Every finding on record at Northgate Postacute Care

Based on interview and record review, the facility failed to ensure timely completion of a physician ordered mental health evaluation for one (1) of four (4) sampled residents (Resident 1).This failure resulted in a six month delay in ordered mental health services, with potential exacerbation in Resident 1's continued fear, anxiety, and care refusals.A review of Resident 1's Face Sheet (a facility demographic) indicated she was admitted to the facility on [DATE] with diagnoses including depression (a serious mood disorder that causes persistent feelings of sadness, emptiness, and a loss of interest in activities) and unspecified symptoms and signs involving cognitive functions and awareness (a medical diagnosis used when a person shows a decline in thinking skills, memory, or awareness, but the exact cause is still unknown).A review of the Minimum Data Set (MDS, resident assessment tool to evaluate each resident's physical, mental, and functional status), dated 7/24/26, indicated Resident 1 had intact cognitive abilities (the individual could process information, reason, and remember things at a level expected for their age and health), and had felt, down, depressed, or hopeless on several recent days.A review of Resident 1's Care Plan Report, initiated 6/22/26, an intervention for Resident 1's psychosocial well-being problem focus indicated the facility would Consult with psych services as needed.A review of facility Progress Notes, dated 8/4/26 at 11:26 a.m., indicated, [Resident 1] verbalized someone took her phone.hit her.and staff were forcing her to stay in bed.A review of facility Progress Notes, dated 8/5/26 at 9:22 a.m., indicated, encouraged [Resident 1] to get up into chair, resident refused x3 (three times).A review of facility Progress Notes, dated 8/7/26 at 1:54 p.m., indicated, offered [Resident 1] to get up into a chair to which resident states, I am not ready yet.A review of facility Progress Notes, dated 8/10/26 at 3:35 p.m., indicated Resident 1 refused to let housekeeping clean her room, and refused to get up into her wheelchair.During an interview on 8/26/26 at 10:30 a.m. with Resident 1, Resident 1 stated she was fearful of receiving rough, painful and injurious personal care, as well as retaliation for now seeking protection against unidentified facility staff. During a concurrent interview and record review on 8/26/26 at 12:20 p.m. with the Director of Nursing (DON), Clinical Physician Orders, dated 8/22/26, was reviewed. This document indicated the facility physician placed two orders on 2/26/26, one for a Psychology Consult as needed, and another for a Psychiatry Consult as needed. A further review of Resident 1's chart indicated the facility did not arrange for either a psychology consultation or a psychiatry consultation to occur prior to 8/27/26.During an interview on 8/27/26 at 2:29 p.m. with the DON, she stated she felt a psychological or psychiatric consultation could have helped Resident 1 to be less anxious if appointments had been made in February following the physician's order. The DON further stated she did not know why the facility mental health provider had not seen Resident 1 sooner. A review of facility policy and procedure titled Ancillary Services, dated 1/2018, indicated, Routine and emergency ancillary services such as dental, eye, podiatry, psychiatry, psychology, optometry, ophthalmology and other services are available to meet the resident's health needs in accordance with the resident's assessment and plan of care.social services or designee will assist residents with appointments, referrals, transportation, arrangements.orders for ancillary services will be relayed to the provider by social services or designee.the ancillary provider will schedule the visit within 1-3 weeks of referral unless the referral is an emergency.

Based on interview and record review, the facility failed to ensure restorative nursing services (RNS) were provided to three of three sampled residents reviewed for RNS (Resident 1, Resident 2 and Resident 3) when services were not provided as ordered by the physician (MD) or provided without an order, not as scheduled and care planned or without active care plans.This failure decreased the facility's potential to provide residents with appropriate services to maintain or improve their limitations in range of motion and mobility.Findings:A review of Resident 1's admission record indicated he was admitted in 12/24 with the diagnosis of hemiplegia (total paralysis of the arm, leg and trunk on the same side of the body) and hemiparesis (weakness on one side of the body) following cerebral infarction (stroke) affecting the left non-dominant side.A review of Resident 1's Minimum Data Set (MDS- a federally mandated resident assessment tool), dated 4/6/26, indicated he had no memory impairment. The MDS also indicated Resident 1 had limitation in range of motion (ROM, the extent or limits of movement in a specific joint or body part) on one upper extremity (UE).A review of Resident 1's MD orders indicated he had an order for RNS, dated 6/5/26, which included AAROM (Active-Assisted Range of Motion, a joint is moved by using one's own muscle power, but partial assistance is received from an external force) of bilateral lower extremities (BLE), daily, five days per week.A review of Resident 1's RNS care plan, initiated 6/17/25, indicated he was receiving RNS for ambulation using a FWW (Front-Wheeled Walker) daily, five times per week and for PROM (Passive Range of Motion, a joint is moved through its available range of motion by an external force) on the lower extremities daily, three times per week as tolerated.A review of the facility's schedule of residents receiving RNS, undated and provided by the Infection Preventionist (IP), indicated Resident 1 was receiving PROM to the left UE (LUE) as tolerated, daily three times per week and ambulation with the FWW as tolerated five times per week for 90 days. RNS scheduled days were Tuesday, Thursday and Saturday.A review of Resident 1's POC (Plan of Care) documentation, dated 6/18/26 and including the prior 30 days, indicated he had received RNS for PROM on the LUE on 5/20/26, 6/12/26 and 6/17/26. There was no documentation of RNS on 5/21, 5/23, 5/26, 5/28, 5/30, 6/2, 6/4, 6/6, 6/9 and 6/11. There was no documentation at all of RNS for ambulation with the FWW for the same time period.A review of Resident 2's admission record indicated she was admitted in 3/23 with a malignant neoplasm (cancerous tumor) of the left breast.A review of Resident 2's MDS, dated [DATE], indicated she had no memory impairment. The MDS also indicated Resident 2 did not use a walker.A review of Resident 2's MD orders indicated she last had an active order for RNS dated 5/30/25 and ending 8/9/25. The order indicated that RNS was to be provided for supervised ambulation using a FWW for 50 feet (ft. a unit of measurement) or as tolerated, daily, three times per week for 90 days.A review of Resident 2's RNS care plans indicated a care plan, initiated 9/1/24, for RNS to provide ambulation with FWW for 30 ft. or as tolerated three times a week for 90 days. A second RNS care plan, initiated 9/9/24, indicated RNS for AROM on bilateral UE with 2 lb. (pounds, a unit of measurement) weights three times a week or as tolerated.A review of the facility's schedule of residents receiving RNS, undated, indicated Resident 2 was receiving RNS for AROM BUE with 2 lb. weights and therapy band three times per week or as tolerated for 90 days. The schedule also indicated RNS to provide AROM with 2 lb. weights on the right UE and PROM on LUE on all planes (refers to the three imaginary flat surfaces used to describe how the human body moves) three times per week or as tolerated for 90 days. RNS scheduled days were Wednesday, Friday and Sunday.A review of Resident 2's POC documentation, dated 6/18/26 and including the prior 30 days, indicated she had received RNS for AROM on the BUE on 5/20/26, 5/21/26, 5/26/26, 6/16/26 and 6/17/26. There was no documentation of RNS on 5/22, 5/24, 5/27, 5/29, 5/31, 6/3, 6/5, 6/7, 6/10, 6/12 and 6/14/26. There was no documentation at all of RNS for ambulation with the FWW for the same time period and PROM on the LUE was not listed.A review of Resident 3's admission record indicated he was admitted in 2/25 with the diagnosis of chronic obstructive pulmonary disease (COPD- a chronic lung disease causing difficulty in breathing).A review of Resident 3's MDS, dated [DATE], indicated he had no memory impairment. The MDS also indicated Resident 3 had a limitation in range of motion on his BLE.A review of Resident 3's MD orders indicated he last had an active order for RNS dated 6/11/25 and ending on 9/5/25. The order indicated that RNS was to be provided for PROM on all planes as tolerated, daily three times a week or as tolerated for 12 weeks.A review of Resident 3's At Risk for decline in function care plan, initiated on 6/11/26 and resolved 11/13/25, indicated an intervention included RNS for BLE with PROM on all planes.A review of the facility's schedule of residents receiving RNS, undated, indicated Resident 3 was receiving RNS to BLE with PROM daily, three times weekly as tolerated for 90 days. RNA scheduled days were Monday, Wednesday and Friday.A review of Resident 3's POC documentation, dated 6/18/26 and including the prior 30 days, indicated he had received RNS for BLE with PROM on 5/20/26, 5/27/26, 6/12/26 and 6/17/26. There was no documentation of RNS on 5/22, 5/25, 5/29, 6/1, 6/3, 6/5, 6/8, 6/10 and 6/15/26.During an interview on 6/18/26 at 10:16 a.m. with Resident 1, Resident 1 stated he had been receiving RNS, but about a month ago the Restorative Nursing Assistant providing the RNS (RNA 1) had gotten sick and he had not gotten RNS as he was supposed to be during her absence. Resident 1 stated RNS had started back last Friday (6/12/26) when RNA 1 returned. Resident 1 stated when he missed exercising regularly he felt like it put him back further.During an interview on 6/18/26 at 10:55 a.m. with Resident 2, Resident 2 stated she had been doing exercises in bed and at the side of her bed with staff. Resident 2 stated she had just started getting the exercises again.During an interview on 6/18/26 at 11:17 a.m. with RNA 2, RNA 2 stated she had filled in for RNA 1 the past month and performed RNS with the residents. RNA 2 stated she documented RNA in the POC for each resident and Resident 1 had refused to use his FWW.During an interview on 6/18/26 at 11:30 a.m. with Resident 3, Resident 3 stated he got RNS three times a week. Resident 3 stated RNA 1 had gotten sick and was out about a month and that no one else had done his exercises with him during that time. Resident 3 stated he felt the exercises had helped him.During an interview on 6/18/26 at 12:30 p.m. with RNA 1, RNA 1 confirmed she had been out sick from the facility from 5/12/26 until her return on 6/12/26.During a concurrent interview and record review on 6/18/26 at 3:10 p.m. with the Director of Staff Development (DSD) and the IP, the DSD stated he oversaw the RNS program and stated a resident on RNS must have an order with start and end dates and an RNS care plan. The DSD stated the RNS schedule, which the RNA worked from, should match the RNS order. The DSD stated the RNA documented care provided in the electronic health record (EHR) in the resident's POC. The DSD agreed if care was not documented, it was not done and stated a resident's refusal of RNS should be documented as such. The DSD confirmed Resident 1's RNS order dated 6/5/26 had no end date and the RNS order did not match the RNS listed on the schedule. The DSD reviewed Resident 1's POC and confirmed there was no documentation Resident 1 had received RNS for ROM on 10 scheduled occasions in the past 30 days and there was no documentation at all of RNS on the POC for the FWW in the past 30 days. The DSD confirmed there was no active order for Resident 2 to have RNS, the RNS schedule and care plan did not match, the FWW was not documented at all and PROM on the LUE was not included on the POC. The DSD confirmed Resident 2 had no documentation for several RNS sessions. The DSD confirmed there was no active order for Resident 3 to have RNS, there was no active care plan for RNS and Resident 3 had missed several scheduled RNS sessions. The DSD stated everything needed an MD order, it is the standard of care and it is how one knows proper care is being given. The DSD stated if a resident was being given the wrong RNS or not getting it, it was possible the resident's mobility and ROM could decline.During a review of the facility's policy titled, Restorative Nursing Services, dated 1/18, the policy stipulated, Restorative goals and objectives are individualized and resident-centered, and are outlined in the resident's plan of care.During a review of the facility's policy titled, Physician Orders, dated 1/18, the policy stipulated, Physician orders are obtained to provide a clear direction in the care of the resident.

Based on interview and record review, the facility failed to ensure medications were administered according to professional standards for one of three sampled residents reviewed for medication administration (Resident 1) when he was not given his blood pressure medication per the physician's (MD) order and missed doses on two consecutive days. This failure had the potential to result in elevated blood pressure and increased leg swelling for Resident 1.Findings: A review of Resident 1's admission record indicated he was admitted in 12/24 with diagnoses of essential hypertension (HTN- high blood pressure with no single identifiable cause) and venous insufficiency, chronic and peripheral (condition in which the vein valves in the legs are weakened or damaged causing blood to pool in the legs). A review of Resident 1's Minimum Data Set (MDS- a federally mandated resident assessment tool), dated 4/6/26, indicated he had no memory impairment. A review of Resident 1's Medication Administration Record (MAR), dated 5/26, indicated a MD order for hydrochlorothiazide (a diuretic used to treat HTN and fluid retention) oral tablet, 1 tablet daily at 9 a.m., hold for SBP (systolic blood pressure- the pressure in the arteries when the heart beats and pumps blood out to the body) < 110. The MAR indicated the daily dose had not been given on 5/29 and 5/30/26. A review of Resident 1's nursing notes, dated 5/29- 5/30/26, indicated there were no notes regarding Resident 1's MD being called and informed of the missed doses of hydrochlorothiazide. During an interview on 6/10/26 at 3:32 p.m. with Resident 1, Resident 1 stated about two weeks ago he was told by Licensed Nurse 1 (LN 1) the facility was out of his blood pressure medication. Resident 1 stated he was not sure how many doses he had missed. During a concurrent interview and record review on 6/11/26 at 10:48 a.m. with LN 1, LN 1 stated she had been Resident 1's nurse on 5/30/26 and the facility had run out of his hydrochlorothiazide. LN 1 stated she called the pharmacy and the pharmacy could not tell her when it would be delivered, so she was unable to administer the medication. LN 1 stated she should have called the MD and notified him of the missed dose but acknowledged there was no documentation in Resident 1's medical record she had done so. LN 1 reviewed Resident 1's MAR, dated 5/26, and confirmed Resident 1 had missed the medication on 5/29/26 as well. During an interview on 6/11/26 at 11:58 a.m. with the Director of Nursing (DON), the DON stated it was her expectation that the LNs followed up and called the pharmacy when a resident's medication was running low. The DON stated if the pharmacy could not tell them when a medication was going to be delivered, the LNs could reach out to her and she could request a STAT (immediate, without delay) delivery. The DON further stated she expected the LNs to call the MD and notify him of the missed medication and document his instructions in a nursing note. The DON confirmed Resident 1 missed two doses of his hydrochlorothiazide and there were no nursing notes regarding either missed dose. The DON agreed these were medication errors and this did not meet her expectations for medication administration. The DON stated the missed doses could have resulted in elevated blood pressure or increased swelling for Resident 1. During a review of the facility's policy and procedure (P&P) titled, Medication Administration- General Guidelines, dated 10/17, the P&P stipulated, Medications are administered as prescribed in accordance with good nursing principles and practices . During a review of the facility's P&P titled, Unavailable Medications, dated 1/26, the P&P stipulated, The facility must make every effort to ensure that medications are available to meet the needs of each resident .Nursing staff shall: Notify the attending physician of the situation and explain the circumstances .

Based on interview and record review, the facility failed to protect one resident (Resident 1) of five sampled residents from misappropriation (the unauthorized use of another person's property or money without permission) of property when Staff 1 made unauthorized charges to Resident 1's credit card.This failure resulted in Staff 1 misappropriating $27,571.50 from Resident 1's bank account which would leave a reasonable person upset, disturbed and financially injured. Findings:A review of Resident 1's admission record indicated she was admitted on [DATE] with diagnosis which included major depressive disorder (a serious mood disorder which causes persistent sadness, hopelessness, and loss of interest which significantly impairs daily life), mild neurocognitive disorder with behavioral disturbance (a condition that impairs mental functions like memory, thinking, and reasoning due to brain damage from various causes), anxiety disorder (a mental condition characterized by excessive fear which can impair daily life), and the need for assistance with personal care. A review of Resident 1's Minimum Data Set (MDS- a federally mandated assessment tool), dated 10/27/25, indicated Resident 1 had severe memory impairment.A review of an undated facility document titled Alleged Abuse written by the Director of Nursing (DON) indicated, Was reported to this writer by the Ombudsman [an independent advocate who investigates and helps to resolve resident complaints] that she received a call from [Resident 1's] bank that [Resident 1's] bank card is connected to a phone number of an employee [Staff 1] charging the card of [Resident 1] in greater than $4000.00 in. transactions. This record further indicates, Resident 1's bank card was connected to [the] phone number [Staff 1]. This document also indicated Resident 1 was only oriented to herself (only knew her identity but was confused about the current date, time, where she was or what was going on) and that the facility notified the local police of the alleged abuse on 12/19/25.A review of the police report dated 12/19/25 indicated, On 12/19/25, [DON] called [the police department] on behalf of. [Resident 1]. Between 1/15/25 to 11/1/25, [Resident 1's] debit card had been fraudulently used by an employee of the care facility [Staff 1]. As of the time of this report, [the bank] has accounted for approximately $27,571.49 missing from [Resident 1's] account.In an interview on 1/7/26 at 12:45 p.m. with the Administrator (ADM) and DON, the ADM confirmed Staff 1's phone number was connected to the charges on Resident 1's credit card. The ADM further confirmed the facility had separated their employment agreement with Staff 1 based on this incident. In an interview on 1/7/26 at 4:02 p.m., Bank Employee (BE) stated a joint account holder of Resident 1's account had contacted the bank to find out why someone had been taking money from Resident 1's account. The BE stated their investigation had indicated the fraud had been going on for about a year and exceeded $4,000.00.In an interview on 1/9/26 at 1:38 p.m. Police Officer (Officer 1) stated Staff 1 was definitely involved in the misappropriation of Resident 1's property. Officer 1 further stated the charges currently amount to $27,571.49 and the investigation was ongoing. In an interview on 1/15/26 at 11:57 a.m., the ADM stated if a large amount of money was stolen from him, he would be very disturbed and would want someone to be held accountable. The ADM further stated any reasonable person would feel the same. A review of the facility's policy titled, Abuse and Neglect Prohibition policy, revised June 2022 indicated, It is the facility's policy to prohibit abuse, mistreatment, neglect, involuntary seclusion and misappropriation of property for all residents.

Based on record review and interview, the facility failed to conduct a thorough background screening for one employee (Staff 1) when Staff 1's criminal background check results indicated it was incomplete. This failure decreased the facility's potential to protect and prevent abuse to their resident population.Findings:A review of Staff 1's personnel record on 1/7/26 indicated Staff 1's criminal background check (a screening process to investigate an individual's criminal history revealing details like felony and misdemeanor convictions, arrests, pending court cases, and active warrants) indicated the 7-year county review need attention. The background check notes indicated, Service closed as incomplete. attempted to obtain information from the applicant/client however a response with the needed information was not received.In an interview on 1/7/26 at 12:45 p.m. with the Administrator (Admin), the Admin stated, he would not have moved the applicant forward until the matter had been satisfied. The Admin further confirmed there was no documentation in Staff 1's file that included completion of this background check.A review of the facility's policy titled Abuse and Neglect Prohibition Policy, dated June 2022, indicated, It is the facility's policy to prohibit abuse. and misappropriation of property for all residents through the following: screening of potential hires .The facility will screen potential employees for a history of abuse, neglect or mistreating residents .The facility will not employ individuals who .Have been found guilty by a court of law of abusing, neglecting, or mistreating others .A review of the facility's policy titled, Background Screening Investigations, dated January 2018, indicted, Our facility conducts employment background screening checks, references checks and criminal investigation checks on all applicants for positions with direct access to residents .Should the background investigation disclose any misrepresentation on the application form or information indicating that the individual has been convicted of abuse, neglect, mistreatment of individuals, and/or misappropriation of property, the applicant is not employed or contracted.

