Every finding on record at Onyx Care of Farmerville

Based on observations, interviews, and record review the facility failed to ensure residents who were unable to carry out activities of daily living received the necessary services to maintain good personal hygiene. The facility failed to ensure a resident's hair was washed and brushed in a timely manner for 1 (#43) of 3 residents reviewed for activities of daily living. Findings:Record review revealed Resident #43 was admitted to the facility on [DATE]. Resident #43's diagnoses included respiratory failure unspecified, unspecified whether with hypoxia or hypercapnia, hypothyroidism, need for assistance with personal care, muscle weakness (generalized), other abnormalities of gait and mobility, type 2 diabetes mellitus with hyperglycemia, anemia, constipation, depression, unspecified diastolic (congestive) heart failure, unspecified asthma, insomnia, severe morbid obesity due to excess calories, anxiety disorder, essential (primary) hypertension. Review of the quarterly MDS assessment dated [DATE] revealed a BIMS score of 15 which indicated Resident #43 was cognitively intact for activities of daily decision making. Further review revealed Resident #43 was dependent on toileting hygiene, shower/bathe, dressing upper and lower body. Resident #43 required setup or clean up assistance with personal hygiene. Review of Resident #43's care plan revealed she had an ADL self-care performance deficit and interventions that included bath/showering and personal hygiene/oral care, both 1 person assist. On 08/10/2026 at 10:00 a.m. an interview with Resident #43 reported she would like to have her hair washed at least once a week, but it has been about 1 month since she had her hair washed. An observation of Resident #43's hair revealed it was slightly oily, unbrushed, and matted in the back. On 08/11/2026 at 9:00 a.m. an observation of Resident #43's hair revealed it was slightly oily, unbrushed, and matted in the back. Resident #43 reported her hair still has not been washed. On 08/11/2026 at 10:00 a.m. an observation conducted with S2DON revealed Resident #43's hair was slightly oily, unbrushed, and matted. An interview with Resident #43 at this time revealed the last time her hair was washed was a month ago. Resident #43 reported she had a wash basin, shampoo, and conditioner in her room. S2DON confirmed Resident #43's hair needed to be washed and brushed.

Based on record review, observations, and interviews, the facility failed to ensure that a resident with an indwelling urinary catheter received the appropriate care and services to prevent urinary tract infections to the extent possible for 1(#7) of 1 resident reviewed for urinary catheters.Findings:Review of the record for Resident #7 revealed an admission date of 05/14/2021 with diagnoses including quadriplegia unspecified, dysuria, neuromuscular dysfunction of bladder, urinary tract infection, bladder disorder, other seizures, chronic pain syndrome, and retention of urine. Review of the Modification of Quarterly MDS assessment dated [DATE] revealed a BIMS score of 15 indicating no cognitive impairment. Further review of the MDS revealed the resident was dependent on staff for all ADLs and had an indwelling urinary catheter. Interview on 08/10/2026 at 9:09 a.m. with Resident #7 revealed she had a urinalysis done last week but had not been notified of the results. Observation at that time revealed cloudy amber urine noted in her catheter tubing. Observations on 08/11/2026 at 10:45 a.m. and 08/12/2026 at 9:58 a.m. of Resident #7 revealed cloudy urine with sediment was noted in the resident's catheter tubing.Interview on 08/12/2026 at 9:50 a.m. with Resident #7 revealed she was having burning in her vaginal area. Review of Resident #7's August 2026 physician's orders revealed an order dated 06/11/2026 to document urine clarity, urine color, and urine odor every shift. Review of Resident #7's August 2026 MAR revealed the following documentation: urine clear on 08/10/2026 and 08/11/2026 (2 shifts each day); and urine clear on 08/12/2026 for the a.m. shift. Further review revealed staff failed to document any sediment in urine on 08/11/2026 and 08/12/2026 for urine clarity.Interview on 08/12/2026 at 9:58 a.m. with S9Treatment RN confirmed through observation with surveyor that Resident #7's urine in her catheter tubing was cloudy with sediment observed. Review of a written verbal order dated 08/05/2026 revealed a urinalysis with culture and sensitivity was ordered; however, this order was not located until the evening of 08/12/2026.Interview on 08/12/2026 at 10:08 a.m. with S9Treatment RN confirmed there was no documented evidence of an order in the nurses notes related to a urinalysis with culture and sensitivity for Resident #7 for the week of 08/03/2026. S9Treatment RN obtained the urinalysis with culture and sensitivity results dated 08/07/2026 for Resident #7 from S2DON on 08/12/2026. Review of the urinalysis dated 08/07/2026 for Resident #7 revealed the urine was collected on 08/07/2026 and dipstick results showed urine was red, cloudy appearance, 3+ leukocyte esterase, 3+ blood, and culture needed.Review of the urine culture and sensitivity final results for Resident #7 dated 08/07/2026 revealed pathogens detected were Enterococcus faecalis, Escherichia coli, and Proteus mirabilis. Interview on 08/12/2026 at 2:05 p.m. with S7NP revealed she was notified on 08/12/2026 of the results of Resident #7's urinalysis with culture and sensitivity results for 08/07/2026. S7NP reported she started Resident #7 on Cipro 500 milligrams by mouth two times a day for 7 days for a urinary tract infection.Interview on 08/13/2026 at 8:10 a.m. with S3Corporate RN revealed the written order for Resident #7 to have a urinalysis with culture and sensitivity dated 08/05/2026 was found on the evening of 08/12/2026.Interview on 08/13/2026 at 4:43 p.m. with S2DON and S3Corporate RN confirmed the following:-S8LPN failed to input verbal order for urinalysis with culture and sensitivity on 08/05/2026 into PCC on Resident #7 and S8LPN failed to document obtaining the urinalysis in the nurses' notes,-facility failed to obtain urinalysis with culture and sensitivity and ensure an antibiotic was ordered in a timely manner (ordered 08/05/2026- collected on 08/07/2026 - antibiotic started on 08/12/2026),-nurses failed to accurately assess urine on 08/10/2026, 08/11/2026, and 08/12/2026 (Nurses documented urine was clear and yellow all 3 days), and -failed to notify nurse practitioner of urinalysis with culture and sensitivity results from 08/07/2026 (facility did not notify until 08/12/2026 when surveyor inquired about urinalysis with culture and sensitivity results).

Based on record reviews and interviews, the facility failed to ensure that laboratory levels were completed as ordered for 1 (#73) of 5 residents reviewed for unnecessary medications.Findings:Review of the record for Resident #73 revealed an admission date of 11/03/2025 with diagnoses that included type 2 diabetes mellitus, insomnia, unspecified mood disorder, cerebrovascular disease, edema, hypertension, depression, and seizure disorder.Review of the quarterly MDS assessment dated [DATE] revealed a BIMS score of 15 which indicated Resident #73 was cognitively intact with daily decision making. Further review revealed Resident #73 received anticonvulsant medication.Review of the physician's orders revealed an order dated 11/03/2025 for a zonisamide level every 6 months due in November and April. Review of the medical record for Resident #73 revealed no documented evidence to support the zonisamide level was collected in April 2026.On 08/13/2026 at 10:28 a.m., S2DON confirmed the zonisamide level was not completed as ordered in April 2026.

Based on record review and interviews, the facility failed to provide access to a copy of the resident's medical record within the required time frames for 1 (#24) of 1 resident reviewed for resident rights. Findings:Review of the facility's Medical Records Processing Policy dated 09/20/2023 revealed in part:Policy Description: Authorization for disclosure of Protected Health Information (PHI) referred to as a request for medical records or health information.Policy: Residents or their personal representative are entitled to obtain a copy of their medical records upon receipt of a written authorization signed by the resident or his/her personal representative.Procedure: 2. All information contained in the resident's medical record is confidential and may only be released with written consent of the resident or his/her legal representative, consistent with federal and state laws and regulations.4. A resident has the right to see your medical records within 24 hours of your request. A resident may have copies of his/her records within 48 hours if currently admitted to the facility. Past residents may have access within 30 days of discharge. Excluding weekends or holidays.5. After receiving a completed Authorization for Disclosure of Protected Health Information (PHI) form a fax sheet should be generated and all documents should be grouped together as a single document. The facility administrator or designee will then upload the document to LINK. Record review revealed Resident #24 was admitted to the facility on [DATE]. Resident #24's diagnoses included unspecified severe protein-calorie malnutrition, acute respiratory failure, unspecified whether with hypoxia or hypercapnia, stage 3 pressure ulcer left buttocks, type 2 diabetes mellitus without complications, seizures, hypertension, generalized anxiety disorder, dyspnea, constipation, gastrostomy status, personal history of UTI, and sepsis unspecified organism. Review of admission MDS assessment dated [DATE] revealed a BIMS score of 7 which indicated Resident #24 had severe cognitive impairment for daily decision making. Resident #27 received hospice services. Further review of the medical record revealed Resident #24's family member was listed as care conference person and #1 emergency contact. On 08/10/2026 at 11:06 a.m., interview with Resident #24's family member revealed he had spoken with the S1Administrator on Monday, 08/03/2026, and requested a copy of Resident #24's medical records. Resident #24's family member reported S1Administrator told him it would take 48 hours to get a copy of the medical records. Resident #24's family member reported he spoke with S1Administrator again on Wednesday, 08/05/2026, and was informed the medical records were not ready yet. On 08/12/2026 at 1:48 p.m., telephone interview with S1Administrator revealed she was responsible for resident medical record requests. Resident #24's family member requested a copy of all of Resident #24's medical records on 08/03/2026. S1Administrator reported she had Resident #24's family member sign the authorization for disclosure of protected Health Information (PMI) form on 08/03/2026 according to their policy. S1Administrator confirmed Resident #24's medical records were not released within 48 hours after the signed request for the release of medical records. S1Administrator further confirmed a copy of Resident #24's medical records have not been released.

Based on record reviews and interviews, the facility failed to ensure it had sufficient nursing staff with appropriate competencies and skills sets to provide nursing and related services by staff failing to administer medication as ordered for 1 (#73) of 5 residents reviewed for unnecessary medications.Findings:Review of the record for Resident #73 revealed an admission date of 11/03/2025 with diagnoses that included type 2 diabetes mellitus, insomnia, unspecified mood disorder, cerebrovascular disease, edema, hypertension, depression, and seizure disorder.Review of the quarterly MDS assessment dated [DATE] revealed a BIMS score of 15 which indicated Resident #73 was cognitively intact with daily decision making.Review of the physician's orders revealed an order dated 11/11/2025 for semaglutide 2 mg subcutaneously one time a day every Friday.Review of the July and August 2026 MARs revealed semaglutide was not administered as ordered on 07/31/2026 and 08/07/2026.On 08/13/2026 at 10:28 a.m., S2DON confirmed semaglutide was not administered as ordered on 07/31/2026 and 08/07/2026 for Resident #73.

Based on record reviews and interviews, the pharmacist failed to identify and report irregularities to the attending physician, the facility's medical director, and director of nursing for 1 (#73) of 5 residents reviewed for unnecessary medications.Findings:Review of the record for Resident #73 revealed an admission date of 11/03/2025 with diagnoses that included type 2 diabetes mellitus, insomnia, unspecified mood disorder, cerebrovascular disease, edema, hypertension, depression, and seizure disorder.Review of the quarterly MDS assessment dated [DATE] revealed a BIMS score of 15 which indicated she was cognitively intact with daily decision making. Further review revealed Resident #73 received an anticonvulsant medication.Review of the physician's orders revealed an order dated 11/03/2025 for a zonisamide level every 6 months due in November and April.Review of the CPOC revealed Resident #73 had a seizure disorder with interventions which included obtain and monitor lab/diagnostic work as ordered.Review of the medical record for Resident #73 revealed no documented evidence to support the zonisamide level was collected in April 2026.Review of the consultant pharmacist medication regimen reviews dated 05/13/2026, 06/14/2026, and 07/09/2026 for Resident #73 revealed no documented evidence to support the pharmacist addressed the zonisamide level was not collected in April 2026.On 08/13/2026 at 10:28 a.m., S2DON confirmed the zonisamide level was not completed as ordered in April 2026 for Resident #73. S2DON further confirmed that the pharmacist did not identify the zonisamide level was not completed as ordered.

Based on observation and interview, the facility failed to distribute and serve food in accordance with professional standards for food service safety for 2 (#33, #34) residents observed during dining observation.Findings:Resident #33On 08/10/2026 at 12:00 p.m. S6CNA was observed touching Resident #33's hamburger bun with her bare hand while she was cutting up his hamburger. On 8/11/2026 at 4:40 p.m. an interview with S6CNA revealed she served lunch to Resident #33 on 08/10/2026 and she confirmed she touched Resident #33's hamburger bun with her bare hand while she was cutting up his hamburger. Review of the Educational In-Service Record dated 07/07/2026 revealed the in-service addressed that staff should not touch the residents' food with their hands. Further review revealed S6CNA's signature was on the sign-in sheet for the in-service which indicated she attended the training. On 08/12/2026 at 2:00 p.m., an interview with S5Regional Dietician revealed the facility dietary manager resigned about a week ago and she was filling in as manager. S5Regional Dietician was informed of the above observation of S6CNA during the lunch meal on 08/10/2026. S5Regional Dietician confirmed that S6CNA should not have touched the resident's food with her bare hand while cutting up the resident's hamburger. On 08/13/2026 at 4:00 p.m during an interview, S2DON confirmed S6CNA should not have touched Resident #33's food with her bare hands. Resident #34On 08/10/2026 at 12:00 p.m. S6CNA was observed holding a covered bowl of jello in her left hand and the bowl was touching her shirt when she walked over to the resident's table. S6CNA served Resident #34 the bowl of jello that came in contact with her clothing. On 8/11/2026 at 4:40 p.m., an interview with S6CNA revealed she served lunch to Resident #34 on 08/10/2026 and she confirmed she held the resident's bowl of jello against her clothing and should not have. Review of the Educational In-Service Record dated 07/07/2026 revealed the in-service addressed that staff should not touch the residents' food with their hands. Further review revealed S6CNA's signature was on the sign-in sheet for the in-service which indicated she attended the training.On 08/12/2026 at 2:00 p.m. the surveyor informed S5Regional Dietician of the above observation of S6CNA during the lunch meal on 08/10/2026. S5Regional Dietician confirmed that S6CNA should not have held the resident's bowl of jello against her clothing. On 08/13/2026 at 4:00 p.m during an interview, S2DON confirmed S6CNA should not have held Resident #34's bowl of jello against her clothing.

