Every finding on record at On With Life Long Term Care

Based on observations, record review, staff interviews, and facility policy review the facility failed to ensure accurate control, accountability, and disposition of scheduled controlled narcotic medication with narcotic medication not disposed of when the resident discharged from the facility for 1(Resident #1) of 1 resident reviewed and narcotic counts not being completed accurately. The facility reported a census of 38 residents. Findings include: The admission Minimum Data Set (MDS) for Resident #1, dated 5/15/25, documented diagnoses of stroke and hemiplegia (paralysis of one side of the body) with the resident dependent on staff for all activities of daily living. The MDS documented a Brief Interview of Mental Status was unable to be performed due to resident rarely/never understood. The Medication Administration Record (MAR), dated 3/1/25 - 3/31/25, for Resident #1 revealed a physician's order for Dronabinol (a Schedule 3 controlled medication that is a form of the main psychotic active component of marijuana plants) four times a day for nausea. The MAR revealed the resident was not administered the Dronabinol from 3/19/25 at noon thru 3/31/25 due to the resident hospitalized .A Clinical Physician's Orders report for Resident #1 revealed an order for Dronabinol started on 4/24/25 and discontinued on 4/25/25. The MAR, dated 4/1/25 - 4/30/25, for Resident #1 documented the resident received Dronabinol 2 times on 4/24/25 and 3 times on 4/25/25. A facility Census List report for Resident #1 revealed the resident status of transfer to the hospital on 3/19/25, discharged from the facility 3/13/25, admitted to the facility on [DATE], transfer to the hospital on 4/30/25 and transfer in from the hospital on 5/8/25. Resident #1's Social Worker Contact Note dated 3/31/25 at 10:07 AM, documented decided to discharge PS (person served-resident) today due to update from hospital. Due to long time frame, we will discharge at this time. Resident #1's History and Physical note dated 4/25/25 documented resident returns to facility after undergoing intensive care at a hospital after being admitted on [DATE] with stroke like symptoms. Continue all previous medications but hold dronabinol per discharge recommendation which I agree with. Resident #1's Health Status Note by Staff B dated 5/28/2025 at 6:42 PM, documented: Dronabinol count is off by 1. This nurse contacted AM nurse regarding the discrepancy. AM nurse stated that she did not give any dronabinol during her shift this AM, nor they checked the Dronabinol during shift change this AM. This nurse contacted on call ADON. On call ADON instructed this nurse to do a dose correction, and leadership will look at it in the morning. Dose corrected by this nurse and Staff C. A picture provided by the facility revealed a pharmacy dispensed medication bubble pack card with prescription #C5670485 dated 3/13/25 for Resident #1 for Dronabinol 5 milligrams four times a day, with 4 pills remaining in the card. A Controlled Drug Receipt Record/Disposition Form, received date 3/13/25, for Resident #1 documented dronabinol 30 pills, with 5 pills left on 4/25/25 and on 5/28/25 at 6:36 PM with no pills given, 4 pills left, and documentation of corrected per ADON and signed by Staff B, Registered Nurse (RN) and Staff C, Licensed Practical Nurse (LPN). State agency Intake Information form, intake # 129523, revealed the Administrator (ADM) submitted on 6/4/25 at 4:59 PM the following information: the ADM was notified by the Director of Nursing on 5/30/25 at 10:35 AM that a Dronabinol pill that had been prescribed for Resident #1 was missing and that facility camera video footage on 5/28/25 at 2:14 AM showed Staff A, RN, agency staff, handling the packaging without cause. The camera video footage revealed Staff A enter the locked medication room, unlock the refrigerator and handle the Dronabinol medication card, when there was no need to, went straight to the breakroom, accessed a locker, sat in the nurses' station for a couple of minutes before going outside on a break. On 5/30/25 the following were notified of the incident: the staffing agency Staff A was contracted through, the pharmacy, and the medical provider and a report was filed with the local police department and the state board of nursing. Facility Self Report document submitted by the ADM on 6/4/25 at 4:59 PM revealed the following: Criminal act occurred 5/28/25 2:15 AM, and date aware 5/30/25. ADM received notification from the DON at 10:35am on 5/30/2025 that we had one 5mg Dronabinol pill missing, and camera footage showed a night shift agency nurse handling the packaging without cause. The Dronabinol had been discontinued for the resident but had not been destroyed. The medication had been prescribed for Resident #1. Resident #1 was discharged to the hospital as after 12 days in the hospital it appeared that she would not return to the facility. Resident #1 was re-admitted to the facility 24 days after her discharge. When she re-admitted back to the facility she was no longer on the Dronabinol, and the order for it was discontinued. Reviewing the camera footage, at 2:14am on 5/28/25, Staff A was observed entering the locked medication room, unlocking the refrigerator and handling the Dronabinol card, when there was no need to, then going straight into the breakroom and accessing a locker. Staff A then sat in the nurses' station for a couple of minutes, before going outside on a break. Interview on 7/28/25 at 12:15 PM, Staff D, RN stated the protocol when counting controlled medications is for the count to be done by 2 nurses and if the count is not correct, to call the on-call nurse. She stated staff are not to leave until the discrepancy is figured out. She stated after the incident of the missing medication, staff received education and the policy for counting narcotics with the policy changed to the green hall nurse counts the controlled medications in the locked medication room/locked refrigerator but before the incident, it was the responsibility of the nurse assigned to the hall to complete the count for the hall the resident was on that had the refrigerated controlled medication. She stated four nurses on duty have keys to get in the locked medication room and locked refrigerator and there is a camera in the medication room with full view.Observation and interview with Staff E, LPN, in the medication room on 7/28/25 at 2 PM, revealed the facility form July Refrigerator Controlled Drug Check Sheet for 7/28/25 off going 6 PM - 6 AM signature spot had already signed by Staff E. Staff E stated she had already signed for the 6P-6A count spot early and should not have signed the count sheet yet as she needs to sign the sheet when she completes the count with the oncoming 6PM nurse. Staff E stated she knew she should not be signing before the count was checked with the oncoming nurse and only sign when the 2 nurses are present and confirm the narcotic count accurate. During an interview on 7/28/25 at 3PM, a local city police officer stated he was notified by the facility of a missing medication (dronabinol). The officer stated he interviewed Staff A and she admitted she took the dronabinol pill and stated she threw the pill away. The officer stated Staff A stated she realized the patient was not prescribed the medication, panicked and threw it away. The officer stated even when he confronted Staff A with the videos and no observation of her throwing the medication away, she still claimed she threw the medication in the trash outside the back door of the facility, and did not report it to the facility. On 7/28/25 at 3 PM, video footage was viewed with the ADM and showed the following for 5/28/25 2:15AM to 2:36 AM : Staff A entered the locked medication room, removed a medication card from the refrigerator, stood by the sink with the card, put the card back, washed hands, placed paper towels over an object, exited medication room, entered and exited breakroom, entered and sat in the nursing office, exited the facility and then reentered the facility, walked by a trashcan on the way out and back in the facility. Interview on 7/29/24 at 2 PM, Staff D, LPN stated she worked on 5/27/25 6 AM - 6 PM and at 6 PM with Staff A, they completed the narcotic count including dronabinol with the count correct and both signed the count sheet. On 7/29/25 at 3:07 PM, reviewed with the DON the copy provided via email of the facility document July Refrigerator Controlled Drug Check Sheet. The DON confirmed that Staff E's signature for 7/28/25 6PM appeared to be whited. The DON stated when she got the form to provide a copy, she noticed Staff E had already signed for 7/28/25 6 PM count and she advised Staff E to mark a line through, write error and her initials. At that time, the DON accessed the original form in the locked med room and confirmed she could still see what appeared to be Staff W's name whited out and then Staff E signed over the whiteout. The DON proceed to call Staff E into the medication room and Staff E stated she did not white out her name, didn't remember if she had marked it with error as instructed, but did sign her name over the white out. Interview on 7/30/25 at 11:53 AM, Staff F, RN stated she did not count the dronabinol card in the medication room on 5/28/25 at 6 AM with Staff A. She stated when she comes on shift she always does the narcotic count but don't know why she didn't do the count that day. Staff F stated after her shift that same day on 5/28/25 after 6 PM, Staff B called her as she had already left the facility, and told her the dronabinol medication count was short 1 pill. Staff F stated she had left the facility for the day and did not count the Dronabinol in the refrigerator with the oncoming nurse, Staff B. Staff F stated she returned to the facility to try to figure out why the count was off by 1, only had 4 pills and per count sheet should have had 5. Staff F stated Staff B called the ADON to report the count off and don't remember what the ADON said but she was able to go home. Staff F stated the facility protocol was to destroy a resident's remaining narcotics when the resident was discharged from the facility but the facility had kept the Dronabinol while the resident was in the hospital as the medication was hard to get. Staff F stated the protocol was to count narcotics every shift change and ensure the count was correct with both nurses present. Interview on 7/30/25 at 12:41 PM, Staff C stated she was working on 5/28/25 when Staff B found the medication count discrepancy. Staff C stated the protocol was to count narcotics with the 2 nurses present, count all narcotics together and sign the count check sheet together. Staff C stated she always counts all narcotics with another nurse and will not take over a medication cart without counting the narcotics and ensuring the counts are accurate. Interview on 8/5/25 at 11AM, the DON stated during her investigation she confirmed Staff F, admitted she didn't complete the narcotic count on 5/28/25 at 6 AM with Staff A. Additionally, the DON stated the facility had not disposed of the Dronabinol during the 24 days Resident #1 was out of the facility and had been discharged . The DON stated Resident #1 was admitted back to the facility after her discharge in April and the facility was told by the provider to hold onto the Dronabinol but not for how long. The DON stated the facility should not have held onto the medication for that long, that the facility protocol is to destroy narcotics when the resident is discharged from the facility. The DON stated her expectation for narcotic counts to be completed with any change of nurse, with both nurses present, both nurses sign after the count is confirmed accurate. The DON further stated her expectation for residents' narcotics to be destroy by 2 nurses when the facility has officially discharged after a 10-day bed hold. On 7/29/25 at 3:15 PM, observed with the ADM the copy of the facility document July Refrigerator Controlled Drug Check Sheet that had been provided from the facility via email. The ADM agreed that it appeared the signature had been whited out and that was not acceptable. Interview on 8/5/25 at 12 PM, the ADON stated that on 7/28/25 she noticed that Staff E had signed the controlled count sheet earlier in the shift, so the ADON whited out her signature and instructed Staff E to resign her name later at the end of the shift with the other nurse that she completes count with at 6 PM. The ADON stated she didn't realize that she was not allowed to white out the signature and was provided education. The ADON stated controlled narcotic counts are to be completed with every nurse change and both nurses are to be present during the count and controlled narcotics are to be destroyed by 2 nurses when any resident is discharged from the facility. Interview on 7/30/25 at 1:15 PM, the ADON stated Staff B, RN called her on 5/28/25 between 6 PM -7PM and stated the dronabinol was missing and unaccounted for. The ADON stated she told Staff B she would talk to the DON and look at it in the morning. The ADON stated the next day she worked on getting camera video footage, looked around for the medication, and concluded that 1 pill was missing from the Dronabinol, as should have been 5 pills and was only 4. The ADON stated the narcotic count sheet was signed as accurate on 5/27/25 at 6 PM so she and the DON reviewed the facility video footage for 5/27/25 6 PM - 5/28/25 6 PM for the camera above the refrigerator where the Dronabinol was stored, and during review of the video footage, Staff A was the only staff member that handled the dronabinol medication card, which was the only medication card in the refrigerator at the time. Interview on 7/31/25 at 12:24 PM, Staff A stated she worked 5/27/25 6PM-6AM and counted the narcotics on the cart with the off going nurse but did not count the Dronabinol in the medication room refrigerator. She stated she did sign the count sheet for the Dronabinol but didn't go and actually count the Dronabinol. Staff A stated around 2 AM she removed 1 Dronabinol pill out of the medication room refrigerator, there was 5 pills which left 4. Staff A stated she put the pill in a medication cup and took the pill out of the medication room with her. She stated she went to get car keys out of the locker, and then then went to computer to verify the medication. Staff A stated she realized Resident #1 did not have an order for the medication. She stated she then went out to her car, was panicking because narcotics are such a big deal in the nursing field, and instead of destroying like she should have, she put it in a cigarette pack and threw it in the back trashcan, which is the trash can before you enter into the back door of the facility, it is an upright trash can with swinging doors on top. Staff A stated she did not report what she did with the medication to anyone. Staff A stated she knew what she should have done, should have disposed of the medication with another nurse observing and documented. She stated she had not had training at the facility on disposing of narcotics but knew the protocol as a nurse, just panicked. Staff A stated during report on 5/27/25 at 6 PM, the off going nurse told her Resident #1's Dronabinol was in the medication room refrigerator but she didn't go count the medication until later in her shift. Staff A stated during her 4 days of orientation, she only remembered 1 nurse, the first night of orientation, checking and counting the Dronabinol during the shift change, the other nurses would look at the Dronabinol count later during their shift. Staff A stated she knew the proper protocol for disposing of a narcotic is for 2 RNs to visibly observe and place the medication in a facility medication disposal container and both nurses sign the medication count sheet. Staff A stated she thought she signed the dronabinol out on the count sheet and didn't know she didn't until she spoke with the officer. Interview on 8/5/25 at 11AM, the DON stated the ADON reported to her on 5/29/25 that the ADON had received a call from an evening shift nurse regarding a medication discrepancy on 5/28/25. The DON stated on 5/29/25 she completed interviews with the nurses and was not able to come to a conclusion for the missing medication. The DON stated on 5/30/25 she received the camera video footage and reviewed all footage for 5/27/25 6 PM - 5/28/25 6 AM. The DON stated during review of the footage she observed Staff A go into the medication room, remove the Dronabinol medication card from the refrigerator, appeared that Staff A put a pill from the card into a cup, covered the cup with a paper towel, removed the cup from the medication room, go into the break room and opened and reached into a locker. The DON notified the ADM on 5/30/25 of her findings after the video observations with her conclusion that she felt Staff A had taken the missing medication. The DON stated on 5/30/25 she reported her findings to the state board of nursing, police and the staffing agency Staff A worked through but did not file a report. The facility policy Controlled Drug Procedure revised 6/25 documented the following:a. The controlled drugs are counted every 12 hours by the nurse reporting on duty with the nurse reporting off duty.b. T he inventory of the controlled drugs must be visually verified and recorded on the narcotic records and signed for correctness of count.c. When the prescribed drug is discontinued, or the person served is discharged , medication is destroyed using the facility's medication disposal system with 2 nurses present. d. Controlled drug distribution is for the use of persons served only.

