Every finding on record at Park Manor of Mckinney

Based on interviews and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported, immediately but not later than 2 hours after the allegation was made, if the events that caused the allegation involved abuse or bodily injury, to the administrator of the facility and to other officials, including the State Survey Agency in accordance with State law through established procedures for 1 of 5 residents (Resident #1) reviewed for reporting allegations of abuse. The facility nursing staff failed to identify, assess and report a skin injury to Resident #1's lower left extremity from 7/10/26 to 7/22/26. This failure placed facility residents at risk for worsening stasis, Cellulitis (skin infection), Osteomyelitis (infection of the bone), Sepsis (infection of the blood) or pain. Findings included: Record review of Resident #1's Face Sheet dated 7/22/26 revealed that she was a [AGE] year-old female resident with an initial admit date of 5/29/26. She had the following diagnosis: ANEMIA, UNSPECIFIED (Low red blood cells), DEMENTIA (decline in mental ability), UNSPECIFIED SEVERITY, WITHOUT BEHAVIORAL DISTURBANCE, PSYCHOTIC DISTURBANCE, MOOD DISTURBANCE, OR ANXIETY and ACUTE KIDNEY FAILURE. Record review of Resident #1's MDS dated [DATE] revealed that Resident #1 had a BIMS Score of 09 meaning Resident #1 had moderate cognitive impairment. Resident #1 required the assistance of 2 or more helpers in the functional abilities areas of: bathing, transfers, toileting and repositioning. Resident #1 was reported as not being on any Anticoagulant medications and required Dialysis. Record Review of Resident #1's Comprehensive Care Plan dated 5/29/26 reflected: Focus: Has potential for pressure ulcer r/t incontinence and immobility. Goal: Pressure ulcer will show signs of healing and remain free from infection by/through review date. Interventions/Tasks: Assess/record/monitor wound healing. Measure length, width and depth where possible. Assess and document status of wound perimeter, wound bed and healing progress. Report improvements and declines to the MD. Record review of Resident #1's active orders dated 7/22/26 found that Resident #1 had no orders for anti-coagulant medications and was not receiving any anticoagulant medications. Record review of Resident #1's Facility Progress Notes from 6/22/26 to 7/22/26 found no entries identifying any bruises on Resident #1's lower left extremity. Record Review of all of Resident #1's Skin assessments from 5/29/26 to 7/22/26 found that Resident #1's skin had been reported as intact with no notations of blemishes or bruising. In an interview on an undisclosed date and time, a Confidential person revealed she had interacted with Resident #1 while providing a medical service on 7/10/26. She stated that she had observed a three-inch diameter bruise on Resident #1's lower left extremity just above the inside of Resident #1's left ankle. She stated that Resident #1 reported to her that the bruise had occurred during incontinent care that was done too fast and Resident #1 had reported it to the facility and had not seen that particular staff member again although she could not remember the staff member's name. Confidential person then related that Resident #1 was not on any type of anticoagulant medications and Resident #1 was affected by dementia but not profoundly. In an observation and interview on 7/22/26 at 11:04 AM Resident #1 was observed supine (laying down in a prone position) with both legs exposed. Two individual areas of discoloration were visible on the exposed skin just above Resident #1's left ankle. The areas of discoloration appeared purple in color and were around 1 to 1.5 inches in diameter and separated by .5 inch between the two. Closer examination revealed a faint yellow outline surrounding both of the skin discolorations that measured approximately 3 inches in diameter. Resident #1 explained that she had got the bruise because two CNAs had changed her too fast and had pulled her left leg too hard and caused the bruise to the inside of her ankle. In an interview on 7/22/26 at 1:41 PM CNA E revealed that she had worked with Resident #1 several times during the month of July 2026, and that she had not noticed any bruising on Resident #1's legs, but she does not normally work that hallway where Resident #1 lives. In an interview on 7/22/26 at 2:18 PM CNA C stated that she had worked with Resident #1 in the last few days. She stated that she had seen the bruise on the resident's leg, but it had looked old and healing so she had thought that it was an older bruise and the nurses were aware of it. In an interview on 7/22/26 at 2:42 PM CNA D stated that she had worked with Resident #1 during the month of July, but not this last week. She stated that she had not seen any bruises on Resident #1. In an interview on 7/22/26 at 3:02 PM CNA A revealed that she generally did not work on Resident #1's hall but she had assisted with cares between 7/7/26 and 7/10/26 for Resident #1. She denied seeing any bruises and denied that anything unusual had occurred during the times she had assisted Resident #1 with cares. She stated that she had not worked on Resident #1's hallway since but had not been told she could not work that hallway, she had just not been scheduled on Resident #1's hallway lately. In an observation and interview on 7/22/26 at 3:24 PM RN B revealed that she is generally the nurse in charge of the hallway that Resident #1 lived on. She stated that there were only 4 residents at the moment on that hallway, and that Resident #1 did not have any bruises. RN B then accompanied the ADON to Resident #1's room. RN B and ADON then examined Resident #1's left lower leg. RN B stated that she had not been informed of a bruise on Resident #1's leg but she agreed that there appeared to be two healing bruises just above Resident #1's left ankle. ADON stated that in her opinion the bruise had been healing and was perhaps two weeks old. In an interview on 7/22/26 at 3:53 PM DON stated that she was completely unaware of any bruise on Resident #1's leg. She stated that the resident did not report anything to her and she agreed that if the bruise happened on 7/10/26 that many staff members would have had a chance to see it and report it. She stated that If a resident is not regularly assessed it could cause untreated wounds, skin conditions, infections, or pressure ulcers. Record review of the facility ' s Abuse, Neglect and Exploitation policy dated 08/15/24 reflected: Policy: It is a policy of this facility to provide protections for the health, welfare, and rights of each resident by developing and implementing policies and procedures that prohibit and prevent, neglect, exploitation, and misappropriation of property. IV. Identification of Abuse, Neglect and Exploitation A. The facility will have written procedures to assist staff in identifying the different types of abuse - mental/verbal abuse, sexual abuse, physical abuse, and the deprivation by an individual of goods and services. This includes staff to resident abuse and certain resident to resident altercations. B. Possible indicators of abuse include, but are not limited to: 2. Physical marks such as bruises or patterned appearances such as a handprint, belt or ring mark on a resident ' s body. 3. Physical injury of a resident, of unknown source. VII. Reporting/Response: The facility will have written procedures that include: Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes: Immediately, but no later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury.

Based on interview and record review, the facility failed to notify the resident or the resident's representative of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand and send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman for one of two residents (Resident #1) reviewed for discharge notices. The facility failed to notify Resident #1 in writing of his transfer/discharge to home due to his behaviors of exit seeking, the reason for the discharge, the right to appeal and they failed to send a copy of the notice to the Ombudsman as soon as practicable. This failure could place residents at risk of being transferred or discharged , and not having access to available advocacy services, discharge/transfer options, and appeal processes. Findings included: Record review of Resident #1's face sheet, dated 03/18/25, reflected the resident was a [AGE] year-old male. The face sheet was incomplete. No admission date, No discharge date , no admitting diagnosis. Record review of an E-Mail sent by the Administrator to the facility management staff on 01/20/25 with an attachment, reflected Resident #1's family had toured the facility and were planning on admission of Resident #1 for long term care placement. Record review of the Attachment provided in the E-mail on 01/20/25 reflected a Neuropsychological Evaluation completed on Resident #1 with dates of services on 10/22/24, 11/01/24, 11/04/24, and 11/05/24. The evaluation reflected, [Resident #1] .was referred for a neuropsychological assessment due to concerns of dementia and history of seizures. [Resident #1] and his family served as primary informants for the current examination. The latter is also his assigned power of attorney .Upon a comprehensive review of [Resident #1's] medical records, diagnostic, functional status, and neuropsychological testing performed; it appears that [Resident #1] presents with a Major neurocognitive disorder due to vascular disease. Psychologically, meets criteria for adjustment disorder with mixed anxiety and depressed mood due to a slight elevation in sadness .During testing, [Resident #1] had trouble remembering what he wanted to say. He needed frequent repetition of instructions. He was slim for his height. Hygiene was unkempt. He was ambulatory. He was distractible and needed refocusing. He seemed depressed and anxious .was reportedly getting lost in familiar places .has feeling that a word is on the tip of his tongue, difficulty understanding others or following conversation, difficulty with naming objects, and has difficulty with expressing his thoughts . Record review of Resident #1's Nurses Notes by LVN A at 09:58 a.m., dated 02/16/25, reflected the following: Resident walked into the facility by his [POA] and [Family member] for admission into the facility. Resident to be admitted per services of [MD B]. Resident alert and confused stating several times that he didn't know why he was here and that he was ready to leave. Spoke with the family in the lobby for a short time collecting information from the family. Family asked did resident have exit seeking tendencies and family confirmed that he did. Resident and family taken to his room to meet his roommate and get oriented to his room. Again, resident is asking which door, he could use to get out of. Called MD on call service and got a return call from [NP C]. Went over home meds which NP agreed with. She also gave an order for labs to be drawn, and a speech consult due to family stating that the resident had swallowing issues. Resident spent a short time in his room then was taken to the dining room by his family. Family stayed until meal was served then left. Resident ate his lunch then continuously asked other residents and staff how to get out to the parking lot so he could go home. At approximately 1:15 pm resident redirected from the front door as he tried to exit the facility. Resident became belligerent and started to curse stating he could leave when he wanted to. Reality orientation given several times with unsuccessful results. Resident then brought to the unit and informed again that all doors on the hall were locked. Resident very upset stating he would throw a chair through the door and leave. Administrator and DON made aware of resident activity. Administrator informed this writer to contact family and ask them to come and pick the resident up recommending a locked unit for safety. At 2:35pm the family notified and told they needed to pick the resident up. The family was very upset stating that's not what they were told, and it was an inconvenience for them. Writer apologized for the inconvenience, but they still had to pick him up. [Family member] stated they could be here in an hour. While writer waited for family, resident continued to exit seek walking up to every door and pushing on it setting off the alarms. Resident ushered into the tv room and monitored one on one to ensure he remained in the building. Family asked, So what are we supposed to do with him? Writer advised a dementia type unit. Family asked if I could call the ambulance to come and pick him up. Writer stated there was no clinical reason for staff to call EMS. Family packed resident belongings and exited the facility. Record review of Resident #1's clinical record reflected there was no documentation showing the resident, the resident's POA and the Ombudsman were notified in writing of the resident's discharge or the reason for the resident's discharge. In an interview with Resident #1' Family member on 03/17/25 at 4:23 p.m. she stated Resident #1 was living at home with his POA who had noticed how advanced Resident #1's dementia had become. She stated they took him to a neurologist in November 2024 who diagnosed him with advanced Vascular dementia. She stated his POA got to where she could not handle him anymore, so she started looking for a place. She stated she visited several places and decided on this facility. She stated she sent all of Resident #1's medical paperwork to the Administrator and arranged for an admission date. She stated the Administrator had told them admissions during the week were better, but if the weekend worked better for them, he would have someone there to assist with the admission. She stated they agreed on a Sunday 02/16/25. She stated when they got to the facility, Resident #1 immediately said he did not like it here and was going to escape. She stated they stayed with him through lunch and thought he had agreed to give it a week. She stated they left and within 3 hours got a call from LVN A who told them they had to come get him. She stated he was kicking the doors, and screaming and was uncontrollable. She stated when they got to the facility, he was highly agitated and they wanted to send him to the hospital, but LVN A said she could not call an ambulance and said they could not call an ambulance from inside the facility. She stated if they wanted to call an ambulance they would have to take him outside. She stated they got him in their car and took him to the hospital where he spent the night in the psych ward. She stated they had to sedate him because he was so angry and aggressive. She stated the hospital then transferred him to a Behavioral health hospital. She stated she did get a call from the Administrator on that Monday (02/17/25) and he apologized that it did not work out. She stated she understood staff should not be physically and verbally abused by residents but stated it was such a negative experience for them. She stated Resident #1 had not been an elopement risk while at home. Family member stated he would go outside but always come back in. She stated Resident #1 is now in a locked unit at another facility and it seems to be going well. Family member stated they were not provided any written discharge information related to their rights or how to appeal the discharge or contact the ombudsman. In an Interview with DON on 03/18/25 at 01:09 p.m. she stated she was out of town the weekend Resident #1 came in. She stated usually she reviewed any of the clinicals on any new admission, but stated since she was out of town it would be the MDS nurse or the marketer who would review any clinicals. She stated she did not know much about what had taken place on the day of Resident #1's admission other than he was exit seeking and they do not have a locked unit. She stated she thought he had only been her about an hour. She stated as to the staff calling an ambulance, she stated 911 will not transport for behaviors only, and will only transport if there is a clinical need. She stated in reading the nurses progress note, most likely the ambulance would not have taken him to the hospital. She stated in hindsight, if the family was not able to stay with the resident, they should have placed him on one on one until the physician could have evaluated him, or he started to adjust, or they ensured a proper transfer or discharge. In an Interview with LVN A on 03/18/25 at 01:26 p.m. on speaker phone in the presences of the Administrator and the DON, she stated she was not aware she was getting a new admission [DATE]. She stated she worked the long-term care hall and did not get a lot of admission on her side. She stated she did not know until the resident and his family arrived at the facility that Sunday (02/16/25). She stated the family gave her a bag of his medications when they arrived around 9:30 a.m. She stated she called the MD on call to get admission orders and took him to his room and gave him a tour and introduced him to his roommate. She stated the family stayed with him through lunch and then left. She stated he visited a little while and then got up and told his roommate he had to get his stuff and go. She stated they tried to do reality orientation on him, but he kept getting more and more agitated. She stated she called the family and let them talk to him and he calmed down a little, but then around 2:00 p.m. he was going to the doors trying to leave, threatening to throw a chair and break the door to get out. She stated she called the Administrator, and he told her to call the family and tell them they had to come get him that they could not meet his needs. She stated she called the family and asked if they could come sit with him and they stated they could not. She stated she told the family they would have to take him back that they did not have a secured unit that they could keep him safe. She stated the family was very upset and wanted her to call an ambulance and she told them there was no clinical reason to call an ambulance. She stated the resident had calmed down once the family got there. She stated the family gathered up his belongings and left with him. She stated she had not been able to get any of his admission paperwork completed. In an interview with the Administrator on 03/18/25 at 01:35 p.m., he stated he had initiated the tour and conversation with Resident #1's family member and had taken her for a tour of the building. He stated there was nothing mentioned about him being an elopement risk. He stated he had told her weekdays were better for admissions but stated they take admission 7 days a week 24 hours a day. He stated he had sent the information to the MDS nurse to determine if he would meet medical necessity. He stated looking back it appeared the admission process fell thought the cracks. He stated they had a new admission person who had just started in January 2025. He stated typically all the initial information that goes on the face sheet is started in the systems along with any other clinicals they may have. He stated it just did not get done. He stated when he got the call from LVN A, he assumed sending Resident #1 back home was the best solution since he did not want to be there. He stated they should have given them a copy of their discharge rights and stated they should have given them a discharge notice due to safety concerns related to his exit seeking behaviors. He stated going forward they would be putting systems in place, especially for residents admitting from home, to ensure they were able to meet the needs of the resident prior to accepting them. Review of the facility's policy Admission, Transfer and Discharge dated January 2022, reflected, It is the policy of this facility that each resident will remain in the facility, and not be transferred or discharged unless the discharge or transfer is appropriate as per the existing criteria. When the Facility transfers or discharges a resident, the Facility shall ensure that the transfer or discharge is documented in the residents' medical record and appropriate information is communicated to the receiving health care institution or provider .The facility shall permit each resident to remain in the facility, and not transfer or discharge the resident from the Facility unless: a. The transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the Facility .If the resident exercises his or her right to appear a transfer or discharge notice, the Facility shall not transfer or discharge the resident while the appeal is pending, unless the failure to discharge or transfer wound endanger the health or safety of the resident or other individuals in the Facility. The facility shall document the danger that failure to transfer, or discharge would pose .If the transfer or discharge is necessary for the resident's welfare and the residents' needs cannot be met in the facility, the resident's physician shall document the following in the resident's medical record a. the specific resident need(s) that cannot be met; b. Facility attempts to meet the resident needs; and c. The service available at the receiving Facility to meet the need(s) .A physician shall document if the transfer or discharge is necessary because the safety of individuals in the Facility is endangered due to the clinical or behavior status of the resident .