Based on interview and record review, the facility failed to provide a Registered Nurse (RN) for eight hours a day for four days in July 2025. This failure had the potential to result in inadequate care for a medically fragile population of 48 residents.Findings:During a concurrent interview and record review on 8/21/2025 at 3:04 p.m. with the Director of Nursing (DON), the facility's, Job Code RN Time Sheet, report dated 1/1/2025 to 8/21/2025 was reviewed. The RN time sheet report indicated an RN worked less than 8 hours as follows:S 7/6/2025, 5.85 RN hoursS 7/12/2025, no RN hours/no RN presentS 7/13/2025, no RN hours/no RN presentS 7/20/2025, 5 RN hoursThe DON confirmed, she did not work on 7/6/2025, 7/12/2025, 7/13/2025 and 7/20/2025 and there was no RN present for eight hours. The DON stated she and the MDS Registered Nurse (MDS RN) did not work weekends and did not know why they didn't see this, or catch this. The DON further stated it was not normal for an RN not to be present for a minimum of eight hours a day and there should have been an RN onsite. During an interview on 8/21/2025 at 3:29 p.m. with the Administrator (Admin), the Admin stated the expectation was to have enough staff in accordance with the Centers for Medicare & Medicaid Services (CMS) guidelines.During a review of the facility's policy and procedure (P&P) titled, Staffing, dated January 2018, the P&P indicated, Our facility maintains adequate staffing on each shift to ensure that our resident's needs and services are met. Licensed registered nursing are available to provide and monitor the delivery of resident care services.

This REQUIREMENT is NOT MET as evidenced by:Based on observation, interview, and record review, the facility failed to ensure food was stored, labeled, and prepared under sanitary conditions when: 1) Staff food items were stored in Refrigerator #2 with the resident food items.2) An unlabeled and undated container of peaches was stored in Refrigerator #2 and was not properly disposed of.3) A dietary staff member with facial hair was observed in the kitchen preparing lunch for the residents without a beard restraint.4) Chopped salad was observed outside the cold holding temperature of 41 degrees Fahrenheit (measurement of temperature) or below.These failures had the potential to place residents at risk for developing food-borne illnesses (sickness by consuming contaminated food or drinks) by exposing residents to contaminated food and unsanitary practices. Findings:1. During a concurrent observation and interview on 8/18/2025 at 3:10 p.m. with the Certified Dietary Manager (CDM), in the facility's kitchen, an unlabeled food item wrapped in a paper towel was observed inside Refrigerator #2 alongside food ingredients for resident meals. CDM confirmed the food item belonged to a staff member who placed it in the refrigerator for cold storage.During an interview on 8/20/2025 at 3:25 p.m. with the Registered Dietitian (RD), the RD stated the improper storage of staff food items in the kitchen refrigerator may result in cross-contamination (unwanted transfer of germs or harmful substances from one food or surface to another food or surface) and resident foodborne illness (sickness caused by contaminated food).During a review of the facility's policy and procedure (P&P) titled, Employee Meals, dated 2023, the P&P indicated, Food brought by employees from outside the facility shall not be kept in the facility's refrigerator in the kitchen nor prepared or reheated in the facility's kitchen.2. During a concurrent observation and interview conducted on 8/18/2025 at 3:10 p.m. with the Certified Dietary Manager (CDM), in the facility's kitchen, an unlabeled and undated container of diced peaches was observed inside Refrigerator #2. CDM confirmed the unlabeled and undated container of peaches should have been thrown away to minimize the risk of foodborne illness to residents.During an interview on 8/20/2025 at 3:25 p.m. with the Registered Dietician (RD), the RD stated the improper storage of expired or unlabeled food items in the kitchen refrigerators was unacceptable due to the risk of food-borne illness (sickness caused by contaminated food).During a review of the Food and Drug Administration (FDA) Food Code (a guide for food safety to prevent foodborne illness), sections S3-302.12 and S3-501.17, dated 2022, the FDA food code indicated, It requires that working containers of food removed from their original packaging must be identified with the common name of the food. Foods that are prepared and held in a refrigerator must be clearly marked with the date they must be consumed, sold, or discarded.3. During an observation on 8/20/2025 at 11:55 a.m. in the facility kitchen, Dietary Staff (DS 1) was observed with an exposed beard and mustache while preparing and cooking food during lunch preparation without a beard restraint to cover his facial hair.During an interview on 8/20/2025 at 3:25 p.m. with the Registered Dietician (RD), the RD stated that it was unacceptable for dietary staff with facial hair to work in the kitchen without a beard restraint because hair can fall into the food and it is not a sanitary practice.During a review of the Food and Drug Administration (FDA) Food Code (a guide for food safety to prevent foodborne illness), section S2-402.11, dated 2022, the FDA food code indicated, Food employees must wear hair restraints and clothing that covers body hair in order to keep hair from contacting food, equipment, and utensils.4. During a concurrent observation and interview on 8/20/2025 at 11:59 a.m. with Dietary Staff (DS 2), in the facility kitchen during lunch preparation, DS 2 was observed using a food thermometer to check and re-check the temperature of chopped salad that had been distributed into 16 bowls. DS 2 confirmed the temperature of the chopped salad measured 63 degrees Fahrenheit (measurement of temperature) and that the salad temperature should measure 40 degrees Fahrenheit or less.During a concurrent observation and interview on 8/21/25 at 9:25 a.m. with DS 1 and the Assistance Maintenance Director (AMD), in the facility's kitchen, AMD was observed measuring the temperature of the kitchen using an infrared thermometer gun. AMD confirmed it read 84.4 degrees Fahrenheit. DS 1 stated two of two air conditioning units in the kitchen were on and blowing cool air during this temperature reading and during lunch preparation the previous day when the temperature was measured at 86 degrees Fahrenheit.During a review of the Food and Drug Administration (FDA) Food Code (a guide for food safety to prevent foodborne illness), section S3-501.16, dated 2022, the FDA food code indicated, Bacterial growth and/or toxin production can occur if time/temperature control for safety food remains in the temperature ‘Danger Zone' of 41 to 135 degrees Fahrenheit too long.Maintaining Time/Temperature Control for Safety [TCS, foods that germs can grow on quickly if they are not kept at the right temperature], foods under the cold temperature control requirements prescribed in this code will limit the growth of pathogens that may be present in or on the food and may help prevent foodborne illness.

Based on observation, interview, and record review, the facility failed to ensure the medication error rate did not exceed five percent when seven identified medication errors out of 26 opportunities were observed:1. The wrong form of aspirin was administered to Resident 29 and Resident 34.2. Senna (medication used to stimulate bowel movement) and docusate sodium (medication used to soften bowel movements) were not held in accordance with the physician order for Resident 25.3. Resident 25 was not instructed to chew a chewable aspirin.4. The wrong form of Vitamin C was administered to Resident 25.5. Resident 25 did not receive dapagliflozin (medication used to treat diabetes mellitus- a condition when the body doesn't create enough insulin) when ordered.These failures resulted in an overall facility medication error rate of 26% and had the potential to result in negative health outcomes for Resident 25, Resident 29, and Resident 34.Findings:1a. During a review of Resident 29's admission Record, dated 8/21/2025, the admission record, indicated Resident 29 was admitted on [DATE] with diagnosis of sudden cardiac arrest (condition when the heart stops beating).During an observation on 8/20/2025 at 8 a.m. in Resident 29's room, Licensed Vocational Nurse (LVN 1) administered one tablet of aspirin 81 milligrams (mg).During a concurrent interview and record review on 8/20/2025 at 11:18 a.m. with LVN 1, Resident 29's Physician Orders, dated 8/20/2025 was reviewed. The physician orders indicated, aspirin EC [enteric coated] tablet delayed release 81 mg. Give 1 tablet by mouth one time a day for PROPHALAXIS [preventative treatment]. LVN 1 confirmed he did not administer Resident 29 the delayed release aspirin and overlooked the order for delayed release aspirin.During an interview on 8/20/2025 at 11:24 a.m. with the Director of Nursing (DON), the DON stated the expectation for licensed nurses administering medication was to follow the doctor order and administer the correct medication.During an interview on 8/21/2025 at 3:43 p.m. with the Pharmacist (Pharm), the Pharm stated delayed release medication is used to prevent gastrointestinal (stomach) discomfort. The Pharm further stated licensed nurses were to follow the doctor's order.During a review of the facility's policy and procedure (P&P) titled, Administering Medications, dated January 2018, the P&P indicated, The individual administering the medication checks the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route of administration) before giving the medication. Medications are administered in accordance with prescribers orders.1b. During a review of Resident 34's admission Record, dated 8/21/2025, the admission record, indicated Resident 34 was admitted on [DATE] with diagnosis of cerebral infarction (ischemic stroke- when the blood flow to the brain is interrupted, leading to tissue damage).During an observation on 8/20/2025 at 8:15 a.m. in Resident 34's room, Licensed Vocational Nurse (LVN 1) administered one tablet of aspirin 81 milligrams (mg).During a concurrent interview and record review on 8/20/2025 at 11:21 a.m. with LVN 1, Resident 34's Physician Orders, dated 8/20/2025 was reviewed. The physician orders indicated, aspirin EC [enteric coated] tablet delayed release 81 mg. Give 1 tablet by mouth one time a day related to CEREBRAL INFARCTION. LVN 1 confirmed he did not administer Resident 34 the delayed release aspirin and stated he should have given delayed release aspirin.During an interview on 8/20/2025 at 11:24 a.m. with the Director of Nursing (DON), the DON stated the expectation for licensed nurses administering medication was to follow the doctor order and administer the correct medication.During an interview on 8/21/2025 at 3:43 p.m. with the Pharmacist (Pharm), the Pharm stated delayed release medication is used to prevent gastrointestinal (stomach) discomfort. The Pharm further stated licensed nurses were to follow the doctor's order.During a review of the facility's policy and procedure (P&P) titled, Administering Medications, dated January 2018, the P&P indicated, The individual administering the medication checks the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route of administration) before giving the medication. Medications are administered in accordance with prescribers orders.2. During a review of Resident 25's admission Record, dated 8/21/2025, the admission record, indicated Resident 25 was admitted on [DATE] with diagnosis of cerebral infarction (ischemic stroke- when the blood flow to the brain is interrupted, leading to tissue damage).During an observation on 8/20/2025 at 9:01 a.m. in Resident 25's room, Licensed Vocational Nurse (LVN 1) prepared Resident 25's medications and placed one tablet of senna 8.6 milligrams (mg) and one capsule of docusate sodium 250 mg in a medicine cup. Resident 25 informed LVN 1 that he had been up majority of the night having multiple bowel movements and needed to be changed because he had a large gushy diaper. A strong foul odor was noted. LVN 1 then administered one tablet of senna 8.6 mg and one capsule of docusate sodium 250 mg.During a concurrent interview and record review on 8/20/2025 at 11:22 a.m. with LVN 1, Resident 25's Physician Orders, dated 8/20/2025 was reviewed. The physician orders indicated, Senna oral tablet 8.6 mg. Give 1 tablet by mouth one time a day for bowel care management. Hold for loose stool. Docusate Sodium oral capsule 250 mg. Give 1 capsule by mouth one time a day for bowel care management. Hold for loose stool. LVN 1 confirmed Resident 25 had multiple bowel movements and stated he should have held both the senna and docusate due to loose bowel movements.During an interview on 8/20/2025 at 11:27 a.m. with the Director of Nursing (DON), the DON stated the expectation for licensed nurses administering medication was to follow the doctor order and hold the medication when instructed.During an interview on 8/21/2025 at 3:43 p.m. with the Pharmacist (Pharm), the Pharm stated there was potential harm for diarrhea and dehydration when continuing to administer senna and docusate after the resident had multiple loose bowel movements. The Pharm further stated licensed nurses were to follow the doctor's order.During a review of the facility's policy and procedure (P&P) titled, Administering Medications, dated January 2018, the P&P indicated, The individual administering the medication checks the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route of administration) before giving the medication. Medications are administered in accordance with prescribers orders.3. During a review of Resident 25's admission Record, dated 8/21/2025, the admission record, indicated Resident 25 was admitted on [DATE] with diagnosis of cerebral infarction (ischemic stroke- when the blood flow to the brain is interrupted, leading to tissue damage).During an observation on 8/20/2025 at 9:01 a.m. in Resident 25's room, Licensed Vocational Nurse (LVN 1) administered one tablet of chewable Aspirin 81 milligrams (mg) to Resident 25 and did not instruct Resident 25 to chew the aspirin.During a concurrent interview and record review on 8/20/2025 at 11:22 a.m. with LVN 1, Resident 25's Physician Orders, dated 8/20/2025 was reviewed. The physician orders indicated, Aspirin 81 mg, oral tablet chewable. Give 1 tablet by mouth one time a day related to CEREBRAL INFARCTION. LVN 1 confirmed he did not instruct Resident 25 to chew the aspirin. LVN 1 further stated, oh I didn't even think about that. LVN 1 stated he should have educated Resident 25 to chew the medication as ordered.During an interview on 8/20/2025 at 11:27 a.m. with the Director of Nursing (DON), the DON stated the expectation for licensed nurses administering medication was to follow the doctor order.During an interview on 8/21/2025 at 3:43 p.m. with the Pharmacist (Pharm), the Pharm stated chewable aspirin is absorbed faster and in the bloodstream versus enteric coated aspirin is absorbed in the small intestines and slower. The Pharm further stated the nurse should follow the direction of the medication form and educate the resident on how it should have been administered.During a review of the facility's policy and procedure (P&P) titled, Administering Medications, dated January 2018, the P&P indicated, The individual administering the medication checks the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route of administration) before giving the medication. Medications are administered in accordance with prescriber's orders.4.During a review of Resident 25's admission Record, dated 8/21/2025, the admission record, indicated Resident 25 was admitted on [DATE] with diagnoses including absence of right great toe and chronic ulcer (open wound) of right foot with necrosis (death) of the bone.During an observation on 8/20/2025 at 9:01 a.m. in Resident 25's room, Licensed Vocational Nurse (LVN 1) administered one tablet of chewable Vitamin C, 500 milligrams (mg) to Resident 25 and did not instruct Resident 25 to chew the Vitamin C tablet.During a concurrent interview and record review on 8/20/2025 at 11:22 a.m. with LVN 1, Resident 25's Physician Orders, dated 8/20/2025 was reviewed. The physician orders indicated, Ascorbic Acid [vitamin c] oral tablet 500mg. Give 1 tablet by mouth two times a day for supplement. LVN 1 confirmed he administered the chewable form of ascorbic acid and did not instruct Resident 25 to chew the medication. LVN 1 stated he didn't look over the order and assumed it was chewable since that was the medication LVN 1 had in the medication cart already. During an interview on 8/20/2025 at 11:27 a.m. with the Director of Nursing (DON), the DON stated the expectation for licensed nurses administering medication was to follow the doctor order.During an interview on 8/21/2025 at 3:43 p.m. with the Pharmacist (Pharm), the Pharm stated chewable ascorbic acid is absorbed faster and in the bloodstream. The Pharm further stated the nurse should follow the direction of the medication form and educate the resident on how it should have been administered.During a review of the facility's policy and procedure (P&P) titled, Administering Medications, dated January 2018, the P&P indicated, The individual administering the medication checks the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route of administration) before giving the medication. Medications are administered in accordance with prescribers orders.5. During a review of Resident 25's admission Record, dated 8/21/2025, the admission record, indicated Resident 25 was admitted on [DATE] with diagnosis of diabetes mellitus (metabolic disease when the body is unable to regulate blood sugars).During an observation on 8/20/2025 at 9:01 a.m. in Resident 25's room, Licensed Vocational Nurse (LVN 1) prepared Resident 25's medications and did not administer dapagliflozin.During a concurrent interview and record review on 8/20/2025 at 11:25 a.m. with LVN 1, Resident 25's Physician Orders, dated 8/20/2025 was reviewed. The physician orders indicated, dapaglifozin propanediol, oral tablet 5 milligrams (mg). Give 1 tablet by mouth in the morning related to TYPE 2 DIABETES MELLITUS. LVN 1 confirmed he did not administer dapaglifozin to Resident 25 because, they didn't have it on hand. LVN 1 further stated pharmacy could deliver it tomorrow afternoon.During an interview on 8/20/2025 at 11:29 a.m. with the Director of Nursing (DON), the DON stated the expectation for licensed nurses were to check all medications were on hand prior to administering medications and if not, order medications with pharmacy and notify the doctor.During an interview on 8/21/2025 at 3:43 p.m. with the Pharmacist (Pharm), the Pharm stated if a resident stops receiving dapaglifozin then the resident could experience hyperglycemic (high blood sugar) episodes or unwanted symptoms associated with hyperglycemia, and it was best to monitor blood sugars while not receiving the medication.During a review of the facility's policy and procedure (P&P) titled, Administering Medications, dated January 2018, the P&P indicated, The individual administering the medication checks the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route of administration) before giving the medication. Medications are administered in accordance with prescriber's orders.

Based on observation, interview, and record review the facility failed to safely store and label drugs in accordance with acceptable standards of practice when:1. One medication cart was left unlocked and unattended. This failure had the potential to result in residents and staff obtaining unauthorized access to medications and supplies that could lead to adverse effects.2. An open bottle of Senna syrup (laxative medication used to stimulate a bowel movement), stored in the medication cart did not have an expiration date. This failure had the potential to result in Senna syrup having a reduced effectiveness, potential bacterial contamination and unpredictable side effects.Findings:1.During an observation on 8/20/2025 at 8:27 a.m. in the hallway of the west wing between room [ROOM NUMBER] and room [ROOM NUMBER], Licensed Vocational Nurse (LVN 1) was standing next to the medication cart and walked away into room [ROOM NUMBER]. The medication cart was left unlocked and unattended.During a concurrent observation and interview on 8/20/2025 at 8:41 a.m. with LVN 1 in front of room [ROOM NUMBER], LVN 1 walked over to the medication cart and started to prepare medications. LVN 1 confirmed the medication cart was unlocked and unattended. LVN 1 stated he made a mistake, and the medication cart should always be locked.During an interview on 8/20/2025 at 12:14 p.m. with the Director of Nursing (DON), the DON stated the medication carts should always be locked when not in use to prevent residents from accessing medications.During a review of the facility's policy and procedure (P&P) titled, Storage of Medications, dated January 2018, the P&P indicated Drugs and biologicals used in the facility are stored in locked compartments. unlocked medication carts are not left unattended.2. During a concurrent observation and interview on 8/20/2025 at 11:36 a.m. with Licensed Vocational Nurse (LVN 2), in the hallway of the east wing between room [ROOM NUMBER] and room [ROOM NUMBER], the medication cart had an opened bottle of Senna syrup that did not have an expiration date. LVN 2 stated the liquid senna needed to be discarded because it did not have an expiration date and was not in the original packaging.During an interview on 8/20/2025 at 12:42 p.m. with the Director of Nursing (DON), the DON stated Senna syrup should have been kept in the original packaging with the expiration date, otherwise it should have been discarded.During an interview on 8/21/2025 at 3:43 p.m. with Pharmacist (Pharm), Pharm stated Senna syrup expiration date was located on the original packaging and should be stored in the box to show the expiration date.During a review of the facility's policy and procedure (P&P) titled, Storage of Medications, dated January 2018, the P&P indicated Drugs and biologicals are stored in the packaging in which they are received.