Kitchen Based on observations, staff interview, and policy review the facility failed to serve food under sanitary conditions to prevent foodborne illness during one of two meals observed. Facility staff also failed to conceal hair completely in a hairnet to prevent foodborne illness. The facility reported a census of 40 residents. Findings include: Observations revealed the following: a. On 12/9/24 at 9:30 AM, the dietary supervisor wore a hairnet covering the hair pulled into a hair tie on the top of her head, but had the front, sides and back of the hair exposed (not in the hairnet). b. On 12/10/24 at 4:49 PM, Staff B, dietary aide, wore gloves while she served food to the residents. Staff B touched the handle of utensils used to serve entrees, and then used her gloved hand, picked up a piece of meat, and placed the meat onto the plates. c. During the lunch meal service on 12/11/24 starting at 11:55 AM, Staff A, dietary cook, wore gloves as he plated food for the residents. Staff A used a paring knife to cut up the chicken parmesan/ noodles and vegetables, then used tongs to place garlic bread onto the plates. Staff A picked the garlic bread up with his gloved hand and then used scissors to cut the garlic bread into bite-sized pieces. Staff A touched bowls and utensils, opened a drawer to obtain a serving scoop, then touched the food with the same gloved hands. d. On 12/11/24 at 12:25 PM, the dietary supervisor donned a pair of gloves, placed a ham and cheese sandwich on a cutting board, then took a knife and applied butter to the bread. The dietary supervisor continued to wear the same gloves, opened a drawer, obtained a spatula, then picked up the ham/cheese sandwich, and placed the sandwich in a frying pan on the stove with the same gloved hand. At 12:28 PM, the dietary supervisor wore the same gloves, used a knife to cut up the grilled ham and cheese sandwich, then placed the sandwich onto a plate. e. On 12/11/24 at 12:35 PM, the dietary supervisor wore gloves, opened the lid to the refrigerated food storage/prep area, removed a block of cheese slices, peeled cheese slices off, and placed the cheese slices on a slice of bread. The dietary supervisor then opened the refrigerator, removed a package of ham slices, placed ham slices onto a paper towel, then placed the ham slices onto the bread. The dietary supervisor picked up a knife and applied butter onto the bread slices. The dietary supervisor picked up the ham and cheese sandwich with her gloved hand and placed the ham and cheese sandwich into the frying pan. The dietary supervisor continued to wear the same gloves and touched food and non-food items. At 12:39 PM, the dietary supervisor placed the grilled ham and cheese sandwich onto a cutting board, took a knife and cut the sandwich up, then picked the cut-up pieces and placed them onto a plate and removed her gloves. f. During the lunch meal service on 12/11/24, the dietary supervisor wore a hairnet that only covered the hair on top of her head. The hair on the front, sides, and back of her head were not covered in the hairnet. Staff C wore a hairnet that covered the hair above the ears only, and had hair exposed to the sides and back of his head. Staff B wore a hairnet that covered only the top of the head, but the back and sides of the head were not restrained in the hairnet. In an interview 12/12/24 at 12:57 PM, the Dietician reported she expected staff wear gloves anytime hands came into contact with ready to eat food. The dietician also reported gloves changed between tasks. The dietician also expected staff wear hairnets and had hair covered when staff worked in the kitchen. An undated Disposable Gloves policy revealed disposable gloves used whenever manual contact with ready to eat food is unavoidable, in order to provide a measure of protection in preventing foodborne illness. Gloves changed when they became soiled or whenever changed tasks. Hands washed after soiled gloves removed. An undated Personal Hygiene policy revealed all dietary staff practiced good hygiene to maintain sanitary working conditions. Hairnets or bonnets must be worn at all times in the kitchen. The hairnet must completely cover the hair.

Based on observation, clinical record review, staff interview, and policy review, the facility failed to maintain infection control standards due to a catheter bag not maintained in a bag cover and lying on the floor under the resident's wheelchair for 1 (Resident #26) of 1 resident reviewed for catheter care. The facility reported a census of 40 residents. Findings include: The Quarterly Minimum Data Set (MDS) for Resident #26, dated 9/12/24, included diagnoses of anoxic (very low oxygen level) brain damage and seizure disorder. The Care Plan for Resident#26 with revision date 12/02/24 documented as focus area as follows; the resident had an indwelling urinary catheter due to urinary retention related to brain injury. The goal of the Care Plan documented the Foley cahteter was to be taken care of per protocol and discontinuation to be reassessed regularly. Interventions of the Care Plan included; monitor/record/ report to doctor for signs or symptoms of urinary tract infection which may include pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, foul smelling urine. Resident #26's order summary report dated 12/12/24 revealed an order for a Foley catheter (tube into bladder to drain urine) for urinary retention on 12/1/24. Observation on 12/09/24 at 11:02 AM, resident sitting in wheelchair in her room with the catheter bag, without a bag cover (bag to protect urinary bag from touching the floor), on the floor under the wheelchair. Facility policy, Closed Urinary Drainage revised 4/30/24, documented attach drainage bag to bed frame, not touching floor within the bag cover. Interview on 12/12/24 at 1:19 PM, the Director of Nursing stated expectation for the catheter bag to be in a cover bag, attached to the chair or bed, and not touching the floor.

Based on clinical record review, staff interview, and the Centers for Disease Control (CDC) guidelines, the facility failed to provide the pneumococcal vaccination as appropriate for 1 of 5 residents reviewed (Res #8). The facility reported a census of 31 residents. Findings include: The Minimum Data Set (MDS) for Resident #8 dated 9/4/23 identified a Brief Interview of Mental Status (BIMS) score of 4 out of 15 indicating severe cognitive impairment. The MDS documented diagnoses that included traumatic brain dysfunction and diabetes mellitus. The MDS reflected an admission to the facility date as 7/2/07 and a birth year of 1952. The immunization portion of the Electronic Health Record reflected Resident #8 received a pneumococcal vaccination on 7/26/07 and had received no further pneumococcal vaccinations since that time. The guidelines from the CDC document the recommendation for adults age 65 older is to receive at least one further vaccination 1 year after the prior vaccination, based on the type of vaccine in order to be considered up to date. On 9/27/23 at 8:04 am the Infection Preventionist Nurse stated the facility used an older computer system in 2007 so they are unaware of which vaccination Resident #8 received. The EHR only showed it documented as Pneumovax Dose 1. She stated she would reach out to the guardian of the resident as well as the physician in order to get the resident up to date on the vaccine. She additionally stated the facility has reached out to coordinator for the EHR system to add a flag to a resident chart who is at or over age 65 so the facility can better track when a resident turns 65.

