4 employees (LPN #1) failed to answer the screening question Sore throat ., 1 of 4 employees (LPN #1) failed to answer the screening question Cough ., 1 of 4 employees (LPN #1) failed to answer the screening question Runny nose ., 1 of 4 scheduled employees (LPN #1) failed to answer the screening question Shortness of breath ., 1 of 4 scheduled employees (LPN #1) failed to answer the screening question Diarrhea ., 2 of 4 scheduled employees (DON and LPN #1) failed to answer the screening question Exposure to individuals with cold or flu-like symptoms ., 4 of 4 scheduled employees (DON, ICP, LPN #1, and CNA #2) failed to answer the screening question Education and/or Materials Provided?, 3 of 4 scheduled employees (ICP CNA #2, and LPN #1) failed to answer the screening question, .Printed materials, 3 of 4 scheduled employees (ICP, CNA #2, and LPN #1) failed to answer the screening question, .Hand hygiene, including return demonstration On 11/18/2020, 3 of 3 scheduled employees (DON, ICP, and CNA #2) failed to answer the screening question Education and/or Materials Provided?, 3 of 3 scheduled employees (DON, ICP, and CNA #2) failed to answer the screening question, .Printed materials, 3 of 3 scheduled employees (DON, ICP, and CNA #2) failed to answer the screening question, .Hand hygiene, including return demonstration. On 11/19/2020, showed of the 9 sampled employees, 6 worked, and the facility failed to provide a screening log for 3 of the 6 employees (CNA #5, LPN #2, and #3). On 11/19/2020, 3 of 3 scheduled employees (DON, ICP, and CNA #2) failed to answer the screening question Education and/or Materials Provided?, 3 of 3 scheduled employees (DON, ICP, and CNA #2) failed to answer the screening question .Printed materials, 3 of 3 scheduled employees (DON, ICP, and CNA #2) failed to answer the screening question .Hand hygiene, including return demonstration. On 11/20 /2020, of the 9 sampled employees, 6 worked, and the facility failed to provide a screening log for 2 of the 6 employees (CNA #4 and LPN #3). On 11/20 /2020, 2 of 4 scheduled employees (DON and ICP) answered yes to screening question If YES, please indicate details: the employees failed to provide details, 3 of 4 scheduled employees (DON, ICP, and CNA #2) failed to answer the screening question Education and/or Materials Provided?, 1 of 4 scheduled employees (CNA #2) failed to answer the screening question .Printed materials, 1 of 4 scheduled employees (CNA #2) failed to answer the screening question .Hand hygiene, including return demonstration. On 11/21/2020 of the 9 sampled employees, 4 worked, and the facility failed to provide a screening log for 3 of the 4 employees (CNA #4, LPN #2, and LPN #3). On 11/21/2020, 1 of 1 employee (LPN #1) failed to answer the screening question Have you traveled by plane or cruise ship within and/or outside the United States ., 1 of 1 employee (LPN #1) failed to answer the screening question .Fever (> 99.6 degrees F) or history of fever ., 1 of 1 of employee (LPN #1) failed to answer the screening question Sore throat ., 1 of 1 employee (LPN #1) failed to answer the screening question Cough ., 1 of 1 employee (LPN #1) failed to answer the screening question Runny nose ., 1 of 1 scheduled employee (LPN #1) failed to answer the screening question Shortness of breath ., 1 of 1 scheduled employee (LPN #1) failed to answer the screening question Diarrhea ., 1 of 1 scheduled employee (LPN #1) failed to answer the screening question Exposure to individuals with cold or flu-like symptoms ., 1 of 1 scheduled employee (LPN #1) failed to answer the screening question Education and/or Materials Provided?, 1 of 1 scheduled employee (LPN #1) failed to answer the screening question .Printed materials, 1 of 1 scheduled employee (LPN #1) failed to answer the screening question, .Hand hygiene, including return demonstration. On 11/22/2020, of the 9 sampled employees, 5 worked, and the facility failed to provide a screening log for 1 of the 5 employees (LPN #3). On 11/22/2020, 1 of 4 employees (LPN #1) failed to answer the screening question Have you traveled by plane or cruise ship within and/or outside the United States ., 1 of 4 employees (LPN #1) failed to answer the screening question .Fever (>99.6 degrees F) or history of fever ., 1 of 4 scheduled employees (LPN #1) failed to answer the screening question Exposure to individuals with cold or flu-like symptoms . On 11/23/2020, of the 9 sampled employees, 4 worked, and the facility failed to provide a screening log for 2 of 4 employees (CNA #3 and the DON). On 11/23/2020, 2 of 2 scheduled employees (ICP and CNA #2) failed to answer the screening question Education and/or Materials Provided?, 2 of 2 scheduled employees (ICP and CNA #2) failed to answer the screening question .Printed materials, 2 of 2 scheduled employees (ICP and CNA #2) failed to answer the screening question .Hand hygiene, including return demonstration. During an interview on 11/24/2020 at 6:30 PM, the Director of Nursing (DON) confirmed that there was not a screening log on the COVID unit. Observation in the COVID unit on 11/24/2020 at 6:36 PM, the Administrator was observed bringing an Employee Screening Tool log to the COVID unit. During a telephone interview conducted on 11/30/2020 at 4:30 AM, LPN #3 was asked what the process was when coming into work. LPN #1 stated, .we check our temperatures .we don't have the screening papers to fill out on the COVID unit, like the other side of the building . During a telephone interview on 11/30/2020 at 5:05 AM, CNA #4 confirmed there was not a screening book to document temperatures or screening questions, they had a book in the main building, but the employees working the COVID unit don't go to the main building. CNA #4 stated, They (facility) told me Wednesday (11/25/2020) when I came into work, we now have a red book with screening logs, and we had to answer the screening questions and the screening sheets ask for our temperatures . During an interview conducted on 12/1/2020 at 11:15 AM, the Administrator confirmed the Employee Screening Tool logs were not completed on the COVID unit until after this surveyor left the unit on 11/24/2020. The Administrator reviewed the Employee Screening Tool logs and confirmed incomplete and missing logs employees. During an interview on 12/1/2020 at 11:38 AM, the Infection Control Preventionist reviewed Employee Screening Tool logs and confirmed logs were incomplete and logs were missing. The Infection Control Preventionist stated, No logs were on COVID Unit until 11/24/2020 .

Based on policy review, grievance log, medical record review, and interview, the facility failed to follow their grievance policy for 3 of 11 sampled residents (Resident #17, #41, and #258) interviewed. The findings include: 1. Review of the facility policy titled, Filing Grievances/Complaints updated 1-16-19, showed, .Our facility will help residents, their representatives (sponsor), other interested family members, or resident advocates file grievances or complaints when such requests are made .The facility will maintain evidence demonstrating the result of all grievances for a period of no less than 3 years from the issuance of the grievance decision . 2. Review of the March, May, and (MONTH) 2019 Grievance/Complaint Log showed there were no grievances documented for Resident #17, #41, and #258. The facility was unable to provide a Grievance/Complaint Log for August, September, October, November, and (MONTH) 2019. 3. Medical record review showed Resident #17 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the annual Minimum Data Set ((MDS) dated [DATE] showed a Brief Interview for Mental Status (BIMS) score of 15 which indicated the resident was cognitively intact for decision making. During an interview on 12/16/19 at 3:24 PM, Resident #17 stated, .had a christmas ball (ornament) stolen out of my room that my sister brought me .I told (Named Administrator) and they looked through my drawers .it had my name on it . During an interview on 12/17/19 at 4:50 PM, the Administrator stated, .she just told me this afternoon, today .someone brought her to my office and she told me .she has two sons but no sisters or daughters .usually I talk with the resident to see if the item is misplaced .Grievance/complaint form is filled out when I determine whether something has actually been stolen . The Administrator was asked how long it takes for a complaint to be resolved. The Administrator stated, .5 business days .I haven't started my typical stuff for (named Resident #17) yet .I haven't filled out a grievance form yet . 3. Medical record review showed Resident #41 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Annual MDS dated [DATE] showed a BIMs of 15. During an interview on 12/17/19 at 8:22 AM, Resident #41 confirmed that she had 2 crosses broken by a member of housekeeping staff while cleaning her room. The resident confirmed she had notified the Administrator 6-7 months ago. The resident stated, .He (Administrator) glued them together but they won't stay .just in pieces .I just wrapped it in a napkin and put it in my drawer. During an interview on 12/17/19 at 5:00 PM, the Administrator confirmed that Resident #41's broken items were not placed on the Grievance Log. 4. Medical record review revealed Resident #258 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Th admission MDS dated [DATE] documented Resident #258 had a BIMs score of 14. The undated INVENTORY OF PERSONAL EFFECTS form labeled with Resident #258's name showed the resident had a .Cell phone . on admission. During an interview on 12/16/19 at 3:47 PM, in Resident #258's room, the resident was asked if he ever had any missing personal property. The resident stated, My telephone charging cord is missing. I have told everyone . During an interview on 12/17/19 at 5:23 PM, the Administrator confirmed no grievances had been placed on the log since July. The Administrator stated, .Sometimes I think it's the severity of what's missing .if it's money that's different .I hate to say that . The Administrator was asked when he should be notified of grievances. The Administrator stated, .Policy is they notify me immediately .

Based on medical record review, observation and interview, the facility failed to ensure practices to prevent the potential spread of infection were maintained for 1 of 2 (Resident #25) sampled residents reviewed receiving oxygen. The findings included: Medical record review revealed Resident #25 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A physician's telephone order dated 3/9/18 documented, .O2 (oxygen) 2-4 LPRN (liters as needed) BNC (bi-nasal cannula) to keep sats (saturation) (arrow for above) 90% (percent) . Observations in Resident #25's room on 3/26/18 at 2:40 PM, 2:55 PM, and 3:45 PM revealed Resident #25's oxygen tubing and cannula lying on the floor under the bed. Observations in Resident #25's room on 3/26/18 at 4:10 PM revealed Resident #25 the oxygen cannula in her nose. Interview with Certifed Nursing Assistant (CNA) #1 on 3/26/18 at 4:35 PM in front of room [ROOM NUMBER] and 17, CNA #1 was asked if she had replaced Resident #1's oxygen. CNA #1 stated, .Yes, I did . CNA #1 was asked if she had picked the cannula up off the floor and placed the oxygen cannula back in Resident #25's nose. CNA #1 looked down and stated, Yes. CNA #1 was asked if it was appropriate to replace an oxygen cannula that had been on the floor in the resident's nose. CNA #1 stated, .No I should have cleaned it or replaced it with a new one . Interview with the Director of Nursing (DON) on 3/27/18 at 2:00 PM on the smoking patio, the DON was asked what she expected her nursing staff to do when finding an oxygen cannula on the floor. The DON stated, Throw it away. The DON was asked if it was acceptable to place an oxygen cannula that has been on the floor back in a resident's nose. The DON stated, No.