Based on observation, interview and record review, the facility failed to promptly notify the resident's physician, physician's assistant, nurse practitioner, or clinical nurse specialist of results that fell outside of clinical reference ranges in accordance with facility policies and procedures for notification of a practitioner or per the ordering physicians' orders for one of three residents (Resident #1) reviewed for notification. 1. The facility failed to notify Resident #1's primary Physician and Infectious Disease Nurse Practitioner for three days when Resident #1 tested positive for C. Diff on 04/19/24. (Per CDC website: C. diff is a bacterium that causes diarrhea and colitis (an inflammation of the colon). Most cases of C. diff infection occur when a resident is taking an antibiotic or not long after resident has finished taking antibiotics. C. diff can be life-threatening. Some of the C. Diff risk factors included: long term use of antibiotics, older age (65 and older), recent stay at a hospital or nursing home, a weakened immune system, or previous infection with C. diff or known exposure to the germs.) An Immediate Jeopardy (IJ) was identified on 04/24/24 at 3:40 PM. The Administrator was notified and provided with the IJ template on 04/24/24 at 3:50 PM and the Plan or Removal was requested. The IJ was removed on 04/25/24 at 11:03 AM the facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm and a scope of pattern due to the facility still monitoring the effectiveness of their Plan of Removal. This deficient practice could place residents at risks for a delay in medical treatment, which could lead to worsening of their condition, hospitalization , or death. Findings included: Record Review of Resident #1's Face Sheet dated 2/27/2024 reflected a re-admitted [DATE] to the facility. Record review of Resident #1's quarterly MDS, dated [DATE], reflected an [AGE] year-old female with an admitted [DATE]. The resident had a BIMS of 14 which indicated she was cognitively intact. She was always urinary and bowel incontinent. Active diagnoses included Heart Failure, Hypertension (high blood pressure), Diabetes Mellitus (high blood glucose), Parkinson's Disease ( brain disorder that caused uncontrolled movements) , and seizure disorder. Record review of Resident #1's care plan dated 04/14/2024, and revised on 04/24/2024 reflected, [Resident #1] Focus: Has infection of UTI- ESBL (Extended-spectrum beta-lactamase (ESBL) is an enzyme found in some strains of bacteria that makes them harder to treat with antibiotics. Urinary tract infections (UTIs) caused by ESBL-producing bacteria are a serious concern for adults), C. diff and requires Contact isolation. Resident and [family member] request that keep door open. She gets anxious and start yelling if door is closed. Family refuses for her to be moved, educated on risks. GOAL: Will be free from complications related to infection through the review date. INTERVENTION: Administer antibiotic as per MD orders. Follow facility policy and procedures for line listing, summarizing, and reporting infections. Maintain standard precautions when providing resident care. Record Review of LVN K's Progress Note dated 4/19/2024 reflected, [Resident #1] is yelling about pain in her rectum due to hemorrhoids, [Resident #1] is also noted to have diarrhea and pain with urination. New orders for CBC, BMP Urine Analysis with w Culture and Sensitivity and Stool with C. Diff sample. Stool and Urine sample have been collected. Samples are in the fridge pending pick up. Lab was called and notified of STAT labs. Record Review of Physician order for Resident #1 dated 4/19/2024 reflected, STAT: CBC, BMP Urine Analysis with w Culture and Sensitivity and Stool with C. Diff sample. Record review of the laboratory result for Resident #1 dated 4/19/2024 reflected the following: Sample Collection Date: 04/19/2024 16:51; Received Date: 04/19/2024 18:54; Reported Date: Date: 04/19/2024 at 19:40 , Positive C. Difficile Toxin EIA Positive (Positive C. diff Toxin Enzyme Immunoassay (EIA) test can indicate that resident's diarrhea and other symptoms are caused by toxin-producing C. diff.) was flagged as Abnormal (An abnormal C. diff lab test result indicates that toxins produced by C. difficile bacteria are present in the stool and causing diarrhea.) Record Review of the LVN K's progress note dated 4/22/2024 reflected [Resident #1] tested positive for C-DIFF. Infectious Disease NP in facility at this time. Received orders for Vancomycin (Antibiotic) 250mg by mouth Four times a day x 14 days related to C. Diff, Lactobacillus (probiotic) 1 capsule by mouth twice a day; push fluids and a CBC and BMP need to be collected every Thursday. Pt to be on isolation related to C. diff. Record Review of the RN progress notes revealed there were no notes charted for 4/20/22 and 4/21/24 for Resident #1. Record Review of the Infectious Disease NP note date 4/22/2024 reflected [Resident #1] reported to have elevated white Blood cells and lot diarrhea. Stool sample was sent for c-diff test and was tested positive. Pt. denies any dysuria (painful or uncomfortable urination) and denies any fever, chills, sweat, sob, cough. Record Review of the Physician's Order for Resident #1 dated 4/23/24 reflected , Contact Isolation for a Diagnosis of ESBL and C-Diff every shift related to ENTEROCOLITIS DUE TO CLOSTRIDIUM DIFFICILE, NOT SPECIFIED AS RECURRENT. Record review of the Physician's Order for Resident #1 dated 4/4/2024 reflected, Contact Isolation for a Diagnosis of ESBL every shift for ESBL IN URINE with end date of 04/14/2024. Record review of the Nursing Schedule for 4/19/24, 4/20/24 and 4/21/24 revealed LVN K, LVN L , LVN M, and LVN N were assigned to Resident #1. In an observation and interview with Resident #1 on 04/23/24 11:02 AM revealed Resident #1 was in an isolation room. Resident #1 was in bed with a scoop mattress; fall mats on either side of the bed and looked physically weak with muscle wasting. Resident #1's room had a foul smell. Resident #1 stated that she was having diarrhea multiple times for last few days, [could not tell the writer exact time frame] and was told on 4/22/24 that she had infection that caused diarrhea by the nurse. Resident #1 stated she was started on an antibiotic on 4/22/24 and had some relief in diarrhea on the day of this interview. Resident #1 stated it would have helped to start the antibiotic medication earlier. She stated staff were not wearing isolation gowns before entering her room since 4/22/24. Resident #1 also stated that she was incontinent of urine and stool and wore briefs. In an interview with LVN K on 4/24/24 at 9:23 AM revealed she worked on 6 am - 2 pm shift on 4/19/2024 and 4/22/2024. She stated that she had received stat orders to send Resident #1's stool sample for C. Diff testing. LVN K stated during her shift, she called the lab services to let them know to collect the stool sample, and it was noted on the 24-hour shift nursing report and communicated with the incoming nurse. She stated when she returned to work on Monday 4/22/24 6-2 shift, she checked the labs that were posted on the EHR and notified the Infectious Disease NP who was rounding the facility. She stated that Infectious Disease NP gave orders for Resident #1 to be on isolation and antibiotics. She stated that it was responsibility of the nurses to check labs and notify the physician about any abnormal significant lab result or change in condition immediately and the risk of not doing so could lead to delay in providing care to the resident. In a phone interview with LVN N on 4/24/24 at 12:01 PM revealed she worked on 4/20/24 and 4/21/24 6 am - 2 pm and 2 pm -10 pm shift on the Resident #1's hall. She stated that Resident #1 was not on isolation on 4/20/24 and 4/21/24. She stated that she did not check the C. Diff laboratory results or nursing progress notes in the EHR since she was not made aware on the 24-hour shift nursing report. She stated the physician was not informed about Resident#1's positive C. Diff lab results since she was not aware herself. LVN N stated that there was no mention of pending labs on the 24-hour shift report. She stated the risk to residents for not informing physician about significant abnormal lab results or change in resident condition was delayed treatment and increased risk of infection throughout the facility. In a phone interview with the Infectious Disease NP on 4/24/24 at 12:09 PM revealed the facility made her aware of Resident #1's of positive C. Diff lab result on 4/22/24 when she was rounding in the facility. The Infectious Disease NP stated once she learned about the positive C. Diff result for Resident #1, she gave orders to start Resident #1 on isolation and treated with antibiotics. She also stated if she would have known about the C. Diff results earlier, she would have started the antibiotics earlier. She stated the risk to residents for not informing the physician earlier was delayed treatment to the residents, lapses in infection control and quality of care could be decreased. In an interview with the ADON 04/24/24 at 12:28 PM revealed that she started working in the facility 3 weeks ago. She stated she thinks Resident #1 tested positive for C. Diff on 4/22/24 or 4/23/24 but she was not sure about the timeframe. She added her expectation was that any change in a resident's condition or significant lab change should be communicated to the physician immediately without any delay. ADON stated that nurses communicated with the on-coming shift Nurses for any pending labs or outstanding results via a 24-hour report and EHR. She stated the risk to residents for not notifying physician regarding residents change in condition can lead to delay in treatment and decreased quality of care. In an interview with LVN L on 4/24/24 at 1:02 PM revealed she worked 2 pm - 10 pm Shift on 4/19/22 and was assigned to Resident #1. LVN L stated that she had received 24-hour shift report from LVN K regarding a stat stool sample testing for C. Diff for Resident #1 and confirmed that laboratory personnel had picked up Resident #1's stool sample for testing. She further added, she thought C. Diff labs often took 2-3 days to get results and was not well versed with checking labs on the EHR, hence she did not check C. Diff labs on her entire shift, nor did she notify the physician about abnormal labs or change in condition. LVN L noted that she did not sought help from other staff member for checking lab results. She became aware that Resident #1 tested positive for C. Diff when she came back for her shift on 4/22/24. She stated Resident #1 was put on isolation on 4/22/24 per the shift 24- hour shift report she was given. She stated it was the nurses' responsibility to check for resident lab results and inform any change in condition for residents including abnormal labs to the physician immediately; and failure to do so could lead to delayed care and decreased quality of care. In a phone interview with LVN M on 4/24/24 at 1:08 PM revealed she worked 10 pm - 6 am shift on 4/19/24 and was assigned to Resident #1. She stated that Resident #1 was on isolation until 4/14/24 for ESBL but she did not remember if Resident #1 was on isolation on 4/19/24. LVN M further stated she did not check Resident #1's lab results or nursing progress notes on her shift because she had 40 residents to take care and did not have time to check the resident's EHR. She stated she only paid attention to the 24-hour nursing report, but she did not remember what was mentioned in the report. LVN M was not aware that Resident #1 had positive C. Diff lab until the time of this interview. LVN M stated she was not aware of the pending lab during the shift change. She stated she did not inform the physician about Resident #1's positive C. Diff report since she herself was not aware about it. LVN M stated she did not want to answer any further questions and the interview was ended. In an interview with the DON on 04/24/24 at 1:31 PM revealed she started at the facility about a month ago. She stated Resident #1 was having diarrhea and hence the stat stool testing was ordered and collected on 4/19/24 and resulted in a positive result for C. Diff on 4/19/24. The DON looked at the EHR and stated per physician's orders Resident #1 was started on isolation on 4/22/24. The DON stated that she became aware of the positive C. Diff lab on the morning of 4/22/24 during a clinical meeting. The DON also mentioned that Resident #1 was in isolation prior for ESBL which ended on 4/14/2024. She stated that they did not have a weekend supervisor and she was the point of contact for any nursing related concerns. The DON stated that she did not get any phone calls or messages notifying her about the positive C Diff result. The DON verbalized that usually the lab company will call the facility with any abnormal labs, but the facility did not get a call from the lab company. The DON also stated that all labs were available online and facility nurses knew how to access labs from the online portal. The DON stated that Resident #1's C. Diff labs results were available on the evening of 4/19/24 around 7 PM and added that the nurses for the 4/19/24 afternoon and night shift as well as nurses on 4/20/24 and 4/21/24 on all shifts failed to notify the physician about critical labs. The DON stated that typically nurses were responsible for checking lab results and notifying the Medical Director for any change in condition or abnormal labs immediately. She stated that she will need to speak with the nurses to identify the failure to communicate with the physician about a significant abnormal C. Diff lab for Resident #1. The DON stated her expectation was that any change of condition for a resident should be communicated to the physician immediately and the risk of not doing so can result in delayed treatment to the resident. The DON also stated that C. Diff is highly contagious disease and should have been started on appropriate treatment earlier. In a phone interview with the Medical Director (MD) on 04/30/24 at 3:13 PM revealed that she was not informed about Resident#1's Positive C. Diff lab until 4/22/24. The MD reviewed Resident #1's EHR during the interview and stated that she noted the C. Diff Toxin Enzyme Immunoassay lab was positive on 4/19/24. The MD stated a positive C. Diff Toxin Enzyme Immunoassay (EIA) test result indicated that diarrhea and other symptoms that Resident #1 was exhibiting were caused by toxin-producing C. Diff bacteria and was sufficient to start C. Diff treatment. The MD stated she should have been notified about positive C. Diff results immediately on the day it was resulted and not doing so exposed the residents to increased infections and a delay in treatment. She also stated if she was informed regarding Resident #1's significant results earlier, she would have started isolation protocols and other treatment earlier for Resident #1. In an interview with the Administrator on 04/24/24 03:16 PM revealed that Resident #1 was on isolation already, started earlier in the month with ESBL. The Administrator added that he was not aware that ESBL isolation orders had ended on 4/14/24. He further added that he became aware that Resident #1 was positive for C. Diff on 4/22/24 since it was brought up in the morning meeting. The Administrator added he will need to check the 24- hour nursing report to see what was said. The Administrator added that change of condition for a resident including significant lab result should be immediately communicated to the physician by the nursing team and failure to do so can result in delay in treatment. In an interview with Clinical Resource RN on 4/25/24 at 10:02 AM revealed that the facility was not able to locate the 24-hour nursing report paper copy dated 4/19/24. She added that there were no electronic copies of the report. Record review of facility's revision date December 2023, titled Significant change of condition, Response reflected, 1. If, at any time, it is recognized by any one of the team members that the condition or care needs of the resident have changed, the Licensed Nurse or Nurse Supervisor should be made aware. Examples would be the following (but not limited to): Any signs or symptoms of infection . Change in output (bowel or bladder) including amount, color, consistency, odor, or frequency .5. There will be certain circumstances where immediate attention will be warranted, and nursing will be responsible for notifying the appropriate department for evaluation. The nurse shall use his / her clinical judgment and shall contact the physician based on the urgency of the situation. The Medical Director shall be notified in the event that the Attending Physician or on-call Physician cannot be reached. The resident/ resident representative will be notified of the change of condition and any changes in the resident's medical or nursing care. Review of the Center for Disease Control (CDC) Website: Nursing Homes and Assisted Living (Long-term care facilities) https://www.cdc.gov/longtermcare/prevention/index.html reflected , C. difficile infection (CDI) is a common cause of acute diarrhea in nursing homes. Individuals with CDI serve as a source for bacterial spread to others, through the contamination of caregiver hands and shared equipment. Contamination of a resident's skin and environment is greatest when a resident has diarrhea from CDI but hasn't started on appropriate treatment. Early identification of CDI can limit the spread of C. difficile by reducing the time from symptom onset to starting therapy. Rapid containment through implementation of contact precautions for symptomatic residents can reduce contamination. Contact precautions include use of gowns/gloves and dedicated equipment during care of residents with new diarrhea An Immediate Jeopardy (IJ) was identified on 04/24/24 at 3:40 PM. The Administrator was notified and provided with the IJ template on 04/24/24 at 3:50 PM and the Plan or Removal was requested. The Plan of Removal was submitted by the facility and accepted on 04/25/24 at 11:03 AM. The Plan of Removal reflected the following: Action: 1. The Medical Director was notified of the IJ on 04/24/24 at 4:11 PM. 2. The resident's physician was notified of positive C-diff lab result on 04/22/24. 3. A facility lab results review of total census was initiated by nursing admin and will be completed on 04/24/24. 4. A facility review of all infectious diseases/lab orders was initiated by nursing admin and will be completed by 04/24/24. 5. On 04/24/24 the facility Clinical Resource who is an RN, completed train the trainer in-servicing for the DON, ADON and Cluster Partners. The training includes obtaining, reporting, and documenting labs and physician notification of resident change in condition. 6. In-service training for licensed nurses was initiated by DON/ADON/Clinical Resource on 04/24/24 related to obtaining, reporting, and documenting labs. Training to be completed by 04/24/24. Any staff who are unable to complete training on 04/24/24, will be required to complete training prior to the beginning of their next scheduled shift. 7.In-service training for licensed nurses was initiated by DON/ADON/Clinical Resource on 04/24/24 related to physician notification of change in resident condition. Training to be completed by 04/24/24. Any staff who are unable to complete training on 04/24/24, will be required to complete training prior to the beginning of their next scheduled shift. 8.A member of management will be at the facility at each change of shift to ensure all staff get trained prior to going to work on the floor. Staff will not be allowed to work unless they have completed the training and competency checks. This training will also be included in the new hire orientation and will be included for agency staff/PRN staff prior to starting work on the floor. 9.DON or designee will review changes in condition daily to ensure that the resident's physician has been notified. Executive Director or designee will monitor to ensure reviews are completed. Findings during review will be reported at the weekly QAPI committee meeting for 4 weeks or until substantial compliance established and continue monthly for 90 days to ensure ongoing compliance and continue monthly for 90 days to ensure ongoing compliance. 10.An ad hoc meeting regarding items in the IJ template was completed on 4/24/24. Attendees included the Medical Director, DON/Infection Preventionist, ADON and other IDT members. Meeting was led by facility Executive Director. Facility will complete weekly QA meeting to review corrective measures for four weeks or until substantial compliance is established. 11.Summary of IJ and corrective action to be reviewed by QAPI Committee weekly for four weeks beginning 4/24/2024 or until substantial compliance established and continue monthly for 90 days to ensure ongoing compliance. On 04/25/24 the Surveyor confirmed the facility implemented their plan of removal sufficiently to remove the IJ by: IJ Monitoring process: Record Review of the in-service dated 4/24/24 Change of Condition and Physician Notification reflected Nurses were in-serviced. The Surveyors attempted interviews for all the nurses that were in-serviced for Change of condition and Physician notification. In an interview with LVN Z on 4/25/24 at 12:52 pm revealed that per in-services provided on 4/24/24 every nurse, every shift would be checking on-coming and out-going lab results. LVN Z stated they needed to notify the physician about any change of condition including significant lab results. She also stated that she would contact the physician immediately regarding significant abnormal labs. In an interview with LVN R on 4/25/24 at 1:20 pm revealed she received an in-service on infection control and physician notification today. LVN R stated she understood to report any change in condition including abnormal labs to the physician immediately. She also stated that she understood to check the labs on her shift and report any lab changes that are abnormal to the physician and the DON. In an interview with LVN A on 4/25/24 at 1:29 PM revealed each nurse was responsible for requesting and sending out labs. If the labs came back positive or abnormal, the nurse would inform the physician immediately. She also stated that all labs, pending or confirmed, must be communicated to the next nurse during rounds. She also stated that any kind of change in condition, change in orientation, change in vital signs, notify MD immediately, notify the family as well. LVN A stated she will report to the DON, MD, ADON and family. She stated that for all transmission-based precautions on a resident with a positive diagnosis, they need to call the Infectious Doctor immediately to obtain orders, if any. In a phone interview with LVN T on 4/25/24 at 2:35 PM revealed she received an in-service regarding notification of change to the physician immediately that includes abnormal critical labs. LVN R stated that any labs that are pending or resulted should be communicated with the incoming nurses and documented as well so the residents can be taken care of. She also stated that any resident with C. Diff or Covid should be on isolation protocol immediately upon diagnosis and symptoms and the physician orders to be followed promptly. In an interview with LVN S on 04/25/24 02:56 PM revealed he was working at the facility for 2 years. He stated that nurses were responsible for checking labs and needed to communicate with the incoming nurses and documented on the 24-hour nursing report. He stated that any change in the resident's condition including abnormal critical lab should be communicated to the physician immediately. He also stated that abnormal labs should be communicated to the DON and ADON as needed. He stated that for any resident with transmission-based precautions such as Covid, C. Diff, should be started on isolation immediately upon diagnosis and symptoms. In an interview with LVN L on 04/25/24 at 03:18 PM revealed she had been working in the facility for about 4 months. She stated that every nurse, on every shift, will check labs that were outgoing or resulted; and notify the physician immediately about any abnormal results. She stated any change of condition in a resident should be communicated to the physician immediately, including the significant abnormal labs. She also stated that for any resident with transmission-based precautions with a positive diagnosis they need to be placed on isolation immediately. In a phone interview with LVN N on 4/25/24 at 4:16 PM revealed that she received in-services about physician notification. LVN N stated that she understood all changes in condition for a resident should be reported to the physician immediately. She also stated that nurses were responsible for checking labs, any abnormal critical labs will be communicated to the physician and DON immediately as well as with the incoming nurses and documented. In a phone interview with LVN K on 4/25/24 at 4:20 PM revealed that she received in-services about physician notification in change in condition including significant labs. She also stated that she understood that any lab results either pending or resulted should be communicated with the oncoming nurses, the DON and the physician. She stated that any resident on transmission-based protocol with a positive diagnosis should be placed on isolation immediately and the physician orders should be carried out immediately. An interview via phone was attempted for RN DD on 4/25/24 at 3:45 PM. The surveyor did not receive a return call until the time of exit. In an interview with ADON on 4/25/24 at 3:03 PM revealed the cause of failure was C Diff, which was a very infectious disease and was not reported to the physician in timely manner. She also stated that the labs were not followed up by the incoming nurses which caused breakdown of the communication failure. She also stated that as an ADON she will ensure that nurses were responsible for reporting labs and the physician would be notified about critical labs daily. She also stated that she planned to pull a lab report on all residents daily, checking the lab portal daily, the lab tracker form will be given to the nursing team, and she will follow-up on that. She also stated that there will be no break in the audit on the weekend; and the ADON or designee will follow-up. She stated that the failure affected the resident because of the delay in getting adequate care, her relief of symptoms would be sooner. She also stated that the risk to other residents because of potential spread of infection. In an interview with the DON on 4/25/24 at 3:19 PM revealed that failure occurred because the positive C. Diff labs came back on the 2-10 PM Shift on 4/19/24 and the nurses on the weekend failed to check labs on the following weekend,4/20/24 and 4/21/24. She stated that nurses were responsible for checking and reporting labs. She also stated that there was a communication breakdown regarding critical lab value such as positive C. Diff lab should have been reported promptly to the physician since C. Diff was a highly contagious disease. The DON stated that in-services for this failure were completed by the clinical Resource RN and the DON. As the DON, her role will be to improve communication between nursing and the incoming and outgoing shifts so that such failures about abnormal lab reporting can be prevented. She also stated that as the DON, she would be monitoring labs daily, increase frequency of skill checks, and monitoring of staff. She also stated that she would increase education with nurses to implement the new processes. She also stated with help of QAPI, they have created a lab tracker form and the DON or designee will oversee it daily. She also stated that Resident #1 was affected by the failure since she received delayed care and chances of infection spreading in the facility increased. In an interview with the Administrator on 4/25/24 at 3:37 PM revealed that the failure occurred because results of stat lab for Positive C. Diff results was not communicated with the physician immediately. He also stated that since various shifts were involved, there was a communication breakdown specially between nursing staff to convey lab results and notification to physician. He also stated that for any resident with transmission-based precautions, isolation protocols should be in place immediately. He stated via the QAPI process all nurses were in-serviced, they will conduct ongoing and as needed IDT meetings to discuss resident labs and interventions needed. He also stated that lab results will be reviewed by the ADON, DON or designee, daily including weekends. He stated QAPI meetings to be held weekly for next 90 days to ensure ongoing compliance. He stated Resident #1 was affected because there was a delay in treatment because of the failure to notify the physician promptly. These failures resulted in the identification of an IJ on 04/24/24 at 3:40 PM. The Administrator was notified and provided with the IJ template on 04/24/24 at 3:50 PM. The Plan of Removal was submitted by the facility and accepted on 04/25/24 at 11:03 AM , the administrator was notified .The facility remained out of compliance at a scope of pattern due to the facility's need to complete inservice training and evaluate the effectiveness of the corrective systems.