Based on clinical record review, observation, staff interviews and family interviews, the facility failed to follow interventions on a comprehensive care plan for 1 of 12 residents reviewed (Resident #11). The facility reported a census of 31 residents. Findings include: The Minimum Data Set (MDS) of Resident #11 dated 9/4/23 identified severely impaired cognitive skills for daily decision making. The MDS revealed the resident totally dependent upon staff assistance for bed mobility, transfers, wheelchair locomotion, dressing, eating, toilet use, personal hygiene and bathing. The MDS coded a functional limitation in range of motion (ROM) with impairments present on both sides of the resident's body in the upper and lower extremities. The Care Plan with a focus area of impaired skin integrity, dated 2/24/22 directed staff to: Place pillows along side body and place arms to side, not across chest during nap during the day Bilateral Upper Extremity Bivalves during nap during the day Hard Wrist Splints during nap during the day Bilateral PRAFO's when lying on back Compression socks turned inside-out The Care Plan with a focus area of Activity of Daily Living (ADL) self-care performance deficit, revision date 4/5/22, directed staff: Resident wears bilateral AFOs; ensure they are put on correctly Bend the resident's knee when applying AFO to facilitate proper placement On 9/25/23 at 1:15 pm, a family member of Resident #11 stated concerns that the braces are not used on days family does not visit. The family member stated he has photos of where Resident #11's braces are stored and the braces are found to be in the exact same spot and position two days in a row as if they have not moved or been used. On 9/27/23 at 12:40 pm, Resident #11 was observed lying in bed. She had bivalves on her arms but her wrist splints were on her shelf, not being utilized. Her AFO boots were on but were observed not to be in proper alignment. There was approximately 1 inch of space between the resident's heel of her feet and the AFO. On 9/27/23 at 1:29 pm, a family member of Resident #11 arrived for a visit. The family member also pointed out the compression sock was not turned inside out as directed on the care plan on the Resident's left foot. The family member removed both AFO's and demonstrated during reapplication that when bending the knee as directed on the care plan, the heel of Resident #11's foot rested flat against the AFO as intended. On 9/27/23 at 2:15 pm, Staff C, Certified Nurse Aide (CNA) and Staff D, CNA entered the room to transfer the resident to her wheelchair. Staff C stated the wrist splints should have also been on Resident #11. Both staff denied they had performed cares to lay the resident down for her nap and were not aware of why her wrist splints were not placed. The resident's Electronic Health Record (EHR) revealed an active order dated 5/26/20 which stated OT/PT (Occupational Therapy/Physical Therapy) to assess, modify and schedule all splints, AFOs, and wheelchairs as necessary. The Task Section of the EHR revealed a task labeled CIRCULATORY which instructed staff as follows: Apply compression stockings inside out to avoid skin irritation from the seams. The task revealed it was signed as completed on 9/27/23 at 7:32 am. The Task Section of the EHR revealed a task labeled Splints Upper Extremity which instructed: Left Upper Extremity, Right Upper Extremity elbow extension bivalve with hand splint on during AM nap. The task revealed it was signed as completed on 9/27/23 at 11:13 am. The Task Section of the EHR revealed an unnamed task which instructed: During the Day: Place pillows along side my body and place my arms to the side not across my chest. BUE bivalves and hard wrist splints during nap. Bilateral PRAFOs when Supine. Compression socks-inside out. The task revelaed it was signed as completed on 9/27/23 at 12:45 pm. On 9/27/23 at 3:03 pm, the Occupational Therapist (OT) stated therapy sets the brace schedule for the CNA's to follow and the CNA's document them in the EHR under the Task section. She stated they also posts the schedules in the resident rooms. The OT stated Resident #11 has had the same brace schedule for over a year with no changes. On 9/27/23 at 3:12 pm the Director of Nursing (DON) stated it is her expectation the CNA's follow the care plan and place all splints/orthotic devices on the residents per therapy orders and as they are documented on the Tasks section of the EHR.

Based on observations, clinical record review, and staff interviews the facility failed to provide respiratory care and services in accordance with professional standards of practice for 2 of 2 residents reviewed (Resident #10 and #15) requiring humidified air through tracheostomy. The facility reported a census of 31 residents. Findings included: 1. The Minimum Data Set (MDS) dated [DATE] for Resident #10 documented the resident is in a persistent vegetative state/no discernible consciousness so was unable to complete a Brief Interview of Mental Status (BIMS). The MDS documented diagnoses to include traumatic brain dysfunction, quadriplegia, tracheostomy and chronic respiratory failure, unspecified with hypoxia or hypercapnia. An observation on 9/25/23 at 12:26 PM in Resident #10's bedroom revealed humidified air bubbler and connection tubing dated 9/1/23. An observation on 9/26/23 at 10:00 AM in Resident #10's bedroom revealed humidified air bubbler and connection tubing dated 9/1/23. Review of Resident #10's Medication Administration Records (MAR) revealed an order to change respiratory tubing, bag, aerosol mask, and humidifier bottle every Friday night. The MAR also had an order to apply humidified air to tracheostomy while in the room as needed. 2. The MDS dated [DATE] for Resident #15 had a BIMS documented as should not be conducted because Resident #15 was rarely/never understood. The MDS documented diagnoses to include cerebral palsy, quadriplegia and tracheostomy. An observation on 9/25/23 at 12:56 PM in Resident #15's bedroom revealed humidified air bubbler and connection tubing dated 9/1/23. An observation on 9/26/23 at 10:06 AM in Resident #15's bedroom revealed humidified air bubbler and connection tubing dated 9/1/23. Review of Resident #15's MAR revealed an order for tracheostomy vent to be worn during the day to help humidify the air through his tracheostomy. Review of the undated document titled Green Hall Night shift revealed tubing to be changed on Fridays. On 9/26/23 at 3:18 PM Staff A, Registered Nurse (RN), stated humidified air bubblers were changed monthly and the rest of the respiratory equipment were changed weekly. On 9/26/23 at 2:15 PM Staff B, Licensed Practical Nurse (LPN), stated the humidification bubblers were changed monthly. Staff B stated the rest of the respiratory equipment were changed weekly. Review of procedure with revisit date 3/7/23, titled Replacement of Suction Canisters and Respiratory Equipment revealed for infection prevention change respiratory equipment weekly (Example, Y-bag, tubing, humidifiers, nebulizer's, and cannula's). On 9/27/23 at 9:33 AM the DON stated the facility's expectation is that the bubbler and tubing connected to the humidification machine are replaced weekly. The DON stated that she expected the tubing and bubbler would have been changed out since 9/1/23. The DON stated it is on the night shift green hall report sheet for respiratory tubing to be changed out on Friday.

Based on clinical record review, staff interview, guidance from the Resident Assessment Instrument (RAI) and the Centers for Disease Control (CDC) guidelines, and facility policy review the facility failed to accurately reflect the pneumococcal vaccination status on the Minimum Data Set (MDS) Assessment for 1 of 5 residents reviewed (Res #8). The facility reported a census of 31 residents. Findings include: The MDS for Resident #8 dated 9/4/23 identified a Brief Interview of Mental Status (BIMS) score of 4 out of 15 indicating severe cognitive impairment. The MDS documented diagnoses that included traumatic brain dysfunction and diabetes mellitus. The MDS reflected an admission to the facility date as 7/2/07 and a birth year of 1952. The clinical record for Resident #8 revealed he had six MDS Assessments completed since last annual survey, dated 7/4/22, 10/4/22, 1/2/23, 4/4/23, 6/9/23 and 9/4/23. Five of the six of the MDS Assessments coded the resident's pneumococcal vaccination up to date. The immunization portion of the Electronic Health Record reflected the resident received a pneumococcal vaccination on 7/26/07 and had received no further pneumococcal vaccinations since that time. The Long Term Care Facility Resident Assessment Instrument (RAI) 3.0, October 2019 directs on page O-12 Up to date means in accordance with current Advisory Committee on Immunization Practices (ACIP) recommendations. The ACIP provides guidance to the CDC regarding use of vaccines. The guidelines from the CDC document the recommendation for adults age 65 older is to receive at least one further vaccination 1 year after the prior vaccination, based on the type of vaccine in order to considered up to date. On 9/27/23 at 12:30 pm, the MDS Coordinator stated it was her error of marking Resident #8's vaccines as up to date. She stated she was unclear that he required a second dose in order to be up to date and she would submit a modification of the MDS. The undated facility policy titled On With Life MDS Policy documented the expectation of the MDS Coordinator Registered Nurse: Accurately codes the MDS to reflect services delivered per RAI guidelines.

Based on policy review, observations, record review and staff interviews, the facility failed to ensure a medication error rate of less than 5% for 2 of 2 Nurses (Staff J and Staff K) observed during Medication Administration. Observations during medication administration revealed there were two medication errors out of 27 opportunities, which resulted in a 7.41% medication error rate. Findings Include: A review of the facility policy titled, Administration of Medications, effective 02/09/2017, revealed, Objectives: To properly and safely administer medications for treating and/or preventing injury and disease .Procedures: .E. Read and check medication label against the electronic (e) MAR (Medication Administration Record) three times before administering medication (before removing medication, as drug is removed from container, before returning drug to medication cart or refrigerator). Check and observe the 6 rights of medication administration (right PS [person served], right medication, right dosage, right time, right route, and right documentation). 1. During an observation of Medication Administration on 06/28/2022 at 7:40 AM, Staff J, Registered Nurse (RN, administered [MEDICATION(S)] ointment onto both of Resident #6's eyelids. A review of the current Medication Review Report revealed a Physician Order, dated 06/22/2022, for [MEDICATION(S)]/[MEDICATION(S)] suspension (drops) 0.3-0.1%. The order directed staff to instill one drop to both eyes four times a day for seven days for a bacterial infection. There was also an order, dated 06/22/2022, for [MEDICATION(S)] ointment 0.3-0.1%. The order directed staff to apply topically to the eyelids of both eyes at bedtime for seven days for a bacterial infection. During an interview on 06/28/2022 at 2:55 PM, Staff J confirmed the ointment was administered instead of the eye drop. 2. During an observation of Medication Administration on 06/28/2022 at 8:48 AM, Staff K, RN, administered one chewable tablet of aspirin 81 milligrams (mg). Staff K indicated the order was for [MEDICATION(S)] coated (a coating to prevent dissolving in the stomach and to avoid gastric distress) but there was not any available. A review of the current Medication Review Report revealed a Physician Order, started 05/28/2020, for aspirin low 81 mg [MEDICATION(S)] coated. The order directed staff to give one tablet by mouth daily with food. During an interview on 06/28/2022 at 3:02 PM, Staff K indicated the facility did not have [MEDICATION(S)] coated aspirin. Staff K stated the Pharmacy had been called but the [MEDICATION(S)] coated aspirin had not been sent. During an interview on 06/29/2022 at 10:35 AM, the Director of Nursing #1 indicated the expectation was for Physician Orders to be followed. During an interview on 06/30/2022 at 11:40 AM, the Executive Director indicated his expectation was for there to be no Medication Administration errors.