Based on observation and interview, the facility failed to store medications at the temperature in accordance with manufacturer specifications for 8 of 52 stored medications in 1 of 1 medication rooms. The findings included: Observation with the Director of Nursing (DON) on 3/14/17 at 1:00 PM, in the medication storage room revealed a thermometer hanging on the wall by the door. Continued observation revealed the temperature of the room was 92 degrees Fahrenheit (F). Continued observation revealed 1 unopened bottle of Poly-Iron 150 (iron supplement) capsules with directions on the label to store at controlled room temperature of 59-86 degrees F. Further observation revealed 4 unopened boxes labeled Naproxen (anti-inflammatory) 220 milligram (mg) with a store temperature indicated as 68-77 degrees F. Continued observation revealed 1 unopened box of Certirizine (allergy) tablets with a store temperature indicated as 68-77 degrees F. Continued observation revealed 3 opened boxes of Acephen (acetaminophen suppositories pain/fever reducer) 650 mg; 1 box containing 2 suppositories, 1 box containing 7 suppositories, and 1 box containing 6 suppositories with a store temperature indicated as 59-86 degrees F. Interview with the DON on 3/14/17 at 1:05 PM in the medication storage room confirmed the medications were available for resident use. Further interview with the DON confirmed the facility had failed to store medications within the manufacturer acceptable temperature range.

Based on facility policy review, medical record review, observation, and interview, the facility failed to update the comprehensive care plan for 1 resident (#69) of 21 residents reviewed. The findings included: Review of facility policy, Care Plans-Comprehensive, revised 12/10 revealed, .Each resident's comprehensive care plan is designed to .Reflect the resident's expressed wishes regarding care and treatment goals .care plans are revised as information about the resident and the resident's condition change . Medical record review revealed Resident #69 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a 60 day Minimum Data Set ((MDS) dated [DATE] revealed Resident #69 was cognitively intact for decision making and required extensive assistance of 2 people for transfers. Medical record review of a Quarterly MDS dated [DATE] revealed the resident was cognitively intact for decision making and was totally dependent with assistance of 2 people for transfers. Observation of Resident #69 on 3/14/17 at 2:10 PM in the common area by the Nurse Station revealed he was seated in a wheelchair with a transfer sling underneath him. Interview with License Practical Nurse (LPN) #1 on 3/14/17 at 4:00 PM at the Nurse station revealed Resident #69 was transferred using a Hoyer lift with 2 person assistance. Observation and interview with Resident #69 on 3/15/17 at 9:10 AM in the resident's room revealed he was lying in bed with 1 mobility rail present to the upper right side of the bed. An overhead trapeze was present but not in reach of the resident. Interview with the resident revealed he used the Hoyer lift to transfer in and out of bed, and into and from the wheelchair with staff assistance at all times. Interview with Certified Nurse Aide (CNA) #1 and CNA #2 on 3/15/17 at 9:20 AM in the hallway outside of Resident #69's room confirmed the resident was transferred using a Hoyer lift with 2 people at all times. Continued interview with CNA #2 revealed the resident previously used a slide board with 2 person assistance to transfer when he was first admitted in October. Further interview with CNA #2 revealed sometime in December the resident asked to be transferred using the Hoyer lift and had been transferred that way ever since. Interview with LPN #2 on 3/15/17 at 9:25 AM in the hallway outside of the resident's room confirmed she was the nurse for the resident and that he was transferred using a Hoyer lift. Continued interview revealed the LPN stated, He used to use the slide board with 2 person assist when he first got here. When asked why the resident was requiring the Hoyer lift for transfers, the LPN stated, His [MEDICAL TREATMENT] takes a lot out of him, and he just won't do it anymore. Medical record review of the comprehensive care plan dated 11/2/16, reviewed 1/14/17 and 2/27/17, revealed a problem of Self Care Deficits related to Bilateral Below Knee Amputation, Muscle Weakness, Impaired Vision, Depression, Peripheral [MEDICAL CONDITION], and End Stage [MEDICAL CONDITION] with [MEDICAL TREATMENT]. Interventions included, .Prosthetic as ordered/as tolerated .Assist bar (times) 1 to aid in bed mobility .trapeze bar . Interview with the Director of Nursing (DON) on 3/15/17 at 9:40 AM in the Nurse Station revealed when asked how Resident #69 transferred, the DON looked at the resident's care plan and stated, He has a trapeze and a mobility rail, so I would use the rail to help him turn in bed and the trapeze to sit him up to transfer to the wheel chair. Continued interview revealed when asked how much assistance the resident required, the DON stated, I don't know that. Further interview revealed the DON looked at the CNA care plan and stated, He has a slide board. The DON confirmed the facility failed to update the comprehensive care plan to reflect the resident's current status for transfers for use of a Hoyer lift.

Based on medical record review and interview, the facility failed to provide the necessary care and services for a resident with swallowing difficulty and at risk for aspiration and receiving Hospice care when a syringe was used to force feed food and liquids for 1 resident (#1) of 6 residents who were totally dependent on staff for eating. This failure placed all residents at risk for aspiration and requiring total dependence on staff for eating in Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment or death of a resident). The Administrator, Director of Nursing and the Quality Assurance Nurse were informed of the Immediate Jeopardy on [DATE] at 3:00 PM in the Administrator's office. The findings included: Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Minimum (MDS) data set [DATE] revealed Resident #1 had adequate hearing, clear speech, could make self understood, was able to understand others, was severely cognitively impaired per the ,[DATE] score on the Brief Interview for Mental Status, was totally dependent with one person assist for eating, had no swallowing disorder, and received 95 minutes of speech therapy. Medical record review of the care plan initiated on [DATE] and updated [DATE] revealed the focus on .At risk for alteration in nutrition with risk for dehydration AEB (as evidenced by) .impaired cognitive ability with episode confusion and fluctuation in po (by mouth) intake .Interventions included .Observe for changes that may effect intake (i.e .difficulty swallowing .) . Further review revealed the interventions were updated on [DATE] to include .swallow precautions . Medical record review of the Physician telephone Orders revealed the following: [DATE] was a regular textured diet. [DATE] .ST (Speech Therapy) to eval (evaluate) + (and) tx (treat) as indicated .for cognitive deficit and swallowing secondary to dementia . [DATE] diet texture was changed to mechanical soft. [DATE] the diet was changed to mechanical soft with pureed (blenderized food) meat. [DATE] the diet was changed to pureed. [DATE] .Offer nectar thick liquids Q 2 (every 2 hours) Hydration while awake . [DATE] .DC (discontinu)) ST services eff (effective) [DATE] . [DATE] .Admit to .Hospice effective this day . Medical record review of the Speech Therapy (ST) Evaluation and Plan of Treatment dated [DATE] revealed Resident #1 had mildly impaired swallowing abilities, and the Assessment for Swallowing section documented .Clinical S/S (signs and symptoms) of Dysphagia (swallowing difficulty): effortful mastication (chewing process) . The ST Recertification and Update of Treatment Plan dated [DATE] to the discharge on [DATE] revealed the skilled services provided was dysphagia therapy and the diet was changed to pureed due to pocketing (food getting stuck in mouth), increased feeding time and lethargy. Further review revealed Resident #1 had used general swallowing techniques/precautions and upright posture during meals 70% (percent) of the time by [DATE], was tolerating the pureed diet while fed by staff, caregiver/staff were educated on safe swallowing strategies including bite/sip, small bites, and positioning. The swallow treatment training included small bites/sips (,[DATE] to ,[DATE] teaspoon) and facilitation of body positioning to increase safety with intake. Resident #1's Swallow Ability was moderately impaired, and had declined since the initial evaluation when he was mildly impaired. Medical record review of the Progress Notes revealed the following: [DATE] at 11:30 PM .No further emesis noted, had earlier after lunch x (times) 1. Afebrile . [DATE] at 2:15 PM .Moderately large emesis noted during activity in dining room. Afebrile . [DATE] at .1:30 PM Res (resident) consumed 100% of meal with asst (assist) with no dysphagia. Res vomited very large amt (amount) of liquid et (and) pureed food. Res entered Cheyne-Stokes (abnormal pattern of breathing characterized by progressively deeper and sometimes faster breathing, followed by a gradual decrease that results in a temporary stop in breathing) respirations et was unresponsive. Nurse at this x (time) went to supply closet to obtain suction equipment .at 1:34 PM Re-entered room. Noted absence of pulse, B/P (blood pressure) et respirations. Skin pale/gray et cool to touch. RN (Registered Nurse) #1 Supervisor notified .at 1:40 PM Pronounced deceased . by RN #1 @ (at) this time. Call placed to Hospice nurse) .at 1:45 PM RP (Responsible Party) et son notified of passing of resident .(RP) instructed funeral home to be called .at 3:50 PM Remains released to funeral home . Interviews with Licensed Practical Nurse (LPN) #5 on [DATE] at 2:55 PM and 4:25 PM on the long hall and the conference room, on [DATE] at 11:10 AM in the conference room, on [DATE] at 4:10 PM in the conference room, and on [DATE] 8:30 AM, on the long hall revealed Resident #1 had general decline as time passed including pocketing food, and had ,[DATE] vomiting episodes after eating. Further interview revealed LPN #5 had .fed (Resident #1) Magic Cup (nutritional supplement) and fluids ,[DATE] times by syringe .a couple of months before hospice started .I gave Magic Cup and water by syringe the morning of [DATE] . and Resident #1 .wanted water and could no longer suck on a straw .I didn't want him dehydrated . When questioned about the resident's advanced directive of no artificial feeding, why was a syringe okay to use, the LPN stated .because not able to suck through straw and when you held a cup to the lips the resident could blow into it so I tried a syringe, he knew to swallow once in mouth . When asked why the LPN used the syringe, the LPN stated .I was trying to help the man out, I don't know if Certified Nurse Aide (CNA) #4 was trained to use syringe . When asked what CNA #4 was doing when the LPN entered the resident's room on [DATE] at lunch, the LPN stated the CNA .was spoon feeding the resident lunch and I told her there was a syringe available if she needed it .When asked what the LPN did after she was aware the resident was projectile vomiting on [DATE] immediately after eating lunch, the LPN stated she got called to the resident's room .I was going to try to suction but he had already passed . When asked what happened to the syringe, the LPN stated .I told (CNA #4) to throw it away because there was no doctor's order for it . When asked if the LPN had informed Hospice, her supervisors, the physician, the resident or responsible party/Power of Attorney of the use of the syringe prior to Resident #1's death, the LPN stated No. Interviews with CNA #4 on [DATE] at 9:25 AM and on [DATE] at 10:15 AM and 12:35 PM, in the conference room and the nursing station revealed CNA #4 had been spoon feeding Resident #1 lunch on [DATE] when LPN #5 entered the resident's room and informed the CNA .syringe in drawer and she told me to try use it. I got syringe out, liquefied the pureed food with the fluid on the tray and put a little in his mouth, he swallowed, I asked if he wanted more and he said 'Uh Huh', I took my time feeding him and he ate all the food, 100%, and when I was done feeding he started vomiting. His head of bed was up but I put it up as high as it could go and yelled for help. (CNA #1) came to the room and she yelled for (LPN #5) to come to the room .(LPN #5) and (RN #1) came in the room .resident had thrown up so bad and stopped breathing . When asked when she was spoon feeding the resident lunch how had the resident been accepting the by mouth food, the CNA stated .he wasn't taking it like before . When asked why she used the syringe, CNA #4 stated .(LPN #5) told her the LPN had been using the syringe throughout the day with magic cup and juice and he did fine . When asked what happened to the syringe, CNA #4 stated .(CNA #1) told her that (LPN #5) told (CNA #1) to tell (CNA #4) to get the syringe out of there, I threw it in the trash in the resident's room then, I removed it and took it to the hopper room trash . Interview with CNA #1 on [DATE] at 2:40 PM, in the conference room when asked regarding events of [DATE] at lunch, the CNA stated she heard her name yelled out with urgency and she went next door and saw Resident #1 vomiting and CNA #1 yelled for LPN #5 to come to the room and .by the time (LPN #5) got to there (to room) (the resident) took 2 breaths and nothing. (LPN #5) whispered to me to tell (CNA #4) to get the syringe out of the room, I looked at (LPN #5) but told (CNA #4) what (LPN #5) had said and I went back to finish feeding my resident . Interview with CNA #7 on [DATE] at 9:15 AM, in the conference room revealed CNA #7 was assigned to Resident #1 mostly toward the end of his life and there were times he refused to open his mouth to eat. Further interview revealed CNA #7 had spoon fed Resident #1 on [DATE] for breakfast with approximately 50% intake and .swallowing good and drank a lot of liquids . Telephone interviews with the Hospice Patient Care Coordinator on [DATE] at 8:45 AM and 10:00 AM, and on [DATE] at 10:30 AM, when asked if hospice syringe fed residents stated .we don't push .eating, we educate .this is part of the dying process when they do not want to eat .body shuts down and no need to eat or drink unless they ask for something . The interview revealed hospice had no policy on syringe use and .Always told not to do it .not even a part of equipment provided staff . When asked if the hospice was aware the facility had used a syringe to feed Magic Cup and fluid on ,[DATE] occasions and lunch on [DATE] after which the resident projectile vomited and died stated No, I was not aware. Why would you do that? Interviews with the Speech Therapist on [DATE] at 11:10 AM, and on [DATE] at 8:40 AM, in the therapist office and the conference room revealed Resident #1 was provided speech therapy for swallowing from [DATE] to [DATE] and the texture of the food was downgraded progressively until was totally pureed due to increasing problems with dysphagia and swallowing problems. Further interview revealed the pureed diet was primarily due to pocketing (food getting stuck in mouth), increased time feeding and lethargy. Further interview revealed .he was definitely an aspiration risk when I changed the diet to pureed due to lethargy and there are no circumstances you should use a syringe .such a high risk for everything to go wrong and my biggest fear was for aspiration . Interviews with the Director of Nursing (DON) on [DATE] at 3:40 PM, on [DATE] at 10:50 AM and 4:40 PM, on [DATE] at 12:53 PM, and on [DATE] at 8:35 AM and 1:45 PM, in the conference room revealed the facility did not have a policy on syringe feeding a resident, and did not have a policy on aspiration/aspiration precautions. Further interview revealed the DON was not aware a syringe was being used to feed a resident prior to the event. The DON stated she had been notified by RN #1 of Resident #1's death on [DATE] and of being fed lunch with syringe, vomiting and then the death after the resident was pronounced and had left the building. When asked what the facility did after they were aware of the syringe feeding, the DON stated .interviewed the CNA and LPN, wrote up and suspended the LPN, and did one-on-one training with the CNA with verbal warning and planning to do full staff in-service on inappropriate use of syringe at next staff meeting . Telephone interviews with the Medical Director on [DATE] at 12:17 PM and on [DATE] at 12:50 PM, revealed when asked when he had become aware the facility had used a syringe stated .aware after the fact fluids given by syringe by the nurse . Further interview revealed when asked if he was aware a CNA had fed Resident #1 lunch by syringe with 100% intake, projectile vomited and then died , stated .I didn't know (Resident #1) got pureed food by syringe. Don't recall facility telling me . Further interview revealed, when asked if feeding with a syringe, thereby forcing the food into mouth, could have contributed to the projectile vomiting and death stated .He had significant issues already and reasonable to say aspirated, but with medical issues something else could be going on . Refer to F154 J, F155 J, F157 J, F224 J SQC, F225 J SQC, F226 J SQC, F241 J SQC, F278 J and F282 J.