Based on observations and interviews, the facility failed to store food and discard expired items in accordance with professional standards for food service safety. This deficient practice had the potential to effect the 63 residents that received meals prepared in the facility's kitchen. Findings: Review of the facility's Food Storage and Sanitation of Dining and Food and Nutrition Areas policies dated 2016 revealed, in part, the following: Food Storage (Dry, Refrigerated, and Frozen) Guideline: Food shall be stored on shelves in a clean, dry area, free from contaminants. Food shall be stored at appropriate temperatures and using appropriate methods to ensure the highest level of food safety. Procedure: 1. General storage guidelines to be followed: a. Rotate products so the oldest are used first. Staff shall be instructed to use products with the earliest expiration date before those with a later expiration date. b. Discard food that has passed expiration date, and discard food that has been prepared in the facility after seven days of storing under proper refrigeration. Sanitation of Dining and Food and Nutrition Areas Guideline: The Food and Nutrition Services staff will uphold sanitation of the dining areas according to a thorough, written schedule. Procedure: The Director of Food and Nutrition Services will record the necessary cleaning and sanitation tasks for the department. 1. Tasks will be designated to specific departmental positions. 2. Staff will be trained on the frequency of cleaning. 3. Proper sanitizing solution will be used by staff when prescribed. 4. A cleaning schedule will be posted for cleaning tasks. Staff will initial the tasks as they are completed. On 06/23/2025 at 8:20 a.m., during an initial tour of the kitchen revealed the following: -walk in freezer: 8 packages of ground beef were observed stored directly on the lower right freezer shelf and not contained in a bin. Below the rack, old food spills and trash were noted on the floor. It was also noted that there was a large accumulation of ice in the upper right corner of the freezer. -large rolling cart was observed near the food preparation area with 2 gallons of expired milk as well as multiple small cartons of expired milk. Additionally, a large bin was observed filled with various lids not stored properly. The lids were stacked on top of each other. -large boiler with lid with yellow drip stains was stored on a table near the deep fryer; -large conveyor toaster had old food particles between the racks; -2 large commercial ovens had dark stain build-up on inside of door and inside both ovens; -the lower compartment of the deep fryer revealed a build-up of grease; -bin with individual tea bags was noted to have old food spills and grime near the handle; -bin with individual coffee packets was noted to have trash and old food in the handle; and -8 large baking sheets with heavy carbon build-up On 06/23/2025 at 12:30 p.m., S8Dietary Manager and S11 Regional Registered Dietician were informed of the issues above and confirmed the areas needed attention.

Resident #46 Review of the medical record for resident #46 revealed an admission date of 11/15/2022. Resident #46 had diagnoses including cerebral infarction, encephalopathy, cerebral aneurysm, occlusion and stenosis of vertebral artery, dementia, depression and anxiety. Review of the quarterly MDS assessment dated [DATE] revealed Resident #46's BIMS score of 00 which indicated severely impaired cognitive skills for daily decision making. Review of the June 2025 physician orders dated 09/03/2024 revealed an order for Resident #46 to use a geri chair while out of bed due to poor trunk control and reposition every two hours with range of motion and toileting. Review of the current care plan revealed Resident #46 used a geri chair for poor trunk control. Resident #46 will sit in a geri chair on bath days, may occasionally refuse to get up to chair, and stays up in chair for short periods of time. On 06/23/2025 at 11:50 a.m. and on 06/25/2025 at 10:00 a.m., Resident #46 was observed sitting in a reclined geri chair. On 06/25/2205 at 12:30 p.m., interview with S2DON confirmed there was no documentation of the staff repositioning Resident #46 every two hours while in the geri chair. Based on observations, record reviews, and interviews, the facility failed to ensure a resident was free from physical restraints imposed for the purpose of discipline or convenience for 2 (#46, #66) of 5 (#20, #32, #33, #46, #66) residents reviewed for restraints. The facility failed to ensure: 1.) a physician's order, pre-restraint assessment, and consent were obtained which resulted in the failure to identify the wheelchair seatbelt was a restraint (#66), 2.) staff monitored and released the specialized seatbelt as required (#66), and 3.) monitoring and repositioning was provided for a resident in a gerichair (#46). Findings: Resident #66 Review of the facility's policy Physician's Order for a Physical Restraint Device (undated) revealed the following: Policy: All residents requiring a physical restraint must have a Physician's Order. Responsibility: All Licensed Nursing Personnel Procedure: 1. Obtain a Physician's Order that includes the medical symptoms for the use of the restraint. 2. The order must state the type of restraint. 3. The resident's plan of care will include a release and reposition schedule, unless otherwise specified by state regulations. 4. The order must state when the restraint is to be worn. Review of the medical record for resident #66 revealed an admission date of 05/01/2025 with diagnoses that included severe intellectual disability, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, age related osteoporosis, and seizures. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 99 which indicated the resident was unable to complete the interview. Further review revealed the resident used a wheelchair for ambulation and had no trunk restraint. Review of Resident #66's medical record revealed there was no documentation the facility obtained a physician's order, pre-restraint assessment or consent for the resident's wheelchair seatbelt, which resulted in the failure to identify the wheelchair seatbelt as a restraint. Also, there was no documentation staff monitored and released his seatbelt as required. On 06/23/2025 at 9:45 a.m., observation revealed Resident #66 was in his specialized wheelchair and the seatbelt was unfastened with the straps hanging down on each side of his wheelchair. On 06/24/2025 at 11:32 a.m., observation revealed Resident #66 was in his bed in his room. The resident's wheelchair with a seatbelt was noted near his bed. An interview with S10Certified Nursing Assistant (CNA) revealed Resident #66 cannot remove his seatbelt on his own. S10CNA confirmed she had used his seatbelt while he was up in his wheelchair since he was admitted on [DATE]. On 06/24/2025 at 5:15 p.m., observation of Resident #66 with S5Unit Manager was conducted. She confirmed Resident #66 had a seatbelt attached to his specialized wheelchair, the straps were hanging down on each side of his wheelchair. S5Unit Manager revealed when Resident # 66 was recently admitted his wheelchair already had the seatbelt attached and most staff knew not to use it but S5Unit Manager confirmed she had observed new staff put his seatbelt on him. S5Unit Manager also confirmed Resident #66 cannot remove his seatbelt without assistance. On 06/24/2025 at 5:30 p.m., an interview with S2Director of Nursing (DON) confirmed there was no physician order, pre-restraint assessment, and no consent obtained. S2DON further confirmed there was no documentation that staff were releasing and monitoring Resident #66's wheelchair seatbelt as required.

Based on record review and interviews, the facility failed to ensure appropriate care and services consistent with professional standards of practice were implemented for 1 of 1 residents (#10) reviewed for dialysis. The facility failed to ensure Resident #10's dialysis access site was assessed and monitored every shift. Findings: Review of Resident #10's medical record revealed an admission date of 01/28/2025 with diagnosis which included, but not limited to congestive heart failure, end stage renal disease, osteomyelitis, amputation of bilateral below the knee, type 2 Diabetes, bipolar disorder, and morbid obesity. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident has a Brief Interview for Mental Status (BIMS) score of 7 which indicated the resident was cognitively impaired and needed assistance with activities of daily living. Review of Resident #10's current physician's order revealed an order for outpatient hemodialysis on Monday, Wednesday and Friday. Further review of Resident #10's medical record revealed she had a tunneled catheter to the right anterior chest wall and to be monitored each shift for bleeding and signs of infection. Review of the current care plan revealed an intervention to monitor, document and report any signs or symptoms of bleeding or infection to the access site. Review of the June 2025 Medication Administration Record revealed no documentation that the right chest wall access site was monitored each shift for bleeding and signs and symptoms of infection since the re-admission to the facility on [DATE]. Interview on 06/25/2025 at 1:30 p.m. with S5Unit Manager confirmed there was no documentation in the medical record that the dialysis site to the right chest wall was monitored for bleeding and signs and symptoms since her re-admission to the facility on [DATE].

Resident #20 Review of the medical record for sampled Resident #20 revealed an admission date of 09/06/2021. Resident #20 had diagnoses including hemiplegia, hemiparesis, diabetes mellitus, cerebral infarction, depression, and epilepsy. Review of the June 2025 physician orders revealed an order dated 01/31/2025 for bed rails to both side of the bed for increased bed mobility and positioning. Review of the quarterly MDS assessment dated [DATE] revealed Resident #20 had a BIMS score of 15 which indicated intact cognition for daily decision making, and was dependent on staff for toileting, showering and transfers. Review of the current care plan revealed the resident had bed rails to bilateral sides of the bed to assist with bed mobility. The interventions included the resident will use bed rails safely to assist with bed mobility and be free from injuries, and staff were to observe the resident using bed rails safely to assist with bed mobility. On 06/23/2025 at 2:47 p.m., 06/24/2025 at 8:10 a.m., and on 06/25/2025 at 12:10 p.m., observations of Resident #20 revealed she was in the bed with quarter bed rails raised on both side of the bed. Review of Resident #20's record revealed no documented evidence of a risk of entrapment assessment prior to the installation of the bed rails. On 06/24/2025 at 6:10 p.m., interview with S2DON confirmed there was no assessment for the risk of entrapment prior to the installation of bed rails for Resident #20. Resident #33 Review of Resident #33's medical record revealed an admission date of 12/01/2023 with diagnoses that included chronic obstructive pulmonary disease, cirrhosis of the liver, portal hypertension, seizures, and pain. Review of Resident #33's June 2025 physician orders revealed an order dated 05/29/2025 for assist rails to both sides of the bed for increased bed mobility and assistance with transfers, not a restraint, monitor for proper functioning each shift. Review of the quarterly MDS assessment dated [DATE] revealed Resident #33 had a BIMS score of 15 which indicated the resident was cognitively aware. Further review revealed Resident #33 needed minimal assistance with all activities of daily living. Review of Resident #33's care plan revealed he had quarter rails to the bilateral sides of the bed to assist with bed mobility. The interventions included use of quarter rails to assist with bed mobility, be free from injuries, staff to observe the resident using quarter rails safely, and to assist with bed mobility. Observations on 06/23/2025 at 9:30 a.m. and 06/24/2025 at 8:33 a.m. revealed bilateral quarter rails were in place on each side of Resident #33's upper bed. Review of Resident #33's record revealed no documentation of a risk of entrapment assessment prior to the installation of the bed rails. On 06/25/2025 at 3:30 p.m., interview with S2DON and S1Administrator confirmed there was no assessment for the risk of entrapment prior to installation of quarter bed rails for Resident #33. Based on observations, interviews, and record reviews, the facility failed to ensure residents were assessed for the risks of entrapment from bed rails prior to the installation of bed rails for 4 (#6, #20, #33, #38) of 4 (#6, #20, #33, #38) residents reviewed for accident hazards. Findings: Review of the facility's (undated) Side Rail Use Evaluation policy revealed in part: Policy: All residents will be evaluated for siderail use upon admission/readmission and reevaluation will be completed quarterly or upon a significant change in condition if siderails are utilized. DEFINITION: Bed rails are adjustable metal or rigid plastic bars that attach to the bed. They are available in a variety of types, shapes, and sizes ranging from full to one-half, one-quarter, or one-eighth lengths. Examples of bed rails include, but not limited to: Side rails, bed side rails, and safety rails; and Grab bars and assist bars Entrapment is an event in which a resident is caught, trapped, or entangled in the space in or about the bed rail. RESPONSIBILITY: All members of the Interdisciplinary Team PROCEDURE: 1. The resident's risk for entrapment should be assessed prior to installation of bedrails. 2. Complete the electronic Siderail Evaluation form (K.5a) or paper version if electronic not available. 3. Documentation should contain the following: a. Alternatives prior to implementation of any type of rail(s). b. Risks and benefits reviewed with resident/resident representative. c. Informed consent obtained from the resident/resident representative 4. Manufacturer's recommendations and specifications for installation and maintenance will be followed 5. The Comprehensive Care Plan will be reviewed/revised with changes. Resident #6 Review of Resident #6's medical record revealed an admission date of 10/19/2015 with diagnoses of dementia with behavioral disturbance, schizophrenia, delusional disorder, anxiety disorder, and essential primary hypertension. Review of Resident #6's June 2025 Physician's Orders revealed an order dated 03/06/2025 for quarter side rails to bilateral sides of the bed used as enablers to help turn and reposition while in bed and monitor for proper functioning every shift. Review of Resident #6's Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview Mental Status (BIMS) of 00 which indicated severe cognitive impairment. Further review of the MDS revealed Resident #6 had no impairment on both sides of upper and lower extremities. Review of Resident #6's care plan revealed he had quarter rails to the bilateral sides of the bed to assist with bed mobility. The interventions included the resident will use the quarter rails to assist with bed mobility and free from injuries and for staff to observe the resident using quarter rails safely to assist with bed mobility. Observations on 06/23/2025 at 9:30 a.m. and 06/24/2025 at 10:33 a.m. revealed bilateral quarter rails were in place on each side of Resident #6's upper bed. Review of Resident #6's record revealed no documentation of a risk of entrapment assessment prior to the installation of the bed rails. On 06/25/2025 at 4:00 p.m. interview with S2DON (Director of Nursing) and S1Administrator confirmed there was no assessment for the risk of entrapment prior to installation of quarter bed rails for Resident #6. Resident #38 Review of Resident #38's medical record revealed an admission date of 05/29/2020 with diagnoses of cerebral infarction with hemiplegia and hemiparesis affecting left non-dominant side. Review of Resident #38's June 2025 Physician's Orders revealed an order dated 02/27/2025 for bilateral quarter rails used as enablers to help turn and reposition while in bed. Review of Resident #38's Quarterly MDS assessment dated [DATE] revealed a BIMS of 15 which indicated no cognitive impairment. Further review of the MDS revealed Resident #38 had no impairment on both sides of upper and lower extremities. Review of Resident #38's care plan revealed he had quarter/assist rails to bilateral sides of the bed to assist with bed mobility. The interventions included the resident will use the quarter/assist rails to assist with bed mobility and be free from injuries and staff will observe the resident using quarter/assist rails safely to assist with bed mobility. Observations on 06/23/2025 at 9:10 a.m. and 06/24/2025 at 11:05 a.m. revealed bilateral quarter rails were in place on each side of Resident #38's upper bed. Review of Resident #38's record revealed no documentation of a risk of entrapment assessment prior to the installation of the bed rails. On 06/25/2025 at 4:00 p.m. interview with S2DON (Director of Nursing) and S1Administrator confirmed there was no assessment for the risk of entrapment prior to installation of quarter bed rails for Resident #38.