Based on observations, staff interviews, and facility policy review, the facility failed to follow accepted infection control practices during a COVID-19 outbreak. Staff failed to: sanitize a hoyer left after using it, two staff members failed to wear gloves while assisting two residents with activities of daily living (ADLS - one of the two staff members had long, artificial nails), and two staff members failed to wear the appropriate Personal Protective Equipment (PPE) while in the room of two residents with COVID-19. The facility reported a census of 31 residents. Findings include: On 9/16/21 at 9:25 AM during the entrance conference, the Administrator stated they had eight residents and six staff members that tested positive for COVID-19. The Administrator indicated all residents were being kept in their rooms. Observation on 9/16/21 at 10:12 AM revealed Staff J Physical Therapist Assistant (PTA) had assisted Resident #5 to a sitting position in his bed. Staff J wore the following PPE: N-95 mask, face shield, gown, and gloves. Staff J failed to don gloves while she touched the [CONDITION(S)] pads on the bed rails and assisted Resident #5 to a sitting position on the side of his bed. Staff J placed her bare hands on Resident #5 as she assisted him and as she handled the sit-to-stand lift. At 10:19 AM Staff J assisted Resident #5 to remain in the sitting position, touched her radio when she asked for assistance, and continued to touch the sit-to-stand lift without gloving. At 10:23 AM other staff members donned gloves and a gown to assist Staff J and Resident #5. Staff J then donned a pair of gloves to continue with the transfer. On 9/16/21 at 10:45 AM Staff K Certified Nursing Assistant (CNA) and Staff L CNA assisted Resident #6 to the bath tub gurney. Staff L wore gloves as she assisted Resident #6, but Staff K did not as she assisted Resident #6 by touching him and the lift with her bare hands and artificial nails that extended past her fingertips. At 10:47 AM Staff K removed the hoyer lift from the bath house, placed it in the hallway by the computer and gowns that hung on the wall, then proceeded about her duties. Staff K failed to disinfect/sanitize the hoyer left after it was used. At 10:57 AM the hoyer lift still had not been disinfected/sanitized. Observation on 9/16/21 at 11:58 AM on the COVID-19 hall revealed signs on rooms 126, 127, 130, 131, 132, and 133 that directed: Full PPE required including N-95 mask properly secured with both elastic bands, face shield, gloves, disposable gown, and shoe covers. After exiting the room, promptly remove all PPE except the N-95 and face shield and deposit into the infectious trash bin. Observation on 9/16/21 at 12:02 PM, showed Staff N CNA, wearing an N-95 and face shield, donned gloves and a gown and then went into room [ROOM NUMBER] with the resident's lunch. Staff N failed to don booties before she entered the room. At 12:03 PM, Staff M CNA walked into room [ROOM NUMBER] wearing an N-95, face shield, gown, and gloves, but failed to don booties before entering the room. At 12:17 PM, Staff M exited room [ROOM NUMBER], doffed his gown and gloves, sanitized his hands, exited the hallway and left the building. Staff M did not have booties to remove and he did not disinfect/sanitize his shoes. At 12:35 PM Staff N exited room [ROOM NUMBER] doffed her gown and gloves, and sanitized her hands. Staff N did not have booties to remove and did not disinfect/sanitize her shoes. Staff N stood at the computer and charted before she donned a gown and gloves to enter room [ROOM NUMBER] again without donning booties. On 9/16/21 at 10:30 AM the Assistant Director of Nursing (ADON) provided a listed of three residents with active signs and symptoms of COVID-19. On 9/16/21 at 11:45 AM when asked what PPE should be worn on the two non COVID-19 halls when caring for the residents, the ADON stated N-95 masks, face shields, cloth gowns, and gloves. The ADON was asked if gloves should be worn when assisting residents to the bath or during transfers, and she replied she personally would wear them. The ADON verified transfer lifts should be sanitized after each use with their residents. The ADON was asked about the facility's artificial nail policy and she indicated she did not know what the policy included. On 9/16/21 at 12:45 PM the Administer was informed of staff not wearing the appropriate PPE while on the COVID-19 hall. She stated she will educate them and confirmed they should wear booties. On 9/17/21 at 1:58 PM the Administrator reported she spoke to the staff about the shoe covers. Staff told her the shoe covers do not fit over their shoes, so they were wiping down their shoes with sani-wipes between rooms. She was informed staff were not observed to be wiping down their shoes prior to leaving the COVID positive rooms. Review of email updates from the Administrator to all facility staff revealed the following: - 9/6/21 at 3:49 PM: more positive test results which included 4 residents and are on the COVID-19 hall. Staff are required to wear full PPE prior to entering the room. All residents that have tested negative require full PPE prior to entering the room. - 9/7/21 at 8:39 AM: As of today, N95's and face shields are to be worn at all times in the facility. In all resident rooms, full PPE is required. - 9/17/21 at 1:47 PM: on non COVID-19 halls gloves must be worn at all times and lifts must be sanitized before and after each use. On the COVID-19 unit shoe covers are provided and a variety of sizes were ordered to ensure all staff can utilize these. Review of the facility's Artificial Nails Policy 2012 stated fingernails should be kept clean, healthy, and short (1/4 inch or less beyond the tip of the finger). Long nails, both artificial and natural, harbor more microorganisms than short nails. Long fingernails may pose a hazed to resident safety when moving or positioning the resident. Artificial nails or nail enhancements should not be worn by any person whose responsibilities include direct hands-on resident contact. Review of the facility's Sanitizing Equipment policy indicated all reusable equipment shall be disinfected with facility approved disinfectant wipes or solution following use of each resident. One the resident is no longer using the equipment, staff will don gloves, and follow the disinfectant manufacturer's instructions for sanitizing. If staff are not immediately available to sanitize the equipment it will be placed in the soiled utility room to prevent anyone from using it until it can be sanitized. After the equipment has been sanitized per manufacturer's instructions it may be put back in service if charged and stored in the appropriate area.