Based on facility policy review, medical record review and interview, the facility failed to be administered in a manner to attain or maintain the highest practicable physical, mental, and psychosocial well-being of the residents by failing to ensure the resident had the right to be informed of the change in method of being fed, failed to honor the advanced directive for no artificial feeding and provide comfort measure, failed to ensure the physician was notified of the resident being force fed with a syringe, failed to prevent neglect when staff force fed a swallow impaired and aspiration risk resident with a syringe, failed to implement the abuse policy when 3 CNAs failed to report a syringe used to feed a swallow-impaired and aspiration-risk resident, failed to accurately assess the resident as swallow impaired and hospice status, and failed to follow the care plan for swallow precautions. These failures placed residents in Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment or death to a resident). The Administrator, Director of Nursing and the Quality Assurance Nurse were informed of the Immediate Jeopardy on 11/2/16 at 3:00 PM in the Administrator's office. The findings included: Interview with the Administrator on 10/26/16 at 3:00 PM, in the Administrator's office revealed the Administrator was not aware of the issues involved when the facility became aware staff was force feeding a swallow-impaired, aspiration-risk resident with a syringe on 10/1/16. Refer to F154 J, F155 J, F157 J, F224 J SQC, F225 J SQC, F226 J SQC, F241 J SQC, F278 J, F282 J and F309 J SQC.

Based on medical record review and interview, the facility failed to inform the responsible party/Power of Attorney of a change in the treatment when a 60 cubic centimeter syringe was used to force feed food and liquid for 1 resident (#1) of 6 residents who were totally dependent on staff for eating. This failure placed all residents at risk for aspiration and requiring total dependence on staff for eating in Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment or death of a resident). The Administrator, Director of Nursing and the Quality Assurance Nurse were informed of the Immediate Jeopardy on [DATE] at 3:00 PM in the Administrator's office. The findings included: Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Physician telephone Orders revealed an order on [DATE] for a pureed (blenderized food) diet. Continued medical record review revealed no physician orders from admission to discharge, to syringe feed Resident #1. Medical record review of the Speech Therapy Evaluation and Plan of Treatment dated [DATE] revealed Resident #1's diet was changed to pureed due to pocketing (food getting stuck in mouth), increased feeding time and lethargy. Further review revealed Resident #1 had used general swallowing techniques/precautions and upright posture during meals 70% (percent) of the time by [DATE], was tolerating the pureed diet while fed by staff, caregiver/staff were educated on safe swallowing strategies including bite/sip, small bites, and positioning. The swallowing treatment training included small bites/sips (,[DATE] to ,[DATE] teaspoon) and facilitation of body positioning to increase safety with intake. Medical record review of the Progress Notes revealed the following: [DATE] at 11:30 PM .No further emesis noted, had earlier after lunch x (times) 1. Afebrile . [DATE] at 2:15 PM .Moderately large emesis noted during activity in dining room. Afebrile . [DATE] at .1:30 PM Res (resident) consumed 100% of meal with asst (assist) with no dysphagia (difficulty swallowing). Res vomited very large amt (amount) of liquid et (and) pureed food. Res entered Cheyne-Stokes (abnormal pattern of breathing characterized by progressively deeper and sometimes faster breathing, followed by a gradual decrease that results in a temporary stop in breathing) respirations et was unresponsive. Nurse at this x (time) went to supply closet to obtain suction equipment .at 1:34 PM Re-entered room. Noted absence of pulse, B/P (blood pressure) et respirations. Skin pale/gray et cool to touch. RN (Registered Nurse) #1 Supervisor notified .at 1:40 PM Pronounced deceased . Interviews with Licensed Practical Nurse (LPN) #5 on [DATE] at 2:55 PM and at 4:25 PM on the long hall and the conference room, on [DATE] at 11:10 AM in the conference room, on [DATE] at 4:10 PM in the conference room, and on [DATE] at 8:30 AM on the long hall revealed Resident #1 had been pocketing food and had ,[DATE] vomiting episodes after eating. Further interview revealed the LPN had .fed (Resident #1) Magic Cup (nutritional supplement) and fluids ,[DATE] times by syringe .a couple of months before hospice started .I gave Magic Cup and water by syringe the morning of [DATE] . and (Resident #1) .wanted water and could no longer suck on a straw .I didn't want him dehydrated . When asked why the LPN used the syringe, the LPN stated .I was trying to help the man out . When asked what happened to the syringe the LPN stated .I told Certified Nurse Aide (CNA) #4 to throw it away because there was no doctor's order for it . When asked when you saw CNA #4 spoon feeding the resident lunch and you told CNA #4 the syringe was available for use you knew there was a possibility the CNA would use it, would you consider that force feeding, the LPN stated I guess I would. Continued interview, when asked if the LPN had informed Hospice, her supervisors, the physician, the resident or responsible party/Power of Attorney of the use of the syringe prior to Resident #1's death, the LPN stated No. Further interview revealed, when asked since the resident did not want artificial feeding and you used a syringe to force food and fluid into his mouth, do you think you violated his right to make the decision in the change of the method of being fed, the LPN stated .it was against his wishes .I took away his autonomy . Interviews with CNA #4 on [DATE] at 9:25 AM and [DATE] at 10:15 AM and 12:35 PM, in the conference room and the nursing station revealed CNA #4 had been spoon feeding Resident #1 lunch on [DATE] when LPN #5 entered the resident's room and informed the CNA .syringe in drawer and she told me to try to use it. I got syringe out, liquefied the pureed food with the fluid on the tray and put a little in his mouth, he swallowed .he ate all the food, 100% and when I was done feeding he started vomiting . When asked when she was spoon feeding the resident lunch how had the resident been accepting the by mouth food, the CNA stated .he wasn't taking it like before . When asked why she used the syringe, CNA #4 stated .(LPN #5) told her the LPN had been using the syringe throughout the day with magic cup and juice and he did fine . When asked what happened to the syringe, CNA #4 stated .(CNA #1) told her that (LPN #5) told (CNA #1) to tell (CNA #4) to get the syringe out of there, I threw it in the trash in the resident's room, and then I removed it and took it to the hopper room trash . Telephone interviews with the Hospice Patient Care Coordinator on [DATE] at 8:45 AM and 10:00 AM, and on [DATE] at 10:30 AM, when asked regarding the resident's POST status and having a syringe used to force food into the mouth how that would affect resident's rights stated .syringe is force feeding . Interviews with the Speech Therapist on [DATE] at 11:10 AM and on [DATE] at 8:40 AM, in the therapist office and the conference room revealed Resident #1's pureed diet was primarily due to pocketing, increased time feeding and lethargy. Further interview revealed .he was definitely an aspiration risk when I changed the diet to pureed (on [DATE]) due to lethargy and there are no circumstances you should use a syringe .such a high risk for everything to go wrong and my biggest fear was for aspiration . Interviews with the Director of Nursing (DON) on [DATE] at 3:40 PM, [DATE] at 10:50 AM and 4:40 PM, [DATE] at 12:53 PM, and [DATE] at 8:35 AM and 1:45 PM. Further interview revealed the DON was not aware a syringe was being used to feed a resident prior to the event. The DON stated she had been notified by RN #1 of Resident #1's death on [DATE] and of being fed lunch with a syringe, vomiting and then the death after the resident was pronounced and had left the building.