Based on observations and interviews, the facility failed to maintain a safe, clean, comfortable and homelike environment for 1 (#62) of 4 (#38, #47, #48, and #62) residents reviewed for environment. The failed practice was evidenced by Resident #62's tube feeding pump and stand contained spills and splatters and the air conditioner/heating unit contained dust in the vents. Findings: On 06/23/2025 at 9:00 a.m., observation revealed Resident #62 was lying in the bed with Glucerna 1.5 infusing at 50 milliliters (ml) per hour. Further observation revealed the tube feeding pump and stand contained spills and splatters and the air conditioner/heating unit contained dust in the vents. On 06/24/2025 at 2:30 p.m., observation revealed Resident #62's tube feeding pump and stand contained spills and splatters and the air conditioner/heating unit contained dust in the vents. On 06/25/2025 at 12:20 p.m., observation of Resident #62's room with S6Licensed Practical Nurse (LPN) confirmed the tube feeding pump and stand contained spills and splatters and the air conditioner/heating unit vents contained a dust buildup and needed to be cleaned. On 06/25/2025 at 12:30 p.m., S2Director of Nursing (DON) was notified of Resident #62's tube feeding pump and stand contained spills and splatters and the air conditioner/heating unit contained dust in the vents.

Based on interviews and record reviews, the facility failed to ensure the Minimum Data Set (MDS) assessment accurately reflected the resident's status for 2 (#4, #55) of 2 residents whose MDS were reviewed for accuracy. Findings: Resident #4 Review of the medical record revealed Resident #4 was admitted to the facility on [DATE]. Review of the 05/12/2025 quarterly MDS assessment indicated Resident #4 received an insulin injection in the previous 7 days. Review of the May 2025 physician orders revealed Resident #5 did not have an order for insulin. Review of the May 2025 Medication Administration Record (MAR) revealed there was no documentation that Resident #33 received an insulin injection. Resident #55 Review of the medical record revealed Resident #55 was admitted to the facility on [DATE]. Review of the 05/15/2025 MDS assessment indicated Resident #55 had received an insulin injection in the previous 7 days. Review of the May 2025 physician orders revealed Resident #55 did not have an order for insulin. Review of the May 2025 Medication Administration Record (MAR) revealed there was no documentation that Resident #55 received an insulin injection. On 06/25/2025 at 10:30 a.m., interview with S4MDS Nurse confirmed the MDS assessments for Residents #4 and #55 were coded incorrectly.

Based on observation, interview, and record review, the facility failed to ensure a resident who was unable to carry out Activities of Daily Living received the necessary services to maintain good grooming and personal hygiene for 2 (#48, #66) of 3 (#56, #57, #66) residents reviewed for Activities of Daily Living (ADL) care. Findings: Resident #48 Resident #48 was admitted to the facility on [DATE] with a diagnoses of cerebral infarction with hemiplegia and hemiparesis affecting left non-dominant side, essential primary hypertension, and congestive heart failure. Review of quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed he had a Brief Interview of Mental Status (BIMS) score of 12 which indicated he was moderately cognitively impaired. Further review of the MDS revealed Resident #48 was dependent on staff for personal hygiene care that included nail care. Review of Resident #48's June 2025 physician orders revealed no order for fingernail care. Further review of the medical record revealed no documentation the resident's nails were trimmed or groomed for June 2025. Observation of Resident #48 on 06/23/2025 at 9:48 a.m. and 06/24/2025 at 3:31 p.m. revealed his fingernails were long and there was a dark substance underneath some of his fingernails. On 06/25/2025 at 3:04 p.m., an observation of Resident #48's fingernails with S5Unit Manager was conducted. S5Unit Manager confirmed Resident #48`s fingernails were long and dirty and were in need of grooming. On 06/25/2025 at 4:00 p.m., an interview with S2Director of Nurses (DON) confirmed Resident #48's fingernails should have been groomed. Resident #66 Resident #66 was admitted to the facility on [DATE] with a diagnoses of severe intellectual disability, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, and seizures. Review of the quarterly MDS assessment dated [DATE] revealed Resident #66 had a BIMS score of 99 which indicated the resident was unable to complete the interview. Further review revealed he was dependent on staff for personal hygiene which included nail care. Review of Resident #66's June 2025 physician orders revealed no order for fingernail care. Further review of the medical record revealed no documentation the resident's nails were groomed for June 2025. Observation of Resident #66 on 06/23/2025 at 9:45 a.m. and 06/24/2025 at 11:32 a.m. revealed his fingernails were long and there was a dark substance underneath some of his fingernails. On 06/25/2025 at 3:04 p.m., an observation of Resident #48's fingernails with S5Unit Manager was conducted. S5Unit Manager confirmed Resident #48`s fingernails were long and dirty and were in need of grooming. On 06/25/2025 at 4:00 p.m., an interview with S2DON confirmed Resident #48's fingernails should have been groomed.

Based on observation, record review, and interviews, the facility failed to ensure the resident's environment remained as free of accident hazards as is possible by failing to ensure bed rails were properly secured for 2 (#6, #38) of 4 (#6, #20, #33, #38) residents reviewed for accident hazards. Findings: Review of the facility's Side Rail Use Evaluation policy (undated) revealed in part: Policy: All residents will be evaluated for siderail use upon admission/readmission and reevaluation will be completed quarterly or upon a significant change in condition if siderails are utilized. DEFINITION: Bed rails are adjustable metal or rigid plastic bars that attach to the bed. They are available in a variety of types, shapes, and sizes ranging from full to one-half, one-quarter, or one-eighth lengths. Examples of bed rails include, but not limited to: Side rails, bed side rails, and safety rails; and Grab bars and assist bars RESPONSIBILITY: All members of the Interdisciplinary Team PROCEDURE: 4. Manufacturer's recommendations and specifications for installation and maintenance will be followed 5. The Comprehensive Care Plan will be reviewed/revised with changes. Resident #6 Review of Resident #6's medical record revealed an admission date of 10/19/2015 with diagnoses of dementia with behavioral disturbance, schizophrenia, delusional disorder, anxiety disorder, and essential primary hypertension. Review of Resident #6's June 2025 Physician's Orders revealed an order dated 03/06/2025 for quarter side rails to bilateral sides of the bed used as enablers to help turn and reposition while in bed and monitor for proper functioning every shift. Review of Resident #6's Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview Mental Status (BIMS) of 00 which indicated the resident had severe cognitive impairment for daily decision making. Further review of the MDS revealed Resident #6 had no impairment on both sides of upper and lower extremities. Review of Resident #6's care plan revealed he had quarter rails to the bilateral sides of the bed to assist with bed mobility. The interventions included the resident will use the quarter rails to assist with bed mobility and free from injuries and for staff to observe the resident using quarter rails safely to assist with bed mobility. On 06/23/2025 at 9:30 a.m. and 06/24/2025 at 10:33 a.m., observations of Resident #6 revealed bilateral quarter rails were raised on each side of his bed. Both quarter bed rails were loose and were not secured properly to his bed. On 06/24/2025 at 3:05 p.m., observation of Resident #6 was conducted with S5Unit Manager. She confirmed the resident's quarter bed rails were too loose and needed to be secured to his bed. On 06/25/2025 at 4:00 p.m., an interview with S1Administrator and S2Director of Nursing (DON) confirmed Resident #6's quarter bed rails should have been secured to his bed. Resident #38 Review of Resident #38's medical record revealed an admission date of 05/29/2020 with diagnoses of cerebral infarction with hemiplegia and hemiparesis affecting left non-dominant side. Review of Resident #38's June 2025 Physician's Orders revealed an order dated 02/27/2025 for bilateral quarter rails used as enablers to help turn and reposition while in bed. Review of Resident #38's Quarterly MDS assessment dated [DATE] revealed a BIMS of 15 which indicated no cognitive impairment. Further review of the MDS revealed Resident #38 had no impairment on both sides of upper and lower extremities. Review of Resident #38's care plan revealed he had quarter rails to bilateral sides of the bed to assist with bed mobility. The interventions included the resident will use the quarter rails to assist with bed mobility and be free from injuries and staff will observe the resident using quarter rails safely to assist with bed mobility. Observations on 06/23/2025 at 9:10 a.m. and 06/24/2025 at 11:05 a.m. revealed bilateral quarter rails were raised on each side of Resident #38's upper bed. Both quarter bed rails were loose and were not secured properly to his bed. On 06/24/2025 at 3:05 p.m., observation of Resident #38 was conducted with S5Unit Manager. She confirmed the resident's quarter bed rails were too loose and needed to be secured to his bed. On 06/25/2025 at 4:00 p.m., an interview with S1Administrator and S2DON confirmed Resident #38's quarter bed rails should have been secured to his bed.

Based on record review and interview, the facility failed to ensure it had sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident by having staff fail to follow the physician orders for 1 (#1) of 6 (#1, #10, #13, #18, #33, #62) residents reviewed for unnecessary medications. Findings: Review of the medical record for Resident #1 revealed an admission date of 11/10/2023. Resident #1 had diagnoses including atrial fibrillation, pulmonary disease, hypertension, heart disease, Parkinson's disease, pain, cerebral infarction, lack of coordination, anxiety and dementia. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 had intact cognition for daily decision making. Review of the June 2025 physician orders revealed an order dated 02/14/2025 for Norco 5-325 milligrams (mg) to be given every 6 hours as needed for pain. Review of the June 2025 Medication Administration Record (MAR) revealed Norco 5-325 mg was administered to Resident #1 on 06/20/2025 at 5:00 p.m. for a pain level of 7 and at 8:00 a.m. for a pain level of 4. On 06/25/2025 at 9:30 a.m., interview with S2Director of Nursing (DON) confirmed Resident #1 received Norco 5-325 mg at 5:00 p.m. and 8:00 p.m. on 06/20/2025 and the physician's order was for Resident #1 to receive the medication every 6 hours as needed.

Based on observations, interviews, and record reviews, the facility failed to ensure it provided routine drugs to its residents by failing to ensure medications were available for administration at the prescribed time for 2 (#67, #49) of 3 (#67, #49, #42) residents observed for medication pass. Findings: On 06/24/2025 at 7:50 a.m., a medication pass was observed for Resident #67. During the medication pass, S3Licensed Practical Nurse (LPN) reported the medication, Simethicone, was not on the cart. On 06/24/2025 at 8:05 a.m., a medication pass was observed for Resident #49. During the medication pass, S3LPN reported the medication, Floraster, was not on the cart. On 06/24/2025 at 8:17 a.m., S3LPN checked the medication room and confirmed the medications were not available for administration at the prescribed time. On 06/24/2025 at 11:15 a.m., S2Director of Nursing was notified of the medications that were not available at the prescribed time.

Based on interviews and record reviews, the facility failed to ensure the physician addressed irregularities identified by the pharmacist for 2 (#33, #1) of 6 (#33, #1, #18, #10, #13, #62) residents whose drug regimens were reviewed. The facility failed to ensure the physician provided a handwritten clinical rationale to deny a gradual dose reduction. Findings: Resident #33 Review of the medical record revealed Resident #33 was admitted to the facility on [DATE]. Review of the June 2025 physician orders revealed Resident #33 received Buspar 5 milligrams (mg) three times daily for the treatment of anxiety, and Ziprasidone 20 mg twice a daily for the treatment of mood disorder. Review of the Consultant Pharmacist Communication to Physician letter dated 11/12/2024 revealed the pharmacist recommended a gradual dose reduction for the psychotropic medications. The physician denied a dose reduction and wrote on the form doing well. On 06/25/2025 at 8:50 a.m., interview with S2Director of Nursing (DON) confirmed the physician did not provide an adequate rationale to deny a gradual dose reduction. Resident #1 Review of the medical record for Resident #1 revealed an admission date of 11/10/2023. Resident #1 had diagnoses including atrial fibrillation, pulmonary disease, hypertension, heart disease, Parkinson's disease, pain, cerebral infarction, lack of coordination, anxiety and dementia. Review of the June 2025 physician orders revealed an order dated 12/10/2024 for Duloxetine Hydrochloric Acid (HCL) enteric coated (EC) 30 mg to be given every day, and 12/18/2024 for Quetiapine Fumarate 25 mg to be given at bedtime. Review of the Consultant Pharmacist Communication to Physician letter dated 02/10/2025 revealed the pharmacist recommended a gradual dose reduction for the psychotropic medications. The physician denied a dose reduction and wrote on the form no. On 06/25/2025 at 8:50 a.m., interview with S2DON confirmed the physician did not provide an adequate rationale to deny a gradual dose reduction. .