Based on observation, interview, and record review, the facility failed to maintain equipment in a safe and operating condition when:One of the laundry machine was covered in rust and was broken.The bed locks for Resident 36 were not working. These failures had the potential to affect the resident's health and safety. Findings:1.During a concurrent observation and interview on 8/19/2025 at 2:05 p.m. with the Housekeeping Staff (HSK) and the Maintenance Director (MDR), in the laundry room, two laundry machines were observed. One of the laundry machine was broken and covered with rust. The MDR confirmed one of the laundry machines was broken. The HSK stated the broken laundry machine had been broken for quite some time, and it delayed the laundry process for the residents. During an interview on 8/21/2025 at 2:53 p.m. and at 4:59 p.m., with the MDR, the MDR stated the broken laundry machine should be repaired as soon as it is found to be broken, to better serve the residents and for the safety of the staff. MDR stated the facility did not do any maintenance for the machines unless there was something wrong with it. The MDR stated this was the wrong practice and regular maintenance was needed to ensure the laundry machines work properly. MDR stated he could not find the laundry machine manual and it was important to keep the manual to refer to troubleshooting. During a review of the facility's policy and procedures (P&P) titled Maintenance Service, dated January 2018, the P&P indicated, 1. The maintenance department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times. 2. Functions of maintenance personnel include but are not limited to: providing routinely scheduled maintenance service to all areas. 3. The maintenance director is responsible for developing and maintaining a schedule of maintenance service to assure that the buildings, grounds, and equipment are maintained in a safe and operable manner. 4. A copy of the maintenance schedule shall be provided to each department director so that appropriate scheduling can be made without interruption of services to residents.2.During a review of Resident 36's admission Record, dated 8/23/2025, the admission record indicated Resident 36 was admitted to the facility on [DATE] with a diagnoses of dislocation of internal left hip prosthesis (a condition where surgically implanted left hip comes out of place), Huntington's disease (a condition in which nerve cells in the brain break down over time), and fall from chair.During a concurrent observation and interview on 8/20/2025 at 12:11 p.m. with Certified Nursing Assistant (CNA 1) and CNA 2 in Resident 36's room, CNA 1 and CNA 2 were observed trying to lock Resident 36's bed. CNA 1 and CNA 2 stated the bed locks were not working. CNA 1 stated the bed needed to be locked to prevent Resident 36 from falling. During a concurrent observation and interview on 8/20/2025 at 12:30 p.m. with the Maintenance Director (MDR), outside of Resident 36's room, MDR stated Resident 36's bed locks' were not working. The MDR further stated it was important for all the beds to have functioning locks for safety. During an interview with the Director of Nursing (DON) on 8/20/2025 at 2:00 p.m., the DON stated it was important to lock all the beds to prevent injury and fall. The DON confirmed Resident 36's bed locks were broken. During a review of the facility's policy and procedures (P&P) titled, Maintenance Service, dated January 2018, the P&P indicated, The maintenance department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times.

Based on observation, interview, and record review, the facility failed to properly dispose of used fentanyl patches (potent opioid medication used to pain management). This failure had the potential to result in drug diversion, inaccurate medication accountability and unsafe medication management.Findings:During a concurrent observation and interview on 8/20/2025 at 11:36 a.m. with Licensed Vocational Nurse (LVN 2), in the east wing hallway, the medication cart had nine opened and used fentanyl patches stored in a plastic cup. LVN 2 stated the fentanyl patches needed to be disposed of by the Director of Nursing (DON).During an interview on 8/20/2025 at 12:39 p.m. with the DON, the DON stated used fentanyl patches should not have been stored in the medication cart and should have been brought to the DON for proper disposal.During an interview on 8/21/2025 at 3:43 p.m. with the Pharmacist (Pharm), the Pharm stated used fentanyl patches should be cut up and placed into a disposal bin that was filled with liquid to ensure it was unable to be reused. The Pharm further stated fentanyl patches have a residual amount of medication that could be dangerous if touched.During a review of the facility's policy and procedure (P&P) titled, Discarding and Destroying Medications, dated January 2018, the P&P indicated Destruction of a controlled substance must render it non-retrievable, meaning that the process permanently alters the physical or chemical properties of the substance so that it is no longer available or usable and cannot be illegally diverted.

Based on interview and record review, the facility failed to complete annual performance evaluations for two of two employees (Certified Nursing Assistant [CNA] 3 and CNA 4). This failure had the potential to result in an inability to correct poor performance and compromise patient safety.Findings:During a concurrent interview and record review on 8/21/2025 at 11:17 a.m. with the Director of Staff Development (DSD), CNA 3's employee record was reviewed. There was no annual performance evaluation for 2024/2025. The DSD stated CNA 3 should have had an annual performance evaluation.During a concurrent interview and record review on 8/21/2025 at 11:38 a.m. with the DSD, CNA 4's employee record was reviewed. There was no annual performance evaluation for 2024/2025. The DSD stated CNA 4 should have had an annual performance evaluation.During an interview on 8/21/2025 at 11:50 a.m. with the Director of Nursing (DON), the DON stated she was unaware of multiple staff not having performance evaluations and the evaluations needed to be completed annually.During a review of the facility's policy and procedure (P&P) titled, Performance Evaluations, dated January 2018, the P&P indicated, A performance evaluation will be completed on each employee at the conclusion of his/her 90-day probationary period, and at least annually thereafter. The completed performance evaluation will be sent by the director or supervisor to the director of human resources to be placed in the employee's personnel record.

Based on observation, interview, and record review, the facility failed to ensure collaborative care with the contracted hospice agency was provided for one of 15 sampled residents (Resident 36). This failure had the potential to affect Resident 36's safety and comfort of care. Findings:During a review of Resident 36's admission Record, dated 8/23/2025, the admission record indicated Resident 36 was admitted to the facility on [DATE] with a diagnoses of dislocation of internal left hip prosthesis (a condition where surgically implanted left hip comes out of place) and Huntington's disease (a condition in which nerve cells in the brain break down over time). During a concurrent observation and interview on 8/20/2025 at 8:20 a.m. with the Hospice Registered Nurse Case Manager (HRN), in Resident 36's room, the HRN was observed standing next to Resident 36 wearing a gown and gloves and wound supplies on the table. The HRN stated she did not have the wound orders and had not updated the binder with wound care plans for Resident 36.During a concurrent interview and record review on 8/20/2025 at 8:42 a.m., with the Director of Nursing (DON), Resident 36's Hospice Aide Coordination of Care, report dated 8/4/2025 was reviewed. The Hospice Aide Coordination of Care report indicated, Resident 36 was enrolled in hospice care (a medical care that focuses on providing comfort and support to patients with terminal illnesses and their families) on 8/4/2025. The DON stated there were no wound orders or care plans for Resident 36 in the hospice binder, where it should have been. The DON further stated, this was overlooked and affected Resident 36's comfort of care. During an interview on 8/21/2025 at 10:00 a.m., with the DON, the DON stated the hospice binder should have been updated with the physician orders, wound change orders, comfort care plans and wound care plans for Resident 36 to ensure smooth communication and collaboration of care between the facility and the hospice agency. During a review of the facility's policy and procedures (P&P) titled, Hospice Program, dated January 2018, the P&P indicated Hospice providers who contract with this facility: are held responsible for meeting the same professional standards and timeliness of service as any contracted individual or agency associated with the facility. Coordinated care plans for residents receiving hospice services will include the most recent hospice plan of care as well as the care and services provided by the facility (including the responsible provider and discipline assigned to specific tasks) in order to maintain the resident's highest practicable physical, mental and psychosocial well-being.During a review of the facility's hospice contract titled, Skilled Nursing Facility And Hospice Contract Agreement, dated 8/30/2022, the hospice contract indicated, Hospice shall provide provider with the following: A written and specified treatment plan for each patient. Facility responsibility includes ensuring collaboration between the facility and the hospice agency and nursing care plan developed by the agency will be part of the resident's record in the facility.

Based on observation, interview, and record review, the facility failed to ensure services provided met professional standards of practice when Licensed Vocational Nurse (LVN 1) provided wound care to one of 15 sampled residents (Resident 1) without a physician's order. This failure had the potential to result in delayed wound healing for Resident 1.Findings:During a review of Resident 1's Face sheet (demographics), [undated], the face sheet indicated Resident 1 was admitted on [DATE] with a diagnoses of Chronic Obstructive Pulmonary Disease (COPD, a lung condition that causes long-term breathing problems) and sepsis (a serious condition in which the body responds improperly to an infection).During an observation on 8/20/2025 at 8:28 a.m. in Resident 1's room, Resident 1 had a white bandage, falling off on her left hand with a skin tear exposed. LVN 1 removed Resident 1's bandage, cleansed with wound cleanser and applied A&D ointment (skin protectant used to treat and prevent minor skin irritations). LVN 1 cut a 2-inch by 2-inch square of calcium alginate (a highly absorbent type of wound dressing) and applied overtop of the A&D ointment. LVN 1 then covered the calcium alginate with a 4-inch by 4-inch island dressing (bandage).During a concurrent interview and record review on 8/20/2025 at 12:49 p.m. with LVN 1, Resident 1's Treatment Administration Record (TAR-document that tracks all non-medication medical treatments given to a resident), dated 8/5/2025 was reviewed. Resident 1's TAR indicated there was no active wound care order. LVN 1 stated he should have called the doctor to request a new wound care order.During an interview on 8/20/2025 at 12:52 p.m. with the Director of Nursing (DON), the DON stated the expectation of staff was to contact the doctor to provide a wound update and obtain a new wound care order.During an interview on 8/21/2025 at 3:43 p.m. with the Pharmacist (Pharm), the Pharm stated calcium alginate was to be used for wounds with moderate drainage for absorption and improper utilization of calcium alginate could cause delay in wound healing.During a review of the facility's policy and procedure (P&P) titled, Wound Care, dated January 2018, the P&P indicated, Verify that there is a physician's order for this procedure.

This REQUIREMENT is NOT MET as evidenced by the following:Based on observation, interview, and record review, the facility failed to ensure garbage was properly disposed of when trash was observed on the ground and in an unsecured garbage dumpster, creating an unsanitary environment with the potential to attract pests.Findings:During an observation on 8/20/2025 at 7:41 a.m. in the facility's garbage storage area, one trash dumpster was observed with both lids unsecured and open due to overflowing garbage. Multiple bags and boxes of trash were also observed on the ground in the garbage storage area.During an interview on 8/20/2025 at 11:20 a.m. with Certified Dietary Manager (CDM), CDM stated leaving trash unsecured and on the ground was unacceptable because it attracts pests and rodents to the facility.During a review of the facility's policy and procedure (P&P) titled, Garbage and Trash, dated 2023, the P&P indicated, Adequate, clean, vermin-proof areas must be provided for storage of garbage and rubbish.all food waste must be placed in sealed leak-proof, non-absorbent, tightly closed containers (i.e., plastic bags) and shall be disposed of as necessary to prevent a nuisance or unsightliness.no debris is on the ground or surrounding area, and that the lids are closed.

Based on observation, interview and record review the facility failed to maintain three out of 13 resident bathrooms when they were found in disrepair. This failure had the potential to result in an unsanitary and uncomfortable homelike environment. t Findings:During a concurrent observation and interview on 8/20/2025 at 7:30 a.m. with the Director of Nursing (DON) in the shared bathroom for room [ROOM NUMBER] and room [ROOM NUMBER], the toilet seat had numerous scratches. The DON stated it was not normal, and it needed to be replaced.During a concurrent observation and interview on 8/20/2025 at 7:34 a.m. with the DON in the shared bathroom for room [ROOM NUMBER] and room [ROOM NUMBER], the door frame was corroded away at the baseboard exposing a large black hole with debris inside. The DON stated it needed to be repaired immediately.During a concurrent observation and interview on 8/20/2025 at 7:37 a.m. with the DON in the shared bathroom for room [ROOM NUMBER] and room [ROOM NUMBER], the baseboard was separated from the wall exposing rust to the toilet plumbing and discoloration on the wall. The DON stated the baseboard needed to be connected to the wall.During a review of the facility's policy and procedure (P&P) titled, Physical Plant Interior Maintenance, dated January 2018, the P&P indicated, Check all areas of vinyl flooring for repairs and cleanliness.During a review of the facility's policy and procedure (P&P) titled, Homelike Environment, dated January 2018, the P&P indicated, Residents are provided with a safe, clean, comfortable and homelike environment. The facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include: clean, sanitary and orderly environment.

Based on observation, interview, and record review, the facility failed to identify the need to place one of 15 sampled residents (Resident 37) on Enhance Barrier Precautions (EBP-infection control strategy used to prevent spread of bacteria), while having multiple open wounds. This failure had the potential to result in the spread of dangerous multidrug-resistant organisms (MDROs) among the residents and staff.Findings:During a review of Resident 37's admission Record, dated 8/21/2025, the admission record indicated Resident 37 was admitted to the facility on [DATE] with diagnosis of complete traumatic amputation (surgical removal) of the left midfoot.During a concurrent observation and interview on 8/18/2025 at 4:08 p.m. with Resident 37, in Resident 37's room, Personal Protective Equipment (PPE, specialized clothing and equipment to protect infectious agents) and EBP signage were not posted outside of Resident 37's room. Resident 37 had a white kerlix (woven gauze used for absorbing fluids), bandage on her left foot. Resident 37 stated she was receiving wound care for her left foot and buttocks.During a concurrent interview and record review on 8/19/2025 at 9:45 a.m. with the Infection Preventionist (IP), Resident 37's Wound Care note, dated 7/24/2025 was reviewed. Resident 37's wound care note indicated, Wound 1: left foot. open wound. moderate serosanguineous [mixture of blood and fluid] drainage. Wound 2: Sacral [triangular bone at the bottom of the spine]. light serosanguineous drainage. IP confirmed Resident 37 was not on EBP and should have been on EBP due to her wounds.During an interview on 8/20/2025 at 5:04 p.m. with the Director of Nursing (DON), the DON stated she was unaware Resident 37 was not on EBP and she should be on EBP due to her wounds.During a review of the facility's policy and procedure (P&P) titled, Enhanced Barrier Precaution (EBP), dated June 2022, the P&P indicated, EBP are an infection control intervention designed to reduce transmission of resistant organisms. EBP applies to: All residents with any of the following: Wounds. make PPE, including gowns and gloves, available immediately outside of the resident room.Post clear signage at the door.

Based on observation, interview, and record review, the facility failed to ensure hospice services met professional standards for one of 15 sampled residents (Resident 36) when:1. The Hospice Registered Nurse (HRN) left Resident 36 exposed to the public for approximately 22 minutes, with no clothes from the waist to the feet.2. The Hospice Registered Nurse's (HRN) conduct was unprofessional towards Resident 36.These failures had the potential to cause physical and psychosocial harm to Resident 36.Findings:1.During a review of Resident 36's admission Record, dated 8/23/2025, the admission record indicated Resident 36 was admitted to the facility on [DATE] with a diagnoses of dislocation of internal left hip prosthesis (a condition where surgically implanted left hip comes out of place) and Huntington's disease (a condition in which nerve cells in the brain break down over time). During a review of Resident 36's Patient Billing/Care Level Change, document dated 8/4/2025, the document indicated, Resident 36 was enrolled in hospice care (medical care that focuses on providing comfort and support to residents with terminal illnesses and their families) on 8/4/2025.During a concurrent observation and interview on 8/20/2025 at 8:20 a.m. with the HRN, in Resident 36's room, the HRN was observed standing next to Resident 36 wearing a gown and gloves and wound supplies observed on the table. Resident 36 was observed with no clothes from the waist to feet, and visible to the public from the door.During a concurrent observation and interview on 8/20/2025 at 8:42 a.m. with the Director of Nursing (DON), in Resident 36's room, Resident 36 still had no clothes from the waist to the feet and wound change had not started. The DON confirmed it had been approximately 22 minutes for Resident 36 to be without clothes from the waist to feet, while waiting for the HRN. The DON stated this could lead to physical and psychological harm. The DON further stated the HRN's conduct was unprofessional. During a review of the facility's policy and procedure (P&P) titled, Accommodation of Needs, [undated], the P&P indicated, In order to accommodate individual needs and preferences, staff attitudes and behaviors are directed towards assisting the residents in maintaining independence, dignity and well-being to the extent possible and in accordance with the residents' wishes. interacting with the residents in ways that accommodate the physical or sensory limitations of the residents, promote communication, and maintain dignity.During a review of the facility's policy and procedure (P&P) titled, Hospice Program, dated January 2018, the P&P indicated, Hospice providers who contract with the facility are held responsible for meeting the same professional standards and timeliness of service as any contracted individual or agency associated with the facility.2. During a review of Resident 36's admission Record, dated 8/23/2025, the admission record indicated Resident 36 was admitted to the facility on [DATE] with a diagnoses of dislocation of internal left hip prosthesis (a condition where surgically implanted left hip comes out of place) and Huntington's disease (a condition in which nerve cells in the brain break down over time). During an observation on 8/20/2025 at 8:42 a.m., in Resident 36's room, the HRN was observed crying and yelling, unprovoked and next to Resident 36. Resident 36 was observed having a confused and scared facial expression. The Director of Nursing (DON) was observed asking the HRN to leave the room. During an interview on 8/21/2025 at 9:30 a.m., with the DON, the DON stated HRN's behavior was unprofessional and was not acceptable. The DON further stated, this caused Resident 36 to feel scared.During an interview on 8/21/2025 at 2:00 p.m., with Resident 36, Resident 36 stated he was scared when the HRN cried and yelled, thinking it was because of his wounds. During a review of the facility's policy and procedure (P&P) titled, Accommodation of Needs, [undated], the P&P indicated, In order to accommodate individual needs and preferences, staff attitudes and behaviors are directed towards assisting the residents in maintaining independence, dignity and well-being to the extent possible and in accordance with the residents' wishes. interacting with the residents in ways that accommodate the physical or sensory limitations of the residents, promote communication, and maintain dignity.During a review of the facility's hospice contract titled, Skilled Nursing Facility And Hospice Contract Agreement, dated 8/30/2022, the hospice contract indicated, The responsibility of the hospice is to assure that the services covered by the agreement shall be performed and rendered in competent, efficient and satisfactory manner.

Based on observation, interview and record review, the facility failed to ensure one handrail was secured to the wall. This failure had the potential to result in residents utilizing an unstable handrail that could subsequently cause a sudden fall and serious injuries.Findings:During an observation on 8/18/2025 at 4:43 p.m. in the east wing hallway, one handrail on the wall between room [ROOM NUMBER] and 10 had a crack along the seam of the handrail and was not firmly secured to the wall.During a concurrent observation and interview on 8/18/2025 at 5:42 p.m. with the Maintenance Director (MDR) in the east wing hallway, the MDR tugged on the handrail between room [ROOM NUMBER] and 10 and the handrail separated from the wall. MDR stated the handrail should have been secured to the wall and it needed to be reenforced.During a review of the facility's policy and procedure (P&P) titled, Maintenance Service, dated January 2018, the P&P indicated, The maintenance department is responsible for maintaining the buildings, grounds and equipment in a safe and operable manner at all times.