Based on medical record review and interview, the facility failed to honor the Advanced Directives for a resident with swallowing and aspiration risks for 1 resident (#1) of 6 residents who were totally dependent on staff for eating. This failure placed all residents at risk for aspiration and requiring total dependence on staff for eating in Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment or death of a resident). The Administrator, Director of Nursing and the Quality Assurance Nurse were informed of the Immediate Jeopardy on [DATE] at 3:00 PM in the Administrator's office. The findings included: Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #1's Physician order [REDACTED].Do Not Attempt Resuscitation, Comfort Measures-Relieve pain and suffering .Use oxygen, suction, and manual treatment of [REDACTED]. was signed by the resident's Power of Attorney and the Medical Director on [DATE]. Medical review of the Speech Therapy (ST) Evaluation and Plan of treatment dated [DATE] revealed Resident #1 had .Clinical S/S (signs and symptoms) of Dysphagia (difficulty swallowing): effortful mastication (chewing process) . The ST Recertification and Update of Treatment Plan dated [DATE] to [DATE] revealed the diet was changed to pureed (blenderized food) due to pocketing (food getting stuck in mouth), increased feeding time and lethargy. The treatment plan further revealed Resident #1 had used general swallowing techniques/precautions and upright posture during meals 70% (percent) of the time by the [DATE] discharge, was tolerating pureed diet while fed by staff, caregiver/staff educated on safe swallowing strategies including bite/sip, small bites, positioning. The swallowing treatment training included small bites/sips (,[DATE] to ,[DATE] teaspoon) and facilitation of body positioning too increase safety with intake. Medical record review of the Progress Notes revealed the following: [DATE] at 11:30 PM .No further emesis noted, had earlier after lunch x (times) 1. Afebrile . [DATE] at 2:15 PM .Moderately large emesis noted during activity in dining room. Afebrile . [DATE] at .1:30 PM Res (resident) consumed 100% of meal with asst (assist) with no dysphagia. Res vomited very large amt (amount) of liquid et (and) pureed food. Res entered Cheyne-Stokes (abnormal pattern of breathing characterized by progressively deeper and sometimes faster breathing, followed by a gradual decrease that results in a temporary stop in breathing) respirations et was unresponsive. Nurse at this x (time) went to supply closet to obtain suction equipment .at 1:34 PM Re-entered room. Noted absence of pulse, B/P (blood pressure) et respirations. Skin pale/gray et cool to touch. RN (Registered Nurse) #1 Supervisor notified .at 1:40 PM Pronounced deceased . Interviews with Licensed Practical Nurse (LPN) #5 on [DATE] at 2:55 PM and at 4:25 PM on the long hall and the conference room, on [DATE] at 11:10 AM in the conference room, on [DATE] at 4:10 PM in the conference room, and on [DATE] at 8:30 AM, on the long hall revealed Resident #) had been pocketing food, and had ,[DATE] vomiting episodes after eating. Further interview revealed the LPN had .fed (Resident #1) Magic Cup (nutritional supplement) and fluids ,[DATE] times by syringe .a couple of months before hospice started .I gave Magic Cup and water by syringe the morning of [DATE] . and (Resident #1) .wanted water and could no longer suck on a straw .I didn't want him dehydrated . When asked why the LPN used the syringe, the LPN stated .I was trying to help the man out . When questioned of the resident's advanced directive of no artificial feeding why was a syringe okay to use, the LPN stated .because not able to suck through straw and when you held a cup to the lips the resident could blow into it so I tried a syringe, he knew to swallow once in mouth . When asked what happened to the syringe, the LPN stated .I told Certified Nurse Aide (CNA) #4 to throw it away because there was no doctor's order for it . When asked when you saw CNA #4 spoon feeding the resident lunch and you told CNA #4 the syringe was available for use you knew there was a possibility the CNA would use it, would you consider that force feeding, the LPN stated I guess I would. When asked since the resident did not want artificial feeding and you used a syringe to force food and fluid into his mouth, do you think you violated his rights, the LPN stated .it was against his wishes .I took away his autonomy . Interviews with CNA #4 on [DATE] at 9:25 AM and on [DATE] at 10:15 AM and 12:35 PM, in the conference room and the nursing station revealed CNA #4 had been spoon feeding Resident #1 lunch on [DATE] when LPN #5 entered the resident's room and informed the CNA .syringe in drawer and she told me to try use it. I got syringe out, liquefied the pureed food with the fluid on the tray and put a little in his mouth, he swallowed .he ate all the food, 100% and when I was done feeding he started vomiting . When asked when she was spoon feeding the resident lunch how had the resident been accepting the by mouth food, the CNA stated .he wasn't taking it like before . When asked why she used the syringe, CNA #4 stated .(LPN #5) told her the LPN had been using the syringe throughout the day with magic cup and juice and he did fine . When asked what happened to the syringe, CNA #4 stated .(CNA #1) told her that (LPN #5) told (CNA #1) to tell (CNA #4) to get the syringe out of there, I threw it in the trash in the resident's room then I removed it and took it to the hopper room trash . Telephone interviews with the Hospice Patient Care Coordinator on [DATE] at 8:45 AM and 10:00 AM, and on [DATE] at 10:30 AM, when asked regarding the resident's POST status and having a syringe used to force food into the mouth how that would affect resident's rights stated .syringe is force feeding . Refer to F154 J.

Based on medical record review and interview, the facility failed to notify the physician and the responsible party a swallow-impaired, aspiration-risk resident was force fed food and liquids by a syringe for 1 resident (#1) of 6 residents who were totally dependent on staff for eating. This failure placed all residents at risk for aspiration and requiring total dependence on staff for eating in Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment or death of a resident). The Administrator, Director of Nursing and the Quality Assurance Nurse were informed of the Immediate Jeopardy on 11/2/16 at 3:00 PM in the Administrator's office. The findings included: Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Interview with Licensed Practical Nurse (LPN) #5 on 10/25/16 at 11:10 AM, in the conference room revealed the LPN had .fed (Resident #1) Magic Cup (nutritional supplement) and fluids 2-3 times by syringe .a couple of months before hospice started .I gave Magic Cup and water by syringe the morning of 10/1/16 ., and Resident #1 .wanted water and could no longer suck on a straw .I didn't want him dehydrated .I had not told the doctor, the resident or the responsible party of the syringe use . Interviews with the Speech Therapist on 10/26/16 at 11:10 AM, and on 11/3/16 at 8:40 AM, in the therapist office and the conference room revealed the pureed (blenderized food) diet was due to pocketing (food getting stuck in mouth), increased time feeding and lethargy. Further interview revealed .he was definitely an aspiration risk when I changed the diet to pureed (5/30/16) due to lethargy and there are no circumstances you should use a syringe .such a high risk for everything to go wrong and my biggest fear was for aspiration . Telephone interview with the Medical Director on 10/27/16 at 12:17 PM, when asked if he was aware Resident #1 had been fed by a syringe stated .I became aware after the fact that fluids were given by syringe by a nurse . Continued interview revealed, when asked if he was aware a Certified Nurse Aide (CNA) had fed Resident #1 food by a syringe, stated .I was not aware a CNA fed food by syringe .don't recall facility telling me that . The facility failed to notify the physician and the responsible party Resident #1 had been syringe fed food and fluids. Refer to F154 J and F155 J.