Based on observations, interviews and record reviews, the facility failed to ensure the medication error rate was not greater than 5% by having a medication error rate of 11%. The facility had 3 medication errors and 27 opportunities. Findings: Resident #67 On 06/24/2025 at 7:50 a.m., a medication pass was observed for Resident #67. During the medication pass, S3Licensed Practical Nurse (LPN) reported the medication, Simethicone, was not on the cart for administration. Also during the medication pass, Resident #67 received Potassium 20 milliequivalents. Review of the June 2025 physician orders revealed Simethicone was due to be given prior to breakfast. On 06/24/2025 at 8:17 a.m., S3LPN checked the medication room and confirmed the Simethicone was not available for administration at the prescribed time. Review of the June 2025 physician orders revealed that there was no active order for the administration of Potassium for Resident #67. On 06/24/2025 at 10:45a.m., interview with S2Director of Nursing (DON) confirmed there was no active order for the administration of Potassium for Resident #67. Resident # 49 On 06/24/2025 at 8:05 a.m., a medication pass was observed for Resident #49. During the medication pass Resident #49 received Zinc 50 milligrams (mg). Review of the June 2025 physician orders revealed there was an order for Zinc 15mg. On 06/24/2025 at 10:40 a.m., an interview with S2DON confirmed Resident #49 should have received Zinc 15mg as ordered instead of 50mg. On 06/24/2025 at 1:15 p.m., S2DON was notified of the medication error rate.

Based on interviews and observations, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes or enhances his or her quality of life for 3 (#1, #39, and #62) of 5 (#1, #39, #40, #62, #65) residents reviewed for dignity. The facility failed to ensure: 1) staff answered call lights in a timely manner (#1, #39) and 2) the Respiratory Therapist informed a resident (#62) of tracheostomy care prior to performing the care. Findings: Resident #1 Review of the medical record for Resident #1 revealed an admission date of 11/10/2023. Resident #1 had diagnoses including atrial fibrillation, pulmonary disease, hypertension, heart disease, Parkinson's disease, pain, cerebral infarction, lack of coordination, and dementia. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had intact cognition for daily decision making. On 06/23/2025 at 3:06 p.m., interview with Resident #1 revealed one time at night she had to go to another hall to get the nurse when she wanted a pain pill because no one answered the call light. Resident #1 was unable to recall the date that this happened or the staff names. On 06/25/2025 at 12:40 p.m., S2Director of Nursing (DON) was notified that Resident #1 informed the surveyor she had to go to another hall at night to get the nurse when she wanted a pain pill because no one answered the call light. Resident # 39 Review of the medical record for Resident #39 revealed an admission date of 02/04/2022 with diagnoses including fibromyalgia, major depressive disorder, chronic obstructive pulmonary disease, chronic pain, and insomnia. Review of the quarterly MDS assessment dated [DATE] revealed the resident was cognitively aware and able to make daily decisions. During the resident council meeting on 06/23/2025, Resident #39 stated when she used the call light during the night shift, the Certified Nursing Assistant (CNA) would enter the room and turn the call light off. The CNA would ask the resident what she needed and instead of providing the care for the resident's needs, the CNA informed the resident they would come back, but they never did. On 06/24/2025 at 9:15 a.m., an interview with Resident #39 in regards to the night CNAs not providing care revealed she stated it was due to the workers just not wanting to do the work. She also stated it happened during the week and weekends. Resident #39 stated she had told the S2DON, but nothing had changed. On 06/25/2025 at 2:40 p.m., S2DON was notified that Resident #39 informed the surveyor of the CNAs not providing care during the night shifts. S2DON confirmed the CNAs should not turn the call light off and leave the room without providing care. Resident #62 Review of the medical record for Resident #62 revealed an admission date of 03/21/2025. Resident #62 had diagnoses including lymphoma, diabetes mellitus, muscle spasms, hypertension, pain, shortness of breath, and convulsions. Review of the June 2025 physician orders revealed an order dated 03/21/2025 for tracheostomy care every day and as needed with #8 cuffed shiley. Review of the current MDS assessment dated [DATE] revealed Resident #62 had severely impaired cognitive skills for daily decision making and required assistance with activities of daily living (ADLs). Review of the current care plan revealed Resident #62 was at risk for inadequate air exchange related to tracheostomy status and an intervention was to perform trach care as ordered and as needed. On 06/24/2025 at 11:00 a.m., observation of Resident #62 revealed S9Respiratory Therapist (RT) provided tracheostomy care for Resident #62. Resident #62's neck was rigid and tilted to the left side. Further observation of the care revealed when S9RT changed the dressing around the tracheostomy site, S9RT had to physically move and hold the resident's head towards the right side. S9RT failed to explain or communicate the process or procedure and failed to prepare Resident #62 prior to performing the tracheostomy care. On 06/24/2025 at 11:15 a.m., S9RT was notified of the observation of the lack of communication and the failure to prepare the resident prior to performing tracheostomy care. On 06/25/2025 at 12:30 p.m., S2DON was notified of the observation during tracheostomy care performed by S9RT. S2DON was also notified that S9RT failed to communicate the process or procedure to Resident #62 prior to moving her head to the right side to perform care.