Based on observation, interview and record review, the facility failed to maintain an Infection Prevention and Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for two (Residents #1 and Resident #6) of four residents observed for infection control. 1. The facility failed to place Resident #1 who tested positive Clostridioides difficile (C. Diff) on 4/19/2024 in isolation until 04/22/2024, three days after the positive C. Diff result were obtained. (Per CDC website : C. diff is a bacterium that causes diarrhea and colitis (an inflammation of the colon) .Most cases of C. diff infection occur when a resident is taking an antibiotic or not long after resident has finished taking antibiotics. C. diff can be life-threatening. Some of the C. Diff risk factors included: long term use of antibiotics, older age (65 and older), recent stay at a hospital or nursing home, a weakened immune system, or previous infection with C. diff or known exposure to the germs.) 2. LVN O and NA P failed to wear appropriate PPE while caring for Resident #6 and Resident #1; who were on contact isolation, on 4/23/24. An Immediate Jeopardy (IJ) was identified on 04/24/24 at 3:40 PM. The IJ template was provided to the facility Administrator on 04/24/24 at 3:50 PM. While the IJ was removed on 04/25/24 at 11:03 AM the facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm and a scope of pattern due to the facility still monitoring the effectiveness of their Plan of Removal. These deficient practices could place residents at risks for spread of infection through cross-contamination of pathogens and illness, which could lead to worsening of their condition, hospitalization , or death. Findings included: 1- Record Review of Resident #1's Face Sheet dated 2/27/2024 reflected a re-admitted [DATE] to the facility. Record review of Resident #1's quarterly MDS, dated [DATE], reflected an [AGE] year-old female with an admitted [DATE]. The resident had a BIMS of 14 which indicated she was cognitively intact. She was always urinary and bowel incontinent. Active diagnoses included Heart Failure, Hypertension (high blood pressure), Diabetes Mellitus (high blood glucose), Parkinson's Disease ( brain disorder that caused uncontrolled movements) , and seizure disorder. Record review of Resident #1's care plan dated 04/14/2024, and revised on 04/24/2024 reflected, [Resident #1] Focus: Has infection of UTI- ESBL (Extended-spectrum beta-lactamase (ESBL) is an enzyme found in some strains of bacteria that makes them harder to treat with antibiotics. Urinary tract infections (UTIs) caused by ESBL-producing bacteria are a serious concern for adults), C. diff and requires Contact isolation. Resident and [family member] request that keep door open. She gets anxious and start yelling if door is closed. Family refuses for her to be moved, educated on risks. GOAL: Will be free from complications related to infection through the review date. INTERVENTION: Administer antibiotic as per MD orders. Follow facility policy and procedures for line listing, summarizing, and reporting infections. Maintain standard precautions when providing resident care. Record Review of LVN K's Progress Note dated 4/19/2024 reflected, [Resident #1] is yelling about pain in her rectum due to hemorrhoids, [Resident #1] is also noted to have diarrhea and pain with urination. New orders for CBC, BMP Urine Analysis with w Culture and Sensitivity and Stool with C. Diff sample. Stool and Urine sample have been collected. Samples are in the fridge pending pick up. Lab was called and notified of STAT labs. Record Review of the LVN K's progress note dated 4/22/2024 reflected [Resident #1] tested positive for C-DIFF. Infectious Disease NP in facility at this time. Received orders for Vancomycin (Antibiotic) 250mg by mouth Four times a day x 14 days related to C. Diff, Lactobacillus (probiotic) 1 capsule by mouth twice a day; push fluids and a CBC and BMP need to be collected every Thursday. Pt to be on isolation related to C. diff. Record Review of the RN progress notes revealed there were no notes charted for 4/20/22 and 4/21/24 for Resident #1. Record review of Physician's Order for Resident #1 dated 4/4/2024 reflected, Contact Isolation for a Diagnosis of ESBL every shift for ESBL IN URINE with end date of 04/14/2024. Record Review of Physician's order for Resident #1 dated 4/19/2024 reflected, STAT: CBC, BMP Urine Analysis with w Culture and Sensitivity and Stool with C. Diff sample. Record Review of Physician's Order for Resident #1 dated 4/23/24 reflected , Contact Isolation for a Diagnosis of ESBL and C-Diff every shift related to ENTEROCOLITIS DUE TO CLOSTRIDIUM DIFFICILE, NOT SPECIFIED AS RECURRENT. Record review of the laboratory result for Resident #1 dated 4/19/2024 reflected the following: Sample Collection Date: 04/19/2024 16:51; Received Date: 04/19/2024 18:54; Reported Date: Date: 04/19/2024 at 19:40 , Positive C. Difficile Toxin EIA Positive (Positive C. diff Toxin Enzyme Immunoassay (EIA) test can indicate that resident's diarrhea and other symptoms are caused by toxin-producing C. diff.) was flagged as Abnormal (An abnormal C. diff lab test result indicates that toxins produced by C. difficile bacteria are present in the stool and causing diarrhea.) Record Review of the Infectious Disease NP note date 4/22/2024 reflected [Resident #1] reported to have elevated white Blood cells and lot diarrhea. Stool sample was sent for c-diff test and was tested positive. Pt. denies any dysuria (painful or uncomfortable urination) and denies any fever, chills, sweat, sob, cough. In an observation and interview with Resident #1 on 04/23/24 11:02 AM observed Resident #1 was in an isolation room; cohorting with Resident #6. Resident #1 was in bed with scoop mattress; fall mats on either side of the bed and cachectic looking. Resident #1's room had a foul smell. Resident stated that she was having diarrhea multiple times for last few days, [could not tell the writer exact time frame] and was told on 4/22/24 that she had infection that caused diarrhea by the Nurse. Resident #1 stated she was started on antibiotic on 4/22/24 and had some relief in diarrhea on the day of this interview. Resident #1 stated it would have helped to start the antibiotic medication earlier. She stated staff were not wearing isolation gowns before entering her room since 4/22/24. Resident #1 also stated that she was incontinent of urine and stool and wore briefs that needed to be changed by staff members. 2-Record Review of Resident #6's Face Sheet dated 3/21/2022 with a readmitted [DATE] to the facility. Record review of Resident #6's quarterly MDS, dated [DATE], reflected an [AGE] year-old female with an admitted [DATE]. The resident had a BIMS of 9 which indicated she had moderate cognitive impairment. She was frequently incontinent of urine and bowel. Resident #6 needed substantial/maximal assistance with toileting and hygiene. Active diagnoses included Pneumonia (infection in lungs), Osteoporosis (decreased bone strength or bone density), Cerebral Palsy (a group of conditions that affect movement and posture), functional urinary incontinence (toileting difficulty), non-Alzheimer's dementia (memory loss) and anxiety disorder. Record review of Resident #6's care plan with revised date of 4/24/24 revealed, Focus: Has a new onset infection ESBL UTI and requires isolation. Goal: Will be free from complications related to infection through the review date. Interventions: Ensure all immunization are up to date. Follow facility policy and procedures for line listing, summarizing, and reporting infections. Maintain isolation status. Maintain standard precautions when providing resident care. Record Review of the Physician's Orders dated 4/23/24 reflected Resident #6 had and order for Contact Isolation for a diagnosis of ESBL every shift related to URINARY TRACT INFECTION. In an observation on 4/23/24 at 2:32 PM from the hallway revealed that Resident #6 and Resident #1 shared the same room. The room was an isolation room with two contact isolation signs that stated See nurse before entering room posted on the door. The room door was open, and Resident #6 was found to be sitting on the floor of her room near the wheelchair. The isolation cart including PPE such as gloves, masks, and hand sanitizer was observed outside the door. Observed NA P rushed to the room, without performing any hand hygiene or wearing PPE. Then observed LVN O entered the isolation room without performing any hand hygiene or wearing PPE. The 2 staff members, LVN O and NA P, then proceeded to pick-up Resident #6 and sat her into the wheelchair in the room. NA P proceeded to move Resident # 6's wheelchair to the restroom. Meanwhile, LVN O came out of the room without performing hand hygiene and walked to the nurse's station. She grabbed a hand cuff blood pressure monitor and rushed back to the isolation room. Observed NA P escorted Resident #6's back from the restroom into her room. LVN O then measured Resident#6's blood pressure and walked out of the room, without performing hand hygiene, to the nurses' station and set the blood pressure monitor on the desk of the nurse's station without sanitizing it. Observed NA P then proceeding to wash her hands with soap and water and exiting the room. In an interview with NA P on 4/23/24 at 2:43 PM, revealed that she was working in the facility as a nurse aide for the last 4 months. She stated that she was not sure that Resident #6 was on isolation and stated she did not see the isolation signage on the door. She stated that Resident #1 was on isolation since 4/22/24; but she did not wear the PPE since she was only going to help Resident #6 who was on the ground. NA P then added that she saw the isolation sign on the door at the time of this interview. NA P stated that she initially thought that Resident #6 had a fall on the ground and rushed to the isolation room but then realized that Resident #6 was on the ground to reach the wheelchair. She stated the risk to residents for not adhering to PPE and infection control guidelines was increased risk of infection and spreading it to other residents. In an Interview with LVN O on 4/23/24 at 2:51 PM revealed that she heard NA P call her to Resident #6's room. LVN O stated that she worked in a different hall than where Resident #6 was located and hence did not notice the two contact isolation signs and the see Nurse signage on the Resident #6's door. She stated she was not provided an in-service on isolation protocols. She stated that for any contact isolation room, she needed to don her gown and gloves and perform adequate hand hygiene before entering the room. She also stated it was a mistake on her part to enter a contact isolation room without performing hand hygiene or donning appropriate PPE. She stated she checked on Resident #6's blood pressure which was 147/100 and rushed out of the room again without performing hand hygiene to inform the nurse assigned to Resident #6. She then set the blood pressure monitor on the nursing station desk and stated she would be sanitizing it after some time. LVN O stated the risk to residents for not performing hand hygiene, not donning PPE, and not sanitizing medical equipment after use within an isolation room was very high risk of spread of infection. In an interview with Resident #6 on 4/23/24 at 2:58 PM, it was revealed that Resident #6 wanted to use the restroom and scooted out of her recliner to sit on the wheelchair. Since the wheelchair was a little away from the recliner, she sat on the floor to scoot towards the wheelchair to climb into it so she could use the restroom. Resident #6 stated she forgot to press the call light to alert the staff members. Resident #6 also stated that she had a urine infection and needed to use the restroom frequently. Resident # 6 stated one of the staff members [could not tell the name of the staff member to the surveyor] told her on 4/24/24 that she had an infection that required everyone entering the room wear isolation gowns and gloves so the infection would not spread to others. She stated that the LVN O and NA P that entered the room while she was on the floor sometime back, did not wear a gown or gloves while assisting her. In an interview with the ADON on 04/23/24 at 3:18 PM revealed that she had only started working at the facility 3 weeks ago. She stated she thinks Resident #6 was on isolation for ESBL on 4/23/24 and the staff were in-serviced about isolation protocols. She added her expectation was for the staff to wear PPE at all times in an isolation room; except when there was an emergency and a resident's safety takes precedence over isolation protocols. She stated that she was not aware of the incident with Resident #6 being on the ground and would investigate to find why NA P and LVN O failed to follow appropriate isolation protocols. She stated that as an ADON she was responsible for overseeing staff follow all isolation precaution guidelines. In an interview with CNA Q on 4/24/24 at 8:58 AM revealed that Resident #1 started isolation on 4/22/24 and Resident #6 started isolation on 4/23/24. CNA Q stated that Residents #1 and #6 were not on isolation on 4/19-4/21. CNA Q stated that for all isolation rooms, CNAs needed to wear a gown and gloves before entering the room and perform adequate hand hygiene. The risk of not doing so could lead to infections. In an interview with Housekeeper F on 4/24/24 at 9:02 AM revealed that she worked on 4/21/24 and 4/22/24 and was assigned to the hall where Resident #1 and Resident #6 resided. She stated that Resident #1 and Resident #6's room was not on isolation on those days. She came back to work on 4/24/24 and was told that room (where Resident # 1 and #6 stayed) was on contact isolation and she needed to wear gloves, gown, and perform hand hygiene before entering the room. In an interview with LVN K on 4/24/24 at 9:23 AM revealed she worked on 6 am - 2 pm shift on 4/19/24 and 4/22/24. She stated that she checked Resident #1's lab results for positive C. Diff that resulted on 4/19/24. She notified the Infectious Disease NP, who gave orders for Resident #1 to be on isolation on 4/22/24. LVN K stated that Resident #1 was not on isolation when she arrived at the facility for her 6 am -2 pm shift on 4/22/24. LVN K stated that the risk to residents for not providing contact isolation was infection control concerns. In a phone interview with LVN N on 4/24/24 at 12:01 PM revealed she worked on 4/20/24 and 4/21/24 6 am - 2 pm and 2 pm -10 pm shift on the Resident #1's hall. She stated that Resident #1 was not on isolation on 4/20/24 and 4/21/24 on those days. She stated that the risk of not isolating residents with positive C. Diff promptly, was increased spread of infection. In a phone interview with the Infectious Disease NP on 4/24/24 at 12:09 PM revealed the facility made her aware of Resident #1 positive C. Diff lab result on 4/22/24 and labs for C. Diff for Resident #1 resulted positive on 4/19/24. The Infectious Disease NP stated once she learned about the positive C. Diff result for Resident #1, she gave orders to start Resident #1 on isolation. She stated the risks to residents for not placing resident on isolation promptly once C. Diff was diagnosed were lapses in infection control and quality of care can be decreased. In an interview with LVN L on 4/24/24 at 1:02 PM revealed she worked 2 pm - 10 pm Shift on 4/22/22 and was assigned to Resident #1. She stated she was provided a shift report that stated Resident #1 started isolation on 4/22/24. LVN L stated that for any contact isolation room, staff needed to wear PPE and perform hand hygiene, and failure to do so could result in risk of spreading the infection. LVN L also stated that it was a nursing protocol to place a resident with infectious disease in prompt isolation to prevent further spread of the disease to other residents. In an interview with the DON on 04/24/24 at 1:31 PM revealed she started at the facility about a month ago. She stated Resident #1's was having diarrhea and hence stat stool testing was order and collected on 4/19/24 and resulted positive for C. Diff on 4/19/24. The DON referred to the EHR and answered that per physician's orders Resident #1 was started on isolation on 4/22/24. The DON stated that she became aware of the positive C. Diff lab results on the morning of 4/22/24 in a clinical meeting. The DON stated that there was a failure to start prompt contact isolation for Resident #1 after a C. Diff diagnosis on 4/19/24. The DON stated her expectation was staff members to follow all isolation protocols for infectious diseases and wear appropriate PPE and perform hand hygiene. The DON also stated that they had started in-services for all staff members on 4/23/24 about wearing appropriate PPE and performing adequate hand hygiene. She stated that LVN O was suspended pending investigation of the incident on 4/23/24. The DON added that LVN O was one of the staff members that entered the isolation room without performing adequate hand hygiene and without doffing appropriate PPE. The DON stated that the risk to residents for not wearing appropriate PPE or not placing residents with diagnosis of infectious disease was very high chances of spreading infections. In a phone Interview with the Medical Director (MD) on 04/30/24 at 3:13 PM revealed that she was not informed about Resident#1's Positive C. Diff lab until 4/22/24. The MD stated that it was her expectation that all staff members follow transmission-based precautions for isolation rooms that included wearing appropriate PPE, performing adequate hand hygiene, and placing residents on appropriate isolation promptly. She also stated that risk for not adhering to infection control guidelines for transmission-based precautions was increased risk of spread of infections throughout the facility. In an interview with the Administrator on 04/24/24 at 03:16 PM revealed that Resident #1 was on isolation already, started earlier in month with ESBL. The Administrator added that he was not aware that ESBL isolation orders had ended on 4/14/24. He further added that he became aware that Resident #1 was positive for C. Diff on 4/22/24 since it was brought up in the morning meeting. The Administrator stated it was his expectation to start contact isolation promptly and wear appropriate PPE before caring for a resident with diagnosis of an infectious disease. The Administrator also added that the DON and the Clinical Resource RN had started in-services with all staff to adhere to wearing PPE and hand hygiene before entering all isolation rooms and failure to do so would lead to lapses in infection control. In an interview with Clinical Resource RN on 4/25/24 at 10:02 am revealed it was her expectation that staff members follow transmission-based precautions including wearing PPE, hand hygiene, starting prompt isolation and failure to do so may potentially cause lapses in infection control though out the facility. Record Review of Facility's titled IPCP Standard and Transmission-Based Precautions Policy revised date October 2022 reflected, .b. Personal protective equipment (PPE): i. Wear a gown and gloves for all interactions that may involve contact with the patient or the patient's environment. ii. DON PPE upon room entry, then doff and properly discard PPE and perform hand hygiene before exiting the patient room to contain pathogens. C. Patient-care equipment (e.g., blood pressure cuffs). It is preferred dedicated or disposable patient-care equipment be used. If common use of equipment for multiple patients is unavoidable, clean and disinfect such equipment before use on another patient .6. Implementation: a. The facility will implement a system to alert staff, residents, and visitors that a resident is on TBP. Post clear signage on the door or wall outside of the resident room indicating the type of Precautions and required PPE (e.g., gown and gloves) . Review of the Center for Disease Control (CDC) Website: Nursing Homes and Assisted Living (Long-term care facilities) https://www.cdc.gov/longtermcare/prevention/index.html dated December 28, 2016, reflected , C. difficile infection (CDI) is a common cause of acute diarrhea in nursing homes. Individuals with CDI serve as a source for bacterial spread to others, through the contamination of caregiver hands and shared equipment. Contamination of a resident's skin and environment is greatest when a resident has diarrhea from CDI but hasn't started on appropriate treatment. Early identification of CDI can limit the spread of C. difficile by reducing the time from symptom onset to starting therapy. Rapid containment through implementation of contact precautions for symptomatic residents can reduce contamination. Contact precautions include use of gowns/gloves and dedicated equipment during care of residents with new diarrhea Review of the CDC website, review date October 25, 2022, reflected: https://www.cdc.gov/cdiff/clinicians/faq.html reflected, Any surface, device, or material (such as commodes, bathtubs, and electronic rectal thermometers) that becomes contaminated with feces could serve as a reservoir for the C. diff spores. C. diff spores can also be transferred to patients via the hands of healthcare personnel who have touched a contaminated surface or item . Isolate patients with possible C. diff immediately, even if you only suspect CDI. Wear gloves and a gown when treating patients with C. diff, even during short visits. Gloves are important because hand sanitizer doesn't kill C. diff and handwashing might not be sufficient alone to eliminate all C. diff spores. As no single method of hand hygiene will eliminate all C. Diff spores, using gloves to prevent hand contamination remains at the cornerstone for preventing C. Diff transmission via the hands of healthcare personnel. These failures resulted in the identification of an IJ on 04/24/24 at 3:40 PM. The Administrator was notified and provided with the IJ template on 04/24/24 at 3:50 PM. The Plan of Removal was submitted by the facility and accepted on 04/25/24 at 11:03 AM The Plan of Removal reflected the following: Action: 1. The Medical Director was notified of the IJ on 04/24/24 at 4:11 PM 2. Charge nurse who failed to wear appropriate PPE was provided education counseling 4/23/24 and was removed from her shift. Nurse aide that entered room without donning and doffing PPE was provided education counseling by Facility Administrator and DON on 04/23/24. 3. Resident's physician was notified of resident's positive C. diff status and the resident was placed in isolation on 04/22/24. 4. On 04/23/24 the facility Clinical Resource who is an RN, completed train the trainer in-servicing for the DON/Infection Preventionist, ADON and Cluster Partners. The training includes donning/doffing PPE, transmission-based precautions, and discontinuation of precautions based on CDC guidance. 5. Training and competency for all staff on donning and doffing PPE, handwashing, transmission-based precautions, and discontinuation of precautions will be completed based on CDC guidance. Training will be completed by the DON, ADON, Clinical Resources, and Clinical Cluster Partners. Initiation of this training began on 4/23/24 will be completed on 4/24/24. Any staff who were unable to complete the training on 4/24/24, will be required to complete the training prior to the start of their next shift. 6. In-service training initiated on 4/24/24 for licensed nursing staff by DON/ADON/Clinical resource related to obtaining, reporting, and documenting labs. Training to be completed by 4/24/24. Any staff who are unable to complete training on 4/24/24 will be required to complete training prior to beginning their next scheduled shift. 7. A member of management will be at the facility at each change of shift to ensure all staff get trained prior to going to work on the floor. Staff will not be allowed to work unless they have completed the training and competency checks. This training will also be included in the new hire orientation and will be included for agency staff/PRN staff prior to starting work on the floor. 8. An ad hoc meeting regarding items in the IJ template was completed on 4/24/24. Attendees included the Medical Director, DON/Infection Preventionist, ADON and other IDT members. Meeting was led by facility Executive Director. Facility will complete weekly QA meeting to review corrective measures for four weeks or until substantial compliance is established. 9. Resident lab results will be reviewed Monday to Friday in daily morning clinical meeting by nursing administration or designee to ensure proper infection control practices are initiated as warranted. Lab results will be reviewed by weekend supervisor or designee on weekends for the same purpose. Facility Director or designee will ensure labs are reviewed as stated. 10. Isolation residents will be reviewed by nursing administration during weekly clinical meeting and the Medical Director will be consulted for any recommendations or suggestions as necessary. Meetings attendees to include but not limited to DON, ADON, Infection Preventionist, and Executive Director. The DON and Executive Director will be responsible for ensuring this meeting is held weekly and isolation residents are reviewed. This meeting will begin on 4/25/24. 11. Meeting minutes related to lab results and isolated residents will be reported to the weekly QAPI committee meeting for 4 weeks or until substantial compliance established and continue monthly for 90 days to ensure ongoing compliance and continue monthly for 90 days to ensure ongoing compliance. 12. The DON or designee will verify staff competency with 10 staff weekly for 4 weeks or until substantial compliance is established. PPE and handwashing competency checklists will be utilized for to determine competency. This will be completed weekly after the initial training and competency began on 4/24/24. Executive Director or designee will ensure staff competencies are completed. 13. DON or designee will review 24hr report daily for potential changes in condition related to signs and symptoms of infection. Executive Director or designee will ensure daily review is completed. Findings related to review will be reported to the weekly QAPI committee meeting for 4 weeks or until substantial compliance established and continue monthly for 90 days to ensure ongoing compliance. 14. Summary of IJ and corrective action to be reviewed by QAPI Committee weekly for four weeks beginning 4/24/2024 or until substantial compliance established and continue monthly for 90 days to ensure ongoing compliance. On 04/25/24 the Surveyor confirmed the facility implemented their plan of removal sufficiently to remove the IJ by: IJ Monitoring process: Record Review of the in-service dated 4/23/24 Infection Control: Observing and following Isolation precautions reflected facility staff were in-serviced. In-services included proper sequencing on donning and doffing PPE; appropriate hand washing techniques. The Surveyors attempted interviewed for all the nurses that were in-serviced for Infection Control: Observing and following Isolation precautions. Record Review of the Inservice, dated 4/23/24 , Infection Control: Standard and Transmission Based precautions reflected facility staff were in-serviced. In-service's included transmission-based precautions and discontinuation of precautions based on CDC guidance. The surveyor attempted interviewed for all the staff that were in-serviced for Infection Control: Standard and Transmission Based precautions. In an interview with LVN Z on 4/25/24 at 12:52 pm revealed, that per in-services provided on 4/24/24 regarding appropriate PPE use, PPE donning and doffing sequence, types of isolation, TBP protocols. LVN Z also stated that all staff members caring for residents on isolation will need to follow all TBP protocols. She verbalized that residents should be placed in isolation promptly following diagnosis of an infectious disease such as C. Diff. In an interview with CNA X on 4/25/24 at 12:54 PM revealed CNA X was observed entering the room after she donned gown and gloves. She stated she received an in-service on morning of 4/24/24 on different kind of isolations, PPE, hand hygiene. She stated that for a resident on enhanced barriers, she needed to use gown and gloves, and mask was not required. For the resident on contact isolation or droplet she should use the mask. CNA X also stated that she needed to Wash her hands before entering the isolation room and after she was done with care and between change of gloves. In an interview with CNA AA on 4/25/24 at 1:01 pm revealed she received in-services on 4/24/24 and verbalized the types of precautions such as contact, droplet and others. Verbalized the PEE to use according to the type of precaution. She stated that there was an isolated signage on the door that alerted the staff members regarding isolation protocols. Verbalized hand hygiene according to the in-service done by the facility this week, and if the resident was in contact isolation for C. Diff, she had to wash hands with soap and water. In an interview with CNA Y on 4/25/24 at 1:04 PM revealed he had been working at the facility for 4 months. He stated that he received an in-service on infection control: PPE to use when going to the residents' rooms, CNAs needed to wear PPE according to the signage at the door. He verbalized different kinds of precautions: contact, droplet, enhanced precaution, donning and doffing PPE. If a resident was on the floor in an isolation room, staff must wear PPE before she assisted the resident on the floor. He stated that all staff need to perform Hand hygiene: before and after they finished providing care and frequently and when they changed gloves. In an interview with CNA C on 4/25/24 at 1:06 PM revealed different types of precaution such as contact, droplet, other. She stated that all staff should be wearing appropriate PPE and perform hand hygiene for all residents on isolation. She also verbalized hand hygiene according to the in-service done by the facility this week, and if the resident was in contact isolation for C. Diff, staff had to wash hands with soap and water. In an interview with LVN R on 4/25/24 at 1:20 pm revealed they received an in-service on infection control regarding proper way of putting PPE; donning the proper PPE for appropriate isolation, hand washing (before and after done with care and as needed), precaution could be contact, droplet or enhanced. If a resident was on the floor in an isolation room, PPE must be donned before assisting the resident on the floor. LVN R also stated that isolation protocols for TBP residents need to be done promptly. In an interview with CNA BB on 04/25/24 at 1:21 PM revealed different types of isolations were contact precaution (touch), droplets (spitting), airborne (breathing). She stated that staff needed to wear PPE and perform hand hygiene during every contact with resident on isolation. She stated that she was in-serviced about proper sequence for donning and doffing PPE. She also stated that handwashing was done upon entering and leaving the room, before and after taking care of the residents, in between taking care of residents, changing gloves and washing hands again. She stated for any TBP isolation rooms, there should be a signage, PPE, hand rub, and a PPE disposal bin in every room. In an interview with CNA Q on 4/25/24 at 1:22 PM revealed she has worked in the facility since February 2024. She stated different types of isolation were precaution droplet, enhanced. For any TBP room, there needed to be a signage on the door, PPE kit outside the room. She stated that she had been provided in-services regarding always wearing a PPE [TRUNCATED]

Based on observations, interviews, and record review, the facility failed to ensure that Residents, who needed respiratory care, was provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for three (Resident #15, #20, and #40) of three residents reviewed for respiratory care. 1. The facility failed to ensure Resident #15's nebulizer mask was properly stored. 2. The facility failed to ensure Resident #20's nasal cannula tubing and humidity bottle were labeled or dated. 3. The facility failed to ensure Resident #40's nasal cannula tubing were labeled or dated. These failures could place the residents at risk for respiratory infection and not having their respiratory needs met. Findings included: 1. Review of Resident #15's Face Sheet dated 04/23/2024 reflected that resident was a [AGE] year-old male admitted on [DATE]. Relevant diagnoses included respiratory failure with hypoxia (insufficient amount of oxygen in the body) or respiratory failure with hypercapnia (high level of carbon dioxide in the blood). Review of Resident #15's Comprehensive MDS assessment dated [DATE] reflected Resident#15 had a moderate impairment in cognition with a BIMS score of 12. The Comprehensive MDS Assessment also indicated Resident #15 was on oxygen therapy while a resident in the facility. Review of Resident #15's Care Plan dated 03/21/2024 reflected resident had an altered respiratory status and one of the interventions was to administer medications/puffers as ordered. Review of Resident #15's Physician Order dated 10/08/2022 reflected, Ipratropium-Albuterol Solution 0.5-2.5 (3) MG/3ML 1 vial inhale orally every 6 hours for SOB/WHEEZING related to CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH (ACUTE) EXACERBATION (J44.1); ACUTE AND CHRONIC RESPIRATORY FAILURE, UNSPECIFIED WHETHER WITH HYPOXIA OR HYPERCAPNIA. Observation on 04/23/2024 at 9:39 AM revealed Resident #15 was on his bed awake. It was also noted that his nebulizer mask was sitting inside on the drawer of his side table. The breathing mask used for the nebulizer was not bagged. Observation and interview with LVN A on 04/23/2024 at 9:46 AM, LVN A stated he administered Resident #15's nebulization and he was the one who removed it after the treatment was done. LVN A said he forgot to bag the breathing mask and just placed it on the drawer. He said the breathing mask should be cleaned after every use and should be bagged when not in use to prevent contamination and infection. LVN A disconnected the breathing mask, put it inside the plastic bag, and said he would change it. In an interview with the ADON on 04/24/2024 at 3:12 PM, the ADON stated the breathing mask should not have been exposed nor touching anything because it could cause infections. The ADON said the breathing mask should have been bagged when not in use. She said the staff administering the breathing treatment was responsible in making sure the breathing mask was clean every time the resident used it and bagged when the resident was not using it. In an interview with the DON on 04/24/2024 at 3:22 PM, the DON stated the breathing mask should be bagged when not in use. The DON said it was the proper way to store the breathing mask after it was used by the resident. She said if the breathing mask was not bagged and touching surfaces that were not clean, then oxygen administration could be compromised. The DON said the staff, including her, were responsible for monitoring that the apparatus used in oxygen therapy were bagged when not in use. She said the expectation was the breathing mask would be stored properly. The DON said she would continually remind the staff to be diligent in making sure the procedures for respiratory care were followed. In an interview with the Administrator on 04/25/2024 at 8:10 AM, the Administrator stated the breathing masks should be stored properly to prevent potential respiratory infections. The Administrator said the expectation was for the staff to be diligent in providing respiratory care in order to provide the highest level of care. He said he would collaborate with the clinical managers to evaluate the situation, discuss it during quality assurance and do in-services. 2. Review of Resident #20's Quarterly MDS assessment dated [DATE] reflected Resident #20 was an [AGE] year-old male with initial admitted to the facility on [DATE]. His diagnoses included hypertension (high blood pressure), heart failure, End stage renal disease, Diabetes Mellitus (high blood glucose levels) , hyperlipidemia (high blood lipid levels), Alzheimer's disease, Chronic Obstructive Pulmonary disease, and Respiratory failure. Resident #20 had a BIMS score of 15 which indicated Resident #20 was cognitively intact. Resident #20 was on Oxygen therapy. Review of Resident #20's Comprehensive Care Plan, revised 1/29/24, reflected the following: Focus: Has BIPAP related to Chronic Obstructive Pulmonary disease and Ineffective gas Exchange. Goals: Will have no signs and symptoms of poor oxygen absorption through the review date. Interventions: Give medications as ordered by physician. Monitor/document side effects and effectiveness. If the resident is allowed to eat, oxygen still must be given to the resident but in a different manner (e.g., changing from mask to a nasal cannula). Return resident to usual oxygen delivery method after the meal. Monitor for signs and symptoms of respiratory distress and report to physician as needed. Record review of Resident #20's Physician order dated 12/18/2023 reflected, Oxygen at 3 Liter per minute via Nasal cannula as needed for Shortness of Breath May titrate 3-4 Liter to keep Oxygen saturation above 90%. Record review of Resident #20's Physician order dated 12/18/2023 reflected, Change Oxygen Tubing and Humidifier BOTTLE every night shift every Sunday. An observation and interview on 04/23/24 at 11:19 AM revealed Resident #20 was sitting on his bed with Oxygen running via nasal cannula. It was observed that the nasal cannula tubing and humidity bottle did not have a label or date on it. Resident #20 stated he was on continuous oxygen and did not remember when the last time was the nurse had changed the nasal cannula tubing. 3. Review of Resident #40's Quarterly MDS assessment dated [DATE] reflected Resident #40 was a 39-year -old female with readmitted [DATE] to the facility. Her diagnoses included Heart failure, Hypertension, Pneumonia, and Respiratory failure. Resident #40 was on oxygen therapy. Resident #40 had a BIMS score of 13 which indicated Resident #40 was cognitively intact. Review of Resident #40's Comprehensive Care Plan dated 1/29/2024 reflected, Focus: Has Oxygen Therapy related to heart failure. Goals: Will have no signs and symptoms of poor oxygen absorption through the review date. Interventions: Give medications as ordered by physician. Monitor/document side effects and effectiveness. If the resident is allowed to eat, oxygen still must be given to the resident but in a different manner (e.g., changing from mask to a nasal cannula). Return resident to usual oxygen delivery method after the meal. Record review of Resident #40's Physician order dated 2/22/2024 reflected, Check and record oxygen saturation every shift. Record review of Resident #40's Physician order dated 2/22/2024 reflected, Oxygen at 1 liter per minute via Nasal cannula as needed for Shortness of Breath. An observation and interview on 4/23/24 at 11:54 AM revealed Resident #40 was sitting in her wheelchair in her room. She had a portable oxygen cylinder on her wheelchair and oxygen was flowing via nasal cannula. Observed nasal cannula tubing was not dated or labeled. Resident #40 stated she was on oxygen frequently and used portable oxygen. In an interview with LVN K on 4/23/24 at 11:39 AM revealed Nurses on the night shift were responsible for changing and dating oxygen equipment every Sunday. LVN K stated that she also observed no date or label on oxygen tubing for both Resident #20 and Resident #40 during the time of this interview and will change the tubing immediately. LVN K stated that it was important to change and date all Oxygen supplies promptly because of lapses in infection control for the residents. In an interview with the ADON on 04/23/24 at 12:16 PM revealed she has been working in the facility for the last three weeks. She stated that it was her expectation that all oxygen supplies should be labeled and dated. The ADON stated that Night shift Nurses were responsible for changing and dating oxygen supplies every Sunday. As the ADON, she conducted daily rounds to ensure that Nursing protocols were followed. The ADON stated that risk for not dating or changing oxygen supplies was staff not knowing when the tubing was changed, and it increased the risk of infections to the resident. In an interview with the DON on 4/25/24 at 9:27 AM her expectation was that all oxygen tubing and supplies should be dated and labeled. It should be changed weekly and on as needed basis. The DON added it was the responsibility of Night shift Nurses every Sunday to change and date all oxygen supplies. She stated that the risk to residents for not following procedures for respiratory care was infection control. She stated as a DON, she ensured that herself or her designee conducted floor rounds daily to address any nursing concerns. The DON also stated that changing and dating medical equipment was a routine nursing protocol and additional physician orders were not required for the same. Record Review of facility policy titled ,Oxygen administration undated reflected, Oxygen tubing and Oxygen masks or nasal prongs is to be replaced weekly . Record review of facility's policy, Departmental (Respiratory Therapy) Nursing - Prevention of Infection 2001 MED-PASS, Inc. revised April 2007 revealed Purpose: The purpose of this procedure is to guide prevention of infection associated with respiratory therapy tasks and equipment . Steps in the Procedure . 7. Keep the . tubing used PRN in a plastic bag when not in use. 48560