Based on medical record review and interview, the facility failed to ensure safe feeding practices were provided to a swallow-impaired, aspiration-risk resident when a syringe was used to force feed food and liquids for 1 resident (#1) of 6 residents who were totally dependent on staff for eating. This failure placed all residents at risk for aspiration and requiring total dependence on staff for eating in Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment or death of a resident). The Administrator, Director of Nursing and the Quality Assurance Nurse were informed of the Immediate Jeopardy on [DATE] at 3:00 PM in the Administrator's office. F224 is Substandard Quality of Care The findings included: Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the 60 day Minimum (MDS) data set [DATE] revealed Resident #1 had adequate hearing, clear speech, could make self understood, was able to understand others, was severely cognitively impaired per the ,[DATE] score on the Brief Interview for Mental Status, was totally dependent with one person assist for eating, had no swallowing disorder, and received 95 minutes of speech therapy. Medical record review of the Physician telephone Orders revealed the following: [DATE] a regular textured diet was ordered. [DATE] .ST (Speech Therapy) to eval (evaluate) + (and) tx (treat) as indicated .for cognitive deficit and swallowing secondary to dementia . [DATE] diet texture changed to mechanical soft. [DATE] the diet was changed to mechanical soft with pureed (blenderized food) meat. [DATE] the diet was changed to pureed. [DATE] .Offer nectar thick liquids Q 2 (every 2 hours) Hydration while awake . [DATE] .DC (discontinue) ST services eff (effective) [DATE] . [DATE] .Admit to Hospice effective this day . Medical record review of the Speech Therapy (ST) Evaluation and Plan of Treatment dated [DATE] revealed Resident #1 had mildly impaired swallowing abilities, and the Assessment for Swallowing section documented .Clinical S/S (signs and symptoms) of Dysphagia (swallowing difficult)): effortful mastication (chewing process) . The ST Recertification and Update of Treatment Plan dated [DATE] to [DATE] revealed the skilled services provided was dysphagia therapy and the diet was changed to pureed due to pocketing (food getting stuck in mouth), increased feeding time and lethargy. Further review revealed Resident #1 had used general swallowing techniques/precautions and upright posture during meals 70% (percent) of the time by [DATE], was tolerating the pureed diet while spoon fed by staff, caregiver/staff were educated on safe swallowing strategies including bite/sip, small bites, and positioning. The swallowing treatment training included small bites/sips (,[DATE] to ,[DATE] teaspoon) and facilitation of body positioning to increase safety with intake. Resident #1's Swallow Ability was moderately impaired and had declined since the initial evaluation when he was mildly impaired. Medical record review of the Progress Notes revealed the following: [DATE] .unable to swallow meds (medications) whole . [DATE] .Is having difficulty swallowing so meds are being crushed in applesauce . [DATE], [DATE], .takes meds crushed . [DATE] .takes meds crushed in applesauce with some problems . [DATE], [DATE], [DATE] .takes meds crushed . or .takes meds crushed in applesauce . [DATE] .Swallowing difficulty at times .Swallowing Deficits . [DATE], [DATE], [DATE] .takes meds crushed . or .takes meds crushed in applesauce . [DATE] .Takes meds crushed in applesauce with some difficulty . [DATE] at 11:26 AM .Unable to make needs known .takes meds crushed . [DATE] at 3:33 PM .takes meds crushed and at 11:08 PM . Has difficulty swallowing at times though able to clear with cough . [DATE] at 3:11 PM .Takes meds crushed in applesauce with extreme encouragement . and at 10:18 PM .takes several minutes to swallow meds. Able to swallow with no cough noted . [DATE] at 12:29 AM .Refused meds this HS (bedtime) with several attempts made . and at 11:44 AM .takes meds crushed . [DATE] at 2:20 AM .Resident noted to be holding crushed meds in mouth for extended time, many attempts made to get resident to swallow at which he eventually does . and at 7:52 PM .Unable to make needs known .Takes meds crushed . [DATE] at 1:19 AM .Refused HS meds with several attempts made . and at 10:44 PM .Has difficulty with swallowing at times. Meds crushed . [DATE] .Takes meds in applesauce with extreme encouragement to swallow . [DATE] at 2:29 PM .Resident had a decline this week, now requiring to be fed, diet changed to puree due to difficulty swallowing, unable to follow directions . and at 10:55 PM .Thickened liquids in use. Holds liquids in mouth for extended period of time . [DATE], [DATE] .Unable to make needs known .Takes meds crushed . [DATE] .Unable to make needs known .Takes meds crushed . [DATE] at 1:48 AM .Refused HS (bedtime) meds with several attempts made . and at 12:46 PM .Takes meds crushed in applesauce with extreme encouragement to swallow . [DATE] .Takes meds crushed in applesauce with extreme encouragement to swallow . [DATE] .Unable to make needs known .Takes meds crushed . [DATE] at 11:21 AM .Unable to make needs known .Takes meds crushed . and at 10:55 PM .Holds fluids in mouth extended periods . [DATE] .Holds fluids in mouth at times though no cough or choking noted. Takes meds crushed . [DATE] at 9:19 AM .Takes meds crushed in applesauce with extreme encouragement . and at 10:25 PM .Continues to have difficulty swallowing at times . [DATE], [DATE] .meds administered crushed in applesauce . or .takes meds crushed . [DATE] at 9:59 AM .Takes meds crushed in applesauce with extreme encouragement . and at 11:47 PM .has difficulty swallowing at times . [DATE] .Takes meds crushed . [DATE] at 3:16 AM .meds administered crushed in applesauce . at 1:47 PM .Takes meds crushed in applesauce with extreme encouragement . and at 2:34 PM .Takes meds crushed in applesauce with some difficulty . [DATE] at 2:25 AM .refused HS meds with several attempts made . and at 2:10 PM .Takes meds crushed in applesauce . [DATE] .Unable to make needs known .Takes meds crushed . [DATE] at 12:04 AM .Takes meds crushed .Holds liquids in mouth at times . and at 10:45 AM .Unable to make needs known .Takes meds crushed . [DATE] at 12:22 AM .crushed meds .; at 10:42 .receiving ST 5 times a week due to Dysphagia and Cognitive Deficits .unable to follow simple directions . and at 9:58 PM .Unable to hold cups or take meds from nurse. Meds crushed, has difficulty swallowing at times . [DATE] .Continues to have swallowing difficulties at times . [DATE] .Takes meds crushed in applesauce . [DATE] at 1:14 AM .takes meds crushed in applesauce with episodes of holding meds in mouth for extended time before swallowing . and at 3:25 PM .Unable to make needs known .Takes meds crushed . [DATE] at 3:19 AM .takes meds crushed in applesauce with episodes of holding meds in mouth for extended time before swallowing . and at 11:40 AM .Unable to make needs known .Takes meds crushed . [DATE] at 2:43 AM .takes meds crushed in applesauce with episodes of holding meds in mouth for extended time before swallowing .; at 10:55 AM .Takes meds crushed . and at 10:48 PM .Continues to have shakiness of hands, unable to use utensils or glass/cup without assist . [DATE] at 10:37 AM .takes meds crushed in applesauce . and at 10:55 PM .has coughed at times with free water, able to clear .has shakiness of hands when attempting to hold cup of liquid . [DATE] .takes meds crushed, unable to hold med cup or drinking cup . [DATE] at 4:18 PM .Takes meds crushed . and at 11:52 PM .takes meds crushed with significant difficulty swallowing . [DATE] at 11:51 AM and 12:07 PM .Unable to make needs known .Takes meds crushed . and at 2:17 PM .spoke with daughter/POA (Power of Attorney) .re (regarding) lethargy . [DATE] at 3:14 AM .takes meds crushed in applesauce with episodes of holding meds in mouth for extended time before swallowing . and at 2:23 PM .Takes meds crushed in applesauce . [DATE] at 3:01 AM .takes meds crushed in applesauce . at 2:50 PM .Meal assist per staff with delayed swallow noted .Takes meds crushed . and at 11:06 PM .Decline in condition noted related to swallowing .increased confusion . [DATE] at 11:31 AM and [DATE] at 1:42 PM .Unable to make needs known .Meal assist per staff with delayed swallow noted .Takes meds crushed . and at 10:15 PM .Swallowing difficulties continues at times . [DATE] at 12:46 AM .Meds administered crushed with difficulty at times . and at 9:55 AM .Takes meds crushed in applesauce with some encouragement . [DATE] at 3:57 PM and [DATE] at 3:26 PM .Unable to make needs known .Meal assist provided per staff with delayed swallowing noted . [DATE] at 10:56 AM and 12:21 PM .Unable to make needs known .Takes meds crushed . [DATE] .takes meds crushed in applesauce with some encouragement . [DATE] .meds administered crushed in applesauce with difficulty at times; will hold in mouth with much encouragement made to swallow . [DATE] and [DATE] .Takes meds crushed in applesauce with some encouragement . [DATE] .patient during meal supper noted coughing during feeding will advise therapy . [DATE] .Takes meds crushed in applesauce with some encouragement . [DATE] at 11:30 PM .No further emesis noted, had earlier after lunch x (times) 1. Afebrile . [DATE] at 2:15 PM .Moderately large emesis noted during activity in dining room. Afebrile . [DATE] at .1:30 PM Res (resident) consumed 100% of meal with asst (assist) with no dysphagia. Res vomited very large amt (amount) of liquid et (and) pureed food. Res entered Cheyne-Stokes (abnormal pattern of breathing characterized by progressively deeper and sometimes faster breathing, followed by a gradual decrease that results in a temporary stop in breathing) respirations et was unresponsive. Nurse at this x (time) went to supply closet to obtain suction equipment .at 1:34 PM Re-entered room. Noted absence of pulse, B/P (blood pressure) et respirations. Skin pale/gray et cool to touch. RN (Registered Nurse) #1 Supervisor notified .at 1:40 PM Pronounced deceased . by (RN #1) @ (at) this time. Call placed (Hospice nurse) .at 1:45 PM RP (Responsible Party) et son notified of passing of resident .(RP) instructed funeral home to be called .at 3:50 PM Remains released to funeral home . Interviews with Licensed Practical Nurse (LPN) #5 on [DATE] at 2:55 PM and at 4:25 PM on the long hall and the conference room, on [DATE] at 11:10 AM in the conference room, on [DATE] at 4:10 PM in the conference room, and on [DATE] at 8:30 AM on the long hall revealed Resident #1 had general decline as time passed including pocketing food, and had ,[DATE] vomiting episodes after eating. Further interview revealed LPN #5 had .fed (Resident #1) Magic Cup (nutritional supplement) and fluids ,[DATE] times by syringe .a couple of months before hospice started .I gave Magic Cup and water by syringe the morning of [DATE] . and (Resident #1) .wanted water and could no longer suck on a straw .I didn't want him dehydrated . When questioned about the resident's advanced directive of no artificial feeding, why was a syringe okay to use, the LPN stated .because not able to suck through straw and when you held a cup to the lips the resident could blow into it so I tried a syringe, he knew to swallow once in mouth . When asked why the LPN used the syringe the LPN stated .I was trying to help the man out, I don't know if Certified Nurse Aide (CNA) #4 was trained to use syringe . When asked what CNA #4 was doing when the LPN entered the resident's room on [DATE] at lunch, the LPN stated the CNA .was spoon feeding the resident lunch and I told her there was a syringe available if she needed it . When asked what the LPN did after she was aware the resident was projectile vomiting on [DATE] immediately after eating lunch, the LPN stated she got called to the resident's room .I was going to try to suction but he had already passed . When asked what happened to the syringe, the LPN stated .I told CNA #4 to throw it away because there was no doctor's order for it . When asked if the LPN had informed Hospice, her supervisors, the physician, the resident or responsible party/Power of Attorney of the use of the syringe prior to Resident #1's death, the LPN stated No. Interviews with CNA #4 on [DATE] at 9:25 AM and on [DATE] at 10:15 AM and 12:35 PM, in the conference room and the nursing station revealed CNA #4 had been spoon feeding Resident #1 lunch on [DATE] when LPN #5 entered the resident's room and informed the CNA .syringe in drawer and she told me to try to use it. I got syringe out, liquefied the pureed food with the fluid on the tray and put a little in his mouth, he swallowed, I asked if he wanted more and he said 'Uh Huh', I took my time feeding him and he ate all the food, 100%, and when I was done feeding he started vomiting. His head of bed was up but I put it up as high as it could go and yelled for help. (CNA #1) came to the room and she yelled for (LPN #5) to come to the room .(LPN #5) and (RN #1) came in the room .resident had thrown up so bad and stopped breathing . When asked when she was spoon feeding the resident lunch, how had the resident been accepting the food by mouth, the CNA stated .he wasn't taking it like before . When asked why she used the syringe, CNA #4 stated .(LPN #5) told her the LPN had been using the syringe throughout the day with magic cup and juice and he did fine . When asked what happened to the syringe, CNA #4 stated .(CNA #1) told her that (LPN #5) told (CNA #1) to tell (CNA #4) to get the syringe out of there, I threw it in the trash in the resident's room then I removed it and took it to the hopper room trash . Interview with CNA #1 on [DATE] at 2:40 PM, in the conference room when asked regarding events of [DATE] at lunch, revealed the CNA heard her name yelled out with urgency and she went next door and saw Resident #1 vomiting and (CNA #1) yelled for (LPN #5) to come to the room and .by the time (LPN #5) got there (to room) (Resident #1) took 2 breaths and nothing .(LPN #5) whispered to me to tell (CNA #4) to get the syringe out of the room, I looked at (LPN #5) but told (CNA #4) what (LPN #5) had said and I went back to finish feeding my resident . Interview with CNA #7 on [DATE] at 9:15 AM, in the conference room revealed CNA #7 was assigned to Resident #1 mostly toward the end of his life and there were times he refused to open his mouth to eat. Further interview revealed CNA #7 had .spoon fed Resident #1 on [DATE] breakfast with approximately 50% intake . Further interview revealed Resident #1 .swallowing good and drank a lot of liquids . Telephone interview with RN #1 on [DATE] at 1:25 PM, revealed when asked when the RN became aware of the syringe use, stated .I was told after the fact. Apparently fed by syringe at lunch according to the (CNA #4) and (LPN #5) had told her to feed with syringe. (LPN #5) told me she had told the CNA that if (resident) didn't eat there was a syringe in there and she could use that .I got the information after he was pronounced . Telephone interviews with Hospice Patient Care Coordinator on [DATE] at 8:45 AM and 10:00 AM, and on [DATE] at 10:30 AM, revealed when asked if hospice syringe fed residents stated .we don't push .eating, we educate .this is part of the dying process when they do not want to eat anymore .their body shuts down and no need to eat or drink unless they ask for something . The interview revealed hospice had no policy on syringe use and .Always told not to do it .not even a part of equipment provided staff . Further interview revealed, when asked if hospice was aware the facility had used a syringe to feed Magic Cup and fluid on ,[DATE] occasions and lunch on [DATE] after which the resident projectile vomited and died , the patient Care Coordinator stated No, was not aware. Why would you do that? Interviews with the Speech Therapist on [DATE] at 11:10 AM and on [DATE] at 8:40 AM, in the therapist office and/or the conference room revealed Resident #1 was provided speech therapy for swallowing from [DATE] to [DATE] and the texture of the food was downgraded progressively until was totally pureed due to increasing problems with dysphagia and swallowing problems. Further interview revealed the pureed diet was primarily due to pocketing, increased time feeding and lethargy. Further interview revealed .he was definitely an aspiration risk when I changed the diet to pureed due to lethargy and there are no circumstances you should use a syringe .such a high risk for everything to go wrong and my biggest fear was for aspiration . Interviews with the Director of Nursing (DON) on [DATE] at 3:40 PM, [DATE] at 10:50 AM and 4:40 PM, [DATE] at 12:53 PM, and [DATE] at 8:35 AM and 1:45 PM, in the conference room revealed the facility did not have a policy on syringe feeding a resident and did not have a policy on aspiration/aspiration precautions. Further interview revealed the DON was not aware a syringe was being used to feed a resident prior to the event. The DON stated she had been notified by RN #1 of Resident #1's death on [DATE] and of being fed lunch with a syringe, vomiting and then the death after the resident was pronounced and had left the building. When asked what the facility did after they were aware of the syringe feeding, the DON stated .interviewed the CNA and LPN, wrote up and suspended the LPN, and did one-on-one training with the CNA with verbal warning and planning to do full staff in-service on inappropriate use of a syringe at next staff meeting . Telephone interviews with the Medical Director on [DATE] at 12:17 PM and [DATE] at 12:50 PM, revealed when asked when he had become aware the facility had used a syringe, stated .aware after the fact fluids given by syringe by the nurse . Further interview revealed, when asked if he was aware a CNA had fed Resident #1 lunch by syringe with 100% intake, projectile vomited and then died , stated .I didn't know (Resident #1) got pureed food by syringe. Don't recall facility telling me . Further interview revealed when asked if feeding with a syringe, thereby forcing the food into mouth, could have contributed to the projectile vomiting and death, stated .He had significant issues already and reasonable to say aspirated but with medical issues something else could be going on . Refer to F154 J, F155 J, and F157 J.