Based on observation, interview, and record review, the facility failed to notify one of two sampled residents (Resident 1) of their responsibilities as a resident when Resident 1 ' s daily rate for room and board increased twice (on 1/1/24 and 1/1/25) with no advanced written notice and required a security deposit with no advanced written notice. These failures caused financial hardship to Resident 1 who stated, It ' s really ruined my life, and stated she felt poor. Finding: During an observation on 2/5/25 at 9:57 a.m., a sign posted in the facility hallway indicated the private pay daily rate was $525 for a two-bed room. During an electronic medical record review on 2/5/25 at 11:42 a.m., Resident 1 ' s face sheet indicated she was admitted [DATE], payor information indicated Private Pay, and Resident 1 ' s power of attorney for healthcare was Family Member (FM) 4. Review of Resident 1 ' s Minimum Data Set (an assessment tool) dated 12/8/24 indicated a BIMS score of 13 (Brief Interview for Mental Status, a score of 13 to 15 indicates no cognitive impairment). During an interview on 2/6/25 at 3:29 p.m., Medical Records Director stated Resident 1 did not have an admission agreement. During an observation and concurrent interview on 3/24/25 at 12:50 p.m., Resident 1 was sitting in her wheelchair in the room where she resided, which was a two-bed room. When queried, Resident 1 stated she did not get an admission agreement when she was first admitted but had just signed one recently. Resident 1 stated she had not been given a copy so she could not provide information on the daily room rate or the security deposit amount that were in the agreement. Resident 1 verified she had had her daily room rate increased during her stay at the facility. Resident 1 stated she was paying $525 per day and then in January the rate increased it to $680 day, which is a lot of money for a place like this. Resident 1 denied she was given 30-days ' written notice of the rate increase. Resident 1 verified the security deposit and the daily rate increase were a financial hardship for her, and stated, It ' s really ruined my life. It makes me feel poor. During a phone interview on 3/24/25 at 1:55 p.m., FM 4 stated Resident 1 had been at the facility for two years now. FM 4 stated the facility took two payments from Resident 1 for January (2025). FM 4 stated the facility staff said one of the payments was being considered a security deposit. FM 4 stated she had handled Resident 1 ' s finances up until June of 2024, and then Resident 1 took over her own finances. FM 4 looked through some documents, and then read from an invoice, Private room and board 6/1/24 to 6/30/24 $15,750, May 2024 was $16,275. FM 4 stated that on 4/23/23 she got a statement that indicated a daily room rate of $412 per day and the January 2024 statement indicated $525 per day. FM 4 stated she got no notification that the rate was going up. FM 4 stated the facility did not send her (FM 4) an admission agreement. During a record review on 3/24/25 at 4:45 p.m., Resident 1 ' s admission agreement indicated an admitted [DATE] and had an electronic signature for Resident 1 dated 2/14/25. Further review of Resident 1 ' s admission agreement indicated a section for private pay daily room rate amounts with these spaces blank, no dollar amounts were listed. Further review of Resident 1 ' s admission agreement indicated a section for security deposits for private pay residents with N/A indicated in the space for the security deposit amount. Continuing the record review on 3/24/25 at 4:45 p.m., Resident 1 ' s billing statements for December 2024, January 2025, February 2025, and March 2025 indicated no bill for a security deposit. Review of Resident 1 ' s statement dated 2/1/25 indicated two checks were received in the amount of $15,079.16, with effective dates of 12/31/24 and 1/8/25. Continuing the record review on 3/24/25 at 4:45 p.m., review of Resident 1 ' s billing statements dated 1/1/24 and 2/1/24 revealed Resident 1 was charged a daily room rate of $412 per day for January and February 2024. Review of Resident 1 ' s billing statement dated 3/1/24 revealed Resident 1 was charged a daily room rate of $525 per day for March 2024 and was retroactively charged $525 per day for the two previous months (January and February 2024) and billed for the difference (an additional $6,780). Review of Resident 1 ' s billing statement dated 1/1/25 revealed Resident 1 was charged a daily room rate of $525 per day for January 2025. Review of Resident 1 ' s billing statement dated 2/1/25 revealed Resident 1 was charged a daily room rate of $680 per day and was retroactively charged $680 per day for the previous month (January 2025) and billed for the difference (an additional $4,805). During a phone interview on 3/25/25 at 1:33 p.m., Accounts Receivable Director (ARD) A verified Resident 1 ' s daily room rate increased from $412 per day to $525 per day in January 2024. When queried, ARD A stated Resident 1 was verbally informed of the increase. ARD A stated the reason the rate went up was because it was time for the rate to go up for everyone. ARD A verified Resident 1 ' s daily room rate increased from $525 per day to $680 per day in January 2025. ARD A stated the company just decided the daily rate would go up again. ARD A stated Resident 1 was verbally informed of the increase. When queried, ARD A stated it was usually the administrator who would inform residents of room rate changes. During an interview on 3/25/25 at 2:10 p.m., Administrator stated she had not informed Resident 1 that her room rate increased because she was not aware Resident 1 ' s room rate increased. Administrator stated either she or her supervisor would be responsible for informing a resident of a room rate increase. Administrator stated this would normally be done months ahead of the increase in rate. Administrator stated she did not know where this would be documented if Resident 1 received notice of the room rate increases. During a record review and concurrent interview on 3/25/25 at 2:13 p.m., Admissions Coordinator (AC) B stated she handled the admission agreements for residents. AC B verified the admission agreement was how the rules, regulations, and resident responsibilities were communicated to the residents. AC B stated generally she did not give a copy to the resident when signed, she offered a copy to everyone, but most declined. AC B stated she had not been documenting that the admission agreement was offered to residents. AC B verified that for private pay residents, paying the daily rate and the security deposit were considered part of the resident ' s responsibilities, and they were included in the admission agreement. AC B verified the admission agreement was the agreement to pay the daily room rate if a resident became private pay later in their stay. AC B stated the reason the admission agreement was important was so that the resident understood the rules and regulations and so the facility staff understood how the resident expected to be treated by staff. AC B reviewed Resident 1 ' s admission agreement. AC B verified Resident 1 ' s admission agreement indicated Resident 1 was admitted [DATE] and was signed by Resident 1 on 2/14/25. AC B verified she signed the admission agreement as witness. AC B stated corporate asked her to have Resident 1 sign it, but she did not know the reason they asked her to get it signed. AC B verified the daily room rates were blank on Resident 1 ' s admission agreement and stated the room rates were normally prefilled by the business office before she had a resident sign one. AC B stated she was not aware Resident 1 ' s room rates were blank, and stated she did not get into the financial aspects of resident ' s agreements. AC B verified that if the daily room rates were blank on the admission agreement, then the resident had not agreed to a particular rate when they signed. During a record review and concurrent interview on 3/25/25 at 2:32 p.m., Administrator stated she instructed AC B to audit all the residents to make sure they each had an admission agreement after this surveyor asked for Resident 1 ' s admission agreement on 2/6/25 and it could not be found. Administrator stated the whole leadership at the facility had a turnover so no one was there who would know if Resident 1 signed an agreement when Resident 1 was admitted (in March 2023). Administrator reviewed Resident 1 ' s admission agreement and verified the admission agreement indicated, We will provide you with a 30-day written notice before increasing the basic daily rate, and stated that was standard in skilled nursing facilities. Administrator stated she would have medical records review Resident 1 ' s chart for any documentation of this notification. During a record review and concurrent interview on 3/25/25 at 3:56 p.m., Administrator reviewed Resident 1 ' s billing statement dated 2/1/24 and verified Resident 1 ' s daily room rate increased. Administrator called Medical Records Director into her office. Medical Records Director entered Administrator ' s office and stated she could not find any documentation that Resident 1 had ever been notified of a room rate increase. Administrator stated Resident 1 should have been notified in writing with 30-days ' notice of the increase, and she will make sure that happened going forward. During a phone interview on 3/27/25 at 10:12 a.m., ARD A stated the second check collected from Resident 1 for January 2025 was a security deposit. ARD A stated it was the policy of the company to get a deposit for private pay residents, so the second check was for Resident 1 ' s deposit. ARD A stated, We never got it at the beginning (of Resident 1 ' s status as private pay), so we were asking for it now. ARD A stated she could just apply the deposit to next month ' s room and board, but was unable to state where it was documented that Resident 1 owed a security deposit to the facility or the amount of the deposit. During a phone interview on 3/28/25 at 10:49 a.m., ARD A stated that if a resident was required to pay a security deposit it should be itemized on the billing statement. ARD A verified Resident 1 ' s billing statements for December 2024 and January 2025 did not indicate she owed or was paying a security deposit. ARD A stated the amount of the deposit was one month room and board, but was not able to explain the reason Resident 1 ' s security deposit was for more than the amount of one month ' s room and board she was paying in 2023 when she became private pay. When asked for a policy for collecting security deposits, ARD A stated, We follow the admission agreement. During a record review and concurrent interview on 3/28/25 at 11:35 a.m., Administrator reviewed Resident 1 ' s admission agreement, and verified the admission agreement indicated N/A in the security deposit section where the amount of the security deposit should have been indicated. Administrator stated, N/A means not applicable. Administrator stated the amount of the deposit was one month room and board, but did not know who was responsible for entering the amount. Administrator denied that there was any other method of communicating the deposit amount to the resident even if they were not private pay on admission and became private pay later in their stay. Administrator verified Resident 1 ' s billing statement should have had the security deposit itemized. Administrator verified that without the itemized statement the purpose of the check collected on 1/8/25 was not clear. Administrator denied there was any documentation that Resident 1 agreed to pay the security deposit or the amount of the security deposit. When queried, Administrator stated the rationale for giving 30-days ' notice of changes in the residents ' bill was, So we know what we are going to pay next. The policy and procedure for collecting security deposits requested from ARD A on 3/28/25 at 10: 49 a.m., was not provided. Review of the facility policy and procedure, [NAME], dated 4/2018, indicated, Each resident will receive an itemized statement for services rendered during the billing cycle. The resident will be notified in writing at least 30 days prior to a change in his/her billing. Review of facility policy and procedure Exercise of Resident Rights, dated 11/2017, indicates, 1. Upon admission, a designated staff member will be responsible for providing the resident with an oral review of his or her rights and responsibilities prior to . or within 5 working days after the admission . 2. The resident or their representative will be required to sign a statement acknowledging his or her receipt of a written copy of resident rights and responsibilities . Review of facility policy and procedure Admission to the Facility, dated 1/2023, indicated, Procedure: Admission: . 4. An Admission and Financial Agreement must be signed for every resident admitted regardless of the payer source. A copy of the Admission and Financial Agreement is provided to the resident, and a copy is placed in the resident ' s permanent financial records.

Based on interview and record review, the facility failed to provide 5 of 5 sampled residents wanting to be discharged (Resident 1, Resident 2, Resident 3, Resident 4 & Resident 5) with a discharge planning process which addresses each resident's discharge goals and needs, including referrals to local contact agencies for placements (Finding a home to meet medical, functional and emotional needs of the residents after discharge from a health care facility), and involved the interdisciplinary team in developing the discharge plan. These findings resulted in severe emotional and psychological harm to Resident 5, including suicidal ideation (Thinking about planning suicide) with the development of a suicide plan by Resident 5, and depression and stress for all the residents involved. Findings: Record review of an e-mail sent to the Surveyor by Witness XX on 8/23/23 at 10:19 a.m., indicated Resident 1, Resident 2, Resident 3, Resident 4 & Resident 5 were awaiting discharge and felt like they were not being helped by the facility with discharge planning (The process of identifying and preparing for a resident's anticipated health care needs after they leave the skilled nursing facility). Resident 1 Record review indicated Resident 1 was admitted to the facility on [DATE] with medical diagnoses including Viral Hepatitis C (A virus that attacks the liver and leads to inflammation), according to the facility Face Sheet (Facility demographic). Record review of Resident 1's MDS (Minimum Data Sheet-An assessment tool) dated 8/25/23 indicated his BIMS (Brief Interview of Mental Status-A cognition [the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses] assessment) score was 15, which indicated his cognition was intact (A score of 1-7 indicates the cognition is severely impaired, 8-12 indicates the cognition is moderately impaired, and 13-15 indicates the cognition is intact). Resident 1's MDS also indicated he required only supervision of one staff for all Activities of Daily Living (ADLs- Activities related to personal care such as dressing, bathing and toileting) including personal hygiene and ambulation (The ability to walk without the need for any kind of assistance). During an interview on 9/20/23 at 10:39 a.m., Resident 1 stated the facility was not helping him find a placement for discharge. Resident 1 stated he was ready to be discharged since July, 2023, and was open to any type of housing, even in other counties, but the facility was not working on housing arrangements for him. Resident 1 stated he did not have a State identification card or health insurance card, since he had lost his wallet prior to admission to the facility. Resident 1 stated he notified the previous Social Services Director (Social Services Director J) he needed a State identification card, but was told to, figure it out, referring to finding out how to go himself to the Department of Motor Vehicles to get a new State identification card. When asked how he felt about this situation, Resident 1 responded, I feel helpless, and explained that he frequently experienced anxiety and depression. During an interview on 9/20/23 at 1:45 p.m., Administrator B was asked to provide all discharge planning notes for Resident 1 from 7/01/23 through 9/20/23, among other documents. All other documents were provided by Administrator B on 9/21/23 at 12:30 p.m., except the discharge planning notes. Resident 2 Record review indicated Resident 2 was admitted to the facility on [DATE] with medical diagnoses including Pulmonary Embolism (A sudden blockage in the pulmonary arteries, the blood vessels that send blood to the lungs) and Chronic Obstructive Pulmonary Disease (A lung disease characterized by chronic obstruction of lung airflow that interferes with normal breathing and is not fully reversible), according to the facility Face Sheet. Record review of Resident 1's MDS dated [DATE] indicated his BIMS score was 15, which indicated his cognition was intact. Resident 1's MDS also indicated he required only supervision for most ADLs including walking and personal hygiene. During an interview with Resident 2 on 9/20/23 at 10:24 a.m., he stated he was waiting for the facility to find him placement for discharge. Resident 2 stated he had been waiting for facility to help him find placement since April of 2023. Resident 2 stated he did not even have a medical insurance card or State identification card. Resident 2 stated he had notified the previous Social Services Director (Social Services Director J) about it, but nobody had helped him obtain these documents. Resident 2 stated he felt like he needed to file a lawsuit against the facility, as they were, leaving him to die. Resident 2 explained that without his documents he could not do anything, not even find a job. Resident 2 added that he frequently experienced depression as a result of this. During an interview on 9/20/23 at 1:45 p.m., Administrator B was asked to provide all discharge planning notes for Resident 2 from 7/01/23 through 9/20/23, among other documents. All other documents were provided by Administrator B on 9/21/23 at 12:30 p.m., except the discharge planning notes. Resident 3 Record review indicated Resident 3 was admitted to the facility on [DATE] with medical diagnoses including Fracture of Lumbar Vertebra (Broken bone of the spine in the region of the lower back), and Osteoarthritis (A condition in which the cartilage that cushions the ends of bones in the joints gradually deteriorates), according to the facility Face Sheet. Record review of Resident 1's MDS dated [DATE] indicated his BIMS score was 15, which indicated his cognition was intact. Resident 1's MDS also indicated he required only supervision for most ADLs including walking and personal hygiene. During an interview on 9/20/23 at 11:40 a.m., Resident 3 stated he had not received help finding housing from the facility, although he could either be discharged or continue living at the facility. Resident 3 stated not having asked the facility to find him housing because he liked living at the facility. Resident 3 stated no meetings had been held at the facility to discuss discharge planning, however, he had recently been given a 30-day notice of discharge, without ensuring he had a place to go. Resident 3 stated he was concerned about this 30-day notice because he did not have immediate family to move with, and no other place to go. During an interview on 9/20/23 at 1:45 p.m., Administrator B was asked to provide all discharge planning notes for Resident 3 from 7/01/23 through 9/20/23, among other documents. All other documents were provided by Administrator B on 9/21/23 at 12:30 p.m., except the discharge planning notes. Record review of an e-mail sent to Administrative Staff C on 9/14/23 at 9:07 a.m., by the Surveyor, indicated a request was made to provide the comprehensive discharge plan for Resident 3, along with the 30-day-discharge notice given to him on 9/05/23. Administrative Staff C responded to this request on 9/15/23 at 8:27 a.m., through e-mail, and provided the 30-day discharge notice, as an attachment in the e-mail that was so tiny, it was unreadable, and responded the following regarding the request for the comprehensive discharge plan, None yet, I believe there is a hearing scheduled for this. This was confirmed by Resident 3 during an interview on 9/20/23 at 11:40 a.m. During an interview on 9/21/23 at 2:01 p.m., the Director of Nursing (DON) confirmed there was no discharge plan developed for Resident 3 or a placement for him to go. Resident 4 Record review indicated Resident 4 was admitted to the facility on [DATE] with medical diagnoses including Fracture of Distal Phalanx of Right Great Toe (Break of the tip of the bone of the right big toe), and Fracture of Cuboid Bone of Left Foot (Break of a bone in the midfoot, right next to the ankle of the left foot), according to the facility Face Sheet. Record review of Resident 4's MDS dated [DATE] indicated his BIMS score was 15, which indicated his cognition was intact. Resident 1's MDS also indicated he required only supervision for most ADLs including walking and personal hygiene. During an interview with Resident 4 on 9/20/23 at 11:43 a.m., he stated nobody from the facility had helped him with housing for discharge. Resident 4 also stated he did not have a health insurance card or State identification card as he had lost them a while back. Resident 4 stated there were no care conference meetings held to discuss housing with him. Resident 4 stated he felt stuck, at the facility, and it made him stressed not knowing clearly what's going on. During an interview on 9/20/23 at 1:45 p.m., Administrator B was asked to provide all discharge planning notes for Resident 4 from 7/01/23 through 9/20/23, among other documents. All other documents were provided by Administrator B on 9/21/23 at 12:30 p.m., except the discharge planning notes. Resident 5 Record review indicated Resident 5 was admitted to the facility on [DATE] with medical diagnoses including Fracture of Right Lower Leg (A break in one or both bones below the knee and above the ankle, of the right foot), and Laceration (A deep cut or tear of the skin or flesh) of Right Hand, according to the facility Face Sheet. Record review of Resident 5's MDS dated [DATE] indicated his BIMS score was 15, which indicated his cognition was intact. During an interview on 9/20/23 at 11:28 a.m., Resident 5 stated the facility was not helping him find housing for discharge, therefore, he was trying to arrange housing himself. Resident 5 stated he had requested assistance to find housing. Resident 5 explained that he was admitted to the facility from a hospital after having suffered an accident while hiking with friends, in which he fractured his right leg. Resident 5 stated that the original plan was for him to get rehabilitation (The action of restoring someone to health or normal life through training and therapy) services and be discharged within 30 days from the facility. Resident 5 stated he did not get rehabilitation services (Substantiated during further investigation, refer to F688), was not allowed to walk on his own by facility staff, and did not get assistance with discharge planning, so he had been living at the facility for more than six months. When asked how he felt about it, Resident 5 responded, Extremely depressed, I should not be here. Resident 5 stated that recently, he had experienced suicidal thoughts and cried for two days. Resident 5 stated he had developed a plan for suicide and discussed the plan with the Surveyor. Resident 5 stated one of the other residents of the facility (did not specify who) noticed how depressed he was and notified one of the Licensed Nurses (did not specify who) at the facility. Resident 5 stated he felt helpless to control what he was up against and was very uncomfortable with that feeling. Resident 5 stated he thought, What if I get stuck here until I die? and felt he needed to reunite with his wife who had already passed. Resident 5 stated not feeling suicidal at the time of this interview on 9/20/23 at 11:28 a.m. Record review of an e-mail sent to Administrator A on 9/05/23 at 12:06 p.m., from the Surveyor indicated a request was made for the last 5 discharge planning notes for Resident 5. Administrative Staff C e-mailed the documents requested to the Surveyor on 9/07/23 at 2:23 a.m., but only provided one discharge planning note for Resident 5, titled, Discharge Planning Review, dated 2/13/23. Record review of the document titled, Discharge Planning Review, e-mailed to the Surveyor on 9/07/23 at 2:23 a.m., by Administrative Staff C, was signed by Resident 5 on 2/13/23, and indicated, Resident is here for short term rehab plan is to discharge. No other discharge planning notes were provided. During an interview on 8/22/23 at 10:28 a.m., Licensed Staff D stated the facility had not had a Social Services Director for a while, but she could not remember how long. License Staff D stated Licensed Nurses were not working on finding discharge placements for residents. During an interview on 8/22/23 at 10:37 a.m., Licensed Staff E stated the facility's previous Social Services Director had left her position the first week of July 2023, and they needed help. Licensed Staff E explained that Licensed Nurses were now the ones arranging discharges, but they could only do the simple discharges in which residents already had a place to go. Licensed Staff E stated that those discharges that needed more work such as finding a placement for discharge were not being done. Record review of an e-mail sent to the previous Social Services Director (Social Services Director J) on 5/25/23 at 10:42 a.m., by Witness YY, a person not from the facility, who was helping Resident 1, Resident 2, Resident 3 and Resident 5 find housing, indicated, Good morning [Social Services Director J] .I was e-mailing to check in on [Resident 5] .Did his medi-cal (State program that pays for a variety of medical services for adults with limited resources) card come through? Also, I need help with [Resident 1, Resident 3, Resident 2] I can not apply for them anywhere (phone or housing) if they do not have an ID (State identification cards) or medi-cal card. Can you help me with these? They all need ID and medi-cal cards. As indicated by the above interviews with Resident 1, Resident 2 and Resident 4, by 9/20/23 these three residents stated still not having health insurance cards of State IDs. During an interview with the DON on 9/21/23 at 2:01 p.m., she confirmed there were no recent (Within the last three months) discharge planning notes for Resident 1, Resident 2, Resident 3, Resident 4 and Resident 5. The DON explained that the facility did not have a Social Services Director since 7/10/23, therefore, nobody had been working on discharge planning for these residents, including placements. Record review of the facility policy titled, Social Services, dated January of 2018, indicated, Our facility provides medically-related social services to assure that each resident can attain or maintain his/her highest practicable physical, metal, or psychosocial well-being .The social services department is responsible for: l. participating in the planning of the resident's admission, return to home and community, or transfer to another facility.