47743 Based on observation, interviews, and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for a resident for two (Resident # 12 and Resident #117) of eight residents reviewed for Care Plans. 1. The facility failed to ensure Resident #12's care plan dated 02/04/2024 included a care plan for catheter care. 2. The facility failed to create a care plan for Resident #117's order for Coumadin (blood thinner.) These failures could place residents at risk for not having care plans they needed. Findings included: 1. Review of Resident #12's Face Sheet dated 04/23/2024 revealed the resident was a [AGE] year-old male admitted on [DATE]. Relevant diagnoses included urinary tract infection and neuromuscular dysfunction of bladder (the muscles and nerves that control the bladder do not work properly due to illness). Review of Resident #12's Physician Order dated 07/13/2023 reflected, CHANGE S/P CATHETER. Review of Resident #12's Quarterly MDS assessment dated [DATE] revealed the resident had a moderate impairment in cognition with a BIMS score of 11. The Quarterly MDS Assessment also indicated resident had an indwelling catheter. Review of Resident #12's Comprehensive Care Plan dated 02/04/2024 reflected resident had no care plan for suprapubic catheter. Review of Resident #12's Comprehensive Care Plan on 04/24/2024 reflected resident's care plan was revised on 04/24/2024 to display the care plan for suprapubic catheter. Observation and interview with LVN A on 04/24/2024 at 10:55 AM, LVN A stated that Resident #12 had a suprapubic catheter since he cared for him. LVN A checked the resident's profile and verified the resident does not have a care plan for catheter care. He said there should be a care plan for catheter care and the interventions should also be listed in the care so the staff would know the care needed on that particular area. He said the care plan would show the direction on how to take care of the resident. He said without the care plan in place, it could reflect that the staff were not taking care of the residents. In an interview and observation with the MDS Coordinator on 04/24/2024 at 3:01 PM, the MDS Coordinator stated care plan served as a communication tool for the family, resident, and facility. She said the care plan must have a clear and accurate reflection of what the facility was doing for the resident. She said without the care plan, there could be confusion on his care or the interventions for having a catheter will not be done. She said she was responsible in doing the care plan based on the assessment of the staff. She added Resident #12's care plan should had been discussed during interdisciplinary meetings but was missed. She said she would go ahead and put the interventions for catheter care. The MDS Coordinator went ahead and added suprapubic catheter on the care plan item as well as the interventions needed for catheter care. In an interview with the ADON on 04/24/2024 at 3:12 PM, the ADON stated every resident must have a care plan to see the steps needed to address their conditions and to evaluate if the goals were being met. She said that without the care plan, the staff would not know the resident's needs at that time resulting into needs not being met. She added if the resident currently had a catheter, it should had been reflected on the care plan. In an interview with the DON on 04/24/2024 at 3:22 PM, the DON stated the purpose of the care plan was to know the resident's needs and for the staff to know what kind of care and interventions were needed. She said without the care plan, the staff would not know the needed care and assistance the residents required. The DON said she there should be a care plan for catheter care if a resident was on catheter as well as the appropriate interventions needed. She said she would continue to educate the staff through an in-service about the significance of a care plan. The DON concluded that moving forward, she will monitor staff's observance to the policy care planning to ensure the best possible care. In an interview with the Administrator on 04/25/2024 at 8:10 AM, the Administrator stated the care plan was important to provide care with consistency. The Administrator said that without a care plan, the resident would not have the care needed and required. The Administrator concluded that the expectation was that the staff would ensure every resident was care planned. 2. Review of Resident #117's admission MDS assessment, dated 02/28/24, revealed the resident was an [AGE] year-old male admitted to the facility on [DATE]. His cognitive status was moderately impaired. His diagnoses included coronary heart disease, and lung transplant, and tracheostomy. Review of Resident #117's Order Summary Report, dated April 2024, reflected: 04/18/24 Warfarin Sodium (Coumadin) 1.5 milligrams at night for a blood thinner. Review of Resident #117's, not dated, Care Plans revealed there was not a care plan for blood thinners or Coumadin. An interview on 04/25/24 at 11:05 AM with the MDS Coordinator revealed the resident should have had an Interdisciplinary Team Meeting to add the Coumadin to Resident #117's care plans. A follow-up interview on 04/25/24 at 11:33 AM with the MDS Coordinator revealed an interdisciplinary team meeting did not occur for Resident #117 because it was over-looked. An interview on 04/25/24 at 1:48 PM with the DON revealed Resident #117 should have had a care plan for Coumadin and she did not know why it was overlooked. The DON said care plans were important for staff to be able to provide care to residents. Record review of facility's policy, Comprehensive Person-Centered Care Planning revised 1.2022 revealed Policy: It is the policy of this facility that the interdisciplinary team (IDT) shall develop a comprehensive person-centered care plan for each resident . Procedure . 4. The facility IDT will develop and implement a comprehensive person-centered care plan for each resident . will include resident's needs identified in the comprehensive assessment . resident's goals and desired outcomes .

Based on interview, and record review, the facility failed to ensure a resident's medical record was kept in accordance with accepted professional standards and practices, including complete and accurately documented for one (Residnet #51) of five residents reviewed for medical records. The facility failed to ensure Resident #51's electronic medical record contained accurately documented information. This failure could place residents at increased risk of decline in overall health and wellness. Findings included: Review of Resident #51's Face Sheet dated 04/23/2024 revealed she was a [AGE] year-old female originally admitted to the facility 04/07/2022. Relevant diagnoses included: dementia (group of symptoms that affects memory and thinking,) dysphagia (difficulty swallowing food or liquid,) Gastroesophageal reflux disease (GERD) (acid reflux,) and malaise (vague feeling of being unwell.) Review of Resident #51's Quarterly MDS assessment dated [DATE] reflected she was severely cognitively impaired with a BIMS score of 6. She was totally dependent upon staff for eating, oral hygiene, and toileting. She was incontinent of bowel and bladder. She was 61 inches and 137 pounds at the time of this assessment. Review of Resident #51's documented weights in her EMR revealed on 01/29/2024, the resident weighed 150.4 lbs. On 04/25/2024, the resident weighed 145 pounds which was a -3.59 % loss between an 87 day, or 2 month and 27-day period. Review of Resident #51's documented weights in her EMR revealed weight fluctuations as follows: 04/25/2024 145.0 pounds 04/16/2024 131.2 pounds 04/05/2024 136.6 pounds 03/01/2024 136.6 pounds 02/01/2024 150.4 pounds 01/29/2024 150.4 pounds 12/13/2023 156.2 pounds 11/16/2023 156.8 pounds 09/12/2023 169.2 pounds 08/16/2023 167.8 pounds Review of Resident #51's Comprehensive Care Plan revised 04/08/2024 revealed a weight loss focus by stating [Resident #51] had significant expected weight loss of 10% in 6 months [related to] diuretic use, [history] of edema with expected fluctuation in weight with intervention that included alert dietician if consumption is poor, diuretic as ordered for edema, monitor and record food intake each meal, and weekly weights .Additionally, she was at an increased risk for decline related to GERD, bowel and bladder incontinence related to dementia, and was dependent upon staff for activities. Additional focus for potential nutritional problems related to malnutrition, dysphagia, and GERD had an intervention that included Obtain and monitor lab/diagnostic work as ordered. Report results to MD and follow up as indicated. Review of Resident #51's physician orders on 04/23/2024 revealed she was prescribed weekly weights in the morning every Wednesday . weight monitoring . with a start date of 04/17/2024. Additional review of her physician orders revealed she was prescribed a regular diet with pureed texture, nectar thick liquids, and a supplement with all meals with a start date of 03/08/2024. She was prescribed a house supplement four times a day with a start date of 03/05/2024 and liquid protein prescribed two times a day with a start fate of 04/23/2024. It was prescribed to encourage fluid . 1 cup every four hours while awake with a start date of 02/05/2024 and to encourage fluid every shift with a start date of 01/09/2024. Finally, she was prescribed Arginald Oral Packet (Nutritional Supplement) by mouth one time a day with a start date of 02/28/2024. Record review of Resident #51's TAR on Thursday 04/25/2024 at 11:05 AM revealed LVN Z documented she completed physician order and obtained Resident #51's weight on Wednesday 04/25/2024 as prescribed. Record review of Resident #51's Clinical Record on 04/25/2024 at 11:06 AM revealed no evidence of Resident #51's weight documented for Wednesday 04/24/2024 or Thursday 04/25/2024. In interview with LVN Z on 04/25/2024 at 11:10 AM revealed she was aware of Resident #51's physician order for weekly weights each Wednesday; but she stated she did not get a chance to check it yet. She stated she documented she completed it the day prior 04/24/2024; but did not state why she did not actually obtain Resident #51's weight. She stated that she was ultimately responsible for obtaining Resident #51's weight but stated that the facility aides can be delegated to obtain resident weights when ordered. LVN Z did not state why she did not delegate this task yesterday. She stated the potential risk of not following and/or completing physician orders as prescribed poses a risk for potential harm for Resident #51, as her weight required to be monitored. In interview with the ADON on 04/25/2024 at 11:25 AM revealed she was aware of Resident #51's weight loss and that she had an order for close monitoring via weekly weights each Wednesday. She stated she was not aware that Resident #51 was not weighed yesterday 04/24/2025. She stated that they typically had an aide that weighs residents with weekly weight orders, but it was ultimately the nurse's responsibly to ensure their resident's weight was obtained. She stated that if LVN Z documented Resident #51's weight was obtained on the TAR, it should have been completed, entered into the Electronic Medical Record (EMR,) and assessed for intervention based on the physician orders and comprehensive care plan. She stated if physician orders were not completed as prescribed, Resident #51 could lose additional weight and [the facility would] not be able to address it. Additionally, she stated that if false data was entered into the EMR, proper interventions may not be in place for the residents. In interview with the DON on 04/25/2024 at 11:35 AM revealed she was aware of Resident #51's weight loss and she had an order for close monitoring via weekly weights each Wednesday. She stated she was not aware that Resident #51 was not weighed yesterday, 04/24/2024, because LVN Z documented in the TAR that it was completed on 04/24/2024. She stated that they typically have an aide that weighs residents with weekly weight orders, but that aide was pulled to work the floor yesterday. She stated she expected the nurse assigned to the resident that day to ensure the weight was obtained so they can assess the need for any intervention. She stated it was her responsibility to ensure the nurses complete this task weekly, and she does this by checking the TAR documentation. She stated Resident #51 was at risk for weight loss and her physician orders of weekly weights not being followed puts her at risk for a change in condition indicating something concerning. She stated she expected LVN Z document accurately and could pose a risk to the residents if not completed. In interview with the Administrator on 04/25/2024 at 12:00 PM revealed he was aware of Resident #51's weight loss and that she required weekly weights for close monitoring. He stated that he typically had an aide weigh residents that require weekly weights, but it was the resident nurses' responsibility to ensure weights were obtained. He stated it puts resident health and wellness at risk if the facility cannot identify weight loss and intervene accordingly. Policy related to deficient practice was requested from the Administrator on 04/25/2024 at 12:03 PM, 1:37 PM, and upon exit; but it was not received prior to exit on 04/25/2024 at 5:00 PM.

Based observation, interview, and record review, the facility failed to ensure that two (Resident #3 and Resident #46) of ten residents were provided medications and/or biologicals and pharmaceutical services to meet the needs of the residents. The facility failed to ensure MA B re-ordered medications in a timely manner for Resident #3 (Eliquis 2.5 mg) and Resident #46 (Gabapentin 300 mg). This failure placed the residents at risk of not receiving medications as ordered by the physician. Findings included: Resident #3 Review of Resident #3's Face Sheet dated 04/24/2024 reflected that resident was an [AGE] year-old female admitted on [DATE]. Relevant diagnoses included transient cerebral ischemic attack (mini strokes) and gastro-esophageal reflux disease with esophagitis (inflammation of the esophagus). Review of Resident #3's Annual MDS assessment dated [DATE] reflected Resident #3 had a severe impairment in cognition with a BIMS score of 07. The Annual MDS Assessment also indicated the resident had a stroke. Review of Resident #3's Comprehensive Care Plan dated 04/20/2024 reflected Resident #3 was in anticoagulant therapy and at risk of bleeding. Review of Resident #3's Physician Order dated 10/06/2023 reflected, Eliquis Oral Tablet 2.5 MG (Apixaban). Give 2.5 mg by mouth two times a day for anticoagulation. Observation and interview with MA B on 04/24/2024 at 8:34 AM revealed MA B was preparing Resident #3's medication. MA B was putting each medication into a small cup. MA B then said he did not have any Eliquis for Resident #3. MA B asked LVN A to pull it from the e-kit because he did not have the blister pack for Resident #3's Eliquis. LVN A came back with a single pack of Eliquis 2.5 mg for Resident #3. MA B opened the single pack and included Eliquis on the medication that he was preparing. MA B administered the medications. MA B then said he was not able to re-order Resident #3's Eliquis 2.5 mg when he saw that the medication was running low. He said he gave the last one the day before and that should had prompted him to re-order the medication. MA B opened Resident 3's eMAR and clicked on Resident #3's Eliquis and clicked the re-order button. Resident #46 Review of Resident #46's Face Sheet, dated 04/23/2024 reflected resident was a [AGE] year-old female admitted on [DATE]. Relevant diagnoses included stiffness of unspecified joint and osteoarthritis. Review of Resident #46's Quarterly MDS assessment dated [DATE] reflected Resident #46 had a severe cognitive impairment with a BIMS score of 07. The Quarterly MDS Assessment also indicated Resident #46 had a medically complex conditions like joint stiffness. Review of Resident #46's Comprehensive Care Plan dated 04/21/2024 reflected Resident #93 had osteoarthritis with potential for increased pain level one of the interventions was to give analgesic as ordered by the physician. Review of Resident #46's Physician Order reflected, Gabapentin Capsule 300 MG Give 1 capsule by mouth two times a day for . pain. Observation and interview with MA B on 04/24/2024 at 7:25 AM revealed MA B was preparing Resident #46's medication. MA B was putting each medication into a small cup. It was noted when MA B pulled Resident #46's blister pack (a type of packaging in which a product is sealed in plastic, often with a cardboard backing) for gabapentin 300 mg, it was noted the blister pack only had one capsule left when MA B placed one capsule on the small cup of medications. MA B gave the medications to Resident #46. MA B then checked the medication cart for another blister pack for gabapentin. MA B said the resident did not have another blister pack for gabapentin. MA B checked the resident's eMAR, confirmed the medication was not re-ordered yet, and then MA then clicked re-order button. MA B said it was easier to re-order medications now because the staff could do it instantly by just clicking the system unlike before that they needed to pull the stickers, put it on the re-order form, and then fax it to the pharmacy. In an interview with LVN A on 04/24/2024 at 10:55 AM, LVN A acknowledged that MA B asked him to get Eliquis for Resident #3. He stated the medications should have been re-ordered when the medications reached the blue portion of the blister pack. LVN A said the medication should be re-ordered four to five days before the medications were consumed. LVN A stated whoever, nurse or MA saw that the medications were running low should re-order the medications. LVN A added if the medications were not re-ordered, the residents would not have any medications to take. He added they did have an e-kit but the e-kit was primarily for emergencies, STAT orders, or when the pharmacy was not able to deliver but not because the medications were not re-ordered. He added that missing Eliquis could blockage of the blood vessels due to blood clots and missing gabapentin could lead to exacerbation of pain. In an interview with MA B on 04/24/2024 at 1:54 PM, MA B stated he missed re-ordering the medications for Residents #3 and #46. He said he should re-order as soon as it was running low or as soon the medications reached the blue portion of the blister pack that said re-order. He said the residents should always have their medications so whatever medical issues they had would not worsen. He said he would edit the carts and check if there were medications needed to be re-ordered. In an interview with the ADON on 04/24/2024 at 3:12 PM, the ADON stated medications should not be re-ordered last minute because the residents would not have adequate supply of medication in circumstances that the delivery was late or did not come. The ADON added if the residents did not have their medications, their medical concerns could get worse. The ADON said the expectation was the medications be re-ordered in a timely manner to make sure that the residents have enough supply of medications. In an interview with the DON on 04/24/2024 at 3:22 PM, the DON stated the e-kit was for medications needed for emergencies or for new orders wherein the pharmacy haven't delivered yet. The DON said medications should be re-ordered 3 to 4 days before the medications run out. The DON said it could be through clicking the re-order button of the medication that needed to be re-ordered. The DON added if the medications were not re-ordered in a timely manner, the resident would run out of medications. The DON stated the Medication Aide and the nurses were responsible for re-ordering the medications. The DON further added if the resident will not have their medications, their condition could get worse. The DON said the expectation was to re-order the medications in a timely manner and said she would do an in-service about re-ordering medications. In an interview with the Administrator on 04/25/2024 at 8:10 AM, the Administrator stated the staff must make sure that the medications were re-ordered in a timely manner to make sure that the residents have the medications they need. The Administrator added the residents' medical issues could exacerbate if they missed their medications. The Administrator stated the expectation is the resident would not run out of medications and all staff should follow the procedure, adhere to the policy, and do the best standard of practice. Record review of facility policy, Ordering Medications, Policy & Procedure revealed Policy: Medications and related products are received from the pharmacy on a timely basis . Procedure: 2. Reorder medication (seven) 7 days in advance of need to assure an adequate supply is on hand . 4. The refill order is called in, faxed, or otherwise transmitted to the pharmacy . 5. New medications . the emergency kit is used when the resident needs the medication prior to pharmacy delivery.

Based on interview, and record review, the facility failed to ensure a resident maintained acceptable parameters of nutritional status, unless the resident's clinical condition demonstrated that this was not possible, for one (Resident #51) of five residents reviewed for nutritional status and weight loss. The facility failed to obtain Resident #51's weight per physician order. This failure could place residents at increased risk of decline in nutritional status, weight loss, and overall health and wellness. Findings included: Review of Resident #51's Face Sheet dated 04/23/2024 revealed she was a [AGE] year-old female originally admitted to the facility 04/07/2022. Relevant diagnoses included: dementia (group of symptoms that affects memory and thinking,) dysphagia (difficulty swallowing food or liquid,) Gastroesophageal reflux disease (GERD) (acid reflux,) and malaise (vague feeling of being unwell.) Review of Resident #51's Quarterly MDS assessment dated [DATE] reflected she was severely cognitively impaired with a BIMS score of 6. She was totally dependent upon staff for eating, oral hygiene, and toileting. She was incontinent of bowel and bladder. She was 61 inches and 137 pounds at the time of this assessment. Review of Resident #51's documented weights in her EMR revealed on 01/29/2024, the resident weighed 150.4 lbs. On 04/25/2024, the resident weighed 145 pounds which was a -3.59 % loss between an 87 day, or 2 month and 27-day period. Review of Resident #51's documented weights in her EMR revealed weight fluctuations as follows: 04/25/2024 145.0 pounds 04/16/2024 131.2 pounds 04/05/2024 136.6 pounds 03/01/2024 136.6 pounds 02/01/2024 150.4 pounds 01/29/2024 150.4 pounds 12/13/2023 156.2 pounds 11/16/2023 156.8 pounds 09/12/2023 169.2 pounds 08/16/2023 167.8 pounds Review of Resident #51's Comprehensive Care Plan revised 04/08/2024 revealed a weight loss focus by stating [Resident #51] had significant expected weight loss of 10% in 6 months [related to] diuretic use, [history] of edema with expected fluctuation in weight with intervention that included alert dietician if consumption is poor, diuretic as ordered for edema, monitor and record food intake each meal, and weekly weights .Additionally, she was at an increased risk for decline related to GERD, bowel and bladder incontinence related to dementia, and was dependent upon staff for activities. Additional focus for potential nutritional problems related to malnutrition, dysphagia, and GERD had an intervention that included Obtain and monitor lab/diagnostic work as ordered. Report results to MD and follow up as indicated. Review of Resident #51's physician orders on 04/23/2024 revealed she was prescribed weekly weights in the morning every Wednesday . weight monitoring . with a start date of 04/17/2024. Additional review of her physician orders revealed she was prescribed a regular diet with pureed texture, nectar thick liquids, and a supplement with all meals with a start date of 03/08/2024. She was prescribed a house supplement four times a day with a start date of 03/05/2024 and liquid protein prescribed two times a day with a start fate of 04/23/2024. It was prescribed to encourage fluid . 1 cup every four hours while awake with a start date of 02/05/2024 and to encourage fluid every shift with a start date of 01/09/2024. Finally, she was prescribed Arginald Oral Packet (Nutritional Supplement) by mouth one time a day with a start date of 02/28/2024. Record review of Resident #51's TAR on Thursday 04/25/2024 at 11:05 AM revealed LVN Z documented she completed physician order and obtained Resident #51's weight on Wednesday 04/25/2024 as prescribed. Record review of Resident #51's Clinical Record on 04/25/2024 at 11:06 AM revealed no evidence of Resident #51's weight documented for Wednesday 04/24/2024 or Thursday 04/25/2024. In interview with LVN Z on 04/25/2024 at 11:10 AM revealed she was aware of Resident #51's physician order for weekly weights each Wednesday; but she stated she did not get a chance to check it yet. She stated she documented she completed it the day prior 04/24/2024; but did not state why she did not actually obtain Resident #51's weight. She stated that she was ultimately responsible for obtaining Resident #51's weight but stated that the facility aides can be delegated to obtain resident weights when ordered. LVN Z did not state why she did not delegate this task yesterday. She stated the potential risk of not following and/or completing physician orders as prescribed poses a risk for potential harm for Resident #51, as her weight required to be monitored. In interview with the ADON on 04/25/2024 at 11:25 AM revealed she was aware of Resident #51's weight loss and that she had an order for close monitoring via weekly weights each Wednesday. She stated she was not aware that Resident #51 was not weighed yesterday 04/24/2025. She stated that they typically had an aide that weighs residents with weekly weight orders, but it was ultimately the nurse's responsibly to ensure their resident's weight was obtained. She stated that if LVN Z documented Resident #51's weight was obtained on the TAR, it should have been completed, entered into the Electronic Medical Record (EMR,) and assessed for intervention based on the physician orders and comprehensive care plan. She stated if physician orders were not completed as prescribed, Resident #51 could lose additional weight and [the facility would] not be able to address it. Additionally, she stated that if false data was entered into the EMR, proper interventions may not be in place for the residents. In interview with the DON on 04/25/2024 at 11:35 AM revealed she was aware of Resident #51's weight loss and she had an order for close monitoring via weekly weights each Wednesday. She stated she was not aware that Resident #51 was not weighed yesterday, 04/24/2024, because LVN Z documented in the TAR that it was completed on 04/24/2024. She stated that they typically have an aide that weighs residents with weekly weight orders, but that aide was pulled to work the floor yesterday. She stated she expected the nurse assigned to the resident that day to ensure the weight was obtained so they can assess the need for any intervention. She stated it was her responsibility to ensure the nurses complete this task weekly, and she does this by checking the TAR documentation. She stated Resident #51 was at risk for weight loss and her physician orders of weekly weights not being followed puts her at risk for a change in condition indicating something concerning. She stated she expected LVN Z document accurately and could pose a risk to the residents if not completed. In interview with the Administrator on 04/25/2024 at 12:00 PM revealed he was aware of Resident #51's weight loss and that she required weekly weights for close monitoring. He stated that he typically had an aide weigh residents that require weekly weights, but it was the resident nurses' responsibility to ensure weights were obtained. He stated it puts resident health and wellness at risk if the facility cannot identify weight loss and intervene accordingly. Policy related to deficient practice was requested from the Administrator on 04/25/2024 at 12:03 PM, 1:37 PM, and upon exit; but it was not received prior to exit on 04/25/2024 at 5:00 PM.

Based on observation, interview and record review the facility failed to ensure that a resident with pressure ulcers received necessary treatment and services consistent with professional standards of practice to promote healing, prevent infections and prevent new ulcers for 1 (Resident #50) of 4 residents reviewed for pressure ulcers . The facility WCN failed to perform hand hygiene or change her gloves after cleaning Resident #50's wounds. This failure could expose the residents to high risk of cross contamination, infection, worsening of wound conditions and serious illness. Findings include: Review of Resident #50's quarterly MDS assessment, dated 03/04/24, reflected he was a [AGE] year-old male admitted to the facility on [DATE]. He was in a persistent vegetative state. His diagnoses included chronic respiratory failure, and brain damage. The resident had 2 stage III (open ulcer with full thickness tissue loss) pressure ulcers and 2 stage IV (open ulcer with full thickness tissue loss with exposed bone, tendon, or muscle) pressure ulcers. An observation on 04/25/24 at 11:47 AM of wound care for Resident #50 revealed the WCN had her supplies prepared. The resident had a wound on his right heel that was a stage III with a very small, open area with surrounding dark pink tissue. The WCN took off the soiled dressing, performed hand hygiene, changed her gloves, cleaned the wound, applied the treatment, and applied the dressing to the wound. The WCN did not perform hand hygiene or change her gloves after cleaning the wound. The resident had a wound on his left ischium (left buttocks area) that was a stage IV. The area was red, raw, and open with dark pink edges. The WCN took off the soiled dressing, performed hand hygiene, changed her gloves, cleaned the wound, applied the treatment, and applied the dressing to the wound. The WCN did not perform hand hygiene or change her gloves after cleaning the wound. The resident had a baseball sized wound with necrotic (dead tissue) tissue on his left back that was a stage IV. The WCN took off the soiled dressing, performed hand hygiene, changed her gloves, cleaned the wound, applied the treatment, and applied the dressing to the wound. The WCN did not perform hand hygiene or change her gloves after cleaning the wound. The resident had a stage IV wound on his sacrum (center of buttocks area). It was a raw, open area with dark pink edges. The WCN took off the soiled dressing, performed hand hygiene, changed her gloves, cleaned the wound, applied the treatment, and applied the dressing to the wound. The WCN did not perform hand hygiene or change her gloves after cleaning the wound. An interview with the WCN on 04/25/24 at 11:55 AM regarding wound care for Resident #50, revealed she did not perform hand hygiene or change her gloves after cleaning the wound because she said it was a clean procedure and was not necessary. An interview on 04/25/24 at 12:10 PM with the DON revealed the WCN was supposed to perform hand hygiene and change her gloves after cleaning Resident #50's wounds. A review of the facility policy for Skin and Wound Monitoring and Management, revised January 2022, reflected: Purpose .The purpose of this policy is that the facility provides care and services to . 2. Promote the healing of pressure injuries that are present (including prevention of infection to the extent possible) . Review of the website: https://cert.vohrawoundcare.com/how-to-change-a-wound-dressing/ , accessed on 04/25/24 reflected: Steps to applying or changing a bandage When applying a new wound care bandage or dressing, it is essential to follow a few simple steps. Because a wound is an opening to the outside it is not sterile and we apply dressings using a clean dressing technique. Step one o Assemble all of your wound care supplies that you will need to change the dressing. o Clean gloves (sterile gloves are not needed) o A clean surface to place everything on (such as a clean piece of aluminum foil or clean paper o The new bandage to be applied o Saline or wound cleanser to clean the wound o Several pieces of gauze to use in cleaning or wiping the wound o Trash bag Step two Wash your hands with soap and warm water for 20-30 seconds. After washing and drying your hands, put on clean gloves to remove the old dressing and perform the dressing removal step. Observe if there is fluid or drainage and note the drainage or wound fluid that is on the gauze. Wounds with a lot of fluid draining from them are exuding wounds. Now clean the wound by wiping with some gauze pads and saline or wound cleanser. Wipe the wound in small circles this from the middle of the wound outward and finally the skin around the wound edge. You may need several pieces of gauze. Dispose of the dirty bandage, gauze used to clean the wound, and dirty gloves in the trash . Step four Rewash your hands with soap and water for 20-30 seconds and dry them. Put on a new pair of clean gloves (you do not need sterile gloves). Now you will apply the new wound treatment and dressing .