I. Based on record reviews and interviews, the facility failed to ensure that 1 (#5) of 3 (#4, #5, #6) residents environment remained free of accident hazards by failing to ensure assistive devices (side rails) were in good repair. This deficient practice resulted in an Immediate Jeopardy situation on 12/11/2024 at approximately 9:35 a.m. when resident #5 fell from his bed while using his right 1/4 side rail to assist with care. Resident #5's side rail was attached to a bed extender that flared approximately 45 degrees away from the bed which resulted in the fall. Resident #5 obtained a closed fracture of the left distal femur and had open reduction and internal fixation surgery (ORIF) with hardware on 12/12/2024. The facility implemented corrective actions which were completed prior to the State Agency's investigation entry on 01/13/2025. It was determined to be a Past Noncompliance Citation. Findings: Review of the record for resident #5 revealed a [AGE] year old with an admitted [DATE]. Diagnoses included but not limited to the following: chronic respiratory failure, congestive heart failure, aphasia following cerebral infarction and fracture of left femur on 12/11/2024. Review of resident #5's annual Minimal Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 9 which indicated moderately impaired cognitive skills for daily decision making. He had no range of motion impairment to upper or lower extremities. Resident #5 was unable to walk and used a wheel chair for locomotion. Resident #5 was dependent on staff for toileting (one person physical assistance) and independent with rolling to the left, back and right side. Resident #5 always incontinent of bowel and bladder. Review of Morse Fall Scale Assessments dated 10/11/2024 revealed resident #5 to score a 55 which noted resident was a low risk. No history of falls in past year. Review of side rails evaluation revealed the evaluation was completed on 09/25/2024 and a consent from the responsible party noted. Resident #5 was assessed to have 1/4 side rails to grasp side rails and assist staff in turning and positioning. Review of an Accident Report for resident #5 dated 12/11/2024 at 9:35 a.m. for a fall during staff assist revealed the following: Incident location: resident #5's room Person preparing report: S13Licensed Practical Nurse (LPN) Description: Resident noted lying on his right side on the floor between the bed and the wall. Resident alert and oriented to person, place, time, and situation. Resident didn't complain of pain, stated multiple times, Baby get me up. Resident stated I fell off the damn bed. Pulse 76, respirations 21, Blood pressure 138/76. Immediate action taken: Resident transferred to hospital per Emergency Medical Services. Intervention: Assist rails checked and old extensions on bed removed and assist rails connected to bed frame. Fracture of left femur reported from hospital. Injury: laceration right forearm Review of the facility's investigation summary form revealed the following: Review of local hospital physician documentation on 12/11/2024 revealed the following: [AGE] year old present to emergency room via emergency medical services with complaints of fall. Details of fall: The patient fell from supine position. Abrasion to right elbow. He was transferred to hospital emergency roiagnom on [DATE] for distal left femur fracture, Long leg splint in place. Resident #5 admitted to another hospital with a closed fracture of the left distal femur and had open reduction and internal fixation surgery (ORIF) with hardware on 12/12/2024. Interview on 01/13/2024 at 12:15 p.m. with S14Certified Nursing Assistant (CNA) revealed she had worked at the facility for a little over 6 months. S14CNA reported on 12/11/2024 around 9:35 a.m. she was assisting resident #5 who had a bowel movement and needed to be changed. S14CNA revealed she asked resident #5 to turn to his right side like he normally would do and he grabbed and pulled himself to his right side in the bed using the 1/4 assistive rail on the right side of the bed. S14CNA reported she asked him to remain still while she cleaned him up. S14CNA reported within 15-20 seconds resident #5 said, It's breaking loose, I am falling. S14CNA reported she immediately went to try to prevent him from falling. S14CNA reported she had made it to the foot of the bed when resident #5 had fallen on the floor between the bed and the wall. S14CNA reported the right side 1/4 assistive rail broke way and leaned at about a 45 degree angle. S14CNA reported the right side of the bed was approximately 2 feet from the wall. S14 CNA reported she hollered out for help and stayed with resident #5 until S13Licensed Practical Nurse (LPN) arrived. S14CNA reported that resident #5 had a skin tear to his right forearm. S14CNA reported resident #5 was sent out to the hospital via ambulance. Interview on 01/14/2025 at 10:32 a.m. with S13LPN revealed that on 12/11/2024 around 9:35 a.m. she was in another resident's room next door to resident #5's room when she heard S14CNA holler out for help. S13LPN reported she immediately went to resident #5's room and observed resident #5 lying on the floor on his right side between the bed and the wall. S13LPN reported that resident #5's left leg was lying across his right leg. S13LPN reported resident #5 had a laceration to his right foreman. S13LPN reported resident #5 did not complain of any pain. S13LPN reported resident #5's right side rail was angled out in a 45 degree angle toward the wall. S13LPN revealed she asked S14CNA what happened. S14CNA reported to S13LPN that she was providing resident #5's incontinent care and she had asked him to turn to his right side like he normally does when she provides his incontinent care. S13LPN reported S14CNA then stated that within 20 seconds of the resident turning to his right side, resident #5 told her he was falling and the rail was letting go. S13LPN reported that S14CNA stated she could not get to the right side of the bed in time to prevent him from falling. S13LPN reported she called the ambulance service for resident #5 to be evaluated at the local hospital. S13LPN reported she provided wound care for laceration and placed a dressing on his right forearm. S13LPN revealed she contacted S10Registered Nurse (RN) unit manager. Interview on 1/13/2025 at 11:30 a.m. with S10RN Unit Manager revealed she was notified by S13LPN that resident #5 was on floor and was being sent to the local emergency room for evaluation. Upon entering the room, resident #5 was on the floor between the bed and wall. S10RN Unit Manager stated that resident #5 was on his stomach leaning toward the right side with his right arm down beside him and his left arm had a small skin tear noted. S10RN Unit Manager stated resident #5 yelled, Get me off of the floor, help me up! S10RN Unit Manager reported that S14CNA stated resident #5 fell from the bed while holding onto the right side rail. S10RN Unit Manager reported that the right side rail was down when she entered the room. Interview on 01/13/2025 at 12:30 p.m. with S9Maintenance Director revealed he was notified on the morning of 12/11/2024 after resident #5 had fallen to check his bed and his side rails. S9Maintenance Director reported the right upper side rail was still in place but it was angled about 45 degrees away from bed toward the wall. S9Maintenance Director reported that the upper extender at the top of the bed had the side rails still attached properly, but the upper extender bracket that rested on top of the bedframe was flared out which allowed the right upper side rail not to function properly. Interview on 01/27/2025 at 8:00 a.m. with S1Executive Director(ED) revealed that he was aware of incident involving resident #5 falling and fracturing his left femur on 12/11/2024. S1ED reported it was determined that there was a problem with the bed extender. The side rail was connected to the bed extender and as a result caused resident #5 to fall. During the survey, in-service records and Quality Assurance (QA) monitoring records were reviewed and it was determined that the facility had implemented the following corrective actions to correct the deficient practice prior to entering the facility. On 12/11/2024, the facility implemented the following actions to correct the deficient practice with a completion date of 12/24/2024. 12/11/2024- S9Maintenance Director examined the side rail for resident #5. It was determined that the bed extensions that held the hand rails were flared out and rotated around the head of the frame. The left side rail was up right and the right side rail was at a 45 degree angle. S9Maintenance Director removed all six bed extensions from the bed of resident #5. 12/11/2024- There are no other bed extensions in use at the facility. The facility will no longer use bed extensions. 12/11/2024- S9Maintenance Director completed an audit of 100% side rails used in the facility. 12/24/2024- S9Maintenance Director completed bed and mattress audit on all beds in the facility. II. Based on observations, record reviews and interviews, the facility failed to ensure 1 (#1) of 3 (#1, #2, #3) residents who were assessed at risk for wandering and elopement, was adequately supervised to prevent him from eloping from the facility. This deficient practice resulted in an Immediate Jeopardy situation on 01/05/2025 at approximately 6:40 a.m. when resident #1 (a moderately impaired resident who was placed on 1 to 1 supervision on 01/04/2025 at approximately 11:00 p.m. for wandering in other residents' rooms) was found approximately 2.4 miles from the facility by the local police department. Resident #1 was located approximately 1 hour and 40 minutes after last being seen by assigned staff at the facility. The facility implemented corrective actions which were completed prior to the State Agency's investigation entry on 01/13/2025. It was determined to be a Past Noncompliance Citation. Findings: Review of policy with the latest revision date of 05/2022 revealed the following: Subject: Missing Resident/Elopements. Policy: the Unit Charge Nurse is responsible for knowing the location of their residents. It is the responsibility of all personnel to report any resident attempting to leave the premises, or suspected of being missing, to the charge nurse as soon as practical. At any time in which a resident is determined missing, the following procedure will be strictly followed: A) Alert: The supervisor/charge nurse will alert all other personnel by all-paging Dr. Wander' and Location: B) Search: a search of the immediate area will be initiated under the Director of Nursing (DON) shift supervisor/charge nurse; all rooms will be searched (including locked rooms). The Nursing shift supervisor/charge nurse will designate staff to search the area surrounding the building, as appropriate (patio, parking area) C) Contacts: If the search of the immediate area is unsuccessful, the nursing shift supervisor will immediately contact the: Executive director and DON; local police department; family/responsible party; vice president of operations; attending Physician/medical director; department of health notification as required; D) Missing resident guidelines: The resident: 1. Determine time and location when last seen. Review of the medical record revealed resident #1 was admitted to the facility on [DATE] with diagnoses of unspecified intracranial injury without loss of consciousness, generalized anxiety disorder, hypertension, non-traumatic subarachnoid hemorrhage, other non-traumatic intracerebral hemorrhage, fracture of condylar process of left mandible subsequent encounter for fracture with routine healing, and diffuse traumatic brain injury w/o loss of consciousness. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed resident #1 had a brief interview for mental status (BIMS) of 10 which indicated that resident #1 had moderately impaired cognitive skills for daily decision making. The assessment also indicated the resident was independent with transfers and did not require mobility devices. Review of the Elopement Risk assessment dated [DATE] at 2:45 p.m. by S9Registered Nurse (RN) revealed resident #1 was oriented to person, place, time and situation upon assessment. Noted episodes of confusion and history of psychoactive meds (Zyprexa); mobility independent. Resident #1 was not deemed an elopement risk. Review of an Incident Report dated 01/05/2025 at 6:40 a.m. completed by S6Licensed Practical Nurse (LPN) revealed that she received a phone call from the local police department asking if we had a resident by the name of resident #1. This nurse stated yes. Officer stated that resident #1 was out by the local apartments wandering (approximately 2.4 miles from facility). S6LPN instructed officer to bring resident #1 back to facility. Resident #1 unable to give clear description of events. Immediate action taken: Local police department returned resident to facility at approximately 6:50 a.m. On 01/13/2025 at 2:00 p.m. interview with S1Executive Director (ED) confirmed resident #1 was currently at an inpatient psychiatric hospital due to aggression toward staff. S1ED confirmed that on 01/05/2025 sometime after 5:00 a.m., resident #1 eloped from the building and it was undetermined as to what door the resident exited out of. S1ED revealed he was contacted by S2Director of Nursing Services (DNS) on 01/05/2025 at around 7:00 a.m. S1ED reported that an immediate investigation was initiated. On 01/14/2025 at 10:00 a.m. interview with S2DNS confirmed resident #1 eloped from the building on 01/05/2025 after being placed on 1 to 1 monitoring for supervision on 01/04/2025 at approximately 11:00 p.m. S2DNS stated that on 01/04/2025 at approximately 9:52 p.m., S1ED called to inform her that resident #10's family member called him and was upset about resident #1 entering into the room of resident #10 and upsetting the resident. Further interview revealed on 01/04/2025 at 10:20 p.m. S2DNS came to the facility to meet with the family member who was upset due to resident #1 attempting to enter the room and bathroom of resident #10. S2DNS stated she then addressed the issue with nursing staff and informed them that resident #1 was disoriented as to where his bathroom and room were. She stated at this time she placed resident #1 on 1 to 1 monitoring supervision and to change out with other workers when they do rounds on other residents. S2DNS stated that she told all the nurses and aides on duty to make sure someone was with resident #1 at all times and that the nurses could switch out with the aides as needed. S2DNS further stated she told them to report to the day shift to continue the 1 to 1 monitoring. S2DNS stated that S5Certified Nursing Assistant (CNA) was assigned the 1 to 1 monitoring for resident #1 and was stationed outside resident #1's room when she left building at approximately 11:00 p.m. S2DNS further confirmed on 01/05/2025 at 6:44 a.m., she received a phone call from S6LPN stating they just received a phone call from the local police department stating that they picked up resident #1 at a local apartment complex and were bringing him back to facility. S2DNS stated she instructed S6LPN to do a head to toe assessment on resident #1's return and to restart a strict 1 to 1 monitoring. She stated that the Administrator was notified and staff placed a Wanderguard monitoring device on resident #1 upon his return. S2DNS stated that she contacted S5CNA who stated she monitored resident #1 until around 5:00 a.m. S2DNS reported that S5CNA then said that S4LPN said she would watch out for resident #1 and that she could go make her rounds on other residents. S2DNS stated she talked with S4LPN on 01/05/2025 at 8:00 a.m. S4LPN stated that she last saw resident #1 around 4:50 a.m. when she administered medication to him. S4LPN stated resident #1 was sitting up in a chair in his room and that S5CNA was outside the door. S2DNS stated she asked S4LPN if S5CNA asked if she would monitor resident #1 while she finished her rounds and S4LPN denied that this was said. S2DNS confirmed that resident #1 was able to elope out of building on 01/05/2025 after 5:00 a.m. due to staff not properly monitoring resident #1 on a 1 on 1 observation status. S2DNS confirmed that the facility did not have a policy on 1 to 1 monitoring supervision. On 01/15/2025 at 7:05 a.m. an interview with S6LPN revealed that on 01/05/2025 at 6:40 a.m. she received a call from the local police department stating that they found resident #1 wandering outside an apartment complex approximately 3 miles from facility. S6LPN asked the police to return resident #1 to facility. S6LPN stated after she got off phone with police, S5CNA came up to nursing station and asked if anyone had seen resident #1. S6LPN told S5CNA that the police found resident #1 wandering around an apartment complex some 3 miles from the facility. S6LPN stated that S5CNA told her that resident #1 was placed on 1 to 1 monitoring last night by S2DNS for wandering behavior. S6LPN said she contacted S2DNS immediately after becoming aware of incident. S6LPN stated that she was not made aware by the night nurses that resident #1 was on a 1 to 1 monitoring for supervision. On 01/15/2025 at 7:50 a.m. an interview with S4LPN revealed that she worked at facility on 01/04/2025 from 6 p.m. to 01/05/2025 to 6 a.m. S4LPN revealed that she was made aware that resident #1 was placed on 1 to 1 monitoring supervision for wandering type behavior on 01/04/2025 around 11:00 p.m. by another nurse. S4LPN stated that S5CNA was assigned 1 to 1 monitoring and was stationed outside the door of resident #1's room. S4LPN stated that she last time she saw resident #1 was around 4:30 a.m. at which time she administered a medication for anxiety. S4LPN stated she was never asked by S5CNA to monitor resident #1 due to her needing to make rounds on other residents. S4LPN stated she was never aware that resident #1 had eloped out of the facility. On 01/15/2025 at 9:15 a.m. an interview with S5CNA revealed that she worked at facility on 01/04/2025 from 7:00 p.m. to 01/05/2025 at 7:00 a.m. S5CNA said she was assigned the hall that resident #1 resided. S5CNA observed resident #1 wandering around facility and into other residents' rooms during her shift. S5CNA reported that S2DNS came to facility on 01/04/2025 around 10:00 p.m. and met with a family member of resident #10. S5CNA stated that S2DNS placed resident #1 on 1 to 1 monitoring supervision and made all staff aware. S5CNA stated that she was assigned the 1 to 1 for resident #1 but it was expected for her to also round and assist other residents she was assigned to. S5CNA stated that around 5:00 a.m. she had to assist another CNA and also do her rounds on other residents. S5CNA asked S4LPN if she could provide the 1 to 1 monitoring for resident #1 and S4LPN stated that she would. S5CNA stated that she returned to check on resident #1 around 6:20 a.m. and realized he was not in his room. S5CNA stated that she attempted to search for resident #1 and looked in other residents' rooms but could not find him. She stated that she asked other CNAs if they had seen him but they denied seeing him. S5CNA stated she asked the day nurse around 6:40 a.m. if she had seen resident #1. S4CNA confirmed that from 5:00 a.m. to 6:20 a.m. she did not perform 1 to 1 monitoring supervision on resident #1. S5CNA confirmed that when she observed that resident #1 was missing, she did not alert a nurse until approximately 20 minutes after noting him missing. On 01/15/2025 at 10:00 a.m. interview with S3Clinical Operation Consultant confirmed the staff did not perform 1 to 1 monitoring supervision for resident #1 as ordered and as a result resident #1 was able to elope from the facility. S3Clinical Operations Consultant confirmed that nursing was not immediately notified when it was determined that resident #1 was missing and that night staff did not communicate with day staff that resident #1 was on 1 to 1 monitoring. S3Clinical Operations Consultant confirmed that the facility did not have a policy for 1 to 1 monitoring supervision. During the survey, in-service records and Quality Assurance (QA) monitoring records were reviewed and it was determined that the facility had implemented the following corrective actions to correct the deficient practice prior to entering the facility. On 01/05/2025 the facility implemented the following actions to correct the deficient practice with a completion of 01/09/2025: Actions: Upon return to the facility on [DATE] at 6:50 a.m., resident #1 was placed on 1:1 monitoring and a wander guard was placed on resident #1. 01/05/2025- 100% census count was completed by Unit Manager, all residents were accounted for. 01/05/2025- Resident #1 Elopement risk evaluation reviewed, re-evaluated and updated to reflect his current elopement risk status. 01/05/2025- 100% Elopement assessments re-evaluated and updated to reflect current elopement status. Facility found that 3 other residents were at risk for elopement status. Elopement evaluation updated to reflect current status. 01/05/2025- 100% audit of all residents with wanderguards was initiated, no resident with wander guards identified. After re-evaluation, facility identified 3 residents who were at risk, received wanderguard after evaluation, all wanderguards were tested and working properly by Unit Manager. 01/05/2025- Executive Director examined exit doors and windows for malfunction, windows and doors are functioning and in proper working order. Doors and windows last checked on 01/01/2025 with resident monitoring system reviewed and Mag lock system checked. All were in proper working order. 01/05/2025- Elopement drill initiated on day shift By Staff Development Coordinator and night shift Facility staff are 12 hours with in-servicing on Policy on wandering and elopements 01/05/2025- Elopement policy reviewed by Clinical Operations Nurse with no changes made at this time. 01/05/2025- Resident #1 BIMS was assessed by Director of Nursing BIMs score was 10 01/05/2025- Social Services Director reviewed and updated elopement binder with current residents at risk. 01/05/2025- Door sign posted by Executive Director to alert staff and visitors to be aware of their surroundings as you enter and exit the building stating please do not let anyone out. 01/05/2025- resident #1 was moved to another room closer to the nurses' station for increased supervision. 01/05/2025 - 01/09/2025 In-servicing of Executive Director and DNS via phone by [NAME] President of Operations regarding any resident who elopes or attempts to elope, displays exit seeking behavior, or Demands to go home, must be placed on 1 to 1 supervision. Supervision to be tapered based on behavior as deemed appropriate. In-service will be on going. 01/05/2025 - 01/09/2025 In-service initiated by Staff Development Coordinator on current staff/agency staff on Incident/accidents, elopement policy, residents who demands wanting to go home, have exit seeking behavior, and wanders the facility must place resident 1 on 1 supervision and must notify the Executive Director and Director of Nursing immediately. Post-test on wandering and elopements. In service will be ongoing. 01/05/2025- In-service initiated by Staff Developed Coordinator with CNA's and Nurses, when putting someone on 1 on 1 this means the resident is in your vision at all times. 1 on 1 is a nursing intervention put into place when close monitoring is warranted, for a certain length of time, until the person behavior/condition/ is re-evaluated by the staff and deemed appropriate to be taken off. This means, when you have to care for another resident, or attend to personal issues, or for any reason you have to step away, you have to ensure you coworker is aware and is actively monitoring the resident, while you are away. At no point is the resident to be left alone while 1 on 1 is in progress. In-service will be ongoing. Director of Nursing and or designee to monitor 24 hours report sheets, nurses notes and incident/accident 2 x daily x 5 days a week x 4 weeks to ensure that residents who exhibit exit seeking behaviors, demands to go home and wanders through out the facility are assessed for the safety of the resident. Any concerns will be immediately addressed. The Executive Director will forward results to the monthly Quality Assurance Committee. The Quality Assurance Committee will recommend the frequency or discontinuation based on results achieved. Director of Nursing and or designee to monitor new interventions that are put in place with observation 2 x daily x 5 days a week x 4 weeks to ensure interventions are in place. Any concerns will be immediately addressed. The Executive Director will forward results to the monthly Quality Assurance Committee. The Quality Assurance Committee will recommend the frequency or discontinuation based on results achieved.