Based on observation, interview and record review, the facility failed to protect two of eight sampled residents (Resident 8 and Resident 96) from resident-to-resident abuse, when a verbal altercation between them, in which profanity was used, was overheard by staff, who failed to report it to facility administration, and initiate appropriate interventions to eliminate abuse and prevent reoccurrence. This failure resulted in reoccurrence of verbal aggression, and emotional distress, to Resident 8 and Resident 96. Findings: Record review indicated Resident 8 was admitted to the facility on [DATE], with medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review indicated Resident 8's MDS (Minimum Data Set - U.S. federally-mandated process for clinical assessment of all residents in Medicare or Medicaid certified nursing homes), dated 01/19/20, indicated Resident 8's BIMS (Brief Interview of Mental Status-Cognition assessment) score was 11, which indicated her cognition was moderately impaired. Record review indicated Resident 96 was initially admitted to the facility on [DATE], and readmitted on [DATE], with medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Face Sheet indicated Resident 96 shared a room with Resident 8. Record review indicated Resident 96's MDS, dated [DATE], indicated her BIMS score was 11, which indicated her cognition was moderately impaired. Record review indicated a nursing care plan for Resident 96 titled, The resident has a behavior problem-disruptive/disorganize thoughts, initiated on 07/24/19, indicated, The resident has a behavior problem-disruptive/disorganize thoughts .Intervene as necessary to protect the rights and safety of others. Approach/Speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed. During an interview on 01/27/20 at 2:15 p.m., Resident 8 stated her roommate, Resident 96, was verbally aggressive towards her, sometimes using profane words to refer to her. Resident 8 stated she planned to speak to facility administration about it because she could not get along with Resident 96 and did not want to continue sharing a room with her. During an interview on 01/28/20 at 8:18 a.m., Resident 96 stated Resident 8 was verbally abusive towards her, especially when her TV was on, as the noise bothered Resident 8. During a second interview on 01/30/20 at 9:24 a.m., Resident 96 stated Resident 8 had been verbally abusive towards her, since her arrival to the facility on [DATE] (second admission). Record review indicated a Nurse's Note, dated 01/02/20 at 1:09 a.m., documented Resident 8 had been verbally aggressive towards Resident 96. Record review indicated a Nurse's Note, dated 01/2/20 at 1:09 a.m., documented by Licensed Staff I, indicated, At 12:30 am, heard resident (Resident 8) throwing profanities to her roommate (Resident 96). Resident noted with aggressive behavior towards roommate. Spoke with the resident together with the other charge nurse (Licensed Staff H) and the cna (Certified Nursing Assistant) assigned, to figure out what's going on. Per resident, she hates her roommate and wants to be transferred someone else. Record review indicated a second Nurse's Note, dated 01/26/20 at 10:34 a.m., documented by Licensed Staff I, which indicated, Resident (Resident 8) noted with unruly attitude towards roommate (Resident 96). During an interview on 01/30/20 at 9:04 a.m., the Administrator stated he was not aware of any verbal aggression between Resident 8 and Resident 96. During a phone interview on 01/30/20 at 1 p.m., with Licensed Staff I, who documented the Nurse's Note on 01/02/20, she confirmed overhearing Resident 8 and Resident 96 yelling to each other on 01/02/20. Licensed Staff I stated Resident 8 called Resident 96 a, b*** and also told her, Nobody comes to visit you because nobody loves you, at least I have a boyfriend that comes to visit me. Licensed Staff I stated Licensed Staff H, who was also the Charge Nurse for the shift, was present. Licensed Staff I also stated, This has been going on for a while. Licensed Staff I stated she only notified Licensed Staff H of this incident, and documented her observations. Licensed Staff I confirmed she did not notify the facility's administration of this incident or create care plans to prevent reocurrence. During a second interview on 01/31/20 at 9:50 a.m., Licensed Staff I stated she did not report the incident of verbal aggression, which occurred on 01/02/20, between Resident 8 and Resident 96 to facility administration, because she thought Licensed Staff H, who was also the Charge Nurse, was going to do it. Licensed Staff I stated the requirement was that these incidents be reported to the facility's abuse coordinator, but explained that at the time, she did not think straight. Licensed Staff I stated night shift staff had reported to her on several occasions that Resident 8 and Resident 96 had disagreements or arguments at night. A request was made to the Administrator on 01/30/20 at 10:30 a.m., to arrange a phone interview with Licensed Staff H. During an interview on 01/30/20 at 3:45 p.m., the Administrator stated Licensed Staff H had not answered her phone, therefore; a voicemail was left, but she had not called back. A request was made to the Director of Nursing (DON) on 02/03/20 at 8:29 a.m., to arrange a phone interview with Licensed Staff H. During an interview with the DON on 02/03/20 at 9:29 a.m., she stated Licensed Staff H had not answered her phone; a voicemail was left, but she had not called back. Record review indicated nursing care plans for Resident 8 did not address aggressive behavior towards her roommate, or incidents of verbal altercations with other residents. No new or updated care plans were found, to reduce or prevent verbal aggression for Resident 8, or Resident 96, after the incident on 01/02/20. During an interview on 01/30/20 at 9:24 a.m., Resident 96 confirmed Resident 8 was very aggressive towards her and sometimes called her a, w****. Resident 96 also stated, She (Resident 8) has been very nasty to me. Resident 96 stated feeling mad and sad about that situation, which had been going on for months, since her admission to the facility in November of 2019. Resident 96 stated she had told facility staff about it, but did not remember who she told. Record review indicated a Nurse's Note, dated 01/28/20 at 12:55 p.m., documented Resident 8 was transferred to an outside acute care hospital for complaints of sharp pain on her right lower abdomen. During an observation and interview with Resident 8 on 01/31/20 at 12:45 p.m., at the acute care facility where she transferred on 01/28/20, Resident 8 stated Resident 96 frequently yelled at her using words such as, F***, W****, and B***. Resident 8 stated she had not told anybody because she was afraid Resident 96 would get back at her, and indicated, If she moves, then she'll really become furious. When asked if she wanted Resident 96 to move to another room, Resident 8 stated, Of course I'd like her to move. Resident 8 stated feeling that all Licensed Nurses at the facility were on Resident 96's side. Resident 8 stated, They're all her friends, and call her sweet angel and darling daughter, referring to staff's interaction with Resident 96. Resident 8 was crying. When asked if she felt she was being abused by Resident 96, Resident 8 stated, Oh, yeah .I think that's why I got sick. When asked for how long this situation had been going on, Resident 8 stated, I don't know, maybe a month. I just want to forget about it. Resident 8 was asked if she had reported this situation to the facility's Administrator, to which Resident 8 responded, I told him that I didn't get along with my roommate but he said nothing. Resident 8 stated not remembering when she told the Administrator that she did not get along with her roommate. During an interview on 01/30/20 at 9:13 a.m., Resident 95 and Resident 15, who shared an adjacent room to where Resident 8 and Resident 96 lived, confirmed having heard Resident 8 and Resident 96 yelling to each other and, although neither of them could distinguish what was being said during those arguments, both thought Resident 96 was the one yelling at Resident 8, especially since they continued to hear Resident 96's voice even when Resident 8 was no longer at the facility (Resident 8 was transferred to an acute care hospital on 01/28/20). Record review indicated Resident 95's BIMS score, dated 01/23/20, was 13, which indicated her cognition was intact. Record review indicated Resident 15's BIMS score, dated 11/15/19, was 15, which indicated her cognition was intact. During an interview on 01/30/20 at 9:32 a.m., Resident 36, who lived in a room across the hall from Resident 8 and Resident 96's room, stated he had heard Resident 8 and Resident 96 yelling at each other almost every night, using words such as, w****, and, b***. Record review indicated Resident 36's BIMS, dated 12/29/19, was scored at 15, which indicated his cognition was intact. During an interview on 01/30/20 at 2:45 p.m., Resident 21, who lived in a room across the hall from Resident 8 and Resident 96's room, confirmed constantly hearing Resident 8 and Resident 96 yell to each other, using words such as, b*** and, w****. Record review indicated Resident 21's BIMS, dated 11/30/19, was scored at 11, which indicated his cognition was moderately impaired. During a second interview on 01/30/20 at 3:45 p.m., the Administrator reiterated he was not aware of Resident 8 and Resident 36 name calling each other. He stated he had offered to switch them to different rooms, but they had declined. The Administrator was not asked when he offered them separate rooms. When asked why he offered them separate rooms, if not aware of the abuse situation, he stated it was because of other minor complaints. When asked if he documented the offer to switch rooms, the Administrator stated, I did not. He stated he was currently working on the required abuse report to send to the DEPARTMENT since he had just become aware of the incident. During an interview on 01/31/20 at 9:55 a.m., Unlicensed Staff D stated Resident 8 and Resident 96 had been roommates for about three months. A facility document titled, EPT (Employment training) ATTENDANCE ROSTER, indicated both Licensed Staff I and Licensed Staff H attended a 60-minute training on abuse reporting and prevention on 08/30/19. Record review indicated the facility policy titled, Abuse Investigation and Reporting, released in February of 2018, indicated, All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source (abuse) shall be promptly reported to local, state and federal agencies (as defined by current regulations) and thoroughly investigated by facility management .The Administrator will ensure that any further potential abuse, neglect exploitation or mistreatment is prevented. During an interview on 01/30/20 at 2:43 p.m., the Director of Staff Development (DSD) stated the facility's expectation, when staff heard residents yelling or name calling each other, was to separate them, de-escalate the situation, notify administration, the DON and the Ombudsman. The DSD stated resident-to-resident abuse was unacceptable. The DSD also stated calling a resident, b****, was considered verbal abuse.