Based on record review, facility investigation review, staff interviews, and facility policy review the facility staff failed to report an injury of unknown origin to their supervisor for 1 of 3 residents (Resident #1) reviewed for injuries of unknown injuries. The facility reported a census of 31 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] for Resident #1 identified a Brief Interview of Mental Status (BIMS) score of 11 which indicated moderate cognitive impairment. The MDS revealed the resident was totally dependent on two staff for bed mobility, transfers and extensive assistance on two staff for dressing. The MDS documented diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The care plan focus area dated 8/27/2020 documented the resident had impaired physical mobility and was unable to complete cares on his own related to a traumatic brain injury and quadriparesis. The care plan provided Resident #1 could help reposition himself by rolling to the right, but could not roll without assistance of two staff to the left side. The progress note dated 9/29/21 at 3:31 PM, documented Resident #1 had a dark purple, swelling bruise under his left eye with a dark red area noted in the outer canthus area which seemed to be progressing posteriorly down his face. Observation on 10/6/21 at 10:54 AM, showed Resident #1 sat in his wheelchair in the blue hall dining room. Observation revealed various shades of blue and yellow to his left periorbital area. His sclera appeared red as well. The facility's investigative file provided the following staff statements: a. On 9/29/21 at 4:12 PM, Staff P Nursing Department Coordinator typed the following statement: Between 9:00 AM and 10:00 AM she walked into the dining room on Resident #1's hall and started talking with him when she noticed that his eye was a little black. She figured the nursing staff already knew about it so she did not say anything. When she was back in dining room during lunch time, Staff M Certified Nursing Assistant (CNA) said to Resident #1 your eye is black, what happened. Staff P looked at his eye and it looked worse than when she saw it earlier in the morning. She asked Staff M, you did not know he had a black eye? Staff M stated he did not notice it this morning when he gave him his bath. Staff P then went to the main nurse's station and reported his black eye. b. On 9/30/21 at 2:45 PM, Staff M typed the following statement: he arrived to work at 6:00 AM and he was the only CNA on the floor until 7:30 AM. He started with Resident #1's bath between 6:15 AM and 6:30 AM. He got the resident ready for his bath, completed the transfer with the hoyer and took him to the tub room. He did not think there were any issues in the tub room during the bath and the resident seemed to be in his usual mood. He does not like baths, so he was agitated, but nothing out of the ordinary for him. After he got him dressed for the day, he took him to the dining room for breakfast. There was no bruising that he noticed at that time. After breakfast the resident stayed in the dining/activity room during the duration of the morning. Between 12:15 PM and 12:45 PM, he noticed the bruising to his left eye. Staff P went and told the nurses while Staff M stayed with the resident. Staff M provided he did not feel that there was anything or anyone that could have caused the bruising. He said he did not remember the hoyer hooks hitting him or anything happening during his bath or dressing. The only thing he could think of would be maybe he glasses got pushed into his eye when they were rolling him but was not positive if the glasses were on during that time or not. On 10/6/21 at 10:17 AM, Staff P stated she went into the blue hall dining room after breakfast, between 9:00 AM and 10:00 AM and saw Resident #1 in the dining room with another resident. When she asked how Resident #1 was doing, she noticed black bruising under his left eye and asked what had happened. He talked inappropriately about nothing related to his eye. She did not report it because she figured staff already knew. Staff P admitted it was her mistake and she should have said something to the nursing staff when she first saw the black bruising to his eye. Resident #1 did not say anything about his eye when she had spoken with him. At lunch time, Staff M was in the blue hall dining room and asked Resident #1 what happened to his eye. Staff P indicated she asked Staff M, you didn't know about it? He said no. She went to look at his eye again and it was black, blue, and swollen. She stated that was when she went and got a nurse to report it. On 10/6/21 at 11:20 AM, Staff E CNA when asked what she would do if she noticed a new bruise to a resident's chin, she stated she would report it to a nurse immediately. On 10/6/21 at 11:32 AM, Staff J CNA when asked if she noticed a new bruise to a resident's chin what she would do, she stated she would report it to the charge nurse. On 10/6/21 at 2:13 PM, Staff M reported he gave Resident #1 his bath between 6:15 AM and 6:30 AM and did not notice anything out of the ordinary. At lunch between 12:15 PM and 12:45 PM, he saw the purplish blue mark, so he Resident #1's glasses off and saw the black eye. Staff M reported Staff P told a nurse at that time about the eye. On 10/7/21 at 11:29 AM, the Administrator was asked if Staff P should have reported when she initially saw Resident #1's black eye between 9:00 AM and 10:00 AM. and the Administrator stated she should have. The Administrator provided Staff P informed her she thought staff already knew about it but educated her that she should have still reported it. Review of the facility's Mistreatment of [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on record review, staff interview, facility investigation view, facility video footage review, and facility policy review, the facility failed to follow recommendations for the use of adaptive equipment when assisting 1 of 3 residents (Resident #2) with their lunch meal. The facility reported a census of 31 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] for Resident #2 identified a Brief Interview of Mental Status (BIMS) test score of 8 the resident demonstrated moderate cognitive impairment. The MDS revealed the resident required extensive assistance of one staff for eating. The MDS documented diagnoses that included non-traumatic [CONDITION(S)], pseudobulbar affect, and [CONDITION(S)]. The care plan focus area dated 8/20/2020 identified the resident as at risk for developing a respiratory infection related to the risk of developing aspiration pneumonia secondary to her brain injury as evidenced by a history of pneumonia. The diet card updated on 5/26/21 directed the resident is to receive nectar thick liquids given at 30 milliliters (mL) at a time via nosey cup, with no straws. Thin liquids are allowed with 10 mL Provale cup only. The progress note dated 5/21/2021 at 5:37 PM documented Resident #2 choked at lunch time when Staff H, Certified Nursing Assistant (CNA), gave her unthickened liquids. An assessment revealed the resident appeared at baseline with clear lung sounds. Staff will continue to monitor throughout the shift. Observation 9/29/21 at 10:30 AM, revealed Resident #2's dietary card in a folder on the refrigerator in the main dining room. At 12:35 PM, the dietary card laid on the table with her food tray and a piece of paper that contained her diet which included both the food and liquid consistencies. Observation of the video camera recording in the large dining on 5/21/21 revealed the following: a. 12:13 PM: Resident #2 sat at the dining room table, in her wheelchair with Staff H. On the table was the resident's plate with food, silverware, white cloth ,and a black cloth. Staff H gave Resident #2 four bites of her food. b. 12:15:19: a staff member gave Staff H a small can of soda, then walked away c. 12:15:37: Resident #2 started to cough d. 12:15:40: Staff H gave her a drink of her pop from the can, with no straw. The resident continued to cough e. 12:15: 50 Staff H gave her another drink of the soda from the same can; resident continued to cough f. 12:15:37: Staff F intervened The diet order sheet documented Resident #2 had the following diet order: nectar thick liquids given 30mL at a time through a nosey cup; no straw. Thin liquids allowed with 10mL provale cup only. The facility's investigative file provided the following staff statements: a. On 5/21/21, Staff D Certified Nursing Assistant (CNA) typed the following statement: Staff H CNA had poured Mountain Dew down Resident #2's throat. She started choking and turned red as a tomato. Staff H kept pouring the pop down her throat as she was choking. Staff F Therapy Activity Specialist ran over and told her it was not ok and she could not do that. b. On 5/21/21, Staff G Therapy Activity Specialist typed the following statement: she was in the large dining room modifying a cooking group lunch and running the blender and noted a rather loud cough. She turned around to see what was going on. Resident #2 was red in the face and coughing very forcefully. Staff F went over to assist Resident #2 and Staff H, as the other CNAs were not. Staff G heard Staff F coach Staff H on the correct cup and consistency Resident #2 used during meals. c. On 5/21/21, Staff F typed the following statement: he was in the large dining room when he heard Resident #2 coughing quite a bit. He saw Staff H assisting Resident #2 with drinking a Mountain Dew; Staff H was holding the Mountain Dew can for Resident #2 and observed some of the liquid spilling down the front side of the can, onto Resident #2's chin. He immediately went over and interrupted. He noted Resident #2 looked flushed in the face with teary eyes. He explained why he interrupted and pointed out the coughing and teary eyes and warned to watch for aspiration while feeding her. He asked Staff H if she was aware that Resident #2 required an adaptive provale cup. She indicated she was not aware of that and he asked if anyone had taken the time to show her the dietary cards with useful information when helping the residents eat or drink. Staff H stated she was not made aware of these cards and thanked him for showing her. Staff F stated he took a few minutes and went over the card with her, then grabbed a cup and showered her how to use it correctly. He then put the pop in the cup for Resident #2, left the dietary card, and recommended she use one whenever helping someone eat or drink. Resident #2 indicated she was ok. d. On 5/21/21, Staff H typed the following statement: she had assisted Resident #2 with her meal. She had lunch made in a cooking class for the group. She had given Resident #2 a bite of her broccoli and started to cough. Staff H reported there was a small can of soda on the table that another CNA brought to her. Staff H stated she had not gotten up to get her a cup because she was coughing and did not want to leave her alone because she was at risk for choking and was already coughing. She was not told she needed a special cup by any of the other CNAs in the room. Staff F kindly approached with the resident's diet cards and showed her the cups Resident #2 used. Staff H then used the cup given to her and read her dietary card so she was aware for the next time. On 9/28/21 at 2:50 PM, Staff E CNA stated the diet cards are used during meals because they list what the residents diet orders, include the adaptive equipment needed, and identify which liquid consistency they require. She stated the diet cards are in a folder on the fridge. Regarding the incident on 5/2/21 in the main dining room, she provided Staff H used to be a facility staff member and she quit then came back as an agency staff. She stated Staff H knew where the dietary cards were but did not use them when she fed Resident #2 that day. Staff E stated she told Staff H that the pop for the resident needed to be thickened but gave her drinks without thickening it and the resident choked. When asked how she knew Resident #2 had been choking she stated she was coughing a lot and eyes had started to water. On 9/28/21 at 3:01 PM, Staff D CNA when asked how staff learn about resident diet orders and adaptive equipment, she replied they go over those things in orientation and the information is on their tables that show what their diets are, what liquid consistency they drink, and what adaptive equipment is to be used. On the day of the incident Staff H had fed Resident #2 her homemade lunch. Staff D said Resident #2 did not have her cup or diet card on the table. When asked if diet cards are supposed to be out on the tables; she stated sometimes they are, sometimes they are not. Staff D stated Staff H gave the resident a drink of Mountain Dew straight from the can with a straw and Resident #2 was choking really bad, her face was turning purple, and she had tears in her eyes. Staff D stated some guy ran over and said that is not acceptable. Staff members informed leadership that the diet cards need to be on the table. When asked what liquid consistency and adaptive equipment Resident #2 was ordered to have, Staff D answered a provale cup or nectar thickened liquids. On 9/29/21 at 9:57 AM, the Assistant Director of Nursing (ADON) acknowledged the dietary cards were to be on the table and to be used. She stated the dietary cards show residents' diet orders, liquid consistency needed and adaptive equipment to be used. On 9/29/21 at 10:33 AM, the Administrator stated the dietary cards are laminated, in each dining in a folder on the fridge, and that folder is labeled so they know where they are. She provided they have completed quite of bit reminder education on diet cards by telling staff they are here for your reference and if unsure how to feed someone, ask. The Administrator indicated after this incident they revamped how they do agency staff orientation versus new staff orientation. On 9/29/21 at 11:06 AM, Staff G stated as she blended the food in the dining room on 5/21/21, she noticed Resident #2 coughing more than normal. She described the cough as loud and forceful and the resident's face was red, so Staff F went and coached her Staff H regarding the consistency as it changed frequently. Once she was coached and given the appropriate equipment, Resident #2 stopped coughing. On 9/29/21 at 3:43 PM Staff F provided on 5/21/21 he was in the dining room modifying the lunch meal, He heard Resident #2 coughing quite a bit, turned around and saw Staff H had gave her a drink without the appropriate adaptive equipment. He went over and interrupted the interaction and asked if she knew what cup she used and if she had been trained, she said she was not aware of the cup used for her. He stated the other staff kept doing what they were doing; feeding, assisting, supervising the other residents. He asked her to stop, got the dietary card that no one had showed or nor was it on the table. He stated he retrieved the appropriate adaptive equipment for Staff H to assist Resident #2 with her drinks. He provided it seemed like she lacked the appropriate training. On 9/30/21 at 9:28 AM Staff H stated she worked at the facility previously as a facility employee then worked as agency. When asked what kind of orientation/training she received when she came back as an agency staff member, she stated the overnight girls walked through the halls and said this is who this is and what their assistance levels are. She remembered stuff from when she worked there before. When asked if she remembered the use of the dietary cards, she acknowledged she spaced the use of the meals and knew she should have asked questions about the adaptive equipment but did not do so. Staff H provided therapy had a cooking class that day, where they make meals with the residents. She remembered they did not have cups laid out per norm. She stated Resident #2 was actively eating, as she sat next to her. When she gave her a bite of her broccoli, Resident #2 began to cough and she saw tears in her eyes. Another staff member had placed a can of pop on the table before she started coughing and once she started to cough she opened it and gave her drinks to help clear her throat. Staff H indicated she did not walk away because she was actively choking. Then Staff F came over to give her the dietary card and the proper cup that needed to be used when giving the resident her liquids. When she was asked if the anyone try to give guidance in the beginning when they gave her the can of pop, she stated no, they dropped it off and left. The facility procedure titled Feeding a Person Served with an effective date of 2/7/2017 instructed staff to feed the residents according to speech orders. Staff are to check food and liquids for the correct level of consistency per speech orders prior to assisting a resident to eat.