Based on medical record review and interview, the facility failed to report an incident of neglect when a resident with swallowing difficulty and at risk for aspiration was force fed food and liquids by a syringe to the state agency for 1 resident (#1) of 6 residents who were totally dependent on staff for eating. This failure placed all residents at risk for aspiration and requiring total dependence on staff for eating in Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment or death of a resident). The Administrator, Director of Nursing and the Quality Assurance Nurse were informed of the Immediate Jeopardy on [DATE] at 3:00 PM in the Administrator's office. The findings included: Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the 60 day Minimum (MDS) data set [DATE] revealed Resident #1 had adequate hearing, clear speech, could make self understood, was able to understand others, was severely cognitively impaired per the ,[DATE] score on the Brief Interview for Mental Status, was totally dependent with one person assist for eating, had no swallowing disorder, and received 95 minutes of speech therapy. Interviews with Licensed Practical Nurse (LPN) #5 on [DATE] at 2:55 PM and at 4:25 PM on the long hall and the conference room, on [DATE] at 11:10 AM in the conference room, on [DATE] at 4:10 PM in the conference room, and on [DATE] at 8:30 AM on the long hall revealed Resident #1 had general decline as time passed including pocketing food, and had ,[DATE] vomiting episodes after eating. Further interview revealed LPN #5 had .fed (Resident #1) Magic Cup (nutritional supplement) and fluids ,[DATE] times by syringe .a couple of months before hospice started .I gave Magic Cup and water by syringe the morning of [DATE] . and (Resident #1) .wanted water and could no longer suck on a straw .I didn't want him dehydrated . When questioned about the resident's advanced directive of no artificial feeding, why was a syringe okay to use, the LPN stated .because not able to suck through straw and when you held a cup to the lips the resident could blow into it so I tried a syringe, he knew to swallow once in mouth . When asked why the LPN used the syringe the LPN stated .I was trying to help the man out, I don't know if Certified Nurse Aide (CNA) #4 was trained to use syringe . When asked what CNA #4 was doing when the LPN entered the resident's room on [DATE] at lunch, the LPN stated the CNA .was spoon feeding the resident lunch and I told her there was a syringe available if she needed it . When asked what the LPN did after she was aware the resident was projectile vomiting on [DATE] immediately after eating lunch, the LPN stated she got called to the resident's room .I was going to try to suction but he had already passed . When asked what happened to the syringe, the LPN stated .I told CNA #4 to throw it away because there was no doctor's order for it . When asked if the LPN had informed Hospice, her supervisors, the physician, the resident or responsible party/Power of Attorney of the use of the syringe prior to Resident #1's death, the LPN stated No. Interviews with CNA #4 on [DATE] at 9:25 AM and on [DATE] at 10:15 AM and 12:35 PM, in the conference room and the nursing station revealed CNA #4 had been spoon feeding Resident #1 lunch on [DATE] when LPN #5 entered the resident's room and informed the CNA .syringe in drawer and she told me to try to use it. I got syringe out, liquefied the pureed food with the fluid on the tray and put a little in his mouth, he swallowed, I asked if he wanted more and he said 'Uh Huh', I took my time feeding him and he ate all the food, 100%, and when I was done feeding he started vomiting. His head of bed was up but I put it up as high as it could go and yelled for help. (CNA #1) came to the room and she yelled for (LPN #5) to come to the room .(LPN #5) and (RN #1) came in the room .resident had thrown up so bad and stopped breathing . When asked when she was spoon feeding the resident lunch, how had the resident been accepting the food by mouth, the CNA stated .he wasn't taking it like before . When asked why she used the syringe, CNA #4 stated .(LPN #5) told her the LPN had been using the syringe throughout the day with magic cup and juice and he did fine . When asked what happened to the syringe, CNA #4 stated .(CNA #1) told her that (LPN #5) told (CNA #1) to tell (CNA #4) to get the syringe out of there, I threw it in the trash in the resident's room then I removed it and took it to the hopper room trash . Interviews with the Director of Nursing (DON) on [DATE] at 3:40 PM, [DATE] at 10:50 AM and 4:40 PM, [DATE] at 12:53 PM, and [DATE] at 8:35 AM and 1:45 PM, in the conference room revealed the DON was not aware a syringe was being used to feed a resident prior to the event. The DON stated she had been notified by RN #1 of Resident #1's death on [DATE] and of being fed lunch with a syringe, vomiting and then the death after the resident was pronounced and had left the building. When asked what the facility did after they were aware of the syringe feeding, the DON stated .interviewed the CNA and LPN, wrote up and suspended the LPN, and did one-on-one training with the CNA with verbal warning and planning to do full staff in-service on inappropriate use of a syringe at next staff meeting . Further interview revealed, when asked if the incident was reported to the state agency, the DON stated, as far as I know nothing was reported to the state. Refer to F154 J, F155 J, F157 J, F224 J SQC