Based on observation, interview and record review, the facility failed to ensure a comfortable and sanitary environment when: 1. Multiple residents (Resident 1, 2, 9, 10, 11, 12, 16, 23, 27, 29, 34, 37, 39, and 50) out of 51 residents complained of being cold inside the facility for weeks, and the facility did not maintain comfortable facility temperatures ranging from 71 to 81 degrees Fahrenheit (°F). On 12/12/18 at 1:56 p.m., due to the facilities failure to provide comfortable facility temperature, Administrative Staff A and Consultant H were verbally notified of the Immediate Jeopardy. The Health Facilities Evaluator Nurses informed Administrative Staff A and Consultant H of the interviews with residents complaining of being cold and facility thermometer indicating the temperatures in three of three hallways were 75 °F. Multiple temperature readings were obtained by Administrative Staff A, and three of out three hallways did not indicate 75 °F. Immediate Jeopardy is a situation in which a provider's noncompliance with one or more requirements of participation has caused or is like to cause serious injury, harm impairment or death to a resident (Standard Operation Manual, Appendix Q). On 12/13/18, at 11:02 a.m. the facility presented a corrective plan of action, including but not limited to: 1) servicing heating system, 2) relocating the three thermostats to the approximate middle point of each hallway, 3) installing thermometers in each resident room and increasing the outflow of heat for entire facility. On 12/13/18 at 11:05 a.m., the abatement (lifted) of Immediate Jeopardy occurred in the presence of Administrative Staff A after interviews and observations confirmed the facility implemented the corrective plan of actions. Administrative Staff A understood the facility would continue to complete plan of action to replace the heating and air-conditioning system. On 12/13/18 at 11:35 a.m. Administrative Staff A, Consultant H and Consultant L were notified of substandard quality of care identified and the facility was on extended survey. Substandard quality of care means one or more deficiencies related to participation requirements under 42 CFR 486.10 resident rights that constitute to immediate jeopardy to resident health or safety (level J, K or L) (Standard Operation Manual, Appendix P) These failures had the potential to cause: a) Resident's susceptibility to loss of body heat and risk of hypothermia (medical emergency that occurs when your body loses heat faster than it can produce, causing dangerous low body temperature) or susceptibility to respiratory ailments and colds, b) immobility issues related to not wanting to get out of bed due to the cold, c) Cross-contamination and spread an infection among residents, and d) negatively impact residents comfort and homelike environment 2. Multiple resident toilets were clogged with feces on a routine basis as indicated in the maintenance logs for the previous six months. This resulted in discomfort with room environment due to the smell, loss of dignity due to reaction of staff regarding fixing the issue and potential infection control related to feces in a standing toilet for a time period. 3. Two resident room's (room [ROOM NUMBER] & 26) privacy curtains where soiled. This failure had the potential to cause cross-contamination and spread the infection if touched by a resident and/or staff member. 4. Multiple residents were effected by soiled and/ or sticky floors (room [ROOM NUMBER], 6, 8, 9, 10, 11, 17, 23, 24, & 25). This failure had the potential to create an infection control issue due to soiled floors, potential safety issue with ambulating on sticky and/or soiled floors, and loss of a comfortable homelike environment. 5. Two resident's (Resident 13 & 29) had dirty wheelchairs, which had the potential to cause cross-contamination and spread the infection related to touching a dirty wheelchair, and loss of comfortable homelike environment. 6. Two resident rooms (room [ROOM NUMBER] & 11) wall's had missing plaster and paint, and the walls were dirty. This failure had the potential to negatively impact residents' comfort and homelike environment. Findings: 1. During a concurrent observation and interview on 12/10/18 at 12:52 p.m., room [ROOM NUMBER] felt very cold. Resident 34 stated she was very cold. Resident 34 stated. Do you see, I have 7 blankets on me. Administrative Staff A controls heat located in his office. During a concurrent observation, and record review on 12/10/18 at 12:52 p.m., room [ROOM NUMBER] felt very cold. Resident 6 was asleep, wearing a hospital gown, and was covered with a sheet and a light weight blanket. A review of the clinical record for Resident 6, the Admission Record, dated 12/13/13, and Resident 6's History and Physical, dated 11/23/14, indicated Resident 6 had a [DIAGNOSES REDACTED]. and her primary language was Chinese. During a concurrent observation and interview on 12/10/18 at 12:54 p.m., room [ROOM NUMBER] felt very cold. Resident 10 stated she had no complaints except being cold. Resident 10 was wearing pajamas and had multiple blankets on her bed. During a concurrent observation and interview on 12/11/18 at 1:54 p.m., room [ROOM NUMBER] felt very cold. Resident 34 was in bed and had multiple layers of clothing and had 7 blankets on the bed. Resident 34 stated the room was extremely cold and she felt very cold. During concurrent interviews and observations at Resident Council on 12/11/18 at 9:25 a.m., Residents stated the rooms were cold and uncomfortable. Resident 9 stated it was freezing and indicated it was always freezing. Resident 9 was observed wearing two T-shirts, thick sweatpants and a thick pull over sweatshirt. Residents 39, 2 and 50 agreed with the rooms being uncomfortably cold. Resident 39 was observed dressed in thick sweatpants, a hooded sweatshirt and jacket. Resident 2 was dressed in pants, shirt, sweater and two blankets draped over her wheelchair. Resident 50 was observed wearing jeans, a t-shirt, sweatshirt and jacket. Resident 27 and 29 were asked if it felt cold, stating it's darn cold in this place. Resident 27 was observed wearing sweatpants, with a sweatshirt and jacket. Resident 29 was observed wearing jeans, T-shirt, sweatshirt and jacket. Resident 11 stated she always felt cold and was observed wearing pajamas, sweatshirt and thick bathrobe. During a concurrent interview and observation on 12/12/18 at 9:02 a.m., Administrative Staff K observed to measure temperatures in the East Wing of the facility, by using a laser thermometer. room [ROOM NUMBER] was 65.5 °F and Resident 34 stated she was very cold and observed to have multiple blankets on her bed. During concurrent interviews and observations, on 12/12/18 at 9:07 a.m., Administrative Staff A indicated he wanted to measure the temperatures in each Resident Room rather than Administrative Staff I. Administrative Staff A held the laser thermometer and measured multiple points of each room. *room [ROOM NUMBER] measured between 58 to 65 °F. *room [ROOM NUMBER] measured 65 °F. *room [ROOM NUMBER] measured 68 °F. *room [ROOM NUMBER] measured 67.5 °F. *room [ROOM NUMBER] measured between 62 -67.5°F. *room [ROOM NUMBER] measured 69°F. Resident 11, who was observed to be in bed, stated she always felt cold. *room [ROOM NUMBER] measured between 66.5 and 70 °F. *room [ROOM NUMBER] measured 66 to 69°F. Resident 2 stated she was cold. During concurrent interviews and observations on 12/12/18 at 9:20 a.m., Administrative Staff A measured room temperatures in the South Wing of the facility: *Activity Room measured 66 to 67°F. Resident 9 was observed sitting at a table, and stated he was cold. *room [ROOM NUMBER] measured 59 to 63°F. Resident 37 stated he was cold, and was wearing a sweatshirt, knit cap and flannel pajama pants. Resident 29 stated he was cold, and was wearing blue jean pants, multiple T-shirts and a coat. During concurrent interviews and observations on 12/12/18 at 9:25 a.m., Administrative Staff A measured resident rooms in the West Wing of the facility: *room [ROOM NUMBER] measured 61.5 to 67°F. Resident 12 was in bed, wearing a knit cap, pajamas and sweatshirt. Resident 12 stated she was very cold. Resident 23 was observed in bed with multiple blankets, and stated she was very cold. Resident 23 became anxious during the encounter when she thought she might have to get out of bed complaining of the cold. * room [ROOM NUMBER] measured 64 to 67°F. Resident 1 was observed to be in bed wearing jeans, T-shirt, sweatshirt and jacket. Resident 1 stated he was cold. *room [ROOM NUMBER] measured 63°F to 68°F. Resident 16 stated, It can get cold here. During an interview on 12/12/18 at 9:55 a.m., Administrative Staff A was asked for a policy addressing the temperature ranges for resident rooms. Administrator A indicated he was not aware of the existence of such a policy. During a concurrent observation and interview on 12/12/18 at 10:30 a.m., room [ROOM NUMBER] felt cold. Resident 10 stated the room was very cold. Resident 10 was wearing pajamas and had multiple blankets on her bed. During an interview on 12/12/18 at 10:36 a.m., Administrative Staff I stated each hallway had its own thermostat and the surveyor was escorted to the Director of Nursing's (DON) office where three thermostats were located next to each other on the wall labeled, East Hallway, South Hallway and West Hallway. The East Hallway thermostat indicated the temperature was 75°F and if the temperature dropped below 71°F, the heater would turn on. Administrative Staff I escorted the surveyor to the main desk area, (proximal to the intersection of all three hallways) just outside of the DON office and measured 69.8°F. Administrative Staff I measured the East Hallway, 70.9°F at the beginning, 68.5°F middle and at the end under the Exit sign, measured 64.5°F. Administrative Staff I, in the South Hallway measured 69.6°F at the beginning, 69.2°F in the middle and the end of the hallway under the Exit sign 65.5°F. Administrative Staff I measured the beginning of West Hallway 69.8°F, the middle 69.9°F and the end of the hallway under the Exit sign 67.4°F. During a concurrent observation and interview on 12/12/18 at 10:47 a.m., Administrative Staff I and surveyor were in the East Hallway. The hallway felt very cold and Administrative Staff I stated, The temperature was dropping the closer we traveled toward room [ROOM NUMBER] and 12, which were located across the hall from one another, and right and left of the Exit door. During an interview on 12/12/18 at 10:52 a.m., Licensed Staff P stated the East Hallway was always cold. Licensed Staff P stated she was running around and always needed to wear a sweater. During an interview on 12/12/18 at 11:56 a.m., Unlicensed Staff K stated the East Hallway felt cold to her. Unlicensed Staff K stated, I feel real cold right now. During interview on 12/12/18 at 1:56 p.m., Administrative Staff A and Consultant H met with surveyors. Consultant H stated when their company acquired the facility, the previous owners were supposed to fix the heating/air conditioning unit, but it did not happen. Consultant H stated the facility had applied to OSHPD (Office of Statewide Health Planning and Development: improves access to quality healthcare for Californians. They ensure hospital buildings are safe, etc.) for a permit to have a new system installed back on 8/31/18. During observations on 12/14/18 at 3:38 p.m., Surveyors checked on where the thermostats were relocated from the DON's office to the three hallways and how the thermostats were mounted to the wall. *Thermostat relocated to West Hallway was anchored by drywall screws, *Thermostat relocated to East Hallway was anchored by drywall screws, *Thermostat relocated to South Hallway was anchored by dry wall screws. During an interview on 12/14/18 at 3:52 p.m. Administrative A was asked with the presence of Consultant L, if he called OSHPD for an Emergency Permit before drilling into the drywall in order to relocate the three thermostats in the varies hallways. Administrative A stated, No I did not. During an interview on 12/14/18 at 4:17 p.m., Surveyors met with Administrative Staff A and Consultant L regarding the OSHPD Project # S 2-21-00 (General Repairs Project), not meeting the HVAC (Heating, Ventilation, and Air Conditioning) requirements, no mention of HVAC for OSHPD Project # S 2-21-00. Administrative Staff A stated he would research further to find out a project number consistent with the HVAC scope of changing a whole new system over. Consultant L stated, I do not know if corporate has a copy of the project number. Administrative Staff A stated, This was all above my pay grade, but I will call and get a number that includes the HVAC project. During an interview on 12/14/18 at 5:02 p.m., conference call with Administrative Staff A, Consultant L, and surveyors on the phone with Consultant Y. Consultant Y stated OSHPD Project # S 2-21-00 (General Repairs Project) related to General Maintenance, but was comprised of two phases. The Phase I was described as removal of the duct work and Phase II would be re-install all new duct work and the new cooler and heater. At 17:04 p.m. Consultant Y transferred phone over to Consultant Z. Consultant Z stated there was a non-compliance of the HVAC system and the General Repair consisted of lighting, generator annunciator panel (group of lights used as a central indicator of status of equipment or systems in an industrial process, building, etc.) and duct work. Consultant Z was asked if there was another project number since the project number did not state HVAC work was being done. Consultant Z stated there was no other number (project number) to reference the HVAC work. Three times Consultant Y and Consultant Z were asked if there was a project number containing HVAC work, and both stated there was not an additional project number and both kept insisting the number being discussed contained the HVAC information. At 5:45 p.m. Consultant L presented a document with the project number, OSHPD Project # S 2-21-00, indicating the Project Description: 1. Demo (3) condensing units and ductwork (previously installed), 2. Install generator annunciator at nurse station (previously installed), and 3. Replace (14) light fixtures in corridor (previously installed). During a concurrent observation and interview on 12/18/18 at 11:38 a.m. room [ROOM NUMBER]'s wall thermometer read 68 degrees Fahrenheit. Resident 10 stated she felt cold. Resident 10 had just woken up and was sitting on the side of the bed. She was wearing pajamas, had a hospital gown over the pajamas, and socks. The facility Policy/Procedure (P/P) titled, Quality of Life-Homelike Environment,1/18, indicated, The facility staff and management shall maximize .clean, sanitary and orderly environment, .comfortable and safe temperatures. The facility P/P titled, Ambient Temperature, 1/18, indicated, Ambient temperature (71 °F -81 °F) will be maintained at comfortable and safe temperature level. 2. During an observation on 12/10/18 at 5:20 p.m., Administrative Staff I stated the toilet in room [ROOM NUMBER] was clogged and could not explain the large amount of feces located in toilet bowl. Administrative Staff I stated the size of the resident did not coincide with amount of feces in the toilet bowl and the conversation continued with Administrative Staff A. Resident 27 stated he hoped with future toilet issues he would not be made to feel badly regarding the back up and amount of feces. There was no acknowledgement or response to Resident 27's comment from Administrative Staff A or Administrative Staff I. The maintenance logs available from 5/27/18 to 11/26/18 indicated the following: Date Description of issue 7/11/18 room [ROOM NUMBER]: toilet not working 7/21/18 room [ROOM NUMBER]: bathroom leaking gasket 9/29/18 room [ROOM NUMBER] to 15: toilet is broken 10/15/18 room [ROOM NUMBER]-19: toilet does not flush 10/28/18 room [ROOM NUMBER]: toilet bowl will not flush Administrative Staff I stated the toilet issues were related to paper towels and other objects being flushed inappropriately down, causing the back up. Administrative Staff I could not state a plan to communicate these issues to the staff and residents in order to further prevent toilet clogging. Administrative Staff I stated he did not routinely enter resident rooms, since he had a maintenance person on site to handle most issues. Administrative Staff I stated when he was hired there was training on how to deal with resident population of the facility and agreed the conversation between himself and Administrative Staff A on 12/10/18 was not respectful to residents who lived in the facility. The facility P/P titled, Quality of Life-Homelike Environment, dated 1/18, indicated The facility staff and management shall maximize, Clean, sanitary and orderly environment During a review of the job description titled, Maintenance Director, dated 10/19/15, Maintenance Director was to, Maintains the building .free of hazards such as those caused by .plumbing .systems etc. and Puts Customer Service First: Ensures that customers and families receive the highest quality of service in a caring and [MEDICATION NAME] atmosphere . 3. During a concurrent observation and interview on 12/11/18 at 1:54 p.m., room [ROOM NUMBER]'s privacy curtain between A and B bed had a brown smear and the walls were dirty. Resident 34 stated the room has never been deep cleaned. During a concurrent observation and interview on 12/18/18, room [ROOM NUMBER]'s privacy curtain between A and B bed had a red/brownish smudge. Resident 37 stated he thought it was from his bloody nose. Resident 37 indicated the smudge was approximately a week old. The facility P/P titled, Quality of Life-Homelike Environment, dated 1/18, indicated The facility staff and management shall maximize, Clean, sanitary and orderly environment 4. During a concurrent observation and interview on 12/10/18 at 10:34 a.m., room [ROOM NUMBER]'s linoleum floor was audibly sticky. Resident 2 stated she felt the staff needed to clean the room better for her health. During an observation on 12/10/18 at 10:56 a.m., room [ROOM NUMBER]'s linoleum floor was audibly sticky. During a concurrent observation and interview on 12/10/18 at 12:27 p.m., room [ROOM NUMBER]'s linoleum floor was peeling, dirty and was audibly sticky. Resident 41 stated there was lack of cleaning in her room. During an observation on 12/11/18 at 10:18 a.m., room [ROOM NUMBER]'s linoleum floor looked dirty, multiple spots throughout flooring. During a concurrent observation and interview on 12/11/18 at 1:54 p.m., room [ROOM NUMBER]'s linoleum floor around the baseboards had a build-up of dust/dirt. During a concurrent observation and interview on 2/12/18 at 11:56 a.m., room [ROOM NUMBER]'s linoleum floor was audibly sticky. When Unlicensed Staff K was asked if the floor felt sticky, Unlicensed Staff K stated, Yes, a lot of the resident floors are sticky. She thinks it has something to do with the housekeepers mop head. During a concurrent observation and interview on 12/13/18 at 1:28 p.m., room [ROOM NUMBER]'s linoleum floor was audibly sticky, dirty, and the linoleum was cracked and tiles were pulling apart at the seams. Resident 17 stated she asked the housekeeper to mop the floor, but she only stocked gloves; housekeeper had not cleaned the room yet. Resident 17 stated the Certified Nursing Assistants will give her a sponge bath and place the dirty towels and bagged briefs on the floor, so the floor needed to be mopped. During multiple observations on 12/13/18, 12/14/18 and 12/18/18, room [ROOM NUMBER]'s floor next to Bed B was audibly sticky. When Resident 32 was asked if he could hear the shoe sticking to the floor, he nodded, Yes, but could not tell surveyor how long the floor had been sticky since he did not get out of bed. During multiple observations on 12/13/18, 12/18/18 and 12/19/18, room [ROOM NUMBER]'s floor, near Bed A, was audibly sticky. When Resident 24 was asked if she could hear the shoe sticking to the floor, resident 24 could not indicate how long the floor had been sticky since she did not get out of bed unless it was Bingo day. During multiple observations on 12/13/18, 12/14/18 and 12/15/18, room [ROOM NUMBER]'s floor near Bed A was audibly sticky when walking past the bed. During multiple observations on 12/11/18, 12/13 and 12/15/18, room [ROOM NUMBER]'s floor was audibly sticky when walking into and around the room. The facility P/P titled, Quality of Life-Homelike Environment, dated 1/18, indicated, The facility staff and management shall maximize, Clean, sanitary and orderly environment During an interview on 12/14/18 at 10:00 a.m., Housekeeper Q with interpreter (Unlicensed Staff R) stated she had a Deep Cleaning schedule. Housekeeper Q stated she cleaned every room daily and deep cleaned one room per day per cleaning schedule. Housekeeper Q stated she was going to deep clean room [ROOM NUMBER], but she was not able to because the resident in 9 A did not want to leave her room, so she would do the daily cleaning of room [ROOM NUMBER]. Housekeeper Q stated when she deep cleaned a room, she cleaned the following: *Cleaned mattresses using Air Fresh spray *Removed privacy curtains and had them cleaned *Windows were cleaned *Tables *Baseboards *Dusted entire room *If she had to clean a room under isolation precautions, she would disinfect the entire room. *Solutions used: One-Step Disinfectant, which had Ammonia Chloride in it Air Fresh for mattresses and furniture Window Cleaner/multi-surface non-ammonia cleaner Review of the facility's Deep Cleaning Schedule. indicated room [ROOM NUMBER] was to be cleaned on Thurs (12/13/18), not Fri (12/14/18). When asked why the rooms felt so sticky, Unlicensed Staff R stated it was because the wax was coming off the linoleum and the linoleum was peeling in the rooms. The residents' floors were very old, wax was worn and linoleum was chipping/peeling. 5. During an observation on 12/11/18 at 3:07 p.m., Resident 13 was up in her wheelchair located in the dining room. Resident 13's wheelchair was very dirty; food particles were all over the cushion part of the armrests. During multiple observations on 12/11/18, 12/12/18 and 12/13/18, Resident 29's wheelchair was dirty with food crumbs, general dirt and grime. Resident 29 was not aware how to get his wheelchair cleaned since it was an electric one and he just received it. During an interview on 12/11/18 at 9:30 a.m., Administrative Staff D stated that there had been a new maintenance person who was reasonable to clean the wheelchairs. The schedule was to clean the wheelchairs once a week but the Administrative Staff D person indicated employment had stared in (MONTH) (YEAR) and trying to become more familiar in the role. 6. During an observation on 2/11/18 at 1:00 p.m., room [ROOM NUMBER]'s wall, right of window and wall next to 9 A's bed had missing plaster and paint. During an observation on 12/11/18 at 1:54 p.m., room [ROOM NUMBER]'s vent screen right of the bathroom door was dirty with missing paint and walls were dirty. The facility P/P titled, Quality of Life-Homelike Environment, dated 1/18, indicated, The facility staff and management shall maximize, Clean, sanitary and orderly environment During an interview on 12/14/18 at 12:08 p.m., Administrative Staff A stated there was no policy for cleaning rooms and/or deep cleaning rooms. Administrative Staff A stated if a privacy curtain became soiled it was up to any person (Administrator, nursing staff, residents, etc.) who saw the soiled privacy curtain to notify housekeeping, so the privacy curtain could be changed. Administrative Staff A stated wheelchairs had not been cleaned for the past two months; the person who used to clean the wheelchairs quit a few months ago. Administrative Staff A stated there was a cleaning schedule for resident wheelchairs, and the wheelchairs were scheduled to be cleaned weekly. During an interview on 12//20/18 at 10:20 a.m., when Administrative Staff A was asked who oversaw housekeeping, he stated, Right now I oversee housekeeping.