Based on observation, interview, and record review the facility failed to provide the necessary services for residents who are unable to carry out activities of daily living to maintain good grooming and personal hygiene for 1 (Resident #20) of 4 residents reviewed for ADLs. The facility failed to ensure Resident #20 had his fingernails cleaned and trimmed. This failure could place residents who were dependent on staff for ADL care at risk for loss of dignity, risk for infections and a decreased quality of life. Findings include: Review of Resident #20's Quarterly MDS assessment dated [DATE] reflected Resident #20 was an [AGE] year-old male with initial admitted to the facility on [DATE]. His diagnoses included hypertension (high blood pressure), heart failure (heart doesn't pump enough blood for body needs), End stage renal disease (kidney failure), Diabetes Mellitus (high blood glucose levels), hyperlipidemia (high blood lipid levels), Alzheimer's disease (brain disorder relating to memory loss), Chronic Obstructive Pulmonary disease (lung disease that causes breathing problem), and Respiratory failure (difficulty breathing). Resident #20 had a BIMS of 15 which indicated Resident #20 was cognitively intact. Resident #20 was always incontinent of bowel and bladder and required substantial assistance with personal hygiene. Review of Resident #20's Comprehensive Care Plan, revised 12/22/23, reflected the following: Focus: ADL Self Care Performance Deficit r/t Alzheimer's Goal: Will maintain current level of function in Bed Mobility, Transfers, Eating, Dressing, Grooming, Toilet Use and Personal Hygiene, ADL Score through the review date. Interventions: Encourage to discuss feelings about self-care deficit. Encourage to participate to the fullest extent possible with each interaction. An observation and interview on 04/23/24 at 11:19 AM revealed Resident #20 was sitting on his bed with oxygen running via nasal cannula. The nails on both hands were approximately 1.0 centimeter in length extending from the tip of her fingers and had dark discoloration underneath the nails. Resident #20 stated he would liked his nails to be cleaned and trimmed by staff member since he did not have adequate dexterity. In an interview with CNA X on 4/23/24 at 11:32 AM revealed that most ADL's such as hair trimming, nail clipping care were completed during shower times. She revealed that since Resident #20 was a diabetic resident, LVNs were responsible for clipping his nails. CNA X stated that fingernail clipping should be done weekly but also as needed. In an interview with LVN K on 4/23/24 at 11:39 AM revealed that there were no specific days for nailcare but should be offered each time during showering. LVN K also stated that the CNA as well as the LVNs were responsible for providing nail care; however, CNAs could not clip nails for residents with diabetes. LVN K stated that ADLs were monitored daily. LVN K stated that risk to the resident for failure to provide ADL including nail care was increased risk of infection. In an interview with the DON on 4/25/24 9:27 AM revealed that her expectation was that nail care should be provided every day, especially during shower time. The DON stated that Resident #20 had history of refusing ADLs, but she did not remember if he had ever refused nail care. She stated that both CNAs and the LVNs were responsible for nail care and her expectation was that CNAs or LVNs to offer to cut and clean nails if they were long and dirty. She also stated that as the DON, either herself or her designee were responsible to do routine rounds for monitoring. The DON stated residents having long and dirty fingernails could be an infection control issue. Record review of the facility's policy titled ADL, services to carry out , revised date July 2020 reflected If a resident is unable to carry out activities of daily living, the necessary services to maintain good nutrition, grooming and personal oral hygiene will be provided by qualified staff .

Based on interviews and record review, the facility failed to ensure each resident received an accurate assessment, reflective of the resident's status for one (Resident #12) of three residents reviewed for accuracy of assessments. The facility failed to ensure Resident #12's Quarterly MDS assessment dated [DATE] accurately reflected that Resident #12 had impairments to both upper extremities and both lower extremities. This failure could place residents at risk for not receiving care and services to meet their needs, diminished function of health, and regressions in their overall health. Findings included: Review of Resident #12's Face Sheet dated 04/23/2024 revealed the resident was a [AGE] year-old male admitted on [DATE]. Relevant diagnoses included cerebral infarction (insufficient oxygen in the brain causing stroke), stiffness of unspecified joints, and muscle atrophy. Review of Resident #12's Quarterly MDS assessment dated [DATE] revealed the resident had a moderate impairment in cognition with a BIMS score of 11. Resident #12's Minimum Data Set, Section GG - Functional Status GG0115 Functional Limitation in Range of Motion specified Resident #12 had no impairment to upper extremity and lower extremity. Review of Resident #12's Comprehensive Care Plan dated 02/04/2024 reflected the resident had an ADL self-care performance deficit r/t to quadriplegia (paralysis of all four limbs). Review of Resident #12's Progress Notes dated 03/19/2024 reflected ROS . musc . Quadriplegic since the age of 45, can't move neck below . Observation and interview on 04/23/2024 at 10:41 AM revealed Resident #12 was in his bed resting. It was noted that the resident was unable to move his upper extremities and lower extremities. According to Resident #12, he had been in that condition since he was on an accident. He said he needed assistance to move all his limbs because he could not do it by himself. In an interview with LVN A on 04/24/2024 at 10:55 AM, LVN A stated Resident #12's both upper extremities and both lower extremities were impaired. He said the resident could not actively move them anymore. He said the resident had been in that condition since he worked in the facility. In an interview and observation with MDS Coordinator on 04/24/2024 at 3:01 PM, the MDS Coordinator stated if the resident cannot move both the upper and lower extremities, then the resident should had been triggered for impairment since the resident was unable to move his limbs. The MDS Coordinator checked Resident #12's profile and saw that the resident's code for his functional limitations was zero for impairment to both upper and lower extremities. The MDS Coordinator went to Resident #12's room and assessed the resident. She asked the resident to wiggle his toes, and the resident was unable to. Then she asked the resident to move his fingers, and the resident was unable to do so. The MDS Coordinator said the resident should had been coded as having an impairment on both upper extremities as well as on both lower extremities. She said she would put the appropriate code for Resident #12's functional limitations. She said an accurate MDS was important because it would be the basis of the care needed by the resident. If the assessment was not accurate, the current status of the resident would not be correct resulting to a possible confusion on his care. That could also result in the resident not getting the appropriate care needed. She said this should had been brought up during meetings. In an interview with the ADON on 04/24/2024 at 3:12 PM, the ADON stated the resident should be thoroughly assessed so the staff would have an idea of the resident's current status and current needs. She said if the resident had impairments, it should be reflected on the MDS. She said accuracy in assessment would help the staff make an appropriate care plan for the resident. The ADON said if there was no accurate assessment, there could be a confusion about the care needed by the resident and might not be able to get the treatment needed. In an interview with the DON on 04/24/2024 at 3:22 PM, the DON stated the MDS should reflect the actual functionality of the resident. She said if the resident had an impairment, it should had been assessed accurately and reflected on the MDS. If the residents were not properly assessed, the proper care and needs would not be met. The DON said the expectation was the residents were properly assessed not only during admission but every day to see if there was a change in condition, any refusal of care, or resident acting different than usual. In an interview with the Administrator on 04/25/2024 at 8:10 AM, the Administrator stated the resident should be assessed carefully to know what they were able to do and what they could do anymore. He said he would collaborate with the clinical managers to evaluate the situation, discuss it during quality assurance and do in-services. In an interview with PT D on 04/25/24 at 11:48 AM, PT D stated the purpose of an assessment was to know the current status or level of function of the resident. She said a thorough assessment is needed to be able to facilitate an accurate problem list and to be able to plan the goals and interventions. She said it was also important to know the resident's functional deficits, weakness, or strengths that could help in planning. She said if a resident cannot move his hands and feet, it would be defined as an impairment. She also said that any assessment should be reflected on the resident's profile. Record review of facility policy, Resident Assessment and Associated Processes revised 1.2022 revealed, Policy: It is the policy of this facility that resident's will be assessed and the findings documented in their clinical health record. These will be comprehensive, accurate, standardized reproducible assessment of each resident . be conducted initially and periodically as part of an ongoing process . goals of care, functional and health status, and strengths and needs will be identified . Procedure: An accurate assessment will be made . Physical functioning and structural problems.

Based on observation, interview, and record reviews, the facility failed to provide a safe, clean, comfortable, and homelike environment for 3 of 5 (Resident #18, Resident #35, and Resident #52) residents reviewed for safe, clean, comfortable, and homelike environment. The facility failed to provide clean privacy curtains for Resident #18, Resident #35, and Resident #52. These failures could place residents at risk for an unsanitary and hazardous living conditions. Findings included: Record review of Resident #18's Quarterly MDS dated [DATE] revealed resident was [AGE] year-old male admitted on [DATE] with diagnoses of cellulitis (bacterial infection) of right lower limb, asthma (lung disease resulting in difficulty breathing) , respiratory failure, metabolic encephalopathy (brain dysfunction), muscle wasting and atrophy, anxiety disorder (persistent and excessive worry), and depression (feelings of sadness). The Resident had a BIMS score of 10 (moderate cognitive impairment). Record review of Resident #18's care plan dated 11/07/2022 revealed facility was to anticipate and meet needs of resident. Observation and interview on 04/24/2024 at 2:37 PM of Resident #18's room revealed his privacy curtain was stained with light and dark brown substances in streaks, smears, and splatters along the bottom inside and outside of the curtain and halfway up the outside edges of the curtain. Resident #18 stated that he was not sure how long they have been like that way, and it was unsanitary. Interview on 04/24/2024 at 2:41 PM with Nurse Aide H in Resident #18's room revealed this was her second week working for facility and Resident #18's curtains did not look clean and had brown marks. Nurse Aide H stated Resident #18 does not have a roommate, was not able to ambulate or get out of bed on his own and did not know why the curtain would be dirty. She stated housekeeping was only responsible for cleaning floors, bathrooms, and surfaces and would let the maintenance director know. Nurse Aide H stated having dirty curtains would be a sanitary risk for residents and she would be concerned about germs. Record review of Resident #35 Quarterly MDS dated [DATE] revealed resident was [AGE] year-old female admitted on [DATE] with an initial admitted [DATE] with diagnoses of nontraumatic intracerebral hemorrhage in cerebellum (stroke), muscle weakness, cognitive communication deficit, dysarthria (weak speech muscles), and hypertension (high blood pressure). The resident had a BIMS score of 7 (moderate cognitive impairment). Record review of Resident #35's care plan dated 02/22/2023 and revised on 02/12/2024 revealed facility was to anticipate and meet needs of resident. Interview and observation on 04/24/2024 at 2:00 PM revealed Resident #35 was sitting outside in an electric wheelchair, with a black hair wrap, was friendly and was a poor historian. Observation on 04/24/2024 at 3:11 PM revealed Resident #35's room had two privacy curtains with dark and light brown substance smeared on privacy curtains. Record review of Resident #52's Quarterly MDS dated [DATE] revealed resident was [AGE] year-old female admitted on [DATE] with an initial admitted [DATE] with diagnoses of seizure disorder, depression (persistent feelings of sadness), asthma (lung disease resulting in difficulty breathing), muscle wasting and atrophy, and metabolic encephalopathy (brain dysfunction). The resident had a BIMS score of 15 (cognitively intact). Record review of Resident #52's care plan dated 11/04/2022 and revised on 12/04/2023 revealed facility was to anticipate and meet needs of resident. Observation and interview on 04/24/2024 at 2:45 PM with CNA E revealed Resident #52's privacy curtain had dried brown drips, splatters, and smears along the bottom half of the curtain and along the sides of the curtain. CNA E stated she did notice Resident #52's privacy curtain was dirty and stained and had told her charge nurse more than two weeks ago and did not realize they had not been replaced yet. CNA E stated Resident #52 was not able to ambulate on her own and was not sure why the curtain was dirty. She stated it was housekeeping or maintenance's responsibility to change the privacy curtains when dirty. She stated dirty or stained privacy curtains were a health risk to resident and would immediately report the concern to her nurse. Observation and interview on 04/24/2024 2:47 PM with Resident #52 revealed she was lying in bed wearing glasses, watching television, affect was flat, and she stated she is in her bed often and had not noticed the curtain was so dirty because it is usually kept closed and hooked to the wall. Interview on 04/24/2024 at 3:27 PM with the Housekeeping Supervisor revealed housekeepers cleaned residents' room each day and were supposed to wipe down surfaces, sweep, mop, and disinfecting high contact surfaces. The Housekeeping Supervisor stated all privacy curtains were washed once a month or when dirty. She stated the housekeepers were responsible for checking if privacy curtains are dirty or stained when they clean residents' room each day and were expected to inform herself or Housekeeper G because Housekeeper G was the one who took down and put-up clean privacy curtains. The Housekeeping Supervisor stated she was aware some resident rooms had stained curtains, but thought they were all addressed and did not know Residents #18, #35, or #52 were still dirty. The Housekeeping Supervisor stated there were some curtains that had old stains because they were unable to get some stains out and they would have to reuse them. She stated each hall was color coded with different curtain and if she didn't have the curtain in the correct color or pattern a stained curtain might be reused. She stated dirty or stained privacy curtains would be a sanitary risk to residents and should immediately be replaced. Interview on 04/24/2024 at 9:15 AM with Housekeeper F revealed she was told about two weeks ago by the Housekeeping Supervisor to check all the resident's privacy curtains for stains. She stated she checked halls 400 and 100 and then wrote which needed to be replaced and gave the list to Housekeeping Supervisor. Housekeeper F stated only Housekeeper G was supposed to replace privacy curtains and that some curtains were not replaced, she informed Housekeeping Supervisor again, and after a couple of days the curtains were replaced. Housekeeper F stated stained or dirty curtains posed a health risk to residents due to possible bacteria and dust build up. Interview on 04/25/2024 at 8:50 AM with the Housekeeping Supervisor revealed only Housekeeper G was supposed to replace privacy curtains because it would be unsanitary for the other housekeepers and could expose them to bodily fluids and they were instructed to inform either Housekeeping Supervisor or Housekeeper G if one needed to be replaced. She stated Housekeeper G replaced privacy curtains. Interview on 04/25/2024 at 9:00 AM with Housekeeper J revealed she cleaned Resident #18, #35, and #52 rooms on 04/24/2024 and did not recall checking their privacy curtains. Housekeeper J was shown pictures of Resident #18, #35, and #52 privacy curtains taken on 04/24/2024 and she stated the stains looked like fecal matter and the solution from feeding tubes. She stated privacy curtains are changed as needed and staff were to inform Housekeeper G if there were privacy curtains that need to be replaced. Interview on 04/25/2024 at 10:49 AM with Housekeeper G revealed he was responsible for replacing stained or dirty privacy curtains and was told by housekeepers or Housekeeping Supervisor when they need to be replaced. Housekeeper G stated sometimes stained curtains were reused because sometimes you can't get out the stains but typically, they were supposed to be thrown away. Record review of facility's policy titled Policy/Procedure .Section: Physical Environment/Homelike Environment, undated, revealed It is the policy of this facility that the facility must provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public.

Based on observation, interview, and record review, the facility failed to ensure the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for two (Resident #3 and Resident #46) of twelve residents reviewed for reasonable accommodation of needs. The facility failed to ensure the call light system in Resident #3 and #46's rooms was in a position that was accessible to the residents. This failure could place the residents at risk of being unable to obtain assistance when needed and help in the event of an emergency. Findings included: Resident #3 Review of Resident #3's Face Sheet dated 04/24/2024 reflected that resident was an [AGE] year-old female admitted on [DATE]. Relevant diagnoses included muscle weakness, stiffness of joints, and difficulty in walking. Review of Resident #3's Annual MDS assessment dated [DATE] reflected Resident #3 had a severe impairment in cognition with a BIMS score of 07. Review of Resident #3's Comprehensive Care Plan dated 04/20/2024 reflected Resident #3 had a risk for falls related to ADL deficits and one of the interventions was to be sure the call light was within reach. The Comprehensive Care Plan also indicated resident had an actual fall on 04/03/2024. Review of Resident #3's Fall-Risk assessment dated [DATE] reflected Resident #3 was at high risk for falls. Observation and interview on 04/23/2024 at 10:51 AM revealed Resident #3 was sitting in her wheelchair beside her bed. It was noted that the resident's call light was on the floor under the bed. Resident #3 stated the CNA who just fixed her bed forgot to put the call light on top of the bed where she could reach it. Resident #3 further said she hoped the CNA would put the call light on top of the bed so that she could reach it when she was on her wheelchair. Resident #3 maneuvered her wheelchair towards the door of the room and said she would wait for someone to get her call light from the floor. Resident #46 Review of Resident #46's Face Sheet, dated 04/23/2024 reflected the resident was a [AGE] year-old female admitted on [DATE]. Relevant diagnoses included history of falling, muscle weakness, and osteoarthritis (a type of arthritis that happens when the cartilage that lines your joints is worn down and your bones rub against each other). Review of Resident #46's Quarterly MDS assessment dated [DATE] reflected Resident #46 had a severe cognitive impairment with a BIMS score of 07. Review of Resident #46's Comprehensive Care Plan dated 04/21/2024 reflected Resident #46 had a decreased mobility and one of the interventions was to keep the call light within reach. Observation and interview on 04/23/2024 at 9:26 AM revealed Resident #46 was on her bed resting. It was noted that the resident's call light was behind a small refrigerator situated at the side of her bed. Resident #46 stated she did not know where her call light was. The Respiratory Therapist then walked inside Resident #46's room. Resident #46 asked her where her call light was. The Respiratory Therapist looked for the call light and found the call light behind the small refrigerator. The Respiratory Therapist tried to pull the cord of the call light but said she was having a hard time pulling it. She said the call light was entangled on the string of the overhead light. The Respiratory Therapist disentangled the cord of the call light from the string of the overbed light and placed the call light where the resident could reach it. In an interview with Resident #46 on 04/23/2024 at 10:39 AM, Resident #46 stated she did not know how long her call light was behind the fridge. She said it would be better if the call light was clipped at the side of the bed so that it would not fall. In an interview with LVN A on 04/24/2024 at 10:55 AM, LVN A stated call light was important for the residents. LVN A said the residents used the call light to signal the staff that they needed assistance. LVN A added if the residents did not have their call lights, they might fall trying to stand up to get what they needed or to go to the bathroom. LVN A further added the residents might get mad or agitated if they cannot communicate their needs. LVN A said if the resident was on the wheelchair, the call light must be with them on the wheelchair. If the resident was mobile and could roll themselves, the call light must be placed on top of the bed where the residents could reach the call lights. LVN A also said all the staff were responsible in making sure the residents had their call lights. Interview with the Respiratory Therapist on 04/24/2024 at 1:26 PM, the Respiratory Therapist stated call lights were important for the residents because the call lights were one of the ways the resident could tell the staff that they needed something. She said because the call lights were important for the residents, the call light should always be within the reach of the residents so they could call the staff if they needed something. She acknowledged that Resident #46's call light was behind the fridge and was intertwined with the string of the overhead light. She said she had a hard time freeing the cord of the call light. She said if the call light was not with the residents, their needs, whether emergent and non-urgent would not be met. In an interview with the ADON on 04/24/2024 at 3:12 PM, the ADON stated the call light must always be accessible for the residents. The ADON said the call lights were the resident's source of help whether for basic reasons such as a glass of water, TV remote, or they needed to be changed. The ADON added the call light could be used also by the residents if they were not feeling well or if they were in pain. She said if the call lights were far from the residents, the residents would not be able to call the staff what they needed and those needs would not be addressed. She said if the call lights were not with the residents, it could result in a fall, dehydration, and annoyance. The ADON said the expectation was for the staff to make sure the call lights were with the reach of residents whether they on their bed or when the residents were up. She said they would do in-services about the call light and would remind the staff to ensure the call lights were with the residents during their rounds. In an interview with the DON on 04/24/2024 at 3:22 PM, the DON stated the call lights were inside the rooms of the residents for a reason. She said the purpose of the call lights was for the residents could call the staff if they needed something. The DON added without the call lights, the residents would not be able to tell the staff they were thirsty, needed a snack, they were in pain, they need to go to the bathroom, or they were not feeling well. The DON further added that when the call lights were not within the reach of the residents, unfavorable incidents like falls, minor hurts, or major injuries could happen. The DON said the expectation was for the staff to ensure that the call lights were always accessible for the residents. The DON concluded that moving forward, she would be on top of this issue to make sure the staff would make certain the call lights were with the residents at all times. In an interview with the Administrator on 04/25/2024 at 8:10 AM, the Administrator stated it was important that the residents had their call lights so their needs could be addressed. The Administrator said if the call lights were not within the reach of the residents, the staff would not know the residents needed something. He said he would collaborate with the clinical managers to evaluate the situation, discuss it during quality assurance and do in-services. Interview with CNA C on 04/25/2024 at 11:24 AM, CNA C stated he placed Resident #46's call light on the side of the bed and clipped it so it will not fall. CNA C said for some residents, the call light was their sense of protection. He said the call light gave them the assurance that when they were in danger or there was an emergency, they could call the staff for help. CNA C added that the resident could fall if they tried to get to their call light that was far from them. CNA C stated he would go and check the call lights on his hall. Record review of facility's policy Call Light, Policy/Procedure - Nursing Clinical, rev. 05/2023, revealed Policy: It is the policy of this facility to provide the resident a means of communication with nursing staff . Procedures . 4. Leave the resident comfortable. Place the call device within resident's reach before leaving room .

Based on observation, interview, and record review, the facility failed to ensure the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility for 2 of 5 (Resident #7, Resident #42) residents reviewed for resident rights. The facility failed to promote Resident #7 and 42's right to communication with kitchen staff who primarily spoke Spanish and little to no English. This failure could affect all residents who communicate food and snack requests, verbally and written, by contributing to unmet nutritional and dietary needs and choices. Findings included: Review of Resident#42's Face Sheet dated 04/25/2024 revealed he was a [AGE] year-old male who was admitted to the facility on [DATE]. Resident's diagnoses included Paraplegia, Myoneural Disorder, and Neuromuscular Dysfunction of bladder. Review of Resident#7's Face Sheet dated 04/25/2024 revealed he was a [AGE] year-old male who was admitted to the facility on [DATE]. Resident's diagnoses included Cellulitis of left lower limb, Unspecified Protein-Calorie malnutrition, and Alcoholic Cirrhosis of liver without ascites. During the confidential group meeting at 10:00am on 04/24/2024, revealed residents were unable to request a snack or correct meal choices on meal tickets with kitchen staff on weekends because the staff were Spanish speaking. An interview with the Dietary Manager on 04/24/24 at 1:05 pm, revealed CNA's relay what resident's want through the google translate app but was unsure if it's a required training. The Dietary manager stated she ordered a communication board to assist kitchen staff and resident communication. The Dietary Manager stated the kitchen staff were learning English. The Dietary Manager stated she comes in on weekends, although she was off work, to assist kitchen staff or the kitchen staff will call with questions. Interview with Resident #42 on 04/24/24 at 1:50 pm, revealed when he runs low on snacks such as cheese and crackers on weekends, he takes the cheese and crackers to the kitchen staff to show what he wants. He said if he asks for something like biscuits or butter, the kitchen staff does not understand what he wants because they don't speak English. He said he learned how to say hot tea in Spanish because there isn't always another staff around to translate if he asks for hot tea in English. Resident #42 revealed sometimes meal tickets were wrong. Resident #42 stated he chooses menu items for breakfast, lunch, dinner daily from a list of menu options but sometimes what he receives was not what he chose. An interview with Resident #7 on 04/24/24 at 1:40pm, revealed 2 weeks ago he asked the kitchen staff for a peanut butter and jelly sandwich, but they didn't understand what he was saying. He said he returned to his room without a peanut butter and jelly sandwich. Resident #7 said another time he requested ice for his cup and pointed to the cup and the staff member responded with a word that sounds like oranges and brought him ice. He said oranges must be Spanish for ice. An interview with [NAME] A on 04/25/24 at 10:20am, revealed she works some weekends and last worked on weekends 2 weeks ago. She stated she speaks English and can read English. She stated the kitchen staff uses google translate to understand resident's request. An attempt was made at 04/25/24 at 10:29am to contact [NAME] B, who works weekends 5:30am-7:30pm, but the mailbox was full. An interview on 04/25/24 at 10:32am with the Dietary Aide, revealed she primarily spoke Spanish and very little English. Surveyor B translated the interview for this Surveyor. The Dietary Aide stated she uses google translate to understand resident's verbal requests. She stated she understands drink request and pictures of food of what the resident circles on meal tickets. The Dietary Aide stated if a resident requests a sandwich, she uses goggle translate or if the item sounds like the Spanish word, she tries to figure it out. She stated she works 6a-2pm Saturday and Sunday. Record review of the confidential group meeting minutes dated 03/07/24 revealed concern: Language barrier, meeting with Dietary Manager not following what's on meal tickets. Record review of the confidential group meeting minutes dated 04/04/24 revealed concern: Evening and weekends, not following what is on meal ticket. An interview on 04/25/24 at 11:25am, with the Administrator, revealed he was aware of the communication issue between residents and kitchen staff. The Administrator confirmed he reads the notes from Residents Council. He stated the Activity Director brings issues resulting from Residents Council to their stand-up meetings for discussion. The Administrator stated there were interventions in place including a resident communication board. The Administrator stated he was informed the communication board was not related to dietary, so another communications board was ordered this week. The Administrator stated there needs to be a way for residents to communicate with kitchen staff. The Administrator stated other interventions include a weekend nurse that speaks Spanish, staff that speaks Spanish, google translate, a language line, and kitchen staff can contact the dietary manager. The Administrator stated the expectation was for resident and staff to be able to communicate with kitchen staff.