Based on facility policy review, medical record review and interview, the facility failed to implement the abuse policy when 3 Certified Nurse Aides were aware a swallow-impaired, aspiration-risk resident was force fed food and fluid by a syringe for 1 resident (#1) of 6 residents who were totally dependent on staff for eating. This failure placed all residents at risk for aspiration and requiring total dependence on staff for eating in Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment or death of a resident). The Administrator, Director of Nursing and the Quality Assurance Nurse were informed of the Immediate Jeopardy on [DATE] at 3:00 PM in the Administrator's office. F226 is Substandard Quality of Care The findings included: Review of policy, Abuse Prevention/Reporting Policy and Procedure, revised [DATE], revealed .Every resident has the right to be free from .neglect .Definitions 6. Negligence: Failing to properly care for a resident in a manner conducive to professional care standards. 7. Neglect: failure to provide goods and services necessary to avoid physical harm, mental anguish or mental illness .Abuse Prevention Procedures .Prevention 5. Staff will be provided with information regarding the process for reporting a witnessed abuse, suspected abuse .Staff will be provided through education .the process for reporting abuse to their immediate Supervisor, Abuse Coordinator, local authorities and State department of health . Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the 60 day Minimum (MDS) data set [DATE] revealed Resident #1 had adequate hearing, clear speech, could make self understood, was able to understand others, was severely cognitively impaired per the ,[DATE] score on the Brief Interview for Mental Status, was totally dependent with one person assist for eating, had no swallowing disorder, and received 95 minutes of speech therapy. Medical record review of the Speech Therapy (ST) Evaluation and Plan of Treatment dated [DATE] revealed Resident #1 had mildly impaired swallowing abilities, and the Assessment for Swallowing section documented .Clinical S/S (signs and symptoms) of Dysphagia (swallowing difficulty): effortful mastication (chewing process) . The ST Recertification and Update of Treatment Plan dated [DATE] to [DATE] revealed the skilled services provided was dysphagia therapy and the diet was changed to pureed (blenderized food) due to pocketing (food getting stuck in mouth), increased feeding time and lethargy. Further review revealed Resident #1 had used general swallowing techniques/precautions and upright posture during meals 70% (percent) of the time by [DATE], was tolerating the pureed diet while fed by staff, caregiver/staff were educated on safe swallowing strategies including bite/sip, small bites, and positioning. The swallowing treatment training included small bites/sips (,[DATE] to ,[DATE] teaspoon) and facilitation of body positioning to increase safety with intake. Resident #1's Swallow Ability was moderately impaired, and had declined since the initial evaluation when he was mildly impaired. Medical record review of the Progress Notes revealed the following: [DATE] at 11:30 PM .No further emesis noted, had earlier after lunch x (times) 1. Afebrile . [DATE] at 2:15 PM .Moderately large emesis noted during activity in dining room. Afebrile . [DATE] at .1:30 PM Res (resident) consumed 100% of meal with asst (assist) with no dysphagia. Res vomited very large amt (amount) of liquid et (and) pureed food. Res entered Cheyne-Stokes (abnormal pattern of breathing characterized by progressively deeper and sometimes faster breathing, followed by a gradual decrease that results in a temporary stop in breathing) respirations et was unresponsive. Nurse at this x (time) went to supply closet to obtain suction equipment .at 1:34 PM Re-entered room. Noted absence of pulse, B/P (blood pressure) et respirations. Skin pale/gray et cool to touch. RN (Registered Nurse) #1 Supervisor notified .at 1:40 PM Pronounced deceased . Interviews with Licensed Practical Nurse (LPN) #5 on [DATE] at 2:55 PM and at 4:25 PM on the long hall and the conference room, [DATE] at 11:10 AM in the conference room, [DATE] at 4:10 PM in the conference room, and on [DATE] at 8:30 AM, on the long hall revealed Resident #1 had general decline as time passed including pocketing food, had ,[DATE] vomiting episodes after eating, had .fed (Resident #1) Magic Cup (nutritional supplement) and fluids ,[DATE] times by syringe .a couple of months before hospice started .I gave Magic Cup and water by syringe the morning of [DATE] . and (Resident #1) .wanted water and could no longer suck on a straw .I didn't want him dehydrated .because not able to suck through straw and when you held a cup to the lips the resident could blow into it so I tried a syringe, he knew to swallow once something in mouth . When asked what Certified Nurse Aide (CNA) #4 was doing when the LPN entered the resident's room on [DATE] at lunch, the LPN stated the CNA .was spoon feeding the resident lunch and I told her there was a syringe available if she needed it . When asked why the LPN used the syringe the LPN stated .I was trying to help the man out, I don't know if (CNA #4) was trained to use syringe . Interviews with CNA #4 on [DATE] at 9:25 AM and [DATE] at 10:15 AM and 12:35 PM, in the conference room and the nursing station revealed CNA #4 had been spoon feeding Resident #1 lunch on [DATE] when LPN #5 entered the resident's room and informed the CNA .syringe in drawer and she told me to try to use it. I got syringe out, liquefied the pureed food with the fluid on the tray and put a little in his mouth, he swallowed, I asked if he wanted more and he said 'Uh Huh', I took my time feeding him and he ate all the food, 100% and when I was done feeding he started vomiting. His head of bed was up but I put it up as high as it could go and yelled for help. (CNA #1) came to room and she yelled for (LPN #5) to come to room . (LPN #5) and (RN #1) came in the room .resident had thrown up so bad and stopped breathing . When asked when she was spoon feeding the resident lunch how had the resident been accepting the food by mouth, the CNA stated .he wasn't taking it like before . When asked why she used the syringe, CNA #4 stated .(LPN #5) told her the LPN had been using the syringe throughout the day with magic cup and juice and he did fine . When asked what happened to the syringe, CNA #4 stated .(CNA #1) told her that (LPN #5) told (CNA #1) to tell (CNA #4) to get the syringe out of there, I threw it in the trash in the resident's room then I removed it and took it to the hopper room trash . Interview with CNA #7 on [DATE] at 9:15 AM, in the conference room revealed when asked if she was aware of a syringe being used, the CNA stated .The first time I saw the syringe was at lunch when (CNA #4) was using it to feed (Resident #1) and I turned and left the room .I went and told (CNA #3) what I had seen .I knew we don't do that syringe feeding . When asked if CNA #7 reported the syringe to supervisors, the CNA stated No, I went back to caring for my residents .I knew we had no physician orders .I don't know why I didn't tell the Charge Nurse .I knew it was wrong to feed with a syringe . Interview with CNA #3 on [DATE] at 11:20 AM, in the conference room revealed when asked what she knew about a syringe being used, the CNA stated .(CNA #7) came to room I was at and said she walked in (Resident #1's) room and saw (CNA #4) feeding him with a syringe. I said 'She what?' and then (CNA #7) left the room and I went on feeding my resident. When I got done with my resident I went to (Resident #1's) room but he had passed . Further interview revealed, when asked if she had reported the use of the syringe to supervisors she stated No. Interviews with the Director of Nursing (DON) on [DATE] at 3:40 PM, [DATE] at 10:50 AM and 4:40 PM, [DATE] at 12:53 PM, and on [DATE] at 8:35 AM and 1:45 PM, in the conference room revealed the facility did not have a policy on syringe feeding a resident, and did not have a policy on aspiration/aspiration precautions. Further interview revealed the DON was not aware a syringe was being used to feed a resident prior to the event. When asked if the DON was aware (CNA #7) had seen (CNA #4) using the syringe to feed (Resident #1) on [DATE] and then (CNA #7) told (CNA #3) what she had seen and none of the CNAs had reported the syringe use stated No, I didn't know that. Refer to F154 J, F155 J, F157 J, F224 J SQC, F225 J SQC

Based on medical record review, review of the hospice forms, and interview, the facility failed to accurately assess the swallowing impairment on the 6/16/16 Minimum Data Set (MDS) and failed to accurately assess the hospice status on the 9/29/16 MDS for 1 resident (#1) of 11 residents. The failure to assess Resident #1 for a swallowing impairment placed Resident #1 in Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment or death of a resident). The Administrator, Director of Nursing and the Quality Assurance Nurse were informed of the Immediate Jeopardy on 11/2/16 at 3:00 PM in the Administrator's office. The findings included: Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Physician telephone Orders dated 4/24/16 revealed .ST (Speech Therapy) to eval (evaluate) + (and) tx (treat) as indicated .ST Clarification: ST to see 2 x wk (week) x 6 wks for cognitive deficit and swallowing secondary to dementia . Medical record review of the Progress Notes revealed the following: 6/8/16 .Holds fluids in mouth at times though no cough or choking noted. Takes meds crushed . 6/9/16 at 9:19 AM .Takes meds crushed in applesauce with extreme encouragement . and at 10:25 PM .Continues to have difficulty swallowing at times . 6/11/16, 6/12/16 .meds administered crushed in applesauce . or .takes meds crushed . 6/14/16 at 9:59 AM .Takes meds crushed in applesauce with extreme encouragement . and at 11:47 PM .has difficulty swallowing at times . 6/16/16 .Takes meds crushed . Medical record review of the 60 day Minimum Data Set ((MDS) dated [DATE] revealed Resident #1 had no swallowing disorder. Medical record review of the Physician telephone Orders dated 9/16/16 revealed .Code Status changed to DNR (Do Not Resuscitate) .Comfort Measure .Admit to .Hospice effective this day . Review of Hospice Informed Consent form revealed the effective date of services was 9/16/16. Medical record review of the Significant Change MDS dated [DATE] revealed the facility failed to accurately assess the hospice services provided. Interview with Registered Nurse (RN) #2, responsible for the accuracy of the MDS information, on 10/25/16 at 10:18 AM, in the conference room when asked how the RN obtained the information to complete the MDS the RN stated .checked the nursing notes, laboratory data .every piece of paper in the chart .the hospice notes .and interviewed staff . Further interview revealed the documentation the RN reviewed and the interviews .had no mention of swallowing or pocketing issues . The facility failed to accurately assess the swallowing status on the 6/16/16 MDS. Further interview confirmed the MDS failed to accurately address the hospice status of the resident. Refer to F154 J, F155 J, F157 J, F224 J SQC, F225 J SQC, F226 J SQC, and F241 J SQC.