Based on observation, record review, and interview, the facility failed to ensure staff adequately supervise a resident diagnosed with [REDACTED].#1) of 6 sampled residents (#1, 2, 3, 4, 5, and 6) in a total sample of 6. The facility further failed to: 1. Monitor a resident diagnosed with [REDACTED]. 2. Conduct a physical count of residents in the facility at midnight according to facility policy. 3. Ensure administrative office doors were closed and locked prior to leaving. 4. Orient agency CNAs regarding Resident #1's needs. The failed practice resulted in an Immediate Jeopardy (IJ) situation for resident #1, identified as a cognitively impaired wandering resident who was at high risk for elopement. On 10/06/17 at 8:39PM resident #1 was observed on the surveillance video to propel self into an administrative staff office and became locked inside the office without supervision. The night staffs were unaware that the resident was missing and did not begin searching for her until 10/07/17 at 7:30AM when the 7a to 7p shift staff could not find her. S1Executive Director and S5Corporate RN were notified of the Immediate Jeopardy situation on 10/11/17 at 2:25PM. A plan of removal was submitted by S1Executive Director which included the following: 1. Resident #1 was placed on every hour monitoring, wanderguard bracelet was placed on resident #1 on 10/09/17 and an assessment of the MDS office did not determine any potential hazards; 2. Inservices were initiated on 10/07/17 by the Executive Director for nursing staff on making rounds timely and will continue until all staff are educated. An audit was completed on 10/10/17 of all residents at risk for wandering and elopement. A self closure was placed on the MDS office door on 10/10/17 and self closures for remaining office doors have been ordered and will be installed upon arrival. S4LPN was suspended as of 10/10/17 pending investigation results; 3. On 10/11/17 the facility initiated a shift to shift charge nurse responsibility - to guide charge nurses for routine duties to include shift - shift visual monitoring. Location Monitoring Tool - documentation of Resident location based on the plan of care will be performed by the LPNs. The agency binder will contain policies on Abuse/Neglect, HIPPA, Missing Residents, Bill of Rights, Monitoring of Resident location and pocket care guide. 4. The Quality Assurance (QA) committee met on 10/11/17 that included the Executive Director, Director of Nurses, Assistant Director of Nurses and Medical Director. No employee including agency staff will be allowed to work until inservices received. Daily Unit Management forms will be utilized by the CNAs to verify with their signature under assignment that rounds and care were provided based on the plan of care. S1Executive Director and S5Corporate RN were notified that the Immediate Jeopardy situation was removed on 10/11/17 at 5:05PM when an acceptable plan of removal was presented. The deficient practice continued at a potential for more than minimal harm for the 6 residents (#1, #2, #3, #4, #5 and #6) identified as wanderers and at high risk for elopement. Findings: Review of Resident #1's medical record revealed an admitted [DATE] with [DIAGNOSES REDACTED]. Review of the MDS (Minimum Data Set) dated 07/27/2017 revealed the BIMS (Brief Interview Mental Status) was not completed because resident is rarely/never understood. The MDS further revealed that Resident #1 requires a two person assist with bed mobility, toileting, and transferring. Resident's mobility is accomplished with using a wheelchair. The resident is unable to walk or transfer on her own. Review of the care plan for Resident #1 revealed the resident was at risk for elopement related to [DIAGNOSES REDACTED]. Resident will also go to the exit doors and try to push doors open and wander on the grounds. Interventions include to evaluate quarterly and prn for risk of elopement, observe for tailgating when visitors are in the building, redirect using verbal and physical cues to persuade exit seeking behaviors, and place in elopement book at nurse's station. Recently added were: Added 10/07/17: Visual checks every hour Added 10/09/17: Wander guard bracelet placed on right ankle Added 10/10/17: Automatic closure placed on MDS office door. Review of the MAR (Medication Administration Record) at 1:45pm on 10/10/2017 revealed Resident #1 had a new order added to the MAR on 10/09/2017 at 12:00 PM for visual checks every hour to monitor location. At 1:45pm, Resident #1's visual checks had not been documented since 8:00am on 10/10/2017. Review of the nurse's note entered on the afternoon of 10/07/2017 by S3LPN revealed the following: Resident was found in MDS room sitting in wheelchair and she was taken to her room. The resident was bathed and given peri care. The resident was taken to dining room for breakfast and she complained of pain to legs and arms, she was given Tylenol 325mg X 2 tabs by mouth as needed for pain. The nurse reassessed her after an hour and the resident stated legs feel better but her arms were still hurting but pain scale was unable to be assessed. Resident was later noted to be in living room in w/c asleep. She was taken to her room and placed in bed on her right lateral side to relieve pressure on buttocks. Hourly monitoring in progress. Review of the Resident Incident Investigation revealed Resident #1 was found on 10/07/2017 at 7:30am locked in the MDS office. Resident was assessed and provided incontinence care and then placed on hourly visual monitoring. An interview was conducted with S2DON and S5Corporate nurse on 10/10/2017 at 2:05PM regarding the incident involving resident #1. S2DON confirmed Resident #1 was found in the MDS office about 7:30am on 10/07/17 after discovering that she was missing that morning. She said according to the video surveillance, Resident #1 entered the MDS office at about 8:30pm on 10/06/17. She stated that the office door should have been locked but was not. She confirmed that there were three agency CNAs working the night of 10/06/17-10/07/17. She confirmed the nurse caring for Resident #1 was S4LPN the night of 10/06/17. S2DON confirmed that this nurse said she did not visualize Resident #1 at all on her shift from 8pm on 10/06/17 until 7am on 10/07/17. She stated agency CNAs have a pocket guide to use that states to do one hour checks on residents but they do not have to document the checks anywhere. At 2:05pm on 10/10/2017 the surveyor presented S2DON a copy of Resident #1's MAR for 10/10/17 that was copied at 1:45pm. She confirmed that the visual checks every hour to monitor location had not been completed since 8:00am on 10/10/17. S2DON stated S7LPN conducted the midnight census on 10/06/2017 but did not observe each resident in the building. She confirmed agency CNAs do not get any type of in-service or orientation training when coming to work at the nursing facility. Review of the Facility's Census Policy revealed the Midnight Census Head Count is completed by nursing personnel. It shows where each resident is within the facility and provides an actual physical head count. It provides an actual physical count of residents in the facility at midnight. Procedure states Charge Nurse is responsible for the physical count of residents in house at midnight (11:59pm). During the interview with S2DON at 2:05pm on 10/10/2017, S2DON confirmed that when nurses conduct the midnight census, they do not do a physical head count but adjust the census number according to whoever is in the hospital or out of the building. S1Executive Director confirmed S7LPN violated company policy by documenting census count that resident was present and in her bed at midnight or was seen at midnight and can verify presence. An interview was conducted with S3LPN on 10/10/2017 at 2:50pm. S3LPN stated she gave Resident #1 the 8:00 pm medications before her shift ended about 8:15 pm. She said at 8:05pm Resident #1 was sitting in her wheelchair at the nurse's station. S3LPN stated when she returned to work the next morning on Saturday, 10/07/17, she was notified by a CNA that she couldn't find Resident #1 that morning. She said they started looking room by room for the resident. S3LPN stated she called the night shift nurse S4LPN at home. S3LPN said she asked S4LPN When was the last time you saw resident #1? S3LPN asked S4LPN, Did you look in on her at all last night? S4LPN informed S3LPN that she did not observe the resident during her shift because she was too busy caring for another resident. S3LPN stated they began looking room by room for resident #1. S3LPN stated the resident was located in a locked MDS office close to her room. As soon as Resident #1 was found, she was given a bed bath and peri care and assessed for skin breakdown. She stated Resident #1 complained of pain in extremities and was given two Tylenol. An interview was conducted with S1Executive Director on 10/11/2017 at 9:00am. She stated that when the employee in the MDS office left for the day on 10/06/2017, she must not have closed the door all the way or locked the door allowing Resident #1 to be able to enter the room and become locked in the room. S1Executive Director confirmed the door should have been locked when the employee left for the day. An interview was conducted with S1Executive Director on 10/11/2017 at 10:45am. She confirmed that an agency CNA, S6CNA, was responsible for the care of Resident #1 on the night of 10/06/2017. S1Executive Director confirmed that agency CNAs do not receive any orientation or training when coming to work at this facility. They are given a pocket care guide to assist them with their assignments.

Based on record review and interview, the facility failed to meet professional standards of quality by not ensuring that nurses were qualified to provide proper emergency [MEDICAL CONDITION] care for 1 (#1) of 5 (#1 - #5) sampled residents with tracheostomies in a total sample of 5. The facility failed to: 1.) establish and implement a policy for emergency [MEDICAL CONDITION] care; 2.) inservice the nurses for emergency care of tracheostomies; 3.) ensure the Director of Nurses continue to supervise and evaluate the nursing staff's education, knowledge, ability, and skills to provide adequate rescue breaths to residents with tracheostomies. The Immediate Jeopardy situation began on [DATE] at 12:30AM when resident #1 was found with the [MEDICAL CONDITION] out and unresponsive. The resident did not have a pulse and CPR (cardiopulmonary resuscitation) was started by S4 LPN. S4 LPN unsuccessfully attempted to reinsert the [MEDICAL CONDITION] and then proceeded to perform rescue breaths via ambu bag with mask over the stoma until emergency personnel arrived. According to the on-staff S3 CRT (Certified Respiratory Therapist), S4 LPN did not follow the correct procedures for performing rescue breaths during CPR for resident #1 after the unsuccessful attempts to re-insert [MEDICAL CONDITION]. On [DATE] at 4:05 PM, the survey team notified S1Administrator and S2 DON (Director of Nurses) of the IJ (Immediate Jeopardy) situation that currently existed in the facility. The IJ situation began on [DATE] at 12:30AM when sampled resident #1 was found in need of cardiopulmonary resuscitation and S4 LPN did not perform the appropriate rescue breaths for [MEDICAL CONDITION] resident #1. The IJ situation ended on [DATE] for resident #1 when emergency personnel arrived at the facility but continued for the other three residents (#2, #4, #5) with tracheostomies from [DATE] through [DATE]. The IJ situation was lifted for resident #5 when the [MEDICAL CONDITION] was discontinued on [DATE]. The IJ situation was lifted for resident #2 when he/she was discharged from the facility on [DATE] and resident #4 when the [MEDICAL CONDITION] was discontinued on [DATE]. The facility did not have any [MEDICAL CONDITION] residents from [DATE] through [DATE]. Resident #3, a resident with a [MEDICAL CONDITION], was placed in an IJ situation on [DATE] when he/she was admitted to the facility and the facility had not taken action to ensure staff had knowledge and skills to provide rescue breaths to a resident with a [MEDICAL CONDITION]. Resident #2, a resident with a [MEDICAL CONDITION], was placed in an IJ situation on [DATE] when he/she returned to the facility and the facility had not taken action to ensure staff had knowledge and skills to provide rescue breaths to a resident with a [MEDICAL CONDITION]. The facility submitted a plan of removal to the survey team on [DATE] at 4:40 PM for the IJ situation. The plan of removal included the following: 1. No new [MEDICAL CONDITION] residents will be accepted until staff has been trained on all aspects of care for trachs including training of reinsertion of [MEDICAL CONDITION] what to do if unable to replace the trach. 2. Respiratory Therapist started retraining at 2:00 PM for staff nurses. Nine nurses have been retrained today, [DATE]. Ten more nurses will receive retraining [MEDICAL CONDITION] and the reinsertion of [MEDICAL CONDITION] what to do if unable to reinsert trach. 3. Nurses will not be allowed to work with [MEDICAL CONDITION] until nurse can do a return demonstration with the Respiratory Therapist. On [DATE] at 4:40 PM, the IJ situation was removed after the facility implemented their plan. The deficient practice was lowered to a level 2 isolated for the other two [MEDICAL CONDITION] residents in the facility. Findings: Review of the Law Governing the Practice of Nursing; Louisiana Revised Statues 37:911; Registered Nurses: (14) "Registered nursing" means the practice of the scope of nursing which is appropriate to the individual's educational level, knowledge, skills, and abilities, including: (b) Establishing a nursing [DIAGNOSES REDACTED]. (c) Establishing goals to meet identified health care needs. (f) Delegating nursing interventions to qualified nursing personnel in accordance with criteria established by the board. (g) Maintaining nursing care rendered directly or indirectly. (i) Teaching the theory and practice of nursing. (j) Managing and supervising the practice of nursing. Record review revealed that resident #1 was admitted on [DATE] with admit [DIAGNOSES REDACTED]. Record review revealed that the resident was a full code. Record review revealed that the resident had a [MEDICAL CONDITION] with a #6 cuffed [MEDICAL CONDITION] at 35% oxygen, continuous percutaneous endoscopic gastrostomy tube feeding with Glucerna at 50 milliliters per hour with a water flush of 150 milliliters every 4 hours and a foley catheter. Review of the nurses' note for resident #1 dated [DATE] at 12:30 AM revealed that: "During 12:00 rounds CNA (certified nurse aide) notified nurse of resident'[MEDICAL CONDITION] being pulled out and resident was unresponsive. Resident was checked for pulse and no pulse was found, CPR was started by nurse until resident was taken out by _______ ambulance." A late entry to the note was timed at 2:07 AM and stated, "Ambu bag to [MEDICAL CONDITION] with suction cup during CPR for rescue breaths." The nurses note entries were both signed by S4 LPN. Review of the ambulance report for resident #1 dated [DATE] revealed in part, '....nursing home staff doing very ineffective CPR....CNA was attempting to stick the mask attachment port of the ambu bag into the pt's stoma...'. On [DATE] at 2:10 PM, an interview was conducted with S4 LPN. When asked what happened with resident #1 on [DATE], she stated that she was called to the room by S10 CNA and found [MEDICAL CONDITION] laying on the resident's chest. She stated that the resident was unresponsive and she attempted to reinsert the tube a couple of times but could not get [MEDICAL CONDITION] reinserted. On [DATE] at 12:41 PM, a telephone interview was conducted with S4 LPN. When asked what she would do if a resident had [MEDICAL CONDITION] come out and she could not replace it, S4 LPN stated she would put the suction cup over [MEDICAL CONDITION] and give breaths. When asked by the surveyor to clarify what she meant by suction cup, she described the face mask. The surveyor asked S4 LPN if she had been inserviced on how to give rescue breaths to a [MEDICAL CONDITION] resident if [MEDICAL CONDITION] came out and the tube could not be reinserted. S4 LPN revealed that she had not been inserviced on what to do in that situation. On [DATE] at 9:00 AM, two attempts to contact S10 CNA, who was present during CPR for resident #1, was made. S11 SDC informed the surveyors that the agency was unable to contact S10 CNA. Therefore, the surveyors were unable to conduct an interview with S10 CNA. On [DATE] at 12:42 PM, a telephone interview was conducted with S5 LPN. The surveyor asked S5 LPN how she would give rescue breaths if a resident'[MEDICAL CONDITION] came out and she could not reinsert [MEDICAL CONDITION]. She stated that she had not been told what to do. She would not guess what she would do in that situation. Observation on [DATE] at 5:22 AM revealed that S5 LPN's assignments included the two [MEDICAL CONDITION] residents currently in the facility. On [DATE] at 9:30 AM, S6 LPN was interviewed and asked if she knew how to give rescue breaths to a resident with [MEDICAL CONDITIONS] could not be reinserted. She went to S7 LPN and asked and they agreed that they would put the mask over the stoma. On [DATE] at 9:35 AM, S7 LPN was interviewed and asked if she knew how to give rescue breaths to a resident with [MEDICAL CONDITIONS] came out and could not be reinserted. She stated that the face mask should be held over the stoma to form a seal on the resident's neck. On [DATE] at 12:35 PM, S8 LPN evening nurse (2PM-10PM), who's assignment included the remaining [MEDICAL CONDITION], was interviewed and asked if she knew how to give rescue breaths to a resident with [MEDICAL CONDITIONS] came out and could not be reinserted. She stated that she did not know what to do if [MEDICAL CONDITION] will not go back in. She reported that they had not told her. On [DATE] at 12:37 PM, S9 LPN (2PM-10PM) was interviewed by phone and was asked if she knew how to give rescue breaths to a resident with [MEDICAL CONDITIONS] came out and could not be reinserted. She stated that she would need to be refreshed on that because she did not know what to do in that situation. On [DATE] at 1:20 PM, an interview with S3 CRT and S2 DON was conducted in the S2 DON's office with two surveyors. S3 CRT revealed that she was responsible for inservicing the nurses [MEDICAL CONDITION]. When asked by the surveyor if she had ever inserviced the nurses how to give rescue breaths if they could not reinsert [MEDICAL CONDITION], S3 CRT stated "No". She stated that she inserviced the nurses how to reinsert the tube but never had inserviced on how to proceed with rescue breaths if the tube could not be reinserted. S2 DON was asked by the surveyor if she knew how to give rescue breaths to [MEDICAL CONDITION] when [MEDICAL CONDITION] could not be reinserted. S2 DON stated that the stoma should be occluded and rescue breaths should be given through the mouth and nose. S3 CRT confirmed that the S2 DON was correct. The surveyor asked the S3 CRT how the stoma should be occluded. S3 CRT stated the stoma should be occluded with a 4x4 gauze and tape, if available. The policy and procedure was requested for emergency care of the [MEDICAL CONDITION] resident. The S2 DON confirmed that there was not a policy for [MEDICAL CONDITION] emergency care.