Based on observation, interview and record review the facility failed to ensure food was stored, prepared, distributed and served in accordance with professional standards for food service safety for the facility's only kitchen reviewed for kitchen sanitation. The facility failed to ensure the Iced Tea Dispenser, located in the facility's only kitchen, had the cover placed on top after filing it with tea. This failure could place residents at risk for cross contamination and other air-borne illnesses. Findings include: Observation and interviews on 03/14/23 at 09:40 AM in the facility's only kitchen revealed an Iced Tea dispenser filled with tea, but it did not have a top and it was exposed to the air. The Dietary Manager stated Cook A made the tea. The Dietary Manager asked Cook A when the tea was made, and Cook A stated the tea was made around 7:00 AM. The Dietary Manager and Cook A stated the container was uncovered for over 2 hours. The Dietary Manager stated they had not served any tea to residents from this dispenser, and it will be thrown out. Interview with the Dietary Manager on 03/16/23 at 1:30 PM revealed she expected her staff to ensure the tea dispenser was covered once it had been filled. She stated Cook A was responsible for filling the Tea dispenser and she should have placed the top on it once it was filled. She stated the risk of not placing the cover on top of the tea dispenser was an infection control concern and residents could get sick. Interview with Cook A on 03/16/23 at 1:40 PM revealed she was the person that prepared the Tea and placed it in the Iced Tea Dispenser. She stated she had forgotten to place the top back onto the dispenser. She stated the risk to residents of the tea being exposed could result in the resident getting some type of bacteria illness. Interview with Administrator on 03/16/23 at 2:00 PM revealed he was made aware of the full Iced Tea Dispenser not having a top placed on it. He stated the expectation was for staff to ensure they are practicing sanitary conditions for residents throughout the facility and the risk to the residents could be that they contract an air-borne illness. Record Review of facility's policy and procedure for Sanitation in Dietary, dated October 2007, revealed It is the policy of this facility that food service area shall be maintained in a clean and sanitary manner.

45055 Based on observation, interview, and record review, the facility failed to ensure residents received adequate supervision and assistance devices to prevent accidents for 1 (Resident #50) of 8 residents reviewed for accidents and hazards. The facility failed to ensure Resident #50 was provided with the appropriate level of assistance to support the resident during transfer to prevent her from bearing weight on her fractured ankle. This failure could place resident #50 at risk of re-injuring the ankle or falling and injuring. Findings Included: Review of Resident #50's Face Sheet, dated 03/16/23, revealed she was a [AGE] year-old female admitted on [DATE]. Relevant diagnoses included Displaced fracture of lateral malleolus of right fibula (right ankle fracture), Diabetes (high blood sugar), Pain, and difficulty walking. Review of Resident #50's MDS, dated [DATE] stated she was cognitively intact with a BIMS score of 14. She required extensive assistance of one staff for bed mobility, toilet use, and personal hygiene. Record review of Resident #50's Comprehensive Care Plan, dated 02/03/2023 revealed the resident had a fractured right ankle and an intervention was to follow MD orders for non-weight bearing status Record review of Physician orders for Resident #50 dated 01/30/23 revealed Non-weight bearing of Right Ankle. In an interview on 03/15/23 at 1:45 PM, Resident #50 said on the night of 03/09/23 or 03/10/23, she used the call button for assistance. She stated it took a long time for someone to respond. She stated when C.N.A. B (Certified Nurse Aide) entered her room to respond to the call light, she told her she needed a bed pan. She said the aide searched for the bed pan and did not find it. She said the aide then told she would go locate a bed pan for her and Resident #50 told the aide she could not wait that long, so the aide told her she would have to go to bathroom instead. Resident #50 said the aide prepared her for transfer and then told her to use the transfer board to slide to the wheelchair. The resident said she told the aide she was not supposed to let her feet touch the floor and she could not bear weight on her ankle. She stated the aide insisted she do it and told her she believed in her. She said the aide told her it would help strengthen her ankle. The resident said the more she protested , the more the aide encouraged her to do it herself. She stated she made it into her wheelchair and the aide wheeled her to the bathroom. The resident stated she could not get the wheelchair close enough to the toilet and asked the aide for help. She said the aide pushed her closer to the toilet and told her to go ahead, she could do it. She stated having to do it all without the aide's help made her cry because she was so scared that she would fall or reinjure her ankle. She stated she had to try hard to not bear weight or as little as possible on her right foot. She stated she transferred herself to the toilet and then the aide told her she was going to locate a bed pan. Resident #50 said once she was done toileting, she pressed the call button and the aide returned with a bedpan in hand. She stated CNA B watched and encouraged her to get back in the chair on her own. She stated after she returned to the chair, the aide pushed her to the bed, and she had to get back in bed on her own. She stated once she was back in the bed, the aide was standing at the foot of her bed and told her, See, I knew you could do it, as she lightly hit her ankle four times as she was fanning her hand against the resident's fractured ankle in a fanning motion. The resident said she asked the aide, So you're just going to beat me up now too? She said the aide then replied, I'm sorry while snickering. Resident #50 said she reported what happened to LVN E and he just looked at her and said he did not know why she (CNA B) would do that. She stated that she had not mentioned this to anyone else. During an interview on 03/16/22 at 2:06 PM, the Director of Rehabilitation stated therapy and nurses did assessments and as a team, they determined what was best for Resident #50, as it pertains to functional status. She stated if a resident was NWB, it would be determined by the person's upper body strength, strength of non-affected side, cognition all play a part in what she needs. She stated Resident #50 basically needed two-person assist. She stated the safest thing would be to go with caution and do two-person assist. She stated one-person assist for a NWB resident was not typical practice. She stated they train direct care staff on how to transfer residents. She said Resident #1 did not mention the incident with C.N.A. B to her. She said Resident #50's order is NWB for eight weeks. She said it had been six weeks, as of this week and there were two weeks remaining, before going back to Ortho. She stated the possible harm which could occur from not following the interventions put in place would be a displaced fracture, displaced screws, or an elemental fall. Interview on 03/16/23 at 3:05 PM, C.N.A. B stated she had been a CNA for over [AGE] years. She stated on 03/10/23, Resident #50 used the call button to alert staff she needed assistance. She stated the resident stated she needed a bedpan, but they could not find it. She stated they decided to go to the bathroom. She stated the resident was in her right mind. She stated the resident could make her needs known. She stated when she entered the room, the resident told her what she needed. She stated she asked her if she wanted to use her bedpan or go to the bathroom. She stated the resident wanted to use the bed pan, however, she could not locate the bed pan, so the resident chose to go to the bathroom. She stated she pulled the resident's wheelchair up to the bed and she was going to help the resident, but the resident told her she could do it herself and told her to move the arm of the chair so she could get in it. She stated she did so and got the board, but the resident stated she could do it herself. She stated she helped the resident, but very little, because the resident said she could do it herself. She stated her back was hurting, so she allowed the resident to do as much as she could, since she said she could do it. She stated she helped the resident to the bathroom and the resident got on the toilet with very little help from her because, again, she stated she could do it. She stated the resident used the call button in the bathroom once she was done. She stated she came to assist her with getting back in bed and then she cleaned the resident up and cleaned the board. She stated while the resident was in the bathroom, she located a bed pan and brought it back with her. She stated this was the first time she had had to assist the resident with getting out of the bed. She stated she did not have any type of conversation with the resident which did not pertain to what she needed. She stated she never touched the resident at all. She stated she had access to the Kardex system, which was how the aides look up how to care for the residents. She stated she did not look at the Kardex prior to going to the resident's room. She stated she went to the room to see what the resident needed first. She stated she did not think to look to see if the resident required one or two-person assist, she just took the resident's word, when she told her she could do it herself, regarding transferring. She stated the possible harm which could have taken place, would have been that the resident could have fallen or her by her putting weight on the ankle, could have re-injured the ankle. During an interview on 03/16/23 at 2:17 PM, Resident #50 stated when she is moving around, one person assists her. She stated when she is moving around in the shower, two-people assist her. Interview on 03/16/23 at 2:31 PM, LVN E revealed he was aware Resident #50 had physician orders for Non-Weight Bearing (NWB) because of her fractured left ankle and required assistance to use the toilet. He advised that staff should all be aware of residents 'care plan to ensure thy are receiving the appropriate personalized care. He stated the possible harm to the resident due the aide having her to bear weight on her ankle could have resulted in her reinjuring the ankle. Interview on 03/16/23 at 2:38 PM, the DON stated she was not aware of any incident involving Resident #50 and C.N.A. B had ever happened since Resident #50 had been in the facility until it was mentioned on 03/15/23. She stated the therapy department determined the extent of assistance which a resident need for ADLs. She stated therapy did not give NWB orders. She stated only physician ordered such a status. She stated she spoke to the C.N.A. B and the aide stated the aide offered the resident a bed pan, so she would not have to keep getting back up. She stated the aide did not say anything about telling the resident to do it herself. She stated the aide told her she entered the room and assisted the resident with her transfer from bed to wheelchair and wheelchair to toilet. She stated the aide told her that she gave the resident time and privacy to use the toilet and told the resident to use the call button in the bathroom when she was finished. She stated she assisted the resident back to bed after cleaning her up. The DON stated the possible adverse effect of not properly assisting the resident would be reinjuring the fracture. She stated she and the Administrator will investigate the incident further and place the employee on suspension until the investigation is complete. Interview with Administrator on 03/16/203 at 4:00 PM, revealed he was made aware of the concerns regarding Resident #50 and can on 03/15/23 and from what he could gather, CNA B was trying to encourage the resident to self-transfer. He was advised Resident #50 had standing orders for non-weight bearing of the right ankle and it was also planned on her care plan. He advised all staff are expected to be knowledgeable of resident's care needs and using the appropriate resources. The Administrator advised the risk of staff not following Resident #50 Physician Order's could result in the resident injuring her ankle again.

Based on observation, interviews, and record review, the facility failed to ensure residents' Care Plan was implemented for 1 of 8 residents (Resident #50) reviewed for Care Plans. The facility failed to ensure the care plan related to resident #50's Non-weight Bearing (NWB) status was implemented . This failure could place residents at risk for reinjury or further injury. Findings Included: Review of Resident #50's Face Sheet, dated 03/16/23, revealed she was a 68 -year-old female admitted on [DATE]. Relevant diagnoses included Displaced fracture of lateral malleolus of right fibula (right ankle fracture), Diabetes (high blood sugar), Pain, and difficulty walking. Review of Resident #50's MDS, dated [DATE] stated she was moderately cognitively intact with a BIMS score of 14. She required extensive assistance of one staff for bed mobility, toilet use, and personal hygiene. Record review of Resident #50's Comprehensive Care Plan, dated 02/03/2023 revealed the resident had a focus on her fractured right ankle and an intervention was to follow MD orders for non-weight bearing status Record review of Physician orders for Resident #50 dated 01/30/23 revealed Non-weight bearing of Right Ankle. Interview on 03/15/23 at 1:45 PM, Resident #50 said on the night of 03/09/23 or 03/10/23, she used the call button for assistance. She stated it took a long time for someone to respond. She stated when C.N.A. B (Certified Nurse Aide) entered her room to respond to the call light, she told her she needed a bed pan. She said the aide searched for the bed pan and did not find it. She said the aide then told she would go locate a bed pan for her and Resident #50 told the aide she could not wait that long, so the aide told her she would have to go to bathroom instead. Resident #50 said the aide prepared her for transfer and then told her to use the transfer board to slide to the wheelchair. The resident said she told the aide she was not supposed to let her feet touch the floor and she could not bear weight on her ankle. She stated the aide insisted she do it and told her she believed in her. She said the aide told her it would help strengthen her ankle. The resident said the more she protested , the more the aide encouraged her to do it herself. She stated she made it into her wheelchair and the aide wheeled her to the bathroom. The resident stated she could not get the wheelchair close enough to the toilet and asked the aide for help. She said the aide pushed her closer to the toilet and told her to go ahead, she could do it. She stated having to do it all without the aide's help made her cry because she was so scared that she would fall or reinjure her ankle. She stated she had to try hard to not bear weight or as little as possible on her right foot. She stated she transferred herself to the toilet and then the aide told her she was going to locate a bed pan. Resident #50 said once she was done toileting, she pressed the call button and the aide returned with a bedpan in hand. She stated CNA B watched and encouraged her to get back in the chair on her own. She stated after she returned to the chair, the aide pushed her to the bed, and she had to get back in bed on her own. She stated once she was back in the bed, the aide was standing at the foot of her bed and told her, See, I knew you could do it, as she lightly hit her ankle four times as she was fanning her hand against the resident's fractured ankle in a fanning motion. The resident said she asked the aide, So you're just going to beat me up now too? She said the aide then replied, I'm sorry while snickering. Resident #50 said she reported what happened to LVN E and he just looked at her and said he did not know why she (CNA B) would do that. She stated that she had not mentioned this to anyone else. During an interview on 03/16/22 at 2:06 PM, the Director of Rehabilitation stated therapy and nurses did assessments and as a team, they determined what was best for Resident #50, as it pertains to functional status. She stated if a resident was NWB, it would be determined by the person's upper body strength, strength of non-affected side, cognition all play a part in what she needs. She stated Resident #50 basically needed two-person assist. She stated the safest thing would be to go with caution and do two-person assist. She stated one-person assist for a NWB resident was not typical practice. She stated they train direct care staff on how to transfer residents. She said Resident #50 did not mention the incident with C.N.A. B to her. She said Resident #50's order is NWB for eight weeks. She said it had been six weeks, as of this week and there were two weeks remaining, before going back to Ortho. She stated the possible harm which could occur from not following the interventions put in place would be a displaced fracture, displaced screws, or an elemental fall. Interview on 03/16/23 at 3:05 PM, C.N.A. B stated she had been a CNA for over [AGE] years. She stated on 03/1023, Resident #50 used the call button to alert staff she needed assistance. She stated the resident stated she needed a bedpan, but they could not find it. She stated they decided to go to the bathroom. She stated the resident was in her right mind. She stated the resident could make her needs known. She stated when she entered the room, the resident told her what she needed. She stated she asked her if she wanted to use her bed pan or go to the bathroom. She stated the resident wanted to use the bed pan, however, she could not locate the bed pan, so the resident chose to go to the bathroom. She stated she pulled the resident's wheelchair up to the bed and she was going to help the resident, but the resident told her she could do it herself and told her to move the arm of the chair so she could get in it. She stated she did so and got the board, but the resident stated she could do it herself. She stated she helped the resident, but very little, because the resident said she could do it herself. She stated her back was hurting, so she allowed the resident to do as much as she could, since she said she could do it. She stated she helped the resident to the bathroom and the resident got on the toilet with very little help from her because, again, she stated she could do it. She stated the resident used the call button in the bathroom once she was done. She stated she came to assist her with getting back in bed and then she cleaned the resident up and cleaned the board. She stated while the resident was in the bathroom, she located a bed pan and brought it back with her. She stated this was the first time she had had to assist the resident with getting out of the bed. She stated she did not have any type of conversation with the resident which did not pertain to what she needed. She stated she never touched the resident at all. She stated she had access to the Kardex system, which was how the aides look up how to care for the residents. She stated she did not look at the Kardex prior to going to the resident's room. She stated she went to the room to see what the resident needed first. She stated she did not think to look to see if the resident required one or two-person assist, she just took the resident's word, when she told her she could do it herself, regarding transferring. She stated the possible harm which could have taken place, would have been that the resident could have fallen or her by her putting weight on the ankle, could have re-injured the ankle. Interview on 03/16/23 at 2:31 PM, LVN E stated Resident #50 had physician orders for NWB because of her fractured left ankle and required assistance to use the toilet. He stated that this was also on her Care plan and staff is required to be familiar with the specific care for each resident. He stated CNA B should have been aware of this as well. He stated the possible harm to the resident due the aide allowing her to bear weight on her ankle would have been that she could have reinjured the ankle. Interview on 03/16/23 at 2:38 PM, the DON stated the incident involving Resident #50 and C.N.A. B had never happened since Resident #50 had been in the facility. She stated the therapy department determines the extent of assistance which a resident need for ADLs. She stated therapy did not give NWB orders. She stated only doctors order such a status. She stated she spoke to the C.N.A. B, and the aide stated the aide offered the resident a bed pan, so she would not have to keep getting back up. She stated the aide did not say anything about telling the resident to do it herself. She stated the aide told her she entered the room and assisted the resident with her transfer from bed to wheelchair and wheelchair to toilet. She stated the aide told her that she gave the resident time and privacy to use the toilet and told the resident to use the call button in the bathroom when she was finished. She stated she assisted the resident back to bed after cleaning her up. She acknowledged that this was also on her Care plan. The DON stated she expects all her staff to follow Care plans and physician orders. The DON stated the possible adverse effect of not properly assisting the resident would be reinjuring the fracture. The DON stated the following policy regarding Care plans was the only one they had. Interview with Administrator on 03/16/203 at 4:00 PM, revealed he was made aware of the concerns regarding Resident #50 and can B and from what he could gather, the CNA B was trying to encourage the resident to self-transfer. He was advised that he is aware that resident #50 had standing orders for non-weight bearing of the right ankle and it was also planned on her care plan. He advised all staff are expected to be knowledgeable of resident's care needs and using the appropriate resources. The Administrator advised the risk of not following residents' Care plans could result in the resident injuring her ankle again. Record review of facility policy, Comprehensive Person-Centered Care Planning, rev. Jan. 2022, revealed Policy It is the policy of this facility that the interdisciplinary team shall develop a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment.

Based on observation, interview, and record review the facility failed to provide residents with a safe, clean, comfortable, and homelike environment for 1 of 1 rooms (room [ROOM NUMBER]) reviewed for environment. The facility failed to ensure residents in room [ROOM NUMBER] were provided with a safe, clean, comfortable, and homelike environment during observations on 03/13/2023 and 03/14/2023. These failures could place residents at risk of not residing in a safe, clean, comfortable, and homelike environment. Findings Included: During observation on 03/14/2023 at 11:13am of #404, the room appeared decorated with personal items, but with various areas of scratched, chipped, and discolored/stained off-white, light brown areas to the walls. The areas of concern were as follows: 1. The wall area separating the bathroom from the resident living area had a crack approximately 2.5 feet long. Areas of wall were jagged and protruding out. 2. The wall area to the right side of the closet had an approximately a 0.5 foot area of scuffed, scratched, and chipped paint and drywall. 3. The shared resident bathroom had significant debris accumulation (dust, various food remnants, paint chips, crumpled up paper products, and dead insects) , linoleum stained with multiple areas of black and/or brown substances, and toilet had significant brown staining present in the toilet bowl. During observation on 03/15/2023 at 10:29am of room # 404, the room appeared decorated with personal items, but with various areas of scratched, chipped, and discolored/stained off-white, light brown areas to the walls. The areas of concern were as follows: 1. The wall area separating the bathroom from the resident living area had a crack approximately 2.5 feet long. Areas of wall were jagged and protruding out. 2. The wall area to the right side of the closet had an approximately a 0.5 foot area of scuffed, scratched, and chipped paint and drywall. 3. The shared resident bathroom had significant debris accumulation (dust, various food remnants, paint chips, crumpled up paper products, and dead insects) , linoleum stained with multiple areas of black and/or brown substances, and toilet had significant brown staining present in the toilet bowl. During interview on 03/14/2023 at 11:13am with residents who lived in room # 404, they stated housekeeping was doing a poor job and it was very frustrating. They stated the walls had been damaged for months. They stated they reported it to maintenance, but it had not been addressed yet. They stated the bathroom did not get cleaned properly and housekeeping only swept and mopped a small linear area in front of the entry door and then would leave. They stated her room needed a deep clean and did not recall the last time the room was cleaned properly. They stated they tried to clean but was unable. They stated the condition of her room made they sad as they were not able to clean the room due to mobility limitations. Additionally, residents stated that cockroaches came in through the cracks in the walls and pointed to the area of the wall referenced (1) above. They stated they were tired of living in a dirty and damaged room. The residents stated the room was also dirty and housekeeping did not do an adequate job cleaning. They stated they asked housekeeping to sweep the perimeter of her room in the past, but they had not done it. She stated there has been a dead cockroach under the head of her bed for a while. They stated it was difficult not to be able to clean the room due to having mobility limitations. During an observation and interview on 03/16/2023 at 9:52am HK A's cleaning service was observed for room # 404 from onset until completion. HK A was not observed sweeping or mopping perimeter. HK A was observed placing the yellow wet floor sign in room and exited the room. She stated she completed her service for the room and the staff were responsible for cleaning the room the last three days. When the debris in the room that remained after her service was brought to her attention, she stated I guess I did not see it. She stated that the residents allowed her to clean the room with no restrictions or limitations on what she can touch or move around to clean. HK A refused to [NAME] why it was important to clean resident rooms thoroughly or why she did not report the damage to the walls. During interview 03/16/2023 at 10:27am with the HK Supervisor she stated her expectations were for staff to clean each resident room daily. She stated she was new to the management position at the facility and was in the process of implementing new protocols and procedures; but did not have any completed cleaning logs or checklists to provide for review at the time of survey. She stated she expected for her staff to clean and move things around to clean if the resident allows it. She stated that some residents do not allow staff to touch their things, but she was not aware of any limitations for Resident #2 or Resident #5. She stated that if her housekeeping staff did not clean resident rooms thoroughly, it could affect the residents' quality of life. She also stated she expected her staff to report any maintenance issues immediately. She said she did not know why the damage to the wall had not been reported despite her staff going in and out of the room daily. During an interview on 03/16/2023 at 10:46am with the MT Supervisor he stated he was not aware of any maintenance issues in room [ROOM NUMBER]. He stated that he addressed maintenance concerns as they were brought to his attention. He stated that if resident walls were compromised, it could hurt somebody. During an interview on 03/16/2023 at 02:25 pm with the DON, she stated her expectations were for resident rooms to be cleaned daily. She stated she expected maintenance to ensure resident walls were intact and the room kept in good condition. She stated that if resident rooms were not clean, it could be an infection control issue. She stated if resident walls were compromised, injury can occur. During an interview on 03/16/2023 at 03:40 pm with the Administrator, he stated his expectations were for resident rooms to be cleaned daily. He stated he also expected any staff members to report maintenance concerns so it could be promptly addressed. He stated if a resident's environment was not maintained, it could affect the quality of care for his residents. Record review of facility grievance log for 11/2022, 12/2022, 01/2023, 02/2023 revealed evidence of repeated housekeeping concerns related to cleanliness from other residents previously discharged from the facility. Review of facility policy, Policy/Procedure Section: Housekeeping, rev. 05/2007, stated Policy: It is the policy of this facility to provide a clean, comfortable, homelike, and sanitary living area . Procedures . 6. Dust mop floors . 10. Report any maintenance repairs needed. Review of facility policy, Resident Rights, rev. 10/04/2026, stated Safe Environment: You have the right to a safe, clean, comfortable and homelike environment .