Based on observation, interview, and record review, the facility failed to provide necessary care and services to maintain highest practicable level of physical well-being for one out of 13 sampled residents (Resident 6) who had a history of [REDACTED]. 1. Unlicensed staff did not demonstrate the ability to recognize and failed to report visible and audible changes in Resident 6's respiratory condition to licensed staff. 2. Licensed staff did not demonstrate the ability to operate emergency suction equipment. 3. Licensed staff could not demonstrate how to perform a complete respiratory assessment. 4. Licensed and unlicensed staff did not accurately document the amount of fluid Resident 6 received and eliminated (intake and output). These failures resulted in the potential for a delay in treatment and for respiratory arrest (the absence of breathing) for Resident 6. This deficient practice also was demonstrated in all levels of nursing staff which increased the potential for affecting more than one resident. Because of the facility's failure to ensure staff were competent to recognize and respond to signs and symptoms of possible impending [MEDICAL CONDITION] ([MEDICAL CONDITION] is a life threatening emergency that may result when insufficient oxygen reaches the blood from the lungs to meet the body's needs or the lungs do not remove enough Carbon [MEDICATION NAME] (a harmful waste gas in excess amounts) from the blood to prevent damage to the body. Symptoms include use of accessory muscles for breathing (neck, spinal), difficulty breathing, increased respiratory rate, increased heart rate, sweating, a bluish color of the skin and mucus membranes (cyanosis), alerted consciousness; and when left untreated coma, respiratory arrest, and death. Merck, 2009), Immediate Jeopardy was called on 1/11/11 at 5 p.m. with Administrative Staff B (AS B), Administrative Staff C (AS C), Director of Nursing Services (DNS), Nurse Consultant D (NC D) and Nurse Consultant E (NC E). Findings: Review of Resident 6's clinical record on 1/10/11 at 3:30 p.m., revealed Resident 6 was admitted to the facility with a history of [MEDICAL CONDITIONS], stroke, and difficulty swallowing. A physician's progress note, dated 1/7/11, indicated Resident 6 had a [MEDICAL CONDITION] (NG) tube (a tube that is passed through the nose, down the esophagus into the stomach, used to deliver nutrients and medications). The progress note indicated Resident 6 was alert, oriented to self, had impaired thought processes, but displayed "appropriate" emotional responses and mood. The note also indicated Resident 6's heart rate was 70, her respiratory rate was 20, and her breath sounds were decreased. A physician order, dated 10/15/10, under the heading of "TUBE FEEDING LIST" that indicated, "ELEVATE HEAD OF BED 30 DEGREES AT ALL TIMES." During an observation and concurrent interview on 1/10/11 at 11:50 a.m., Resident 6 was in her room, located at the far end of the south wing of the facility, across from the activity/dining room, lying supine (on her back, facing upward) in bed. The nurse's station was located on the North side of the facility next to the main entrance. The head of Resident 6's bed was elevated approximately 45 degrees. A sign posted above the head of Resident 6's bed indicated Resident 6 could not receive oral intake. An NG tube was inserted in Resident 6's left nostril and taped to the tip of her nose. The free end of the NG tube was not attached to the nutritional supplement hanging on a feeding pump next to the bed. Resident 6 stated she recently suffered a stroke and was not able to use the left side of her body. Resident 6 stated she did not know how to get the nurse to come to her room if she needed help. During an observation on 1/10/11 at 3:15 p.m., Resident 6 was supine in bed. The head of Resident 6's bed was elevated approximately 45 degrees. Resident 6 was coughing. Frothy, white sputum bubbled from Resident 6's mouth. An NG tube was in Resident 6's left nostril and attached to a feeding pump that was running at 85 milliliters (ml) per hour. During an observation on 1/11/11 at 10:45 a.m., Resident 6 was supine in her bed. The head of Resident 6's bed was elevated approximately 30 degrees. Resident 6 frequently turned her head back and forth, restlessly moved her left arm and left leg without purpose, frequently moaned, and stated, "I'm coughing, coughing, coughing... I feel awful." Resident 6's chest wall moved rapidly and slightly as she breathed. Unlicensed Staff L (US L) and Unlicensed Staff M (US M) changed Resident 6's protective undergarments. Neither US L nor US M left Resident 6's bedside to report Resident 6's condition to licensed staff. 1. During continued observation on 1/11/11 at 10:55 a.m., Unlicensed Staff N (US N) entered Resident 6's room. Resident 6 was supine in bed. The head of Resident 6's bed was parallel with the floor. US L, US M, and US N changed Resident 6's bed linen. Resident 6 coughed and made gurgling sounds. Clear, bubbly sputum ran from the corners of Resident 6's mouth as US L, US M, and US N turned Resident 6 from side to side during the linen change. Audible respiratory congestion was noted. Neither US L, US M, nor US N, left Resident 6's room to report Resident 6's condition to licensed staff. During continued observation on 1/11/11 at 11 a.m., Resident 6 was supine in bed. The head of Resident 6's bed was parallel with the floor. US L was changing Resident 6's gown. US N and US O were assisting with care. Resident 6 coughed, moaned, and attempted to speak. Resident 6's speech was muffled by gurgling sounds. Neither US L, US N, nor US O left Resident 6's room to report Resident 6's condition to licensed staff. US M exited Resident 6's room. During an interview on 1/11/11 at 12:30 p.m., US M stated Resident 6's problem at 10:45 a.m., was related to Resident 6 needing her undergarments changed. US M stated he did not know if Resident 6 was experiencing any other problems that would require him to report to a licensed nurse, even though it was observed that Resident 6 was coughing, gurgling sounds were audible and sputum ran from her mouth. During continued observation on 1/11/11 at 11:05 a.m., Resident 6 was supine in bed. The head of Resident 6's bed was parallel with the floor. US L, US N, and US O continued delivering personal care to Resident 6. US O elevated the head of Resident 6's bed to approximately 90 degrees. Resident 6 coughed and foamy, white secretions bubbled and ran from her mouth. US O wiped Resident 6's mouth and asked US N to tell Licensed Nurse Q (LN Q) Resident 6's NG tube needed to be attached to the feeding pump. US N exited Resident 6's room. During an interview on 1/11/11 at 12:35 p.m., US N stated she (US N) went to get LN Q after exiting Resident 6's room. US N stated she reported Resident 6 did not want to get out of bed to LN Q. US N stated Resident 6's problem at 10:45 a.m., was related to needing her undergarments and linen changed. US N stated she did not report anything else to LN Q, even though it was observed that Resident 6 was coughing, gurgling sounds were audible and sputum ran from her mouth. During an interview on 1/18/11 at 9:50 a.m., Administrator B stated unlicensed staff were required to pass a skills competency test upon hire. Record review on 1/18/11 at 3 p.m., revealed documents, entitled, "CNAs Skills Checklist," dated 6/11/10-6/13/10, which indicated the DSD documented US L, M, N, and O were proficient in reporting. The documents revealed a box entitled, "reporting". There was a hashmark in the box. The documents lacked information indicating what CNAs were proficient at reporting. During an interview on 1/18/11 at 2:10 p.m., the Director of Staff Development (DSD), stated the, "CNAs' Skills Checklist" was the only competency or training documentation the facility had for CNAs. 2. During an observation and interview on 1/11/11 at 12:07 p.m., LN Q attempted to operate the facility's emergency suction equipment when queried. LN Q attached connecting tubes and a suction catheter to the suction machine in various fashions, but was not able to get the emergency suction equipment to function. LN Q stated in an emergency situation she would get another licensed nurse to help her (LN Q) if she was not able to operate the emergency suction equipment. LN Q left the emergency cart to find a second licensed nurse. During continued observation and interview on 1/11/11 at 12:14 p.m., Licensed Nurse R (LN R) approached the emergency suction equipment and asked, "Do I just turn it on?" LN R attached connecting tubes and a suction catheter to the suction machine in various fashions, but was not able to get the emergency suction equipment to function. During continued observation and interview on 1/11/11 at 12:19 p.m., at the emergency supply cart, LN Q stated since both licensed nurses (LN Q and LN R) were unable to operate the emergency suction equipment, she (LN Q) would call 911, 12 minutes after being queried about how to use emergency suction equipment. During continued observation and interview on 1/11/11 at 12:20 p.m., LN R stated she would attempt putting water in the suction canister and in the sterile box which came in the package with the suction catheter. LN R attempted these strategies with the assistance of DNS. LN R and DNS were not able to get the emergency suction equipment to function. During continued observation and interview on 1/11/11 at 12:23 p.m., at the emergency supply cart, DNS stated she would check for a second emergency suction machine in the facility. During an interview on 1/11/11 at 12:39 p.m., DNS stated the Maintenance Supervisor assisted licensed nursing with the operation of both emergency suction machines, neither machine had been inoperable, and both machines were in working order, 32 minutes after initially attempting to use the emergency suction equipment. 3. Review of the clinical record on 1/10/11 at 3:30 p.m., revealed a physician order, dated 10/15/10, which indicated nursing staff was to assess Resident 6's breath sounds each shift. Nurse's notes, dated 1/1/11-1/10/11, lacked documented description of Resident 6's breath sounds. A document entitled, "Tube Feeding Record," (TFR) dated 1/1/11-1/11/11, revealed licensed nurses inconsistently documented checking Resident 6's breath sounds each shift. The nurse's notes and the TFR lacked documented evidence that indicated when Resident 6 began coughing, making audible gurgling sounds, and had sputum running from her mouth. During an interview and concurrent record review on 1/18/11 at 8:45 a.m., DNS stated the clinical record lacked evidence of documentation by licensed nurse's which described Resident 6's breath sounds. During an interview on 1/11/11 at 11:55 a.m., LN Q stated she assessed Resident 6 at 7 a.m. on 1/11/11. LN Q stated her assessment of Resident 6 included ensuring; the feeding pump was running at the correct rate and Resident 6 was, "sitting up in bed." LN Q stated she did not perform any other assessment, "Unless there is something obvious." LN Q stated she last entered Resident 6's room, "slightly" before 10 a.m. on 1/11/11, at which time she checked the placement of Resident 6's NG tube and asked Resident 6 if she was having pain. During an observation on 1/11/11 at 1 p.m., Resident 6 was lying supine in bed. The head of Resident 6's bed was parallel with the floor. Resident 6 made gurgling sounds when she attempted to speak as unlicensed (unidentified) staff were delivering personal care and changing the bed linens. When queried, LN Q entered Resident 6's room to assess Resident 6. LN Q approached Resident 6's bedside, held Resident 6's hand, and asked if Resident 6 was all right or having pain. LN Q assisted unlicensed staff with personal care. Clear oral secretions ran from the right side of Resident 6's mouth. LN Q did not assess Resident 6's respiratory status. During continued observation on 1/11/11 at 1:09 p.m., Resident 6 was lying supine in bed. The head of Resident 6's bed was parallel with the floor. Resident 6 began coughing on oral secretions. LN Q elevated the head of Resident 6's bed approximately 45 degrees, asked Resident 6 if she had pain and stated she was going to get a pain pill. When queried about Resident 6's respiratory assessment a second time, LN Q placed her stethoscope on Resident 6's back (just below the shoulder blades, on each side of the spinal cord) and listened to Resident 6's breath sounds. LN Q repeated the procedure in the same location. LN Q did not place her stethoscope on any other location on Resident 6's body. LN Q did not listen to Resident 6's breath sounds in the upper lobes or at the bases of Resident 6's lungs. LN Q stated Resident 6's breath sounds were clear. DNS brought equipment to the room for LN Q to measure Resident 6's vital signs. LN Q measured Resident 6's oxygen saturation at 96% and Resident 6's heart rate was 101. LN Q did not report Resident 6's respiratory rate. During continued observation and interview on 1/11/11 at 1:21 p.m., DNS checked Resident 6's vital signs. DNS stated Resident 6's heart rate was 96 and her respiratory rate was 32. DNS did not listen to Resident 6's breath sounds. During an interview on 1/11/11 at 1:35 p.m., DNS stated Resident 6 had a cough and her vitals signs were stable at 1:09 p.m. DNS stated a rapid respiratory rate was a rate "over 70" (according to Lippincott, a normal adult respiratory rate is 12-20). Upon query, DNS was not able to demonstrate auscultation (listening to a person's internal sounds, usually with a stethoscope) of the lung fields. DNS demonstrated auscultation of breath sounds by placing her stethoscope on the front of another staff member's chest in four locations; 1. on the right, along the middle of the collar bone, down to the level of the middle of the breast bone, 2. the corresponding position on the left, 3. on the right, perpendicular to the middle of the collar bone, beneath right breast and, 4. the corresponding position on the left. When queried as to which lung fields DNS was auscultating, DNS pointed to the bases of the lungs (the lowest portion, near the diaphragm) and stated she was listening to the, "upper quadrants". During an interview on 1/11/11 at 2:30 p.m., Resident 6's physician stated he expected licensed nurse's were following his orders: elevating the head of Resident 6's bed 30 degrees at all times as well as assessing Resident 6's breath sounds every shift Review of the facility policy on 1/18/11 at 1:50 p.m., entitled, "Nursing Department", dated 9/09, the facility established professional standards based eleven specific sources including "The Lippincott Manual of Nursing." The "Nursing Department" policy indicated, "The Lippincott Manual of Nursing" (Lippincott) served as the facility procedure manual. According to Lippincott, breath sounds are auscultated in 16 different positions during one full inspiration and one full exhalation through the mouth. Lippincott identifies the order and location of auscultation as: 1. start on the front of the chest, one inch below the middle of the right clavicle (collar bone), 2. move to the corresponding position on the left side of the chest, 3. on the front of the chest, move the stethoscope down approximately 1.5-2 inches below the middle of the right clavicle, 4. move to the corresponding position on the left side of the chest, 5. on the front of the chest, on the right side, move the stethoscope down an additional 1-2 inches along the mid-clavicular line (approximately in-line with the tip of the breast bone), 6. move to the corresponding position on the left side of the chest, 7. move to the posterior chest (back), have the person lean forward and cross arms; start two inches below the shoulders and two inches to the right of the spine, 8. move to the corresponding position on the left side of the spine, 9. move the stethoscope downward 2-2.5 inches, 10. move to the corresponding position on the right side of the spine, 11. move the stethoscope downward 2-2.5 inches, 12. move to the corresponding position on the left of the spine, 13. move the stethoscope to an area just below the shoulder blade on the right, 14. move to the corresponding position on the left, 15. move the stethoscope to an area along the lower rib cage on the right, and 16. move to the corresponding position on the left. 4. During an interview and concurrent review of the clinical record on 1/18/11 at 8:45 a.m., DNS reviewed a physician order, dated 10/8/10, which indicated the amount of fluid Resident 6 received and the amount of fluid Resident 6 eliminated (intake and output, I&O) was to be recorded each shift. DNS reviewed documents entitled, "Tube Feeding Record," dated 11/9/10-1/10/11, which lacked documented evidence of Resident 6's [MEDICAL CONDITION] residual output volume (the volume remaining in the stomach between the previous feeding and the next scheduled feeding). DNS stated licensed nurses should have been recording the residual volume. Upon review of documents entitled, "Total Intake and Output Record," dated 10/8/10 - 1/11/11, DNS stated licensed nurses did not record urinary output volumes for Resident 6. DNS stated total output volumes or residual amounts could not be determined from the documents. The "Total Intake and Output Record," dated 10/8/10 - 1/11/11, lacked documented evidence of output volumes on any shifts and documentation of intake volumes on 141 shifts. During an interview on 1/11/11 at 2:30 p.m., Resident 6's physician stated he expected licensed nurse's were following his orders to monitor Resident 6's intake and output. Review of the clinical record on 1/18/11 at 8:30 a.m., revealed physician's orders, dated 1/11/11, for transfer to an acute care hospital, oral suction every 2 hours, and supplemental oxygen. A physician's order dated 1/12/11 indicated that, [MEDICATION NAME] (a medication used to decrease fluid in the lungs for people with [MEDICAL CONDITION]) 10 mg was to be given once a day. An acute care radiology report, dated 1/11/11, revealed Resident 6 suffered [MEDICAL CONDITION] vascular congestion. According to Merck 2006, people with [MEDICAL CONDITION] develop [MEDICAL CONDITION] vascular congestion as a result of fluid entering the lungs. The process is ultimately similar to drowning. Because of the facility's failure to ensure staff were competent to recognize and respond to signs and symptoms of possible impending [MEDICAL CONDITION] ([MEDICAL CONDITION] is a life threatening emergency that may result when insufficient oxygen reaches the blood from the lungs to meet the body's needs or the lungs do not remove enough Carbon [MEDICATION NAME] (a harmful waste gas in excess amounts) from the blood to prevent damage to the body. Symptoms include use of accessory muscles for breathing (neck, spinal), difficulty breathing, increased respiratory rate, increased heart rate, sweating, a bluish color of the skin and mucus membranes (cyanosis), alerted consciousness; and when left untreated coma, respiratory arrest, and death. Merck, 2009), the team called Immediate Jeopardy on 1/11/11 at 5 p.m. with Administrative Staff B (AS B), Administrative Staff C (AS C), Director of Nursing Services (DNS), Nurse Consultant D (NC D) and Nurse Consultant E (NC E). On 1/11/11 at 6:22 p.m., the facility presented a plan of action to surveyor 2388. The plan of action was revised on 1/12/11 and 1/13/11. The plan of action consisted of the following elements: 1. A nurse consultant provided an in-service to DNS and licensed nurses on assessment of residents with NG tubes, respiratory and gastro-intestinal assessment, and use of the suction machine. 2. DNS determined the facility had three operational suction machines. 3. The oxygen tank was replaced on the emergency cart and an additional oxygen tank was placed near the emergency cart. 4. The day and evening shift charge nurses checked the emergency cart and restocked it to ensure "all" equipment and supplies were available and "properly" functioning. 5. A licensed nurse checked the suction machine daily to ensure the machine was functioning "properly." If the machine was not functioning it would be replaced by a new machine. A log would be kept on the emergency cart. 6. A licensed nurse checked the emergency cart daily to ensure "all " supplies were present and the oxygen tank was at least half full. A log would be kept on the emergency cart. 7. Any broken equipment would be replaced immediately and reported to the maintenance supervisor via the maintenance log. Licensed staff were re-educated regarding use of the maintenance log. 8. A nurse consultant in-serviced DNS on proper connection and use of the suction machine. DNS and the nurse consultant in-serviced licensed nurses on use of the suction machine. 9. A licensed nurse set up a suction machine at Resident 6's bedside and placed additional tubing in the nightstand drawer. A nurse consultant confirmed set up of the machine and placement of tubing. 10. DNS assessed Resident 6 and notified the physician. A chest x-ray and electrocardiogram were done. 11. Resident 6 was transferred to an acute care hospital for evaluation. 12. LN Q was removed from the schedule pending determination of competency. 13. Upon readmission to the facility on [DATE], visual checks (every 30 minutes) were implemented for Resident 6. 14. Resident 6 was moved to a room closer to the nurse's station. 15. Resident 6's care plan was updated to include reminding Resident 6 to use the call light and the IDT assessing for an alternate call system. 16. A care plan for potential respiratory distress and complications related to Resident 6's NG tube was updated to reflect individual needs. 17. A nurse consultant in-serviced the nursing staff on monitoring residents that are not able to use their call lights. 18. "All nursing staff on duty including housekeepers and maintenance staff received in-service training on recognizing signs and symptoms of respiratory distress..." 19. "The DSD will continue to be responsible for regular in-service training for nursing staff on recognizing signs and symptoms of respiratory distress to be completed yearly." 20. A nurse consultant in-serviced licensed nurses who were working on 1/11/11, regarding signs and symptoms of respiratory distress, assessing for complications of NG tubes, and care of NG tubes. 21. A nurse consultant provided an in-service on 1/13/11, to "all" licensed staff regarding respiratory assessment (including lung sounds), GI assessment (including bowel sounds), and suctioning. Written handouts were provided and a return demonstration was required to verify competency. On 1/13/11 at 5:22 p.m., surveyors 2259 and 2388 met with Administrative Staff B (AS B), Administrative Staff C (AS C), Director of Nursing Services (DNS), Nurse Consultant D (NC D) and Nurse Consultant E (NC E) and informed them the Immediate Jeopardy was abated.