Based on medical record review and interview, the facility failed to follow the care plan for safe feeding practices to be provided to a swallow-impaired, aspiration-risk resident when a syringe was used to force feed food and liquids for 1 resident (#1) of 6 residents who were totally dependent on staff for eating. This failure placed all residents at risk for aspiration and requiring total dependence on staff for eating in Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment or death of a resident). The Administrator, Director of Nursing and the Quality Assurance Nurse were informed of the Immediate Jeopardy on 11/2/16 at 3:00 PM in the Administrator's office. The findings included: Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the 60 day Minimum (MDS) data set [DATE] revealed Resident #1 had adequate hearing, clear speech, could make self understood, was able to understand others, was severely cognitively impaired per the 3/15 score on the Brief Interview for Mental Status, was totally dependent with one person assist for eating, had no swallowing disorder, and received 95 minutes of speech therapy. Medical record review of the care plan initiated on 5/3/16 and updated 7/27/16 revealed .At risk for alteration in nutrition with risk for dehydration AEB (as evidenced by) .impaired cognitive ability with episode confusion and fluctuation in po (by mouth) intake .Interventions included .Observe for changes that may effect intake (i.e .difficulty swallowing .) . Further review revealed the interventions were updated on 8/23/16 to include .swallow precautions . Medical record review of the Speech Therapy (ST) Evaluation and Plan of Treatment dated 4/24/16 revealed Resident #1 had mildly impaired swallowing abilities, and the Assessment for Swallowing section documented .Clinical S/S (signs and symptoms) of Dysphagia (swallowing difficulty): effortful mastication (chewing proces)) . The ST Recertification and Update of Treatment Plan dated 6/6/16 to 7/3/16 revealed the skilled services provided was dysphagia therapy and the diet was changed to pureed (blenderized food) due to pocketing (food getting stuck in mouth), increased feeding time and lethargy. Further review revealed Resident #1 had used general swallowing techniques/precautions and upright posture during meals 70% (percent) of the time by 7/3/16, was tolerating the pureed diet while fed by staff, caregiver/staff were educated on safe swallow strategies including bite/sip, small bites, and positioning. The swallow treatment training included small bites/sips (1/2 to 1/3 teaspoon) and facilitation of body positioning to increase safety with intake. Resident #1's Swallow Ability was moderately impaired, and had declined since the initial evaluation when he was mildly impaired. Interviews with Licensed Practical Nurse (LPN) #5 on 10/24/16 at 2:55 PM and 4:25 PM on the long hall and the conference room, on 10/25/16 at 11:10 AM in the conference room, on 10/26/16 at 4:10 PM in the conference room, and on 11/3/16 8:30 AM, on the long hall revealed Resident #1 had general decline as time passed including pocketing food, had 2-3 vomiting episodes after eating, had .fed (Resident #1) Magic Cup (nutritional supplement) and fluids 2-3 times by syringe .a couple of months before hospice started .I gave Magic Cup and water by syringe the morning of 10/1/16 . (Resident #1) .wanted water and could no longer suck on a straw .I didn't want him dehydrated . When asked since the resident's advanced directive stated no artificial feeding why was a syringe okay to use, the LPN stated .because not able to suck through straw and when you held a cup to the lips the resident could blow into it so I tried a syringe, he knew to swallow once in mouth . When asked what Certified Nurse Aide (CNA) #4 was doing when the LPN entered the resident's room on 10/1/16 at lunch, the LPN stated the CNA .was spoon feeding the resident lunch and I told her there was a syringe available if she needed it . When asked why the LPN used the syringe, the LPN stated .I was trying to help the man out, I don't know if CNA #4 was trained to use syringe . Interviews with CNA #4 on 10/25/16 at 9:25 AM and 11/2/16 at 10:15 AM and 12:35 PM, in the conference room and the nursing station revealed CNA #4 had been spoon feeding Resident #1 lunch on 10/1/16 when LPN #5 entered the resident's room and informed the CNA .syringe in drawer and she told me to try use it. I got syringe out, liquefied the pureed food with the fluid on the tray and put a little in his mouth, he swallowed, I asked if he wanted more and he said 'Uh Huh', I took my time feeding him and he ate all the food, 100% and when I was done feeding he started vomiting. His head of bed was up but I put it up as high as it could go and yelled for help. (CNA #1) came to room and she yelled for (LPN #5) to come to room .(LPN #5) and (RN #1) came in the room .resident had thrown up so bad and stopped breathing . When asked when she was spoon feeding the resident lunch how had the resident been accepting the by mouth food, the CNA stated .he wasn't taking it like before . When asked why she used the syringe, CNA #4 stated .(LPN #5) told her the LPN had been using the syringe throughout the day with magic cup and juice and he did fine . When asked what happened to the syringe, CNA #4 stated .(CNA #)1 told her that (LPN #5) told (CNA #1) to tell (CNA #4) to get the syringe out of there, I threw it in the trash in the resident's room, and then I removed it and took it to the hopper room trash . Interviews with the Speech Therapist on 10/26/16 at 11:10 AM, andon 11/3/16 at 8:40 AM, in the therapist office and the conference room revealed Resident #1 was provided speech therapy for swallowing from 4/24/16 to 7/3/16 and the pureed diet was initiated due to increased swallowing problems and later due to pocketing, increased time feeding and lethargy. Further interview revealed .he was definitely an aspiration risk when I changed the diet to puree due to lethargy and there are no circumstances you should use a syringe .such a high risk for everything to go wrong and my biggest fear was for aspiration . The facility failed to follow the swallow precaution intervention on the care plan. Refer to F154 J, F155 J, F157 J, F224 J SQC, F225 J SQC, F226 J SQC, F 241 J SQC, and F278 J.

Based on medical record review, committee minutes review, and interview, the Quality Assurance and Performance Improvement Committee failed to identify facility staff had force fed a swallow impaired and aspiration risk resident with a syringe as neglect, failed to implement the facility abuse policy for reporting when 3 Certified Nurse Aides (CNAs) failed to report the syringe used to feed a swallow impaired and aspiration risk resident, failed to identify the inaccurate assessments and failed to identify the care plans were not followed. These failures placed residents in Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment or death to a resident). The Administrator, Director of Nursing, and the Quality Assurance Nurse were informed of the Immediate Jeopardy on 11/2/16 at 3:00 PM in the Administrator's office. The findings included: Interviews with the Director of Nursing on 10/24/16 at 3:40 PM and on 11/2/16 at 1:45 PM in the conference room confirmed the facility had not accurately identified the magnitude of the issues involved when the facility became aware staff was force feeding a swallow impaired, aspiration risk resident with a syringe on 10/1/16. Refer to F154 J, F155 J, F157 J, F224 J SQC, F225 J SQC, F226 J SQC, F241 J SQC, F278 J, F282 J, F309 J SQC, and F490.

Based on facility policy review, medical record review and interview, the facility failed to maintain the dignity to a swallow-impaired, aspiration risk resident when a syringe was used to force feed food and liquids for 1 resident (#1) of 6 residents who were totally dependent on staff for eating. This failure placed all residents at risk for aspiration and requiring total dependence on staff for eating in Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment or death of a resident). The Administrator, Director of Nursing and the Quality Assurance Nurse were informed of the Immediate Jeopardy on 11/2/16 at 3:00 PM in the Administrator's office. The findings included: Review of facility policy, Quality of Life-Dignity, revised 12/11/15, revealed .Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality .Policy Interpretation and Implementation .'Treated with dignity' means the resident will be assisted in maintaining and enhancing his or her self-esteem and self-worth .Staff shall keep the resident informed .Procedures shall be explained before they are performed .Demeaning practices and standards of care that compromise dignity are prohibited. Staff shall promote dignity and assist residents as needed .Staff shall treat cognitively impaired residents with dignity and sensitively . Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Minimum (MDS) data set [DATE] revealed Resident #1 had adequate hearing, clear speech, could make self understood, was able to understand others, was severely cognitively impaired per the 3/15 score on the Brief Interview for Mental Status, was totally dependent with one person assist for eating, and had no swallowing disorder. Interviews with Licensed Practical Nurse (LPN) #5 on 10/24/16 at 2:55 PM and 4:25 PM on the long hall and the conference room, on 10/25/16 at 11:10 AM in the conference room, on 10/26/16 at 4:10 PM in the conference room, and on 11/3/16 8:30 AM, on the long hall revealed Resident #1 had general decline as time passed including pocketing (food getting stuck in mouth) food, and had 2-3 vomiting episodes after eating. Further interview revealed LPN #5 had .fed (Resident #1) Magic Cup (nutritional supplement) and fluids 2-3 times by syringe .a couple of months before hospice started .I gave Magic Cup and water by syringe the morning of 10/1/16 . and Resident #1 .wanted water and could no longer suck on a straw .I didn't want him dehydrated . When questioned about the resident's advanced directive of no artificial feeding, why was a syringe okay to use, the LPN stated .because not able to suck through straw and when you held a cup to the lips the resident could blow into it so I tried a syringe, he knew to swallow once in mouth . When asked why the LPN used the syringe, the LPN stated .I was trying to help the man out, I don't know if Certified Nurse Aide (CNA) #4 was trained to use syringe . When asked what CNA #4 was doing when the LPN entered the resident's room on 10/1/16 at lunch, the LPN stated the CNA .was spoon feeding the resident lunch and I told her there was a syringe available if she needed it . When asked since you used a syringe to force food and fluid into his mouth and informed another staff member to use the syringe, do you think you violated his dignity, the LPN stated .it was against his wishes .I took away his autonomy . Interviews with CNA #4 on 10/25/16 at 9:25 AM and on 11/2/16 at 10:15 AM and 12:35 PM, in the conference room and the nursing station revealed CNA #4 had been spoon feeding Resident #1 lunch on 10/1/16 when LPN #5 entered the resident's room and informed the CNA .syringe in drawer and she told me to try use it. I got syringe out, liquefied the pureed food with the fluid on the tray and put a little in his mouth, he swallowed, I asked if he wanted more and he said 'Uh Huh', I took my time feeding him and he ate all the food, 100%, and when I was done feeding he started vomiting. His head of bed was up but I put it up as high as it could go and yelled for help. (CNA #1) came to the room and she yelled for (LPN #5) to come to the room .(LPN #5) and (RN #1) came in the room .resident had thrown up so bad and stopped breathing . When asked when she was spoon feeding the resident lunch how had the resident been accepting the by mouth food, the CNA stated .he wasn't taking it like before . When asked why she used the syringe, CNA #4 stated .(LPN #5) told her the LPN had been using the syringe throughout the day with magic cup and juice and he did fine . When asked what happened to the syringe, CNA #4 stated .(CNA #1) told her that (LPN #5) told (CNA #1) to tell (CNA #4) to get the syringe out of there, I threw it in the trash in the resident's room, and then I removed it and took it to the hopper room trash . Interviews with the Director of Nursing (DON) on 10/24/16 at 3:40 PM, on 10/25/16 at 10:50 AM and 4:40 PM, on 10/26/16 at 12:53 PM, and on 11/2/16 at 8:35 AM and 1:45 PM, in the conference room revealed the DON was not aware a syringe was being used to feed a resident prior to the event. When asked if the facility maintained the resident's dignity, the DON stated No. Refer to F154 J, F155 J, F157 J, F224 J SQC, F225 J SQC and F226 J SQC.