Based on observation, interviews, and record review the facility failed to ensure all drugs and biologicals were stored securely for one (medication cart #1) of 1 medication carts reviewed for storage of medications. The facility failed to ensure medication cart #1 was locked while unattended. This failure could place residents at risk of having access to unauthorized medications and/or lead to possible harm or drug diversions. Findings included: An observation on 09/16/22 at 9:19 AM revealed, medication cart #1 was unlocked and unattended with no staff within eyesight of the medication cart. All drawers could be opened, medication and supplies (needles, prescription medications, gauze, lancet, etc.) could be easily accessed. In an interview on 09/16/22 at 9:20 AM,LVN B stated the medication cart was hers. She stated that when she stepped away, she should have locked her medication cart to prevent residents, visitors, or staff from gaining access to medication and supplies in the cart. In an interview on 09/16/22 at 9:58 AM, the DON stated her expectation was that all medication carts were locked when not in use to prevent drug diversions. Review of facility policy titled Medication Access and Treatment last revised on 05/2007 reflected: It is the policy of this facility to store all drugs and biological and locked compartments .The medication supply is accessible only to licensed nursing personnel, pharmacy personnel or staff members lawfully authorized to administer medications

Based on interview and record review, the facility failed to immediately consult with the resident's physician when there was a significant change in the resident's physical status, a need to alter treatment significantly, and did not ensure that all pertinent information were available and provided to the physician for two (Resident #1 and #23) of ten residents reviewed for notification of changes. 1. The facility failed to immediately notify the attending physician when it was discovered Resident #1, who had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #1 received IV fluids for dehydration. 2. The facility failed to immediately notify the attending physician when Resident #23 had blood in his urine on [DATE] and was receiving [MEDICATION(S)], an anti-coagulant. Resident #23 was hospitalized from [DATE] until [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident received a blood transfusion while hospitalized and was at risk for death. An Immediate Jeopardy (IJ) was identified during the administrative review process, it was determined that an IJ existed from [DATE] to [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a severity level of actual harm that was not immediate jeopardy and a scope of isolated because the facility was still monitoring the effectiveness of their Plan of Removal (POR). These failures could place residents at risk for a delay in treatment or diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings included: Record Review of Resident #1's face sheet dated [DATE] reflected she was a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record Review of Resident #1's quarterly MDS dated [DATE] indicated the resident had a severe cognitive impairment. The resident had a g-tube and received more than 51% of nutrition and hydration via the g-tube. Record Review of Resident #1's un-dated Care Plan indicated the resident was dependent on staff for all ADL needs, required total care including g-tube for nourishment, and was unable to communicate needs. The care plan reflected Resident #1 was NPO and was dependent on staff for all nutrition. Interventions included reporting to the physician, as needed, signs of malnutrition, weight loss, or significant weight loss. Further interventions were administering tube feeding and water flushes as ordered, checking tube placement per protocol, reporting to the physician any tube malfunction, and RD to evaluate quarterly and PRN. Review of Resident #1's physician orders, dated [DATE], reflected the following orders: -NPO (start date [DATE]) -Check g-tube placement prior to feeding and/or medication administration (start date [DATE]) -Document total intake Q shift to include formula and free water (start date [DATE]) -Flush g-tube with 40mL/hr for 22 hours per day (start date [DATE]) -Give [MEDICATION(S)] 1.5 at 45mL/hr for 22 hours per day (start day [DATE]) -Change g-tube feeding tubing with each close system administered (start date [DATE]) -Flush g-tube with 30mL of water before and after meds, flush with 10mL of water between meds (start date [DATE]) Review of Resident #1's February 2022 MARs reflected an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's [DATE] MARs reflected an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's [DATE] MARs reflected an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's hospital records dated [DATE] reflected Resident #1 was admitted to the hospital on [DATE]. Resident #1's admission labs at the hospital on [DATE] were: Sodium 157 H (normal ,d+[DATE]) and BUN 48 (normal ,d+[DATE]). A physician's note on [DATE] reflected her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The records also reflected a RD consult was requested for resumption of g-tube feedings and free water. Resident #1 was discharged back to the facility on [DATE]. In a telephone interview on [DATE] at 9:43 AM, RP #11 said she had concerns for Resident #1's care. She stated during Resident #1's most recent hospitalization on [DATE], she was diagnosed with severe dehydration. RP #11 said that was unacceptable because Resident #1 had a g-tube, and all nutrition and hydration was via the feeding tube and administered by the facility nurses. RP #11 said that was Resident #1's second hospitalization this year (2022) with dehydration. In an observation and interview on [DATE] at 12:44 PM, LVN D entered Resident #1's room. LVN D said she worked with Resident #1 on [DATE] on the 2 PM to 10PM shift. LVN D said Resident #1 was supposed to receive 40mL of water every hour. LVN D stated she would normally check the tube feeding pump settings every time she entered the room of a resident with a feeding pump. Upon observing Resident #1's feeding pump flush settings, LVN D said Oh, it's set to every 0 hours. LVN D stated she could not recall if that was the setting on [DATE]. LVN D said the 72-hour history displayed by the feeding pump could not be cleared or changed. LVN D then corrected the tube feeding pump settings to deliver 40mL of water ever 1 hour. In an observation, interview on [DATE] at 11:33 AM, Resident #1 was lying in bed. She had a feeding pump on a pole next to her bed running and connected to her g-tube. The tube feeding hanging on the pole was a [MEDICATION(S)] 1.5 bottle dated [DATE] but was not labeled with the time or initials of the person who set up the bottle. The tubing used in the pump was a spike set (type of pump tubing with a piercing spike for use with ready-to-hang/ closed system bottle) with a connected bag that contained approximately 900mL of a clear liquid. The bag was not labeled with content, date, time, or initials of who set it up. The settings on the feeding pump displayed the pump set to deliver feeding at 45mL per hours; the flush was set to deliver 40mL every zero hours. HHSC Surveyor intervened, asked LVN A was asked to come to Resident #1's room and to review of the 72-hour feeding pump history (maximum history). Resident #1's 72-hour feeding pump history from [DATE] to [DATE] with LVN A revealed Resident #1 had received 2442mL of feeding in the previous 72 hours zero mL of water in the previous 72 hours. LVN A stated he was the nurse assigned to Resident #1 that day, ([DATE]), for the 6 AM to 2PM shift. He stated he had not set up Resident #1's feeding on that day. LVN A stated he did not check pump settings during his shift, because that was the night nurses' responsibility. Upon observing Resident #1's flush was set to deliver 40mL every 0 hours, LVN stated he did not know if that was the correct setting and said it depended on the doctor's orders. Upon observing Resident #1 had not received any water via the feeding pump in the previous 72-hours, LVN A stated he did not believe the flush setting was correct because the pump should have been set to deliver the feeding and water hourly. LVN A stated Resident #1 needed the hourly water flush for hydration and if she did not receive it, she might be somewhat dehydrated. LVN A said he did not know if Resident #1 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . In a telephone interview on [DATE] at 7:58 AM, LVN C stated she was the nurse who worked with Resident #1 overnight on [DATE] and into [DATE]. LVN C stated she replaced Resident #1's formula bottle but she did not replace the tubing or the water (flush) bag because there was still about 800mL of water in the bag. LVN C said she did not check the pump settings when setting up new feedings. She stated she would place the pump on hold while replacing the formula bottle and then hit continue to resume the pump administration at the previous settings. In an observation and interview on [DATE] at 12:45 PM, the DON verified Resident #1 had not receive any water via the pump in the previous 72-hours. The DON said there was a discrepancy, she had fixed the order, and would get a new pump. The DON stated she expected the nurses to check the feeding pump settings every shift. In a telephone interview on [DATE] at 12:51 PM, MD I said she had not been notified Resident #1 had not received her hourly water flush the previous 72-hours but said one of her two NPs (NP J and NP K) may have been called. She stated when the nurse notified her, she would order STAT labs and IV fluids. MD I said if Resident #1 did not receive her ordered hourly water flush for 72-hours, her greatest concern would be for dehydration and said Resident #1 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . In a telephone interview on [DATE] at 12:54 PM, NP J said if Resident #1 did not receive her ordered hourly water flush could affect her overall clinical status and could lead to dehydration or constipation. NP J said she did not know if Resident #1 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . In a telephone interview on [DATE] at 12:57 PM, NP K said the facility nurses had not called her to notify her Resident #1 had not received her ordered hourly water flushes. NP K said there should not be a reason Resident #1 was not receiving her ordered hourly water. NP K said Resident #1 had last been admitted to the hospital with an electrolyte imbalance and dehydration. NP K said nurses should be checking the feeding pump settings at least every shift, every time the pump is turned on or off, and said that's a facility protocol. NP K said labs for Resident #1 needed to be drawn right away to check if she's dehydrated. In an interview on [DATE] at 1:43 PM, the DON stated when it was discovered Resident #1 had not received her ordered water for at least 72-hours the physician was notified right away. In an interview on [DATE] at 3PM, the Regional Nurse stated she notified MD I on [DATE] at 3:37 PM Resident #1 had not received the ordered water for at least 72-hours and received the order for STAT labs and IV fluids. Review of Resident #1's lab report dated [DATE] reflected the following: 1. [DATE]- Sodium 135 (normal ,d+[DATE]), BUN 29 (normal ,d+[DATE]) 2. [DATE]- Sodium 138 (normal ,d+[DATE]), BUN 21 (normal ,d+[DATE]) Review of Resident #1's lab report dated [DATE] reflected the following: 1. [DATE]- Sodium 135 (normal ,d+[DATE]), BUN 16 (normal ,d+[DATE]) 2. [DATE]- Sodium 142 (normal ,d+[DATE]), BUN 29 H (normal ,d+[DATE]) In a telephone interview on [DATE] at 9:49 AM, MD I said Resident #1 received IV fluids overnight and she had been notified of the STAT lab results. MD I said Resident #1's BUN was increased and that could happen if the resident gets less water. MD I said Resident #1's electrolytes [were] ok, and IV fluids could take care of the water loss. MD I said she planned to re-check Resident #1's labs on [DATE]. MD I said she ordered IV fluids for Resident #1 to prevent her from becoming significantly dehydrated, and she wanted her BUN down to or below lower level of 20. 2. Review of Resident #23's face sheet reflected he was an [AGE] year-old male admitted to the facility on [DATE]. His diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #23's MDS dated [DATE] reflected he had a BIMS score of 8 and indicated a moderately impaired cognitive status. His functional status reflected he required extensive assistance with bed mobility, transfers, eating, toilet use, personal hygiene, and he had an indwelling catheter. Review of Resident #23's care plans in the EHR on [DATE] reflected the Regional Nurse had created the following care plans on [DATE]: a. [Resident #23] has altered cardiovascular status related to [CONDITION(S)] b. [Resident #23] is on Anticoagulant therapy related to [CONDITION(S)] c. [Resident #23] is on diuretic therapy related to [CONDITION(S)] d. [Resident #23] has Essential tremors e. [Resident #23] has impaired circulation related to [CONDITION(S)] f. [Resident #23] has fluid overload or potential fluid volume overload r/t Disease process g. [Resident #23] has an ADL Self Care Performance Deficit r/t Impaired balance, Limited Mobility, tremors, cognitive impairment h. [Resident #23] has a code status of Full Code/CPR Review of Resident #23's [DATE] MARs reflected he received [MEDICATION(S)] 5mg once on [DATE] and twice from [DATE] to [DATE]. It was held on [DATE] and [DATE] and given twice on [DATE]. Review of Resident #23's progress notes from [DATE] until [DATE] in the EHR on [DATE] reflected the following: a. LVN HH documented on [DATE] at 8:18 PM: At around [7:22 PM], patient was admitted under the care of [MD I] , via a stretcher by EMS from [hospital]. Patient was [alert and oriented x 3] and was able to answer all questions . Foley catheter in situ [in its original place], patent and draining a yellow colored urine . b. LVN II documented on [DATE] at 3:31 AM: new admit alert x 3, able to verbalize needs know to staff, [respirations] even and [non-labored] no [shortness of breath] noted, bowel sound active in all 4 quad, denied pain, call light within reach, assist x 1 with ADLS needs. c. LVN D documented on [DATE] 7:53 PM: new admit day 2 under the care of [MD I] . very poor appetite need assistance with feeding . dressing and reposition . reposition every 2 [hour] . incontinence of care urine and stool . alert and oriented x1 . refused food this evening shift . nurse notified wife and she stated to this nurse to always encourage food and drink because resident will continue to refused and stated that resident need to sit on his [wheelchair]. d. LVN D documented on [DATE] at 9:49 PM: Resident hand shaking when eat Resident need Assistance with feeding all meals hand unable to drink water or eat on his own , hand shaking . e. LVN D documented on [DATE] at 10:35 PM: lab result back send to [MD I] no new order noted cbc cmp sent f. LVN BB documented on [DATE] at 3:52 PM: resident is stable and continues on antibiotic . dark colored urine in catheter . MD has been notified of urine color. g. LVN JJ documented on [DATE] at 2:55 PM: writer observed blood in patients foley catheter bag. patient has no complaints of pain or any recent trauma to private from what he remembers . [NP J] notified and will see patient today regarding so. h. Record review of NP J's note on [DATE] revealed she documented, .Patient presents with Foley catheter today is having some hematuria. Is awake and alert but appears tired Admit labs [DATE]: WBC 12.3, Hgb 8.4, NA 131, BUN 9, CR 0.65 . [DATE] Ordered stat CBC CMP and UA . ASSESSMENT AND PLAN hematuria: Flush Foley catheter, hold [MEDICATION(S)] for 2 days, follow-up labs to review CBC-UA order . i. LVN D documented on [DATE] at 10:40 PM: Order from [NP J] to start on [MEDICATION(S)] ,d+[DATE] bid and collect urine for a [urine analysis and culture and sensitivity] incoming nurse notify about urine. j. LVN JJ documented on [DATE] at 4:00 AM: Writer observed patient laying on right shoulder and back and legs on the bed, patient does not complain of any pain, no bruising noted, range of motion to upper extremities normal. when asked patient what happened he said he was reaching for his phone and accidently fell . MD notified of incident, DON notified, spouse also called but no answer, voicemail left regarding event. k. LVN BB documented on [DATE] at 9:46 AM: bruised found on right upper arm on the side of arm. Resident denies any pain . resident denies hitting his head. foley clean and w/o signs of tugging or infection . NP called with new orders and order for x ray. NP asked to be notified if urine is still the same after ordered normal saline IV given . l. LVN BB documented on [DATE] at 1:07 PM: Midline inserted per MD orders Administration of normal saline via IV has began at 75 ml/hr per MD orders . m. LVN BB documented on [DATE] at 2:35 PM: Resident continues on [oral] antibiotic for [CONDITION(S)] . per NP orders resident was given Potassium 40 mEq [oral] one time at 12 pm .Nurse reported NP orders to oncoming nurse. 20 Meq potassium will be given 2hr after . n. LVN JJ documented on [DATE] at 5:55 AM: patient on IV NS for hydration related to recent U/A , midline to right arm. resident has increased confusion, MD notified o. LVN JJ documented on [DATE] at 6:40 AM: patient has increased confusion, MD notified. IV NS running as ordered. midline to right arm p. ADON M documented on [DATE] at 8:17 AM: [MD I] notified of negative shoulder x ray. Wife also notified q. LVN BB documented on [DATE] 2:31 PM: resident is stable. currently continuing antibiotic [oral] . Resident midline is clean and free of signs of infection. Resident denies any pain to midline at this time. IV normal saline is being continued at 75 ml/hr for 72hr. first administration was ,d+[DATE]. Resident is tolerating fluids well. urine results and xray result from previous fall sent to Dr. Dr. sent over new orders for [MEDICATION(S)] [antibiotic] 500 [oral] daily for 7 days and Lactobacillus [probiotic] one tablet [oral] daily for 7 days . r. NP K documented on[DATE] at 8:29 PM: . [CONDITION(S)]/ Elevated WBC . referred by [MD I] for positive UA and elevated WBC . on [MEDICATION(S)] for DVT and was reported to have hematuria . Foley with mild hematuria . [CONDITION(S)]- UA positive, culture pending . started on [MEDICATION(S)] 500 mg po daily with probiotics for 7 days . Elevated WBC- WBC on [DATE] was 12.3, WBC on [DATE] is 8.0 . s. LVN D documented on [DATE] at 11:15 PM: Resident in bed continue with normal saline iv @75ml hr midline to right upper arm , no redness noted . no sign of infection noted at this time order from [MD I] to HOLD [MEDICATION(S)] x2 day. t. LVN C documented on [DATE] at 5:05 AM: . IV to right arm patent infusing NS@75cc/hour . [foley catheter] patent draining coffee-colored urine noted . u. ADON M documented on [DATE] at 5:55 AM: .noted with generalized weakness and requires assistance with feeding and adls. v. LVN KK documented on [DATE] at 10:55 PM: .noted with generalized weakness and requires assistance with feeding and adls. w. ADON M documented on [DATE] at 5:55 AM: .noted with generalized weakness and requires assistance with feeding and adls. Has Midline to L arm with NS running @ 75cc/hr. Residnt remains confused. [MD I] called and updated on resident's condition and no improvement x. ADON M documented on [DATE] at 6:07 PM: New orders received from [MD I] 20 meq of K+ now and 10 meq daily, NS @ 100ml/hr x 3 days, [foley catheter] flush for hematuria @ 200 cc BID. [MD I] has spoken to wife and son in regards to current treatment and plans, She has also started the palliative care conversation with them . y. LVN D documented on [DATE] at 10:43 PM: resident continue with IV normal saline 100ml/hr iv site to left arm clean. Foley cath flush as order . z. LVN II documented on [DATE] at 1:44 AM: resident continue IV normal saline @ 100ml/hr x 3days . aa. ADON M documented on [DATE] at 12:02 PM: Resident ate less than 50% of meal MD aware labs ordered and fluids are being encouraged. Wife and son are discussing palliative care bb. ADON M documented on [DATE] at 1:43 PM: Resident noted to have further decline. [NP J] in house and is evaluating resident at this time. cc. ADON M documented on [DATE] at 2:31 PM: Spoke to wife about decline and to let her know resident did not eat breakfast or lunch. Resident is getting IV fluids @ 100ml/hr for hydration. Wife provided Son's contact info and asked that resident be sent to hospital. [MD I] notified and [NP J] for [MD I] in house is aware as well. dd. LVN BB documented on [DATE] at 2:35 PM: resident has increased confusion. He is not eating nor drinking. Resident is alert x 1 only can state his name. his urine is dark red. He continues IV NS 75ml for 72hr. Resident continues to ramble and he is very lethargic. [vital signs within normal limits] and he is unable to communicate to the staff. Doctor, family and ADON has been has been notified ee. ADON M documented on [DATE] at 3:17 PM: Resident was sent to [hospital] Wife followed. [MD I] called to find out which hospital resident went to. She states she will follow up with son ff. LVN BB documented on [DATE] at 10:39 PM: Resident sent to [hospital] via ambulance per doctor's order @ [2PM] today. Adon was notified and assist in the transfer of the resident. Family member has been notified. Review of Resident #23's hospital records dated [DATE] reflected he was hospitalized from [DATE] to [DATE]. He was diagnosed with gross hematuria, dehydration, acute blood [CONDITION(S)], acute GI bleed, lumbar spine infection, essential tremors, and [CONDITION(S)]. On admission his labs were: WBC 8.2 (normal, 4.,d+[DATE].0), RBC 2.8 (low, normal 4.,d+[DATE].1), hemoglobin 8.3(low, normal 13.,d+[DATE].2), and hematocrit 25.3 (low, normal ,d+[DATE]). He was given one blood transfusion and IV iron supplements. Discharge instructions included a dose decrease of [MEDICATION(S)] from 5mg twice a day to 2.5mg twice a day. An interview and observation on [DATE] at 2:40 PM revealed Resident #23 was lying in bed. He said he was hospitalized last month but did not recall the events leading to his hospitalization s. Resident #23 said he had a foley catheter prior to his hospitalization but did not recall what his urine looked like. He said the facility staff were giving him a lot of fluids to drink and also inserted an IV for fluids. In an interview on [DATE] at 12PM, LVN BB stated she had not worked with Resident #23 since his re-admission from the hospital on [DATE], but said he was eating much better, I see him out in the hallway, and he talks to me and we have conversations. LVN BB said Resident #23 was no longer confused. LVN BB said she was instructed to use the messaging system on a tablet to communicate with the providers. LVN BB stated anytime she documented MD notified it indicated she sent a text message to the provider in the messaging system. LVN BB said she did not have the NPs telephone numbers until a couple of weeks ago when they had provided their numbers to her. LVN BB stated she currently did not have the telephone number for MD I or any of the other physicians. LVN BB said if she needed to notify a provider of anything urgent, she would have notified the ADON. LVN BB said if an ADON was not around, she would notify the DON. LVN BB said Resident #23 was admitted from the hospital on [DATE] with blood in his urine and she did not know if that was a regular thing for him. LVN BB said she was the nurse who got [Resident #23] sent out [to the hospital] on [DATE]. She said she was concerned because his urine color was not changing despite ordered interventions, by NP J, including flushing his foley catheter, antibiotics, and IV fluids. She stated he had increased confusion and he wasn't looking. His demeanor, he just seemed off. He was more tired than normal; he was eating less. [ADON M] got the order from the doctor to send him. In an interview on [DATE] at 12:23 PM, ADON M nurses communicated with providers with an application on a tablet. ADON M said if a resident had a change of condition or emergency, nurses should immediately pick up the phone and call the NP or MD, whoever answers. ADON M said in addition to documenting a provider was notified, nurses should document anything the doctor told them to do. ADON M said nurses should have followed-up and documented on Resident #23's hematuria [blood in urine] and eating every shift until it resolved. ADON M said she notified MD I on [DATE] that Resident #23 was declining, and she knew MD I was going to visit [Resident #23]. She stated she did not believe MD I gave any orders, just continue to monitor. ADON M said in order to review what the NPs and MDs were notified of regarding Resident #23, We would have to go back on the [tablet] to see what was actually put in there. In a telephone interview on [DATE] at 11:30 AM, LVN JJ said he was an agency nurse who started working at the facility around [DATE], and only worked a few times before he was hired on as a staff nurse at the facility in [DATE]. He said he recalled on [DATE] one of the CNAs or therapy told him Resident #23 had dark, coffee colored blood in his urine. LVN JJ said Resident #23 was stable at the time and right away I notified the NP about it. LVN JJ said he could not recall how he notified the NP, if it was via phone or the tablet messaging system and he stated he could not recall what instructions she gave him. LVN JJ said he did not receive training at the facility on physician notification. LVN JJ said there were hard copies of the 24-hour nursing reports that were used when giving report to the oncoming shift as a quick reference tool on everything going on with a resident such as new orders, labs, and falls. In a telephone interview on [DATE] at 3:58PM, LVN C said she did not call the provider when she noted Resident #23 had coffee colored urine on [DATE] at 5:05 AM because she was told by another nurse that his urine had looked like that since he was admitted . In an interview on [DATE] at 12:11 PM, RN V said she had worked at the facility since [DATE]. She said she was trained on notifying the physician about 2 weeks ago. She said the training included the numbers of the providers. RN V said she would consider blood in urine a change in condition. RN V said when she needed to speak to a provider she would Usually .text them first and ask if it's ok for me to call them, if they say yes then I'll call them. If it's really urgent, then I'll call them. RN V said when she received the training for physician notification, she was handed a binder full of in-services and she was told here, sign-it. In an interview on [DATE] at 12:45 PM, LVN BB said she had worked at the facility for one month. She stated she first learned the process for physician notification on [DATE] when she was in-serviced on the policies. LVN BB said she started contacting the NPs via telephone a couple of weeks ago when they provided her with their telephone numbers. She said she was notified on [DATE] of a resource binder which included MD I's telephone number as well and the facility also added attending physician's telephone number to the residents' face sheets. LVN BB said at the time Resident #23 had his change in condition, the facility nurses were using the tablet to communicate with the providers. LVN BB said the providers could also communicate back with the nurses to give orders or instructions but they would need to check the tablet to see if the provider had responded. LVN BB said she was not aware how many tablets there were in the facility but it was common nurses would need to go find a tablet to communicate with a provider. LVN BB said the 24-hour nursing report included everything you need to know about that particular patient. Med changes, change in mental status, new orders, new labs, arguments between roommates, or discharges. LVN BB said the 24-hour nursing report usually matched the residents' EHR. In an interview on [DATE] at 1:43 PM, the DON stated all nurses, including agency nurses were trained on how and when to notify the doctor. The DON stated there was a tablet which included an app for communication with the providers via a text message. She stated a phone call to the provider would be required for significant changes like a critical lab, but stated the messaging system was used for routine things. The DON said the doctor should have asked the nurse on [DATE] if the resident was on any anti-coagulants and asked Why didn't the doctor give the nurse the order to hold the anti-coagulant when she was first notified on [DATE]? The nurse can't be responsible for remembering everything. In an interview on [DATE] at 3PM, the Regional Nurse stated it was her expectation the nurse notifies a NP or MD if a Resident had a change in condition and notification could be made anytime during their shift. The Regional Nurse stated she was not familiar with the messaging system being used for communication with the providers. The Regional Nurse said it was acceptable for a nurse to notify the MD or NP of a change of condition because she would expect to get the same answer, whether communicating with a NP or an MD. The Regional Nurse stated nurses should document any communication with the provider in a note. In an interview on [DATE] at 10:39 AM, NP J said recently there had been issues with communication between the floor nurses and the providers and because of that, she communicated primarily with the ADONs and the DON. NP J said the tablet messaging system was a work in process and the communication is always a work in process. NP J said typically, the nurses contact us directly, because we want to know in real time what's going on with the resident. NP J said when the nurses communicated with her with the tablet, she would receive messages on her work phone. She said recently that process stopped .because there was an issue with responding back directly, not knowing who is communicating on the other end and moved to communicating with ADON and DON. NP J said providers would have to ask who was contacting them, and they would not know which nurse they gave orders to. In an interview on [DATE] at 11:07 AM, ADON M said they no longer used the tablet messaging system because they discovered issues with messages from the providers not being received by the nurses. ADON M said she had been trained on physician notification and stated she was no longer allowed to take order from NP, only MD. ADON M did not know of specific time frames for notification of the physician regarding emergent and non-emergent situations. She stated she received the training on physician notification on [DATE] and stated if a nurse could not reach a physician, she should pass it on to the next shift. In a telephone interview on [DATE] at 1PM, MD I, who was also the facility's medical director, stated it was reasonable that a provider be notified there was a significant change in the resident's physical status or a need to alter treatment significantly within 24 hours. MD I said she spoke with Resident #23's son and wife prior to his hospitalization on [DATE] and they wer [TRUNCATED]