Based on record review, staff interview, facility investigation review, and facility policy review, the facility failed to ensure 1 of 3 residents (Resident #1) was treated in a dignified manner during personal cares. The facility reported a census of 31 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] for Resident #1 identified a Brief Interview of Mental Status (BIMS) score of 11 which indicated moderate cognitive impairment. The MDS revealed the resident was totally dependent on two staff for bed mobility, transfers and extensive assistance on two staff for dressing. The MDS documented diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The care plan focus area dated 8/27/2020 documented Resident #1 had quadriparesis, impaired physical mobility, and was unable to complete cares on his own related to a traumatic brain injury. and The care plan provided Resident #1 was able to help reposition with rolling to the right, but not able to roll without assistance of two staff to the left side. The progress note dated 6/30/21 at 11:18 AM documented Staff C Licensed Practical Nurse (LPN) assessed Resident #1 due to being flicked in the head by a staff member, which caused him to bite his right hand. The assessment revealed no red marks or bruising, and his right hand had no new marks or other bruising. The facility's investigative file provided the following staff statements: a. On 6/30/21, Staff A, Certified Nursing Assistant (CNA) typed statement provided: after breakfast she and Staff B CNA assisted Resident #1 in his room. Staff A informed Staff B of him hitting staff. Staff B indicated she had worked with him before. Staff A asked Resident #1 to be nice. He was assisted to roll to the side that Staff B was on and he hit her. Staff B looked at him and said boy I wish it was like the older days where we could swing back. Resident #1 then said [OBSCENITY] you and Staff B flicked him on the head. Staff A told her she could not do that. b. On 6/30/21, Staff C's typed statement provided: around 8:45 AM, Staff A approached her with a concern. She informed Staff C that while in Resident #1's room, she witnessed Staff B flick the resident on the head. This caused him to have a behavior and bit his hand. Staff A stated she overheard Staff B tell the resident, I wish I could [OBSCENITY] ing hit you back. Staff C reported the incident to the Assistant Director of Nursing (ADON) and explained to the Administrator what happened. c. On 6/30/21, Staff B's written statement provided: during her interactions with Resident #1 he had hit her in the stomach. She said to him, if I could hit you back but indicated she said this in a joking manner and was not mean about it. She wrote she would not hit any of the residents and she never said [OBSCENITY] to him. d. On 6/30/21, the Administrator's typed statement provided: she was approached by Staff O the previous Administrator, the ADON, and Staff C at approximately 9:04 AM in her office. Staff C stated Staff A reported to her that Staff B spoke to and treated Resident #1 inappropriately and in a threatening manner. Staff C immediately reported the situation to the ADON and previous Administrator. An investigation was immediately started. The Social Worker and Staff C approached Resident #1 following the incident to ensure he was calm and comfortable, followed by a physical assessment. Due to his cognitive deficits and significant communication barriers, the staff members were unable to retrieve verbal information from him regarding this incident. On 9/28/21 at 1:18 PM, Staff A was asked to describe what happened 6/30/21 in Resident #1's room. Staff A reported she had warned Staff B about his behaviors which included the use of vulgar words and hitting staff members. Staff B told her she knew of these behaviors because she had worked on his hall before. Staff A stated they were in his room getting him ready for pool and Staff B she was on the side he swings at, so Resident #1 swung at Staff B and hit her in the chest area. Staff A stated Staff B said to Resident #1 do I need to have my boyfriend come in and show you respect? She also stated she wished it was like the old days where they could hit back; Resident #1 responded and said [OBSCENITY] you. When asked how Staff B said if it was like the older days, Staff A stated she said it with an attitude; she took it seriously and not as a joke. On 9/28/21 at 1:56 PM, Staff C was asked to describe what happened on 6/30/21. She stated Staff A came to her and reported that Staff B was aggressive with Resident #1 and it was not ok how she talked to him. Staff A told her Staff B told the resident if it was the old days she would him hit back. Staff C said she talked with Staff B and had asked her what happened. At first, Staff B denied the allegation then confirmed she did say she wished it was like the old days. Staff C then assessed the resident and found no new skin issues, red marks, or bruising, and then she reported the allegation to the ADON. On 9/29/21 at 10:39 AM, the Administrator stated the ADON told her Staff A reported to her that Staff B was rude to Resident #1. The Administrator indicated when Staff B wrote her statement she admitted to saying that if it was the older days, but shared that it was a joke. The Administrator reported she spoke to Staff B and explained she cannot talk to the residents like that. In an attempted interview with Resident #1 while he sat in the dining room on his hall, watching television 0n 9/29/21 at 11:47 AM, the resident was asked if anyone had ever been mean to him. The resident stated Yeah and when asked to name the person, he said, Your mom, and began to use vulgar language. The resident did not provide any pertinent information. On 9/30/21 at 11:47 AM, Staff B reported she assisted Staff A with Resident #1 and went to his right side of the resident, the side he hits from. Resident #1 hit her and she stated to the resident boy if I could hit you back. Staff B stated she was joking and added Staff A did not say anything to her after she made that comment to Resident #1. Review of the facility's Behavioral Interview Policy, with a revised date of 1/2020, provided staff members are expected to take into account the cognitive challenges that are often associated with brain injuries. This impairment may not only cause emotional and behavioral challenges, but it may also make it difficult for the person served to effectively manage these challenges. It is essential that no matter what emotional or behavioral challenges staff members face, they are to remember that they are in charge with delivering professional, caring, and compassionate services unconditionally. Facility residents have the right to feel safe and know that staff members are there to help and support them through both the positive and the difficult times of their rehabilitation process.

Based on observation, record review, and resident and staff interviews the facility failed to adequately assess for self administration of medication for 1 of 1 residents reviewed for self-administration of medications (Resident #25). The facility reported a census of 31 residents. Findings include: According to the quarterly Minimum Data Set assessment tool dated 3/10/20, Resident #25 scored 15/15 on his Brief Interview of Mental Status test, which meant he demonstrated intact cognition. The Nursing Service Procedure for self administration of medication dated 2/12/17 directed staff to obtain a physician's orders [REDACTED]. Review of the Care Plan dated 1/17/20 revealed no documentation to indicate the resident administered his own medication. The Physician order [REDACTED]. The Medication Administration Record [REDACTED]. During meal observation on 3/10/20 at 12:10 PM the resident propelled himself into the dining room in his electric scooter. The resident had several medications in a medication cup on top of his wheelchair tray. The resident reported his noon medications were in the cup. He added he convinces the nurses to leave the medications with him to take on his own. During an interview with the Director of Nursing on 3/10/20 at 1:20 PM she stated the facility does not have any residents currently assessed as safe to administer their own medications. She reported at one time, Resident #25 used to administer his own meds, but he had started to drop them and/or forget to take them. When asked, she stated expected staff to stay with him while he takes his medications.

Based on observation, record review and staff interview the facility failed to provide catheter care using correct infection control practices in an attempt to prevent infections for Resident #25. The facility reported a census of 31 residents. Findings include: According to the quarterly Minimum Data Set assessment tool dated 1/10/20, Resident #25 had [DIAGNOSES REDACTED]. The MDS documented the resident required extensive assist of 2 staff for bed mobility, and transfers, and utilized an indwelling catheter for urinary elimination. The Nursing Services Procedure for catheter care dated 1/17/17 directed staff to cleanse the area well at catheter insertion site, then move distally away from body, taking care not to pull on catheter or advance it further. The Care Plan dated 1/17/20 documented resident has suprapubic catheter due to [MEDICAL CONDITION] bladder (a name given to a number of urinary conditions in people who lack bladder control due to a brain, spinal cord, or nerve problem). The care plan contained a goal for Resident #25 to be free form urinary tract infections [MEDICAL CONDITION]. The current physician's orders [REDACTED]. During an interview with the resident on 3/9/20 at 12:23 PM, he stated that he has had UTI's before and takes preventative medicine for them. During observation of cares on 3/10/20 at 8:50 AM Staff A and Staff B provided catheter care and perineal care to Resident #25. Staff A provided the care while Staff B maintained clean hands to hand her the wet wipes. Both aides began by sanitizing their hands and donning gloves. Staff A began by using two separate wipes to clean the catheter tube. She took one wipe and wiped from the end of the tube where it connects to the drainage bag toward the body to the entry of the catheter at the suprapubic site. Staff A took the second wipe and again wiped from the drainage bag toward the catheter insertion site. She then used 3 wipes to clean the perineal and groin area and finished by using 1 wipe to clean around the head of the penis. Staff A then removed her gloves and used hand sanitizer and donned new gloves. She then applied a clean 4 x 4 around the suprapubic catheter and secured the catheter to the leg with a strap. During an interview with the Director of Nursing on 3/10/20 at 10:09 AM, she stated all aides are instructed on proper catheter care on hire and then annually. She also stated that they are trained to clean the catheter from the catheter insertion site and away from the body.