Based on record review and interview, the facility failed to ensure nurses were qualified to provide care for tracheostomies in an emergency situation for 1 (#1) of 5 (#1 - #5) sampled residents with tracheostomies in a total sample of 5. The facility failed to: 1.) establish and implement a policy for emergency [MEDICAL CONDITION] care; 2.) inservice the nurses for emergency care of tracheostomies; 3.) ensure staff provide adequate rescue breaths to residents with tracheostomies. The Immediate Jeopardy situation began on [DATE] at 12:30AM when resident #1 was found with the [MEDICAL CONDITION] out and unresponsive. The resident did not have a pulse and CPR (cardiopulmonary resuscitation) was started by S4 LPN. S4 LPN unsuccessfully attempted to reinsert the [MEDICAL CONDITION] and then proceeded to perform rescue breaths via ambu bag with mask over the stoma until emergency personnel arrived. According to the on-staff S3 CRT (Certified Respiratory Therapist), S4 LPN did not follow the correct procedures for performing rescue breaths during CPR for resident #1 after the unsuccessful attempts to re-insert [MEDICAL CONDITION]. On [DATE] at 4:05 PM, the survey team notified S1Administrator and S2 DON (Director of Nurses) of the IJ (Immediate Jeopardy) situation that currently existed in the facility. The IJ situation began on [DATE] at 12:30AM when sampled resident #1 was found in need of cardiopulmonary resuscitation and S4 LPN did not perform the appropriate rescue breaths for [MEDICAL CONDITION] resident #1. The IJ situation ended on [DATE] for resident #1 when emergency personnel arrived at the facility but continued for the other three residents (#2, #4, #5) with tracheostomies from [DATE] through [DATE]. The IJ situation was lifted for resident #5 when the [MEDICAL CONDITION] was discontinued on [DATE]. The IJ situation was lifted for resident #2 when he/she was discharged from the facility on [DATE] and resident #4 when the [MEDICAL CONDITION] was discontinued on [DATE]. The facility did not have any [MEDICAL CONDITION] residents from [DATE] through [DATE]. Resident #3, a resident with a [MEDICAL CONDITION], was placed in an IJ situation on [DATE] when he/she was admitted to the facility and the facility had not taken action to ensure staff had knowledge and skills to provide rescue breaths to a resident with a [MEDICAL CONDITION]. Resident #2, a resident with a [MEDICAL CONDITION], was placed in an IJ situation on [DATE] when he/she returned to the facility and the facility had not taken action to ensure staff had knowledge and skills to provide rescue breaths to a resident with a [MEDICAL CONDITION]. The facility submitted a plan of removal to the survey team on [DATE] at 4:40 PM for the IJ situation. The plan of removal included the following: 1. No new [MEDICAL CONDITION] residents will be accepted until staff has been trained on all aspects of care for trachs including training of reinsertion of [MEDICAL CONDITION] what to do if unable to replace the trach. 2. Respiratory Therapist started retraining at 2:00 PM for staff nurses. Nine nurses have been retrained today, [DATE]. Ten more nurses will receive retraining [MEDICAL CONDITION] and the reinsertion of [MEDICAL CONDITION] what to do if unable to reinsert trach. 3. Nurses will not be allowed to work with [MEDICAL CONDITION] until nurse can do a return demonstration with the Respiratory Therapist. On [DATE] at 4:40 PM, the IJ situation was removed after the facility implemented their plan. The deficient practice was lowered to a level 2 isolated for the other two [MEDICAL CONDITION] residents in the facility. Findings: Record review revealed that resident #1 was admitted on [DATE] with admit [DIAGNOSES REDACTED]. Record review revealed that the resident was a full code. Record review revealed that the resident had a [MEDICAL CONDITION] with a #6 cuffed [MEDICAL CONDITION] at 35% oxygen, continuous percutaneous endoscopic gastrostomy tube feeding with Glucerna at 50 milliliters per hour with a water flush of 150 milliliters every 4 hours and a foley catheter. Review of the nurses' note for resident #1 dated [DATE] at 12:30 AM revealed that: "During 12:00 rounds CNA (certified nurse aide) notified nurse of resident'[MEDICAL CONDITION] being pulled out and resident was unresponsive. Resident was checked for pulse and no pulse was found, CPR was started by nurse until resident was taken out by _______ ambulance." A late entry to the note was timed at 2:07 AM and stated, "Ambu bag to [MEDICAL CONDITION] with suction cup during CPR for rescue breaths." The nurses note entries were both signed by S4 LPN. Review of the ambulance report for resident #1 dated [DATE] revealed in part, '....nursing home staff doing very ineffective CPR....CNA was attempting to stick the mask attachment port of the ambu bag into the pt's stoma...'. On [DATE] at 2:10 PM, an interview was conducted with S4 LPN. When asked what happened with resident #1 on [DATE], she stated that she was called to the room by S10 CNA and found [MEDICAL CONDITION] laying on the resident's chest. She stated that the resident was unresponsive and she attempted to reinsert the tube a couple of times but could not get [MEDICAL CONDITION] reinserted. On [DATE] at 12:41 PM, a telephone interview was conducted with S4 LPN. When asked what she would do if a resident had [MEDICAL CONDITION] come out and she could not replace it, S4 LPN stated she would put the suction cup over [MEDICAL CONDITION] and give breaths. When asked by the surveyor to clarify what she meant by suction cup, she described the face mask. The surveyor asked S4 LPN if she had been inserviced on how to give rescue breaths to a [MEDICAL CONDITION] resident if [MEDICAL CONDITION] came out and the tube could not be reinserted. S4 LPN revealed that she had not been inserviced on what to do in that situation. On [DATE] at 9:00 AM, two attempts to contact S10 CNA, who was present during CPR for resident #1, was made. S11 SDC informed the surveyors that the agency was unable to contact S10 CNA. Therefore, the surveyors were unable to conduct an interview with S10 CNA. On [DATE] at 12:42 PM, a telephone interview was conducted with S5 LPN. The surveyor asked S5 LPN how she would give rescue breaths if a resident'[MEDICAL CONDITION] came out and she could not reinsert [MEDICAL CONDITION]. She stated that she had not been told what to do. She would not guess what she would do in that situation. Observation on [DATE] at 5:22 AM revealed that S5 LPN's assignments included the two [MEDICAL CONDITION] residents currently in the facility. On [DATE] at 9:30 AM, S6 LPN was interviewed and asked if she knew how to give rescue breaths to a resident with [MEDICAL CONDITIONS] could not be reinserted. She went to S7 LPN and asked and they agreed that they would put the mask over the stoma. On [DATE] at 9:35 AM, S7 LPN was interviewed and asked if she knew how to give rescue breaths to a resident with [MEDICAL CONDITIONS] came out and could not be reinserted. She stated that the face mask should be held over the stoma to form a seal on the resident's neck. On [DATE] at 12:35 PM, S8 LPN evening nurse (2PM-10PM), who's assignment included the remaining [MEDICAL CONDITION], was interviewed and asked if she knew how to give rescue breaths to a resident with [MEDICAL CONDITIONS] came out and could not be reinserted. She stated that she did not know what to do if [MEDICAL CONDITION] will not go back in. She reported that they had not told her. On [DATE] at 12:37 PM, S9 LPN (2PM-10PM) was interviewed by phone and was asked if she knew how to give rescue breaths to a resident with [MEDICAL CONDITIONS] came out and could not be reinserted. She stated that she would need to be refreshed on that because she did not know what to do in that situation. On [DATE] at 1:20 PM, an interview with S3 CRT and S2 DON was conducted in the S2 DON's office with two surveyors. S3 CRT revealed that she was responsible for inservicing the nurses [MEDICAL CONDITION]. When asked by the surveyor if she had ever inserviced the nurses how to give rescue breaths if they could not reinsert [MEDICAL CONDITION], S3 CRT stated "No". She stated that she inserviced the nurses how to reinsert the tube but never had inserviced on how to proceed with rescue breaths if the tube could not be reinserted. S2 DON was asked by the surveyor if she knew how to give rescue breaths to [MEDICAL CONDITION] when [MEDICAL CONDITION] could not be reinserted. S2 DON stated that the stoma should be occluded and rescue breaths should be given through the mouth and nose. S3 CRT confirmed that the S2 DON was correct. The surveyor asked the S3 CRT how the stoma should be occluded. S3 CRT stated the stoma should be occluded with a 4x4 gauze and tape, if available. The policy and procedure was requested for emergency care of the [MEDICAL CONDITION] resident. The S2 DON confirmed that there was not a policy for [MEDICAL CONDITION] emergency care.