Based on observation, interview, and record review, the facility failed to provide services to prevent complications from a [MEDICAL CONDITION] (NG) tube (a tube that is passed through the nose, down the esophagus into the stomach, used to deliver nutrients and medications) for one of 13 Sampled Residents (Resident 6). Complications of using an NG tube can include aspiration pneumonia (a lung infection caused by inhaling mouth secretions and/or stomach contents). In alert people, aspiration may occur due to reflux (abnormal backward flow) of stomach contents into the lungs or as a consequence of having difficulty swallowing oral secretions (Merck 2010). Aspiration can be prevented by keeping the head of the bed elevated, monitoring the tube position and the amount of liquid formula absorbed, and monitoring the resident for any signs or symptoms of airway congestion. Another, emergency-type of prevention care is immediately helping the resident clear oral or respiratory secretions through the use of a suction machine, if necessary. Untreated inhalation of liquids into the lung, can result in life threatening emergencies such as lung collapse, coma or death. The facility failed to provide services to prevent complications of an NG tube as evidenced by: 1. Licensed staff and unlicensed staff did not elevate Resident 6's head 30 degrees at all times, to enhance peristalsis (movement of stomach contents downward into the intestines) and avoid reflux of the feeding into the upper stomach or windpipe area, which can lead to inhaled liquids, causing aspiration. 2. Unlicensed staff did not recognize or report changes in Resident 6 ' s respiratory condition to licensed staff. Changes in respiratory condition can indicate aspiration of stomach contents into the lungs, or other complications of NG tubes such as nasal, throat, or windpipe irritation or erosion from the tube. 3. Licensed staff did not demonstrate the ability to operate emergency suction equipment, to facilitate removal of oral secretions and/or stomach contents, preventing inhalation of the tube feeding and/or oral secretions and aspiration pneumonia. 4. Licensed staff could not demonstrate assessment of the lungs (breath sounds). Assessment of breath sounds is used to assist in determining if fluid has entered the lungs. 5. Licensed staff demonstrated a lack of knowledge regarding a physician's order to hold Resident 6's tube feeding if the volume of her [MEDICAL CONDITION] residual the exceeded 100 milliliters (ml) and did not document the volume of Resident 6's [MEDICAL CONDITION] residual each shift. [MEDICAL CONDITION] residual is the volume remaining in the stomach between the previous feeding and the next scheduled feeding. Checking the [MEDICAL CONDITION] residual helps to ensure that the feedings are being absorbed. Unabsorbed fluids can cause reflux of stomach contents into the airway, which can lead to inhaled liquids. 6. The Social Services Director (SSD) did not follow up on a physician's order for an evaluation for a [MEDICAL CONDITION] tube. NG tube placement is meant to be a short-term solution for feeding problems. Patients that require long term tube feeding should have surgical placement of a gastrostomy tube or gastrostomy button. Long-term NG tube usage can cause nasal erosion, sinusitis, esophagitis, [MEDICAL CONDITION] ulceration, [MEDICAL CONDITION]-tracheal fistula formation, oral infections and respiratory infections. Because of the facility's failure to ensure staff were competent to recognize and respond to signs, symptoms, and potential complications related to use of an NG tube, the team called Immediate Jeopardy on 1/11/11 at 5 p.m. with Administrative Staff B (AS B), Administrative Staff C (AS C), Director of Nursing Services (DNS), Nurse Consultant D (NC D) and Nurse Consultant E (NC E). Findings: Review of Resident 6 's clinical record on 1/10/11 at 3:30 p.m., revealed Resident 6 was admitted to the facility with a history of stroke, difficulty swallowing, and had a [MEDICAL CONDITION] (NG) tube. A physician's progress note, dated 1/7/11, indicated Resident 6 was alert, oriented to self, had impaired thought processes, but displayed "appropriate" emotional responses and mood. In addition, the physicians progress note also indicated Resident 6 's respiratory rate was 20 and her breath sounds were decreased. 1. Review of the clinical record for Resident 6 on 1/10/11 at 3:30 p.m., revealed a physician's order, dated 10/15/10, under the heading of "TUBE FEEDING LIST" that indicated, "ELEVATE HEAD OF BED 30 DEGREES AT ALL TIMES." During an observation on 1/11/11 at 10:55 a.m., Unlicensed Staff N (US N) entered Resident 6's room. Resident 6 was supine (on her back, facing upward) in bed. The head of Resident 6's bed was parallel with the floor. US L, US M, and US N changed Resident 6's bed linen. Resident 6 coughed and made gurgling sounds. Clear, bubbly sputum ran from the corners of Resident 6's mouth as US L, US M, and US N turned Resident 6 from side to side during the linen change. Audible respiratory congestion was noted. Neither US L, US M, nor US N elevated the head of Resident 6's bed. During observation on 1/11/11 at 11 a.m., Resident 6 was supine in bed. The head of Resident 6's bed was parallel with the floor. US L was changing Resident 6's gown. US N and US O were assisting with care. Resident 6 coughed, moaned, and attempted to speak. Resident 6's speech was muffled by gurgling sounds. Neither US L, US N, nor US O elevated the head of Resident 6's bed. During continued observation on 1/11/11 at 11:05 a.m., Resident 6 was supine in bed. The head of Resident 6's bed was parallel with the floor. US L, US N, and US O continued delivering personal care to Resident 6. US O elevated the head of Resident 6's bed to approximately 90 degrees. Resident 6 coughed and foamy, white secretions bubbled and ran from her mouth. US O wiped Resident 6's mouth and asked US N to tell Licensed Nurse Q (LN Q) Resident 6's NG tube needed to be attached to the feeding pump. US N exited Resident 6's room. During an interview on 1/11/11 at 2:30 p.m., Resident 6's physician stated he expected licensed nurse's were following his orders and elevating the head of Resident 6's bed 30 degrees at all times. 2. During an observation on 1/11/11 at 10:45 a.m., Resident 6 was supine in her bed. The head of Resident 6's bed was elevated approximately 30 degrees. Resident 6 frequently turned her head back and forth, restlessly moved her left arm and left leg without purpose, frequently moaned, and stated, "I'm coughing, coughing, coughing... I feel awful." Resident 6's chest wall moved rapidly and slightly as she breathed. Unlicensed Staff L (US L) and Unlicensed Staff M (US M) changed Resident 6's protective undergarments. Neither US L nor US M left Resident 6's bedside to report Resident 6's condition to licensed staff. During continued observation on 1/11/11 at 10:55 a.m., Unlicensed Staff N (US N) entered Resident 6's room. Resident 6 was supine in bed. The head of Resident 6's bed was parallel with the floor. US L, US M, and US N changed Resident 6's bed linen. Resident 6 coughed and made gurgling sounds. Clear, bubbly sputum ran from the corners of Resident 6's mouth as US L, US M, and US N turned Resident 6 from side to side during the linen change. Audible respiratory congestion was noted. Neither US L, US M, nor US N, left Resident 6's room to report Resident 6's condition to licensed staff. During continued observation on 1/11/11 at 11 a.m., Resident 6 was supine in bed. The head of Resident 6's bed was parallel with the floor. US L was changing Resident 6's gown. US N and US O were assisting with care. Resident 6 coughed, moaned, and attempted to speak. Resident 6's speech was muffled by gurgling sounds. Neither US L, US N, nor US O left Resident 6's room to report Resident 6's condition to licensed staff. US M exited Resident 6's room. During an interview on 1/11/11 at 12:30 p.m., US M stated Resident 6's problem at 10:45 a.m., was related to Resident 6 needing her undergarments changed. US M stated he did not know if Resident 6 was experiencing any other problems that would require him to report to a licensed nurse, even though it was observed that Resident 6 was coughing, gurgling sounds were audible and sputum ran from her mouth. During an interview on 1/11/11 at 12:35 p.m., US N stated she (US N) went to get LN Q after exiting Resident 6's room. US N stated she reported Resident 6 did not want to get out of bed to LN Q. US N stated Resident 6's problem at 10:45 a.m., was related to needing her undergarments and linen changed. US N stated she did not report anything else to LN Q, even though it was observed that Resident 6 was coughing, gurgling sounds were audible and sputum ran from her mouth. During an interview on 1/18/11 at 9:50 a.m., Administrator B stated unlicensed staff were required to pass a skills competency test upon hire. Record review on 1/18/11 at 3 p.m., revealed documents, entitled, "CNAs Skills Checklist," dated 6/11/10-6/13/10, which indicated the DSD documented US L, M, N, and O were proficient in reporting. The documents revealed a box entitled, "reporting". There was a hashmark in the box. The documents lacked information indicating what CNAs were proficient at reporting. During an interview on 1/18/11 at 2:10 p.m., the Director of Staff Development (DSD), stated the, "CNAs' Skills Checklist" was the only competency or training documentation the facility had for CNAs. 3. During an observation and interview on 1/11/11 at 12:07 p.m., LN Q attempted to operate the facility's emergency suction equipment when queried. LN Q attached connecting tubes and a suction catheter to the suction machine in various fashions, but was not able to get the emergency suction equipment to function. LN Q stated in an emergency situation she would get another licensed nurse to help her (LN Q) if she was not able to operate the emergency suction equipment. LN Q left the emergency cart to find a second licensed nurse. During continued observation and interview on 1/11/11 at 12:14 p.m., Licensed Nurse R (LN R) approached the emergency suction equipment and asked, "Do I just turn it on?" LN R attached connecting tubes and a suction catheter to the suction machine in various fashions, but was not able to get the emergency suction equipment to function. During continued observation and interview on 1/11/11 at 12:19 p.m., at the emergency supply cart, LN Q stated since both licensed nurses (LN Q and LN R) were unable to operate the emergency suction equipment, she (LN Q) would call 911, 12 minutes after being queried about how to use emergency suction equipment. During continued observation and interview on 1/11/11 at 12:20 p.m., LN R stated she would attempt putting water in the suction canister and in the sterile box which came in the package with the suction catheter. LN R attempted these strategies with the assistance of the DNS. LN R and the DNS were not able to get the emergency suction equipment to function. During continued observation and interview on 1/11/11 at 12:23 p.m., at the emergency supply cart, the DNS stated she would check for a second emergency suction machine in the facility. During an interview on 1/11/11 at 12:39 p.m., the DNS stated the Maintenance Supervisor assisted licensed nursing with the operation of both emergency suction machines, neither machine had been inoperable, and both machines were in working order, 32 minutes after initially attempting to use the emergency suction equipment. (Interruption of [MEDICAL CONDITION] gas exchange for greater than 5 min may irreversibly damage vital organs, especially the brain. Merck 2010) 4. Review of the clinical record on 1/10/11 at 3:30 p.m., revealed a physician order, dated 10/15/10, which indicated nursing staff was to assess Resident 6's breath sounds each shift. Nurse's notes, dated 1/1/11-1/10/11, lacked documented description of Resident 6's breath sounds. During an interview and concurrent record review on 1/18/11 at 8:45 a.m., the DNS stated the clinical record lacked evidence of documentation by licensed nurses which described Resident 6's breath sounds. During an interview on 1/11/11 at 11:55 a.m., LN Q stated she assessed Resident 6 at 7 a.m. on 1/11/11. LN Q stated her assessment of Resident 6 included ensuring; the feeding pump was running at the correct rate and Resident 6 was "sitting up in bed". LN Q stated she did not perform any other assessment, "unless there is something obvious". LN Q stated she last entered Resident 6's room, "slightly " before 10 a.m. on 1/11/11, at which time she checked the placement of Resident 6's NG tube and asked Resident 6 if she was having pain. During an observation on 1/11/11 at 1 p.m., Resident 6 was lying supine in bed. The head of Resident 6's bed was parallel with the floor. Resident 6 made gurgling sounds when she attempted to speak as unlicensed (unidentified) staff were delivering personal care and changing the bed linens. When queried, LN Q entered Resident 6's room to assess Resident 6. LN Q approached Resident 6's bedside, held Resident 6's hand, and asked if Resident 6 was all right or having pain. LN Q assisted unlicensed staff with personal care. Clear oral secretions ran from the right side of Resident 6's mouth. LN Q did not assess Resident 6's respiratory status. During continued observation on 1/11/11 at 1:09 p.m., Resident 6 was lying supine in bed. The head of Resident 6's bed was parallel with the floor. Resident 6 began coughing on oral secretions. LN Q elevated the head of Resident 6's bed approximately 45 degrees, asked Resident 6 if she had pain and stated she was going to get a pain pill. When queried about Resident 6's respiratory assessment a second time, LN Q placed her stethoscope on Resident 6's back (just below the shoulder blades, on each side of the spinal cord) and listened to Resident 6's breath sounds. LN Q repeated the procedure in the same location. LN Q did not place her stethoscope on any other location on Resident 6's body. LN Q did not listen to Resident 6's breath sounds in the upper lobes or at the bases of Resident 6's lungs. LN Q stated Resident 6's breath sounds were clear. The DNS brought equipment to the room for LN Q to measure Resident 6's vital signs. LN Q measured Resident 6 ' s oxygen saturation at 96% and Resident 6's heart rate was 101. LN Q did not report Resident 6's respiratory rate. During continued observation and interview on 1/11/11 at 1:21 p.m., the DNS checked Resident 6's vital signs. The DNS stated Resident 6's heart rate was 96 and her respiratory rate was 32. The DNS did not listen to Resident 6's breath sounds. During an interview on 1/11/11 at 1:35 p.m., the DNS stated Resident 6 had a cough and her vitals signs were stable at 1:09 p.m. The DNS stated a rapid respiratory rate was a rate exceeding 70 breaths per minute (according to Lippincott, a normal adult respiratory rate is 12-20). Upon query, the DNS was not able to demonstrate auscultation (listening to a person's internal sounds, usually with a stethoscope) of the lung fields. The DNS demonstrated auscultation of breath sounds by placing her stethoscope on the front of another staff member's chest in four locations; 1. on the right, along the middle of the collar bone, down to the level of the middle of the breast bone, 2. the corresponding position on the left, 3. on the right, perpendicular to the middle of the collar bone, beneath right breast and, 4. the corresponding position on the left. When queried as to which lung fields DNS was auscultating, DNS pointed to the bases of the lungs (the lowest portion, near the diaphragm) and stated she was listening to the, "upper quadrants". During an interview on 1/11/11 at 2:30 p.m., Resident 6's physician stated he expected licensed nurse's were following his orders: elevating the head of Resident 6's bed 30 degrees at all times as well as assessing Resident 6's breath sounds every shift Review of the facility policy on 1/18/11 at 1:50 p.m., entitled, "Nursing Department", dated 9/09, the facility established professional standards based eleven specific sources including "The Lippincott Manual of Nursing." The "Nursing Department" policy indicated, "The Lippincott Manual of Nursing" (Lippincott) served as the facility procedure manual. According to Lippincott, breath sounds are auscultated in 16 different positions during one full inspiration and one full exhalation through the mouth. Lippincott identifies the order and location of auscultation as: 1. start on the front of the chest, one inch below the middle of the right clavicle (collar bone), 2. move to the corresponding position on the left side of the chest, 3. on the front of the chest, move the stethoscope down approximately 1.5-2 inches below the middle of the right clavicle, 4. move to the corresponding position on the left side of the chest, 5. on the front of the chest, on the right side, move the stethoscope down an additional 1-2 inches along the mid-clavicular line (approximately in-line with the tip of the breast bone), 6. move to the corresponding position on the left side of the chest, 7. move to the posterior chest (back), have the person lean forward and cross arms; start two inches below the shoulders and two inches to the right of the spine, 8. move to the corresponding position on the left side of the spine, 9. move the stethoscope downward 2-2.5 inches, 10. move to the corresponding position on the right side of the spine, 11. move the stethoscope downward 2-2.5 inches, 12. move to the corresponding position on the left of the spine, 13. move the stethoscope to an area just below the shoulder blade on the right, 14. move to the corresponding position on the left, 15. move the stethoscope to an area along the lower rib cage on the right, and 16. move to the corresponding position on the left. 5. During an interview and concurrent record review on 1/12/11 at 4 p.m., Licensed Nurse X (LN X) stated she was Resident 6's nurse. LN X stated she checked Resident 6's [MEDICAL CONDITION] residual each shift, but did not record the volume. LN X stated she would hold Resident 6's tube feed if Resident 6's [MEDICAL CONDITION] residual was greater than 30 ml. Review of a physician order, dated 10/8/10, indicated licensed nurses were to hold Resident 6's tube feeding for two hours if the amount of her [MEDICAL CONDITION] residual exceeded 100 milliliters (ml), versus the 30 ml reported by LN X. The order indicated licensed nurse's were to recheck Resident 6's [MEDICAL CONDITION] residual after two hours and notify the physician if more than 100 ml was returned. LN X stated she was following the directions on the tube feed record. Review of a document entitled, "Tube Feeding Record," (TFR) dated 1/11, revealed the record did not reflect the amount of [MEDICAL CONDITION] residual volume at which licensed nurses were to hold Resident 6's tube feed. When reviewing the physician's orders, LN X stated the TFR did not match the physician's orders. LN X stated there was no documented evidence in the clinical record of a physician order related to holding Resident 6's tube feed based on a different [MEDICAL CONDITION] residual volume other than the 10/8/10 physician order 100 ml. During an interview and concurrent review of the clinical record on 1/18/11 at 8:45 a.m., the DNS reviewed the physician order, dated 10/8/10, which indicated licensed nurses were to hold Resident 6's tube feeding for two hours if the amount of her [MEDICAL CONDITION] residual exceeded 100 milliliters (ml). Review of a document entitled, "Tube Feeding Record," dated 11/9/10-1/12/11, revealed the record did not reflect the amount of [MEDICAL CONDITION] residual volume at which licensed nurses were to hold Resident 6's tube feeding and licensed nurses did not document Resident 6's residual output volume. The DNS stated licensed nurses should have been recording Resident 6's residual volume. During an interview on 1/11/11 at 2:30 p.m., Resident 6's physician stated he expected licensed nurses were following his orders to monitor Resident 6's residual volumes. 6. Review of the clinical record on 1/10/11 at 3:30 p.m., revealed a physician order, dated 1/6/11, to schedule an appointment for Resident 6 to be evaluated for placement of a percutaneous endoscopic gastrostomy (PEG) tube (placement of a feeding tube through the skin and abdominal wall, directly into the stomach). During an interview on 1/12/11 at 4:45 p.m., the Social Services Director (SSD) stated he was notified of the order on 1/6/11. The SSD stated he did not schedule Resident 6's appointment to be evaluated for placement of a PEG tube. Because of the facility's failure to ensure staff were competent to recognize and respond to signs, symptoms, and potential complications related to use of an NG tube, the team called Immediate Jeopardy on 1/11/11 at 5 p.m. with Administrative Staff B (AS B), Administrative Staff C (AS C), Director of Nursing Services (DNS), Nurse Consultant D (NC D) and Nurse Consultant E (NC E). On 1/11/11 at 6:22 p.m., the facility presented a plan of action to surveyor 2388. The plan of action was revised on 1/12/11 and 1/13/11. The plan of action consisted of the following elements: 1. A nurse consultant provided an in-service to DNS and licensed nurses on assessment of residents with NG tubes, respiratory and gastro-intestinal assessment, and use of the suction machine. 2. DNS determined the facility had three operational suction machines. 3. The oxygen tank was replaced on the emergency cart and an additional oxygen tank was placed near the emergency cart. 4. The day and evening shift charge nurses checked the emergency cart and restocked it to ensure "all" equipment and supplies were available and "properly" functioning. 5. A licensed nurse checked the suction machine daily to ensure the machine was functioning "properly." If the machine was not functioning it would be replaced by a new machine. A log would be kept on the emergency cart. 6. A licensed nurse checked the emergency cart daily to ensure "all " supplies were present and the oxygen tank was at least half full. A log would be kept on the emergency cart. 7. Any broken equipment would be replaced immediately and reported to the maintenance supervisor via the maintenance log. Licensed staff were re-educated regarding use of the maintenance log. 8. A nurse consultant in-serviced DNS on proper connection and use of the suction machine. DNS and the nurse consultant in-serviced licensed nurses on use of the suction machine. 9. A licensed nurse set up a suction machine at Resident 6's bedside and placed additional tubing in the nightstand drawer. A nurse consultant confirmed set up of the machine and placement of tubing. 10. DNS assessed Resident 6 and notified the physician. A chest x-ray and electrocardiogram were done. 11. Resident 6 was transferred to an acute care hospital for evaluation. 12. LN Q was removed from the schedule pending determination of competency. 13. Upon readmission to the facility on [DATE], visual checks (every 30 minutes) were implemented for Resident 6. 14. Resident 6 was moved to a room closer to the nurse's station. 15. Resident 6's care plan was updated to include reminding Resident 6 to use the call light and the IDT assessing for an alternate call system. 16. A care plan for potential respiratory distress and complications related to Resident 6's NG tube was updated to reflect individual needs. 17. A nurse consultant in-serviced the nursing staff on monitoring residents that are not able to use their call lights. 18. "All nursing staff on duty including housekeepers and maintenance staff received in-service training on recognizing signs and symptoms of respiratory distress..." 19. "The DSD will continue to be responsible for regular in-service training for nursing staff on recognizing signs and symptoms of respiratory distress to be completed yearly." 20. A nurse consultant in-serviced licensed nurses who were working on 1/11/11, regarding signs and symptoms of respiratory distress, assessing for complications of NG tubes, and care of NG tubes. 21. A nurse consultant provided an in-service on 1/13/11, to "all" licensed staff regarding respiratory assessment (including lung sounds), GI assessment (including bowel sounds), and suctioning. Written handouts were provided and a return demonstration was required to verify competency. On 1/13/11 at 5:22 p.m., surveyors 2259 and 2388 met with Administrative Staff B (AS B), Administrative Staff C (AS C), Director of Nursing Services (DNS), Nurse Consultant D (NC D) and Nurse Consultant E (NC E) and informed them the Immediate Jeopardy was abated.