Based on clinical record review and staff interviews, the facility failed to notify the physician in a timely manner in order to obtain orders for a change in condition for one of five residents reviewed (Resident #17). The facility reported a census of 31 residents. Findings include: According to the Minimum Data Set (MDS) assessment dated [DATE], Resident #27 demonstrated short term memory problems and severely impaired skills for daily decision making. The resident could not speak and depended on staff assistance for all activities of daily living. He required a catheter for urination and a feeding tube. The resident's [DIAGNOSES REDACTED]. The resident's current Care Plan dated 1/3/19 identified that he may have pain but may be unable to communicate this to staff. The interventions included to report to the nurse any of the resident's nonverbal cues or body language (such as facial expression, body tone, level of consciousness, blotchy red areas on skin, or a change in vital signs indicating distress) that may indicate he hurt. The resident's Tylenol/[MEDICATION NAME] Administration History dated 2/19/19 documented on 1/25/19 at 11:44 p.m. the resident received [MEDICATION NAME] for a fever. The Nurse's Notes dated 1/26/19 at 1:58 p.m. documented the resident had occasional labored breathing, short periods of hyperventilation, repeated troubled calling out, loud moaning or groaning, crying, moaning and coughing a lot, sad, frightened, frowned, and with facial grimacing. At 6:55 a.m. the resident had a temperature (temp) of 103.2 degrees temporally, and his heart rate measured 130 beats per minute (normal rate is 60-100 beats per minute) . At 7:05 a.m. the resident received [MEDICATION NAME] and [MEDICATION NAME] DM (cough suppressant/[MEDICATION NAME]), via the gastric tube and a cool washcloth on his head. At 8:07 a.m. the resident's temp came down to 98.9 and his heart rate to 113, with an oxygen (O2) saturation (sat) level measuring 94-95% on room air (a normal reading is at or above 90%). At 11:35 a.m. the resident moaned a little bit again. At 11:45 a.m. staff gave Tylenol as the resident appeared uncomfortable/having discomfort. An hour later, his temp measured 97.7 and the resident appeared to rest comfortably. Respiratory findings included a nonproductive, congested cough. The Nurse's Notes dated 1/27/19 at 2:02 p.m. documented staff sent a facsimile (fax) sent to the physician regarding the resident's change in condition. The results documented they would await a response via fax on Monday 1/28/19. The resident's parent visited him for a short time around 11 a.m. The notes documented Resident #17 had occasional labored breathing, short periods of hyperventilation, occasional moaning or groaning, sadness, frightened, a frown, and facial grimacing. The resident had a dry nonproductive cough a couple times, and once had a productive cough, but staff did not see sputum; he swallowed it. Resident #17's O2 sat measured 95%. He had been afebrile (had a normal temperature) but continued to appear uncomfortable. The facsimile to the physician dated 1/27/19 at 9:28 a.m. regarding a change in the resident's condition documented on 1/25/19 at 11:40 p.m. the resident had an elevated temp of 101.4 degrees and received as needed (PRN) Tylenol at 11:48 p.m. At 12:59 the temp came down to 98.3. On 1/26/19 at 6:55 a.m. the resident had a very red face and his temp registered 103.2 degrees, blood pressure 124/84, pulse 130, respirations 18, and oxygen saturation 94%. The resident received Tylenol and [MEDICATION NAME] DM (he sounded congested and coughing). At 8:07 a.m. the resident's temp went down to 98.9 and his heart rate to 113. The resident's temps registered 97.4 at 11:35 a.m. and 98.5 at 3:45 p.m. The resident received Tylenol at 11:45 a.m. with temp 97.7 at 12:50 p.m. and 98.5 at 3:45 p.m. and down to 97.9. Early in the morning, 1/27/19 at 1:05 a.m., the resident spiked a temp of 100.3 and the night nurse gave the resident Tylenol. At 2 a.m. the resident had a temp of 100 and at 3 a.m. a temp of 99.3. At 7:09 a.m. the resident had a temp of 98.7 and heart rate of 119. The oxygen saturation was 93%. Tylenol given at 7:14 a.m. with temp down to 97.9 at 8:22 a.m. The resident continued not to feel well and moaned out when he coughed. He did not sound congested anymore. Staff attempted to assess the resident's throat but he was not very cooperative. The resident's parent wanted to see if he needed a swab to test for influenza. The resident's lung sounds were clear in all fields. Staff asked for any suggestions other than Tylenol every 4 hours. The Nurse's Notes dated 1/28/19 at 5:11 a.m. documented at 4 a.m. the nurse walked by the resident's room and heard him breathing loudly. The resident was pale and diaphoretic, with O2 sats in the mid 50's. Staff called for a nurse to assess the resident and another nurse to bring oxygen. Staff placed oxygen on at 10 liters via non re-breather and the resident's O2 sats ranged from 87-94%. Staff suctioned the resident several times with clear sputum suctioned and elevated the head of his bed. The resident's lungs sounded clear in the lower lobes with rhonchi in the upper lobes. A nurse notified the physician at 4:02 a.m. and 911 at 4:05 a.m., with 911 arriving at 4:10 a.m. and leaving with the resident at 4:18 a.m. to take him to the hospital. At 10:03 a.m. hospital staff notified the facility Resident #17 admitted to the hospital with [REDACTED]. The facility received a fax from the physician regarding the fax sent Sunday 1/27/19 recommending to call the on-call doctor on weekends or at night. A History and Physical dated 1/28/19 documented the resident reportedly developed an intermittent fever in the last 24-48 hours. At approximately 3:30 a.m. nursing staff found the resident with labored breathing and an initial oxygen saturation of 70% on room air. The rescue squad was called and placed the resident on non re-breather. Oxygen sats improved to 95%. A [MEDICATION NAME] nebulizer treatment was administered enroute and oxygen titrated to 8 liters via mask. In the emergency room the resident had a temp of 102.3 degrees, was [MEDICAL CONDITION] (heart rate over 100), but normotensive (normal blood pressure). Chest X-ray suggested pneumonia. Antibiotics were administered intravenously and the resident admitted to the hospital. A Discharge Summary dated 1/30/19 documented the resident's discharge [DIAGNOSES REDACTED]. During an interview on 2/19/19 at 8:10 a.m. the Director of Nursing (DON) stated the nurse working the weekend of the 1/27/19 worked a weekend package and probably didn't think about the doctor not getting the fax to the office until the next day. She said the nurse should have picked up the phone and called the on-call physician. She said the physician may have told them to continue the Tylenol for the elevated temp, or maybe ordered a portable chest x-ray. She did not know what they would have said. During an interview on 2/19/19 at 10:35 a.m. Staff A Registered Nurse (RN) stated she worked the weekend of 1/25 to 1/27/19. She stated she felt she took good care of the resident that weekend. She said he did run a temp but it was warm in his room and he did not show any symptoms except fever. Staff A stated Resident #17 had general malaise and fever and she thought he had something [MEDICAL CONDITION]. She said she only faxed the physician because the resident's parent requested a test for influenza. The resident had a cough on and off but was in no distress. She stated the physician response to her fax probably meant she should have called on the resident's condition. In retrospect, she thought she should have called but she was shocked when she found out he was hospitalized . She was aware the physician would not get the fax until the following day. During an interview on 2/19/19 at 12:09 p.m. the Assistant Director of Nursing (ADON) stated it is very subjective when to call the doctor. He said if a resident had a fever during physician working hours they would notify the physician. He said it would be life or death to notify the physician on off hours. He said they would not be able to get antibiotics until Monday (if on the weekend). When asked if the facility had an emergency box, he said the facility would have some antibiotics in the emergency med box. He then changed his earlier statement saying it would not have to be life or death to call the doctor on off hours. He said if the doctor recommended to call the doctor on call on the fax sent on 1/27/19, they should have called rather than faxing. A Suspected LRI (lower respiratory tract infection) SBAR (situation, background, assessment, and recommendations) form (communication tool between caregivers) found in the facility Antibiotic Stewardship Program manual indicated if criteria were met a resident may have a lower respiratory tract infection including: a. The resident had a fever of 102 degrees or higher and a new or worsened cough (the resident had a fever of 103.2 degrees and sounded congested and coughing 1/26/19 at 6:55 a.m.). b. The resident had a fever of at least 100 degrees and less than 102 degrees, a cough, and a pulse greater than 100 (the resident had documented elevated temp, pulse, and cough). The document indicated if criteria were met a resident may have a lower respiratory tract infection and need a prescription for an antibiotic. The facility did not complete an SBAR for the resident. During an interview regarding infection control and antibiotic stewardship on 2/20/19 at 10:03 a.m. the Assistant Director of Nursing (ADON) stated they use the McGreer's criteria (criteria to indicate infection) for urinary tract infections (UTI's), but not the respiratory infections because their population is so susceptible to respiratory infection and they could not wait that long for treatment or they got too sick. The facility had no other policies or protocols on parameters for calling the physician for a change in condition. During an interview on 2/20/19 at 11:05 a.m. the resident's physician stated it was never a bad idea to call the doctor on the weekend or nights if needed for a change in condition. He said if a resident had a low grade temp, 100 or lower, he may just have the facility monitor the resident. He said with a temp of 103.2 he would want to be notified and would probably have started antibiotics. The physician could not speculate if Resident #17's hospitalization could have been avoided if antibiotics were started earlier.

Based on clinical record review and staff interview, the facility failed to ensure one of one sampled resident's (Resident #30) continued use of an as needed (PRN) medication showed an approved rationale for use. The facility reported a census of 31 residents. Findings include: According to Resident #30's Minimum Data Set (MDS) assessment dated [DATE] indicated he had a Brief Interview for Mental Status score of 15 indicating no cognitive impairment. The MDS listed [DIAGNOSES REDACTED]. The MDS indicated he received daily antipsychotic, antianxiety, and antidepressant medications in the last 7 days. Review of Resident #30's care plan with a review date of 2/8/19 revealed the resident's risk for injuring himself because he had [MEDICAL CONDITION], had a change in environment, and an unexpected loss of abilities. Resident #30 stated thoughts that he would be better off dead but he did not have a clear plan at the time and had no intent to harm himself at this time. The care plan directed staff to assist with creating a dignity plan, evaluate effectiveness of medications and refer him to his psychiatrist. Staff should be aware of his stressors and offer him choices. It encouraged therapeutic recreational staff to provide him with his favorite things. Review of Resident #30's physician's orders [REDACTED]. The Medication Regimen Review (MRR) dated 1/22/19 addressed the use of PRN [MEDICATION NAME] 0.25 mg BID PRN for anxiety and indicated no use since ordered over 30 days ago. The physician checked continue PRN [MEDICATION NAME] as ordered for a duration of 6 months. The document identified that **Per regulations, clinical rationale is required. This part of the document had been left blank. The physician signed and dated the form on 1/30/19. Review of Resident #30's Medication Administration Record [REDACTED]. During interview on 2/19/19 at 12:12 PM the Assistant Director of Nursing (ADON) stated Resident #30 has not received the PRN since being here. During interview on 2/19/19 at 2:30 PM the Director of Nursing (DON) stated he talks with the resident's physician every other week about how he is feeling. The physician bases his decisions on what he tells him.

Based on clinical record review and staff interview, the facility failed to have a resident's primary physician individually address [MEDICAL CONDITION] medications individually during a medication regimen review for one of five residents reviewed (Resident #21). The facility reported a census of 31 residents. Findings include: According to Resident #21's Minimum Data Set (MDS) assessment dated [DATE], she had a Brief Interview of Mental Status (BIMS) score of 10 indicating moderate cognitive impairment. The MDS indicated Resident #21 was not currently considered by the state level II Preadmission Screening and Resident Review (PASRR) process to have a serious mental illness and/or intellectual disability or a related condition. The MDS listed [MEDICAL CONDITION] as a [DIAGNOSES REDACTED]. Resident #21 received daily antipsychotic, antianxiety, antidepressant and hypnotic medications during the 7-day review period. Review of Resident #21's care plan with a review date of 1/17/19 revealed she had the potential to feel anxious, depressed, sad, confused or forgetful because she had a [MEDICAL CONDITION], a diagnosed mood disorder and had lost some of her independence. She is currently grieving that loss and had episodes of depression. The care plan indicated Resident #21 took [MEDICAL CONDITION] medications and had a history of [REDACTED]. Review of Resident #21's physician's orders [REDACTED]. a. [MEDICATION NAME] (antianxiety) 15 milligrams (mg) twice a day (BID) initiated on 1/18/18; b. [MEDICATION NAME] (antidepressant) 40 mg at bedtime initiated on 1/18/18; c. [MEDICATION NAME] (anticonvulsant but can be used to aid in mood disorders) 200 mg at bedtime initiated on 1/18/18; d. [MEDICATION NAME] (antipsychotic) 25 mg BID initiated on 3/2/18. A Medication Regimen Review (MRR) dated 7/13/18 listed the following medications for review: [MEDICATION NAME] and Nudexta. The physician checked no, a dosage reduction is contraindicated. The use of this medication is in accordance with relevant current standards of practice. The form asked for a specific explanation below and if an explanation for contraindication is not provided, a state surveyor may contact you to obtain this information during the annual survey. The physician documented the last reduction led to suicidal ideation and decompensation and he signed and dated the form on 7/20/18. The form did not address each of the resident's [MEDICAL CONDITION] medications individually. A Medication Regimen Review (MRR) dated 1/22/19 listed the following medications for review: [MEDICATION NAME], and [MEDICATION NAME]. The physician checked no, a dosage reduction is contraindicated. The use of this medication is in accordance with relevant current standards of practice. The form asked for a specific explanation below and if an explanation for contraindication is not provided, a state surveyor may contact you to obtain this information during the annual survey. The physician documented the plan to see Resident #21 the following month and the resident had increased suicidal tendencies last time dose was reduced (verified by the Assistant Director of Nursing (ADON) as the handwriting was not clear). The physician signed and dated the form on 2/18/19. The form did not address each of the resident's [MEDICAL CONDITION] medications individually. On 2/19/19 at 2:30 PM the Director of Nursing (DON) stated she did not know medications needed to be addressed individually when reviewed.