Based on record review and interview, the facility failed to ensure that residents received proper emergency [MEDICAL CONDITION] care for 1 (#1) of 5 (#1 - #5) sampled residents with tracheostomies in a total sample of 5. The facility failed to: 1.) establish and implement a policy for emergency [MEDICAL CONDITION] care; 2.) inservice the nurses for emergency care of tracheostomies; 3.) ensure nurses were qualified to provide care for tracheostomies in an emergency situation; 4.) ensure staff provide adequate rescue breaths to residents with tracheostomies. The Immediate Jeopardy situation began on [DATE] at 12:30AM when resident #1 was found with the [MEDICAL CONDITION] out and unresponsive. The resident did not have a pulse and CPR (cardiopulmonary resuscitation) was started by S4 LPN. S4 LPN unsuccessfully attempted to reinsert the [MEDICAL CONDITION] and then proceeded to perform rescue breaths via ambu bag with mask over the stoma until emergency personnel arrived. According to the on-staff S3 CRT (Certified Respiratory Therapist), S4 LPN did not follow the correct procedures for performing rescue breaths during CPR for resident #1 after the unsuccessful attempts to re-insert [MEDICAL CONDITION]. On [DATE] at 4:05 PM, the survey team notified S1Administrator and S2 DON (Director of Nurses) of the IJ (Immediate Jeopardy) situation that currently existed in the facility. The IJ situation began on [DATE] at 12:30AM when sampled resident #1 was found in need of cardiopulmonary resuscitation and S4 LPN did not perform the appropriate rescue breaths for [MEDICAL CONDITION] resident #1. The IJ situation ended on [DATE] for resident #1 when emergency personnel arrived at the facility but continued for the other three residents (#2, #4, #5) with tracheostomies from [DATE] through [DATE]. The IJ situation was lifted for resident #5 when the [MEDICAL CONDITION] was discontinued on [DATE]. The IJ situation was lifted for resident #2 when he/she was discharged from the facility on [DATE] and resident #4 when the [MEDICAL CONDITION] was discontinued on [DATE]. The facility did not have any [MEDICAL CONDITION] residents from [DATE] through [DATE]. Resident #3, a resident with a [MEDICAL CONDITION], was placed in an IJ situation on [DATE] when he/she was admitted to the facility and the facility had not taken action to ensure staff had knowledge and skills to provide rescue breaths to a resident with a [MEDICAL CONDITION]. Resident #2, a resident with a [MEDICAL CONDITION], was placed in an IJ situation on [DATE] when he/she returned to the facility and the facility had not taken action to ensure staff had knowledge and skills to provide rescue breaths to a resident with a [MEDICAL CONDITION]. The facility submitted a plan of removal to the survey team on [DATE] at 4:40 PM for the IJ situation. The plan of removal included the following: 1. No new [MEDICAL CONDITION] residents will be accepted until staff has been trained on all aspects of care for trachs including training of reinsertion of [MEDICAL CONDITION] what to do if unable to replace the trach. 2. Respiratory Therapist started retraining at 2:00 PM for staff nurses. Nine nurses have been retrained today, [DATE]. Ten more nurses will receive retraining [MEDICAL CONDITION] and the reinsertion of [MEDICAL CONDITION] what to do if unable to reinsert trach. 3. Nurses will not be allowed to work with [MEDICAL CONDITION] until nurse can do a return demonstration with the Respiratory Therapist. On [DATE] at 4:40 PM, the IJ situation was removed after the facility implemented their plan. The deficient practice was lowered to a level 2 isolated for the other two [MEDICAL CONDITION] residents in the facility. Findings: Record review revealed that resident #1 was admitted on [DATE] with admit [DIAGNOSES REDACTED]. Record review revealed that the resident was a full code. Record review revealed that the resident had a [MEDICAL CONDITION] with a #6 cuffed [MEDICAL CONDITION] at 35% oxygen, continuous percutaneous endoscopic gastrostomy tube feeding with Glucerna at 50 milliliters per hour with a water flush of 150 milliliters every 4 hours and a foley catheter. Review of the nurses' note for resident #1 dated [DATE] at 12:30 AM revealed that: "During 12:00 rounds CNA (certified nurse aide) notified nurse of resident'[MEDICAL CONDITION] being pulled out and resident was unresponsive. Resident was checked for pulse and no pulse was found, CPR was started by nurse until resident was taken out by _______ ambulance." A late entry to the note was timed at 2:07 AM and stated, "Ambu bag to [MEDICAL CONDITION] with suction cup during CPR for rescue breaths." The nurses note entries were both signed by S4 LPN. Review of the ambulance report for resident #1 dated [DATE] revealed in part, '....nursing home staff doing very ineffective CPR....CNA was attempting to stick the mask attachment port of the ambu bag into the pt's stoma...'. On [DATE] at 2:10 PM, an interview was conducted with S4 LPN. When asked what happened with resident #1 on [DATE], she stated that she was called to the room by S10 CNA and found [MEDICAL CONDITION] laying on the resident's chest. She stated that the resident was unresponsive and she attempted to reinsert the tube a couple of times but could not get [MEDICAL CONDITION] reinserted. On [DATE] at 12:41 PM, a telephone interview was conducted with S4 LPN. When asked what she would do if a resident had [MEDICAL CONDITION] come out and she could not replace it, S4 LPN stated she would put the suction cup over [MEDICAL CONDITION] and give breaths. When asked by the surveyor to clarify what she meant by suction cup, she described the face mask. The surveyor asked S4 LPN if she had been inserviced on how to give rescue breaths to a [MEDICAL CONDITION] resident if [MEDICAL CONDITION] came out and the tube could not be reinserted. S4 LPN revealed that she had not been inserviced on what to do in that situation. On [DATE] at 9:00 AM, two attempts to contact S10 CNA, who was present during CPR for resident #1, was made. S11 SDC informed the surveyors that the agency was unable to contact S10 CNA. Therefore, the surveyors were unable to conduct an interview with S10 CNA. On [DATE] at 12:42 PM, a telephone interview was conducted with S5 LPN. The surveyor asked S5 LPN how she would give rescue breaths if a resident'[MEDICAL CONDITION] came out and she could not reinsert [MEDICAL CONDITION]. She stated that she had not been told what to do. She would not guess what she would do in that situation. Observation on [DATE] at 5:22 AM revealed that S5 LPN's assignments included the two [MEDICAL CONDITION] residents currently in the facility. On [DATE] at 9:30 AM, S6 LPN was interviewed and asked if she knew how to give rescue breaths to a resident with [MEDICAL CONDITIONS] could not be reinserted. She went to S7 LPN and asked and they agreed that they would put the mask over the stoma. On [DATE] at 9:35 AM, S7 LPN was interviewed and asked if she knew how to give rescue breaths to a resident with [MEDICAL CONDITIONS] came out and could not be reinserted. She stated that the face mask should be held over the stoma to form a seal on the resident's neck. On [DATE] at 12:35 PM, S8 LPN evening nurse (2PM-10PM), who's assignment included the remaining [MEDICAL CONDITION], was interviewed and asked if she knew how to give rescue breaths to a resident with [MEDICAL CONDITIONS] came out and could not be reinserted. She stated that she did not know what to do if [MEDICAL CONDITION] will not go back in. She reported that they had not told her. On [DATE] at 12:37 PM, S9 LPN (2PM-10PM) was interviewed by phone and was asked if she knew how to give rescue breaths to a resident with [MEDICAL CONDITIONS] came out and could not be reinserted. She stated that she would need to be refreshed on that because she did not know what to do in that situation. On [DATE] at 1:20 PM, an interview with S3 CRT and S2 DON was conducted in the S2 DON's office with two surveyors. S3 CRT revealed that she was responsible for inservicing the nurses [MEDICAL CONDITION]. When asked by the surveyor if she had ever inserviced the nurses how to give rescue breaths if they could not reinsert [MEDICAL CONDITION], S3 CRT stated "No". She stated that she inserviced the nurses how to reinsert the tube but never had inserviced on how to proceed with rescue breaths if the tube could not be reinserted. S2 DON was asked by the surveyor if she knew how to give rescue breaths to [MEDICAL CONDITION] when [MEDICAL CONDITION] could not be reinserted. S2 DON stated that the stoma should be occluded and rescue breaths should be given through the mouth and nose. S3 CRT confirmed that the S2 DON was correct. The surveyor asked the S3 CRT how the stoma should be occluded. S3 CRT stated the stoma should be occluded with a 4x4 gauze and tape, if available. The policy and procedure was requested for emergency care of the [MEDICAL CONDITION] resident. The S2 DON confirmed that there was not a policy for [MEDICAL CONDITION] emergency care.

Based on record review and interview, the facility failed to be administered in a manner that enables it to use its resources effectively and efficiently to care for a resident during an emergency situation with a [MEDICAL CONDITION] for 1 (#1) of 5 (#1 - #5) sampled residents with tracheostomies in a total sample of 5. The facility failed to: 1.) establish and implement a policy for emergency [MEDICAL CONDITION] care; 2.) inservice the nurses for emergency care of tracheostomies; 3.) ensure nurses were qualified to provide care for tracheostomies in an emergency situation; 4.) ensure staff provide adequate rescue breaths to residents with tracheostomies. The Immediate Jeopardy situation began on [DATE] at 12:30AM when resident #1 was found with the [MEDICAL CONDITION] out and unresponsive. The resident did not have a pulse and CPR (cardiopulmonary resuscitation) was started by S4 LPN. S4 LPN unsuccessfully attempted to reinsert the [MEDICAL CONDITION] and then proceeded to perform rescue breaths via ambu bag with mask over the stoma until emergency personnel arrived. According to the on-staff S3 CRT (Certified Respiratory Therapist), S4 LPN did not follow the correct procedures for performing rescue breaths during CPR for resident #1 after the unsuccessful attempts to re-insert [MEDICAL CONDITION]. On [DATE] at 4:05 PM, the survey team notified S1Administrator and S2 DON (Director of Nurses) of the IJ (Immediate Jeopardy) situation that currently existed in the facility. The IJ situation began on [DATE] at 12:30AM when sampled resident #1 was found in need of cardiopulmonary resuscitation and S4 LPN did not perform the appropriate rescue breaths for [MEDICAL CONDITION] resident #1. The IJ situation ended on [DATE] for resident #1 when emergency personnel arrived at the facility but continued for the other three residents (#2, #4, #5) with tracheostomies from [DATE] through [DATE]. The IJ situation was lifted for resident #5 when the [MEDICAL CONDITION] was discontinued on [DATE]. The IJ situation was lifted for resident #2 when he/she was discharged from the facility on [DATE] and resident #4 when the [MEDICAL CONDITION] was discontinued on [DATE]. The facility did not have any [MEDICAL CONDITION] residents from [DATE] through [DATE]. Resident #3, a resident with a [MEDICAL CONDITION], was placed in an IJ situation on [DATE] when he/she was admitted to the facility and the facility had not taken action to ensure staff had knowledge and skills to provide rescue breaths to a resident with a [MEDICAL CONDITION]. Resident #2, a resident with a [MEDICAL CONDITION], was placed in an IJ situation on [DATE] when he/she returned to the facility and the facility had not taken action to ensure staff had knowledge and skills to provide rescue breaths to a resident with a [MEDICAL CONDITION]. The facility submitted a plan of removal to the survey team on [DATE] at 4:40 PM for the IJ situation. The plan of removal included the following: 1. No new [MEDICAL CONDITION] residents will be accepted until staff has been trained on all aspects of care for trachs including training of reinsertion of [MEDICAL CONDITION] what to do if unable to replace the trach. 2. Respiratory Therapist started retraining at 2:00 PM for staff nurses. Nine nurses have been retrained today, [DATE]. Ten more nurses will receive retraining [MEDICAL CONDITION] and the reinsertion of [MEDICAL CONDITION] what to do if unable to reinsert trach. 3. Nurses will not be allowed to work with [MEDICAL CONDITION] until nurse can do a return demonstration with the Respiratory Therapist. On [DATE] at 4:40 PM, the IJ situation was removed after the facility implemented their plan. The deficient practice was lowered to a level 2 isolated for the other two [MEDICAL CONDITION] residents in the facility. Findings: Record review revealed that resident #1 was admitted on [DATE] with admit [DIAGNOSES REDACTED]. Record review revealed that the resident was a full code. Record review revealed that the resident had a [MEDICAL CONDITION] with a #6 cuffed [MEDICAL CONDITION] at 35% oxygen, continuous percutaneous endoscopic gastrostomy tube feeding with Glucerna at 50 milliliters per hour with a water flush of 150 milliliters every 4 hours and a foley catheter. Review of the nurses' note for resident #1 dated [DATE] at 12:30 AM revealed that: "During 12:00 rounds CNA (certified nurse aide) notified nurse of resident'[MEDICAL CONDITION] being pulled out and resident was unresponsive. Resident was checked for pulse and no pulse was found, CPR was started by nurse until resident was taken out by _______ ambulance." A late entry to the note was timed at 2:07 AM and stated, "Ambu bag to [MEDICAL CONDITION] with suction cup during CPR for rescue breaths." The nurses note entries were both signed by S4 LPN. Review of the ambulance report for resident #1 dated [DATE] revealed in part, '....nursing home staff doing very ineffective CPR....CNA was attempting to stick the mask attachment port of the ambu bag into the pt's stoma...'. On [DATE] at 2:10 PM, an interview was conducted with S4 LPN. When asked what happened with resident #1 on [DATE], she stated that she was called to the room by S10 CNA and found [MEDICAL CONDITION] laying on the resident's chest. She stated that the resident was unresponsive and she attempted to reinsert the tube a couple of times but could not get [MEDICAL CONDITION] reinserted. On [DATE] at 12:41 PM, a telephone interview was conducted with S4 LPN. When asked what she would do if a resident had [MEDICAL CONDITION] come out and she could not replace it, S4 LPN stated she would put the suction cup over [MEDICAL CONDITION] and give breaths. When asked by the surveyor to clarify what she meant by suction cup, she described the face mask. The surveyor asked S4 LPN if she had been inserviced on how to give rescue breaths to a [MEDICAL CONDITION] resident if [MEDICAL CONDITION] came out and the tube could not be reinserted. S4 LPN revealed that she had not been inserviced on what to do in that situation. On [DATE] at 9:00 AM, two attempts to contact S10 CNA, who was present during CPR for resident #1, was made. S11 SDC informed the surveyors that the agency was unable to contact S10 CNA. Therefore, the surveyors were unable to conduct an interview with S10 CNA. On [DATE] at 12:42 PM, a telephone interview was conducted with S5 LPN. The surveyor asked S5 LPN how she would give rescue breaths if a resident'[MEDICAL CONDITION] came out and she could not reinsert [MEDICAL CONDITION]. She stated that she had not been told what to do. She would not guess what she would do in that situation. Observation on [DATE] at 5:22 AM revealed that S5 LPN's assignments included the two [MEDICAL CONDITION] residents currently in the facility. On [DATE] at 9:30 AM, S6 LPN was interviewed and asked if she knew how to give rescue breaths to a resident with [MEDICAL CONDITIONS] could not be reinserted. She went to S7 LPN and asked and they agreed that they would put the mask over the stoma. On [DATE] at 9:35 AM, S7 LPN was interviewed and asked if she knew how to give rescue breaths to a resident with [MEDICAL CONDITIONS] came out and could not be reinserted. She stated that the face mask should be held over the stoma to form a seal on the resident's neck. On [DATE] at 12:35 PM, S8 LPN evening nurse (2PM-10PM), who's assignment included the remaining [MEDICAL CONDITION], was interviewed and asked if she knew how to give rescue breaths to a resident with [MEDICAL CONDITIONS] came out and could not be reinserted. She stated that she did not know what to do if [MEDICAL CONDITION] will not go back in. She reported that they had not told her. On [DATE] at 12:37 PM, S9 LPN (2PM-10PM) was interviewed by phone and was asked if she knew how to give rescue breaths to a resident with [MEDICAL CONDITIONS] came out and could not be reinserted. She stated that she would need to be refreshed on that because she did not know what to do in that situation. On [DATE] at 1:20 PM, an interview with S3 CRT and S2 DON was conducted in the S2 DON's office with two surveyors. S3 CRT revealed that she was responsible for inservicing the nurses [MEDICAL CONDITION]. When asked by the surveyor if she had ever inserviced the nurses how to give rescue breaths if they could not reinsert [MEDICAL CONDITION], S3 CRT stated "No". She stated that she inserviced the nurses how to reinsert the tube but never had inserviced on how to proceed with rescue breaths if the tube could not be reinserted. S2 DON was asked by the surveyor if she knew how to give rescue breaths to [MEDICAL CONDITION] when [MEDICAL CONDITION] could not be reinserted. S2 DON stated that the stoma should be occluded and rescue breaths should be given through the mouth and nose. S3 CRT confirmed that the S2 DON was correct. The surveyor asked the S3 CRT how the stoma should be occluded. S3 CRT stated the stoma should be occluded with a 4x4 gauze and tape, if available. The policy and procedure was requested for emergency care of the [MEDICAL CONDITION] resident. The S2 DON confirmed that there was not a policy for [MEDICAL CONDITION] emergency care.