Based on clinical record review and staff interviews, the facility failed to notify the physician of a change in condition for one of five residents reviewed (Resident #17). The facility reported a census of 31 residents. Findings include: According to the Minimum Data Set (MDS) assessment dated [DATE], Resident #27 demonstrated short term memory problems and severely impaired skills for daily decision making. The resident could not speak and depended on staff assistance for all activities of daily living. He required a catheter for urination and a feeding tube. The resident's [DIAGNOSES REDACTED]. The Nurse's Notes dated 1/26/19 at 1:58 p.m. documented the resident had occasional labored breathing, short periods of hyperventilation, repeated troubled calling out, loud moaning or groaning, crying, moaning and coughing a lot, sad, frightened, frowned, and with facial grimacing. At 6:55 a.m. the resident had a temperature (temp) of 103.2 degrees temporally, and his heart rate measured 130 beats per minute (normal rate is 60-100 beats per minute) . At 7:05 a.m. the resident received [MEDICATION NAME] and [MEDICATION NAME] DM (cough suppressant/[MEDICATION NAME]), via the gastric tube and a cool washcloth on his head. At 8:07 a.m. the resident's temp came down to 98.9 and his heart rate to 113, with an oxygen (O2) saturation (sat) level measuring 94-95% on room air (a normal reading is at or above 90%). At 11:35 a.m. the resident moaned a little bit again. At 11:45 a.m. staff gave Tylenol as the resident appeared uncomfortable/having discomfort. An hour later, his temp measured 97.7 and the resident appeared to rest comfortably. Respiratory findings included a nonproductive, congested cough. The facsimile to the physician dated 1/27/19 at 9:28 a.m. regarding a change in the resident's condition documented on 1/25/19 at 11:40 p.m. the resident had an elevated temp of 101.4 degrees and received as needed (PRN) Tylenol at 11:48 p.m. At 12:59 the temp came down to 98.3. On 1/26/19 at 6:55 a.m. the resident had a very red face and his temp registered 103.2 degrees, blood pressure 124/84, pulse 130, respirations 18, and oxygen saturation 94%. The resident received Tylenol and [MEDICATION NAME] DM (he sounded congested and coughing). At 8:07 a.m. the resident's temp went down to 98.9 and his heart rate to 113. The resident's temps registered 97.4 at 11:35 a.m. and 98.5 at 3:45 p.m. The resident received Tylenol at 11:45 a.m. with temp 97.7 at 12:50 p.m. and 98.5 at 3:45 p.m. and down to 97.9. Early in the morning, 1/27/19 at 1:05 a.m., the resident spiked a temp of 100.3 and the night nurse gave the resident Tylenol. At 2 a.m. the resident had a temp of 100 and at 3 a.m. a temp of 99.3. At 7:09 a.m. the resident had a temp of 98.7 and heart rate of 119. The oxygen saturation was 93%. Tylenol given at 7:14 a.m. with temp down to 97.9 at 8:22 a.m. The resident continued not to feel well and moaned out when he coughed. He did not sound congested anymore. Staff attempted to assess the resident's throat but he was not very cooperative. The resident's parent wanted to see if he needed a swab to test for influenza. The resident's lung sounds were clear in all fields. Staff asked for any suggestions other than Tylenol every 4 hours. The Nurse's Notes dated 1/28/19 at 5:11 a.m. documented at 4 a.m. the nurse walked by the resident's room and heard him breathing loudly. The resident was pale and diaphoretic, with O2 sats in the mid 50's. Staff called for a nurse to assess the resident and another nurse to bring oxygen. Staff placed oxygen on at 10 liters via non re-breather and the resident's O2 sats ranged from 87-94%. Staff suctioned the resident several times with clear sputum suctioned and elevated the head of his bed. The resident's lungs sounded clear in the lower lobes with rhonchi in the upper lobes. A nurse notified the physician at 4:02 a.m. and 911 at 4:05 a.m., with 911 arriving at 4:10 a.m. and leaving with the resident at 4:18 a.m. to take him to the hospital. At 10:03 a.m. hospital staff notified the facility Resident #17 admitted to the hospital with [REDACTED]. The facility received a fax from the physician regarding the fax sent Sunday 1/27/19 recommending to call the on-call doctor on weekends or at night. A Discharge Summary dated 1/30/19 documented the resident's discharge [DIAGNOSES REDACTED]. During an interview on 2/19/19 at 8:10 a.m. the Director of Nursing (DON) stated the nurse working the weekend of the 1/27/19 worked a weekend package and probably didn't think about the doctor not getting the fax to the office until the next day. She said the nurse should have picked up the phone and called the on-call physician. She said the physician may have told them to continue the Tylenol for the elevated temp, or maybe ordered a portable chest x-ray. She did not know what they would have said. During an interview on 2/19/19 at 10:35 a.m. Staff A Registered Nurse (RN) stated she worked the weekend of 1/25 to 1/27/19. She said she only faxed the physician because the resident's parent requested a test for influenza. The resident had a cough on and off but was in no distress. She stated the physician response to her fax probably meant she should have called on the resident's condition. In retrospect, she thought she should have called but she was shocked when she found out he was hospitalized . She was aware the physician would not get the fax until the following day. During an interview on 2/20/19 at 11:05 a.m. the resident's physician stated it was never a bad idea to call the doctor on the weekend or nights if needed for a change in condition. He said if a resident had a low grade temp, 100 or lower, he may just have the facility monitor the resident. He said with a temp of 103.2 he would want to be notified and would probably have started antibiotics.

Based on clinical record review and staff interviews, facility staff failed to resubmit the proper paperwork for Preadmission Screening and Resident review after a resident's short-term nursing facility approval expired (Resident #21). The facility reported a census of 31 residents. Findings include: According to Resident #21's Minimum Data Set (MDS) assessment dated [DATE], she had a Brief Interview of Mental Status (BIMS) score of 10 indicating moderate cognitive impairment. The MDS indicated Resident #21 was not currently considered by the state level II Preadmission Screening and Resident Review (PASRR) process to have a serious mental illness and/or intellectual disability or a related condition. The MDS listed [MEDICAL CONDITION] as a [DIAGNOSES REDACTED]. Resident #21 received daily antipsychotic, antianxiety, antidepressant and hypnotic medications during the 7-day review period. Review of Resident #21's care plan with a review date of [DATE] revealed she had the potential to feel anxious, depressed, sad, confused or forgetful because she had a [MEDICAL CONDITION], a diagnosed mood disorder, had lost some of her independence. She is currently grieving that loss and had episodes of depression. The care plan indicated Resident #21 took [MEDICAL CONDITION] medications and had a history of [REDACTED]. Review of Resident #21's Ascend (a screening company) documentation with a date of determination of [DATE] revealed a PASRR Notice of Short-Term Nursing Facility Approval with an expiration date of [DATE]. Resident #21's clinical record lacked a new PASRR evaluation. On [DATE] at 8:40 AM, the Director of Nursing (DON) stated they were waiting on the status of Resident #21's Medicare approval before submitting the new paperwork. During interview on [DATE] at 10:04 AM, the Social Worker stated she submitted a new form to Ascend for Resident #21.

Based on clinical record review and staff interviews, the facility failed to care plan specialized services documented in PASSAR (Pre Admission Screening and Resident Review) Level 2 approval for two of two residents reviewed (Residents #5 and #30). The facility reported a census of 31 residents. Findings include: 1. Resident #5's Minimum Data Set (MDS) assessment dated [DATE] recorded the resident had severe impairment with cognitive skills for daily decision making. The assessment documented [DIAGNOSES REDACTED]. The PASSAR assessment dated [DATE] identified the need for specialized services including ongoing psychiatric services by a psychiatrist to evaluate the response and effectiveness of [MEDICAL CONDITION] medications on target symptoms, to modify the resident's medication orders and to evaluate the ongoing need for additional behavioral health services. Review of the resident's care plan dated 12/6/18 showed an intervention to contact his physician with updates or any changes in condition, to notify a specific physician (not the resident's primary provider) of any need to change medications and for the specified physician to evaluate the effectiveness of medications and assess for the potential to eliminate or decrease them. Resident #5's care plan did not identify the specified physician as a psychiatrist, did not show when services began, how often services would be provided or the duration of services to be provided. In review of American Board of Psychiatry and Neurology certification report showed the specified physician to be a psychiatric specialist. In review of Resident History and Physical dated 11/21/18 showed [DIAGNOSES REDACTED]. A Psychiatric Evaluation dated 12/10/18 showed the physician (the resident's psychiatrist) asked for a follow up visit with Resident #5 in one month. Nursing documentation dated 1/7/19 showed staff spoke with the resident's psychiatrist, updated him on resident's current condition and he would evaluate Resident #5 the next time he is in Ankeny. In an interview on 2/19/19 at 8:20 AM, the Director of Nursing (DON) stated the facility has not heard anything from the psychiatrist's office for another appointment since the 1/7/19 communication and Resident #5 had not had an appointment since 12/10/18. At 3:43 PM with DON stated the facility does not care plan initiation of psychiatric treatment, duration of treatment or frequency of treatment. The DON stated no one had told the facility they need to do this and the facility only keep tracks of appointments, but does not care plan them. 2. According to Resident #30's MDS assessment dated [DATE], the resident had a Brief Interview for Mental Status score of 15 indicating no cognitive impairment. The MDS listed [DIAGNOSES REDACTED]. The MDS indicated he received daily antipsychotic, antianxiety, and antidepressant medications during the 7-day review period. Review of Resident #30's care plan with a review date of 2/8/19 revealed he is at risk for injuring himself because he has [MEDICAL CONDITION], had a change in environment, and an unexpected loss of abilities. He has stated thoughts that he would be better off dead but does not have a clear plan at this time and does not intend to harm himself at this time. The care plan directed staff to assist with creating a dignity plan, evaluate effectiveness of medications and refer him to his psychiatrist. Staff should be aware of his stressors and offer him choices and therapeutic recreational staff to provide him with his favorite things. Review of Resident #30's Ascend (screening company) documentation with a date of determination of 5/9/18 revealed a PASRR Notice of Nursing Facility Approval with the following identified specialized services listed: ongoing psychiatric services by a psychiatrist to evaluate the response and effectiveness of [MEDICAL CONDITION] medications on target symptoms, to modify the resident's medication orders and to evaluate the ongoing need for additional behavioral health services. The care plan lacked the recommendations in reference to who provided the services, the start date of services, the frequency of services and anticipated duration of services. During an interview on 2/19/19 at 2:30 PM the DON stated Resident #30 was initially evaluated by the psychiatrist with an office by their other location (Ankeny). She confirmed that Resident #30 attended weekly clinical counseling sessions here and speaks with his primary physician every other week.