Based on observation, interview, and record review, the facility failed to ensure [MEDICATION(S)] fluids were administered consistent with professional standards for 2 (Resident #20 and #22) of 4 residents reviewed for intravenous fluids. The facility failed to obtain physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . This resulted in Resident #20's PICC line dressing becoming dislodged and not being replaced from 03/18/22 until HHSC Surveyor intervened on 04/29/22. An Immediate Jeopardy (IJ) was identified during the administrative review process, it was determined that an IJ existed from 04/29/22 to 05/27/22. The ADM, DON, and the Regional Nurse were notified on 05/24/22 5:50 PM of the IJ and a POR was requested. While the IJ was removed on 05/26/22 at 5:38 PM, the facility remained out of compliance at a scope of pattern at the severity level of potential harm that is not immediate jeopardy due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. These failures could affect residents with CVCs by placing them at risk for infections such as [CONDITION(S)], complications with blockage or restrictive access, dislodgement, hospitalization , or death. Findings included: Review of Resident #20's face sheet dated 04/29/22 reflected she was an [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #20's Order Summary Report dated 04/29/22 reflected an order on 03/21/22 to admit the resident to the facility for right upper arm abscess and [CONDITION(S)] (infection in the bone). On 04/29/22, orders were entered for IV tubing change, monitoring of PICC line site, PICC line flushes, or PICC line dressing changes. There were no orders, prior 04/29/22, for IV tubing change, monitoring of PICC line site, PICC line flushes, or PICC line dressing changes. Review of Resident #20's March 2022 MARs reflected [MEDICATION(S)] (antibiotic) 2G given IV every 8 hours for bacteria causing infection ordered on 03/22/22 through 04/29/22. Review of Resident #20's care plans dated with admitted [DATE] reflected there was not a care plan for the care and management of Resident #20's PICC line. An observation and interview on 04/29/22 at 11:08 AM revealed Resident #20 sat in a recliner in her room and there was an IV pole next to the recliner. Resident #20 had a PICC line to her left upper, inner arm. The dressing over the PICC line was dated 03/18/22 and all four edges of the dressing were off Resident #20's skin. There was not a Bio-patch (anti-microbial IV dressing) over the PICC line insertion site leaving the site open air. There was not any redness or swelling noted to the PICC line insertions site. Resident #20 said the dressing to her PICC line had not been changed since she returned from the hospital. In an observation and interview on 04/29/22 at 11:25AM, LVN T said she was an agency nurse and that day was her first shift working at the facility. LVN T said the date on Resident #20's PICC line dressing was 03/18/22 and she had just notified ADON N. LVN T said PICC line dressings were to be changed every 7 days or as needed if they were soiled or dislodged. LVN T said Resident #20's PICC line dressing was peeling off but LVNs were not typically allowed to change PICC line dressing. LVN T said Resident #20 did not have orders to flush her PICC line, monitor the PICC line site, or change the PICC line dressing. LVN T said she flushed Resident #20's PICC line with 10mL of NS before and after she administered her IV antibiotics. LVN T said if a resident's PICC line dressing was not routinely changed it could cause infections. In an interview on 04/29/22 at 11:28 AM, ADON N said it was the IP Nurse's responsibility to change PICC line dressings. In an interview and observation on 04/29/22 at 11:38 AM, the DON observed Resident #20's PICC line dressing and stated the date on the dressing was 03/18/22. The DON said the dressing needed to be changed because it was off Resident #20's skin. The DON said PICC line dressings should be immediately changed if compromised, or routinely every 48-72 hours. She stated she would get a nurse to change Resident #20's PICC line dressing right away. HHSC Surveyor requested all trainings and skills checkoffs completed with the nurses on IVs and PICC lines. In an interview on 04/29/22 at 12:03 PM, RN V said she was the facility's IP Nurse and had worked at the facility for 2 months. RN V said she was aware Resident #20 was receiving IV antibiotics and had a PICC since March but could not recall the exact date. RN V said PICC line dressings should be changed at a frequency ordered by the physician and could only be changed by an RN. RN V said any RN could change the PICC line dressings and she had not been told it was her responsibility. RN V said since Resident #20 did not have any physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . RN V said if a PICC line dressing was not routinely changed or changed when it was dislodged it could lead to another infection or another complication like [CONDITION(S)]. RN V said it was the ADONs responsibility to make sure there was an order to care for the PICC line. RN V said she replaced Resident #20's PICC line dressing after she was instructed to do so by the DON on 04/29/22. In an interview on 04/29/22 at 1:35 PM, RN W said he was an agency nurse who worked at the facility on a PRN basis. RN W said he worked with Resident #20 on 04/28/22 and he thought he administered her antibiotics. RN W said Resident #20 had a PICC line to her left upper arm which he observed on 04/28/22 and said her PICC line dressing was dated, but he did not remember the date. RN W said he flushed Resident #20's PICC line with 10mL of NS before and after her IV antibiotics. RN W said he did not remember if he looked up the orders for the care of Resident #20's PICC line, but it normally residents with PICC lines had orders to flush their PICC lines with 10mL of NS before and after antibiotics. RN W said PICC line dressings should be changed weekly, and usually when the doctor gave an order for [MEDICAL RECORD OR PHYSICIAN ORDER] In an interview on 04/29/22 at 2:02 PM, LVN D said she had worked with Resident #20 last week. She said Resident #20 had a PICC line for antibiotics due to an infection to her right arm. LVN D said she administered Resident #20's IV antibiotics when she worked with her and flushed her PICC line with 10mL of NS before and after the antibiotics. LVN D said she did not monitor Resident #20's PICC line site and she did not look for the orders for the management of Resident #20's PICC line. LVN D said PICC line dressings should be changed every 7 days, and LVNs were able to change PICC line dressings. LVN D said the care for PICC lines was important because line went to the heart, so if it became infected it could be very dangerous for the resident. HHSC Surveyor attempted to interview LVN AA, Resident #20's admitting nurse, on 04/29/22 at 3:20 PM but was unsuccessful in making telephone contact. HHSC Surveyor attempted to interview MD Y, Resident #20's physician, on 04/29/22 at 3:23 PM but was unsuccessful in making telephone contact. Review of Resident #22's face sheet dated 05/24/22 reflected he was a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . 2. Review of Resident #22's admission MDS dated [DATE] reflected he had a BIMS score of 14, and indicated he was cognitively intact. Review of Resident #22's May 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #22's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #22's daily skilled nurses notes reflected: 1. On 05/17/22 at 5PM ADON M assessed Resident #22. Her assessment reflected Resident #22 had an IV line for [MEDICATION(S)] . Her assessment did not indicate Resident #22 had a PICC line, the PICC line site, or an assessment of the PICC line site or dressing. 2. On 05/18/22 at 3PM RN W assessed Resident #22. His assessment reflected Resident #22 was on [MEDICATION(S)] and [MEDICATION(S)] for a wound but did not include mention of a PICC line nor an assessment of the PICC line site and dressing. 3. On 05/19/22 at 3PM RN W assessed Resident #22. His assessment reflected Resident #22 was on IV antibiotics but did not include mention of a PICC line nor an assessment of the PICC line site and dressing. 4. On 05/20/22 at 2AM, LVN BB assessed Resident #22. Her assessment reflected Resident #22 was on IV antibiotics and he had a midline which was flushed every shift before and after the IV antibiotics. Her assessment reflected there were no signs or symptoms of infection to Resident #22's midline but did not mention an assessment of the midline dressing. 5. On 05/21/22 there was not a daily skilled assessment completed. This was verified on 05/27/22 at 11:20 AM in the EHR. 6. On 05/22/22 at 11 AM, LVN CC assessed Resident #22. Her assessment reflected Resident #22 had a midline to his right arm with no signs of infection but did not mention an assessment of the midline dressing. In an interview and observation on 05/24/22 at 9:30 AM, Resident #22 was lying in bed and was awake and alert. He had a PICC line to his right upper arm. The dressing was clean, dry, intact, and dated 05/24/22. Resident #22 stated the dressing to his PICC line had been changed 20 minutes ago, on 05/24/22 at 9:10AM. Resident #22 stated the PICC line was for IV antibiotics to treat an infected wound. Review of Resident #22's EHR on 05/24/22 at 10AM reflected he did not have an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #22's baseline care plan reflected the section for IV therapy which should have included documentation of IV location, fluids, labs, and dressing was blank. In an interview and observation on 05/24/22 at 12:23 PM, ADON M said Resident #22 was admitted with a PICC line to his right upper arm and orders for care of his PICC line should be in the EHR. She stated orders should include flushing before and after IV antibiotic, PICC line dressing changes every 7 days and PRN, and monitoring the PICC line site every shift. ADON M said the admitting nurse was responsible for putting those orders into the EHR. ADON reviewed Resident #22's orders in his EHR and she said she did not see an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . In an interview on 05/25/22 at 12:11 PM, RN V stated she changed Resident #22's PICC line dressing on 05/24/22 because it was due for changing. RN V said she knew the PICC line dressing was due for changing because she knew the date of the old dressing when it was discussed in the daily morning clinical meeting and because ADON M asked her on 05/24/22 to replaced Resident #22's PICC line dressing. RN V said it was the facility's policy that only an RN could change a PICC line dressing. RN V stated she looked at Resident #22's orders prior to changing PICC line dressing and when she noted Resident #22 did not have an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . RN V said if she completed a procedure without a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . RN V stated she should have called the doctor to obtain an order prior to changing Resident #22's PICC line dressing. RN V said she received an in-service regarding PICC line dressings but could not recall on which date she was handed a binder full of in-services and was told here, sign-it. In a telephone interview on 05/24/22 at 1PM, MD I said if PICC line dressing changes were not completed every 7 days or when the dressing became compromised, the resident would be predisposed for infection. In an interview on 04/29/22 at 5:05 PM, the DON said the admitting nurse was responsible for obtaining orders for care when a resident was admitted with a PICC line. The DON said LVNs, or RNs could change PICC line dressings. The DON said if a PICC line dressing was not routinely changed or not changed when compromised it may cause infection. Record review of the facility's policy Midline Dressing Changes dated April 2016 reflected the purpose the procedure was to prevent catheter-related infections associated with contaminated, loosened, or soiled catheter-site dressings. Change midline catheter dressings 24 hours after catheter insertion, every 7-10 days, or if wet, dirty, not intact, or compromised in any way. Verify with the state Nurse Practice Act as to LPN [LVN]/RN scope of practice . Review of the facility's policy Care and Maintenance of Peripherally Inserted Central Catheter (PICC) and Central Line undated skills check-off reflected: . Nurse reviews physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Assessed need for irrigation and dressing change . According to the Center for Disease Control (CDC) accessed from https://www.cdc.gov/hai/bsi/catheter_faqs.html indicated a central venous catheter is a tube placed in a large vein in the neck, chest, groin, or arm to give fluids, blood, or medications or to do medical tests quickly. These long, flexible catheters empty out in or near the heart, allowing the catheter to give the needed treatment within seconds. According to the American Nurse Today (journal of the American Nurses Association) article, Providing optimal care for patients with central catheters, dated 05/11/14, accessed from https://www.americannursetoday.com/providing-optimal-care-for-patients-with-central-catheters/ indicated care and maintenance of central venous catheters requires vigilance and attention to detail to prevent complications and maintain patency. The article revealed more than 80% of bloodstream infections are linked to vascular access devices and 50% of these infections are preventable. The article indicated dressings at the insertion site help protect the catheter and transparent dressings should be changed every 7 days and gauze dressings every 48 hours. The article also revealed the catheter must be flushed to maintain patency, and failure to maintain patency could lead to occlusion, malfunction, and infection. The article indicated all central catheters should be flushed with normal saline solution before and after medication administration and additional flushing should be based on the facility's guidelines. According to the article competent, confident central-catheter care and maintenance can help prevent dangerous complications that imperil a patient's life. According to the Center for Disease Control and Prevention's Guidelines for the Prevention of Intravascular Catheter-Related Infections, updated 02/2017, accessed from https://www.cdc.gov/infectioncontrol/guidelines/bsi/recommendations.html, indicated catheter sites should be monitored visually when the dressing is changed and by palpation through an intact dressing on a regular basis, depending on the clinical situation of the individual patient. The guidelines indicated needleless components should be changed based on the facility's determination or according to the manufactures' recommendations. The guidelines also reflected a facility should: educate healthcare personnel regarding the indications for intravascular catheter use, proper procedures for the insertion and maintenance of intravascular catheters, and appropriate infection control measures to prevent intravascular catheter-related infections. Periodically assess knowledge of and adherence to guidelines for all personnel involved in the insertion and maintenance of intravascular catheters. Designate only trained personnel who demonstrate competence for the insertion and maintenance of peripheral and central intravascular catheters . Central venous catheters-Weigh the risks and benefits of placing a central venous device at a recommended site to reduce infectious complications against the risk for mechanical complications (e.g., pneumothorax, [MEDICATION(S)] artery puncture, [MEDICATION(S)] vein laceration, [MEDICATION(S)] vein stenosis, hemothorax, [CONDITION(S)], air embolism, and catheter misplacement) . Use either sterile gauze or sterile, transparent, semipermeable dressing to cover the catheter site . Replace catheter site dressing if the dressing becomes damp, loosened, or visibly soiled . Do not submerge the catheter or catheter site in water. Showering should be permitted if precautions can be taken to reduce the likelihood of introducing organisms into the catheter. An Immediate Jeopardy (IJ) situation was identified on 05/24/22 5:50 PM. The ADM, DON, and the Regional Nurse were notified, and a POR was requested. While the IJ was removed on , the facility remained out of compliance at a scope of pattern at the severity level of potential harm that is not immediate jeopardy due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. The facility's Plan of Removal was accepted on 05/25/22 at 4:42PM and included: [Facility] submits the following Plan of Removal for the alleged failure too obtain proper orders and care plans for PICC lines. By submitting this plan of removal [Facility] does not admit to the accuracy of the alleged deficient practice. What corrective actions have been implemented for the identified residents? 1. The following action items were implemented immediately on 4/29/22. a. Resident #21 . was immediately assessed on 4/29/22 by the Director of Nursing, and DON changed the dressing. No adverse effects to the resident were noted during the assessment by Director of Nursing. b. All resident's with IV's were assessed by Assistant Director of Nurses, and Director of Nursing on 4/29/22 to ensure all dressing were appropriately changed and dated. No discrepancies were identified in the completed audit. c. Resident #22 . IV site was assessed by Infection Control Nurse, on 5/24/22 and no adverse effects were noted during the assessment. d. Assistant Director of Nursing transcribed all appropriate orders and care plan for PICC line dressing changes, monitoring, and IV tubing on 5/24/22. Director of Nursing verified that all batch orders and Interim plan of care were in place 5/24/22 for the PICC line on Resident #22 . e. An audit was completed on 5/24/22 by the Director of Nursing and Clinical Services Director on all residents with PICC lines to ensure all had appropriate orders and baseline care plans for the dressing changes, monitoring, and IV tubing changes. No missing orders or care plans were identified in the audit completed on 5/24/22. What does the facility need to change immediately to keep residents safe and ensure it does not happen again? a. On 4/29/22 Corporate Clinical Services Director in-serviced the DON and nurse managers on assessing the patients dressing changes to ensure they are intact and changed according to the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . DON and nurse managers Nurses completed return demonstration to the trainees of the information provided to then in the in-service to verify their understanding. b. An in-service was initiated on 4/29/22, by the Infection Control Nurse with all nursing staff on assessing the patients dressing changes to ensure they are intact and changed according to the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . c. Each charge nurse was in-service and checked off on dressing changes prior to working their shift by Infection Control Nurse Director of Nursing or an Assistant Director of Nursing. d. An in-service was initiated by Infection Control Nurse Director of Nursing or an Assistant Director of Nursing on 5/24/22 on ensuring orders are in place for PICC lines and that baseline care plans are in place for PICC line dressing changes, monitoring, or IV tubing changes. Nurses completed return demonstration to the trainees of the information provided to then in the in-service to verify their understanding. e. Each charge nurse will be in-serviced and return demonstration of PICC line orders and base line care plans prior to working their shift by Infection Control Nurse Director of Nursing or an Assistant Director of. How will the system be monitored to ensure compliance? f. Dressing changes will be visualized daily by Infection Control Nurse, Treatment Nurses, Director of Nursing, or an Assistant Director of Nursing to ensure they have been properly assessed and changed according to the physician orders. Discrepancies noted during reviews will be immediately corrected by person who identified the discrepancy changing the dressing according to the physician order. Further training will be provided as identified by nurse manager who identified the discrepancy when and if necessary. g. order listing report will be reviewed daily to ensure that all new PICC lines have orders and baseline care plans for PICC line dressing changes, monitoring, or IV tubing changes on a daily basis by Infection Control Nurse, Treatment Nurses, Director of Nursing, or an Assistant Director of Nursing. Discrepancies noted during reviews will be immediately corrected by obtaining and following through appropriate PICC orders and base line care plan for PICC by the individual who identified the discrepancy. Further training will be provided as identified by nurse manager who identified the discrepancy when and if necessary. h. The DON/designee will review 24 hour report to ensure nurses document appropriate notification to the attending physician 2x week X 6 weeks. Review will be documented on an audit report form. f. Administrator will review the audit reports on a weekly basis to ensure nurse managers are following the plan of correction for six weeks. Review will be documented on an audit report form. Quality Assurance An impromptu Quality Assurance and Performance Improvement review of the plan of removal was completed on 5/24/22 with the Medical Director. The Medical Director has reviewed and agrees with this plan. Monitoring of the POR included: An interview on 05/26/22 at 1:05 PM, revealed ADON N was in-serviced on PICC lines by the Regional Nurse on 05/25/22. She was knowledgeable regarding the care and requirements when caring for a resident with a PICC line and regarding her responsibilities in implementing the POR. An interview on 05/26/22 at 1:10 PM with LVN DD revealed she was an agency nurse on her first shift working at the facility. She had been in-serviced on PICC lines and was knowledgeable regarding the care and requirements when caring for a resident with a PICC line. An interview on 05/26/22 at 1:15PM with LVN EE revealed she was a facility nurse who had worked at the facility for 8 years. She worked the 6AM to 2PM, and 2PM to 10PM shifts. She had been in-serviced on PICC lines and was knowledgeable regarding the care and requirements when caring for a resident with a PICC line. An interview on 05/26/22 at 1:33 PM, revealed LVN L was in-serviced on PICC lines on 05/25/22. She was knowledgeable regarding the care and requirements when caring for a resident with a PICC line. An interview on 05/26/22 at 3:03 PM, revealed LVN B was a facility nurse who worked the evening and night shifts. He stated he was in-serviced on PICC lines on 05/25/22. She was knowledgeable regarding the care and requirements when caring for a resident with a PICC line. An interview on 05/26/22 at 3:20 PM, revealed LVN D was a facility nurse who worked the morning and evening shifts. She stated he was in-serviced on PICC lines on 05/25/22. She was knowledgeable regarding the care and requirements when caring for a resident with a PICC line. An observation and record review on 05/26/22 at 1:30 PM revealed Resident # 22 was lying in bed awake and alert. The dressing to his right upper arm PICC line was clean, dry, intact, and dated 05/24/22. There was not any redness, swelling, or drainage to the PICC line insertion site. Resident #22 denied pain. Record review of Resident #22's orders in the EHR reflected he had orders for PICC line care and management. An observation on 05/26/22 at 1:38PM revealed Resident #24 was in his room sitting in his wheelchair. He had a PICC line to his left upper arm. The dressing was clean, dry, intact, and dated 05/26/22. There was not any redness, swelling, or drainage to the PICC line insertion site. Resident #24 denied pain. Record review of Resident #24's orders in the EHR reflected he had orders for PICC line care and management. An interview on 05/26/22 at 1:45 PM with LVN FF revealed she was an agency nurse on her first shift working at the facility. She had been in-serviced on PICC lines and was knowledgeable regarding the care and requirements when caring for a resident with a PICC line. A telephone interview on 05/26/22 at 4:09 PM with LVN GG revealed she was an agency nurse who worked double weekends. She had been in-serviced on PICC lines and was knowledgeable regarding the care and requirements when caring for a resident with a PICC line. An interview on 05/26/22 at 5:26 PM with the DON revealed she was in-serviced on PICC lines by the Regional Nurse on 05/24/22. She was knowledgeable regarding the care and requirements when caring for a resident with a PICC line and regarding her responsibilities in implementing the POR. An Immediate Jeopardy (IJ) situation was identified on 05/24/22 5:50 PM. The ADM, DON, and the Regional Nurse were notified, and a POR was requested. On 05/26/22 at 5:38 PM, the ADM, the DON, the Regional Nurse, the VP of Clinical Operations, and the Regional IP Nurse were notified that the IJ was removed. While the IJ was removed on 05/26/22 at 5:38 PM, the facility remained out of compliance at a scope of pattern at the severity level of potential harm that is not immediate jeopardy due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems.

Based on observation, interview, and record review the facility failed to ensure residents who are fed by enteral means receives the appropriate treatment and services to prevent complications of enteral feeding including but not limited dehydration and metabolic abnormalities for 3 (Resident #1, #2, and #3) of 5 residents reviewed for enteral feedings. The facility failed to administer adequate amounts of free water to Residents #1, #2, and #3 via their g-tubes. This resulted in: 1. Resident #1 being hospitalized from 03/10/22 to 03/18/22 with [CONDITION(S)] (high sodium level of 157, normal 135-145) likely due to dehydration per the hospital report. 2. Resident #2 being hospitalized from 02/28/22 to 03/07/22 with [CONDITION(S)] due to lack of free water per the hospital report. 3. Resident #3 having elevated BUNs (indicating dehydration) and RD recommendations not being implemented. An Immediate Jeopardy (IJ) situation was identified on 04/27/22 at 3:20 PM. While the IJ was removed 04/29/22 at 5:29 PM, the facility remained out of compliance at actual harm that was not immediate jeopardy with a scope identified as a pattern, due to the facility's need to complete in-service training and evaluate the effectiveness of corrective systems. These failures could affect residents who are dependent on g-tubes and lead to complications of enteral feeding including but not limited to dehydration, metabolic abnormalities, hospitalization s, and death. Findings included: 1.Record Review of Resident #1's face sheet dated 04/26/22 reflected she was a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record Review of Resident #1's quarterly MDS dated [DATE] indicated the resident had a severe cognitive impairment. The resident had a g-tube and received more than 51% of nutrition and hydration via the g-tube. Record Review of Resident #1's un-dated Care Plan indicated the resident was dependent on staff for all ADL needs, required total care including g-tube for nourishment, and was unable to communicate needs. The care plan reflected Resident #1 was NPO and was dependent on staff for all nutrition. Interventions included reporting to the physician, as needed, signs of malnutrition, weight loss, or significant weight loss. Further interventions were administering tube feeding and water flushes as ordered, checking tube placement per protocol, reporting to the physician any tube malfunction, and RD to evaluate quarterly and PRN. Review of Resident #1's physician orders, dated 04/26/22, reflected the following orders: -NPO (start date 03/28/22) -Check g-tube placement prior to feeding and/or medication administration (start date 03/25/22) -Document total intake Q shift to include formula and free water (start date 03/28/22) -Flush g-tube with 40mL/hr for 22 hours per day (start date 03/28/22) -Give [MEDICATION(S)] 1.5 at 45mL/hr for 22 hours per day (start day 03/25/22) -Change g-tube feeding tubing with each close system administered (start date 03/25/22) -Flush g-tube with 30mL of water before and after meds, flush with 10mL of water between meds (start date 03/25/22) Review of Resident #1's February 2022 MARs reflected an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's March 2022 MARs reflected an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's APRIL 2022 MARs reflected an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's hospital records dated 03/17/22 reflected Resident #1 was admitted to the hospital on 03/10/22. Resident #1's admission labs at the hospital on 03/10/22 were: Sodium 157 H (normal 135-145) and BUN 48 (normal 3-23). A physician's note on 03/17/22 reflected her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The records also reflected a RD consult was requested for resumption of g-tube feedings and free water. Resident #1 was discharged back to the facility on [DATE]. In a telephone interview on 04/26/22 at 9:43 AM, RP #11 said she had concerns for Resident #1's care. She stated during Resident #1's most recent hospitalization on [DATE], she was diagnosed with severe dehydration. RP #11 said that was unacceptable because Resident #1 had a g-tube, and all nutrition and hydration was via the feeding tube and administered by the facility nurses. RP #11 said that was Resident #1's second hospitalization this year (2022) with dehydration. In an observation and interview on 04/26/22 at 12:44 PM, LVN D entered Resident #1's room. LVN D said she worked with Resident #1 on 04/25/22 on the 2 PM to 10PM shift. LVN D said Resident #1 was supposed to receive 40mL of water every hour. LVN D stated she would normally check the tube feeding pump settings every time she entered the room of a resident with a feeding pump. Upon observing Resident #1's feeding pump flush settings, LVN D said Oh, it's set to every 0 hours. LVN D stated she could not recall if that was the setting on 04/25/22. LVN D said the 72-hour history displayed by the feeding pump could not be cleared or changed. LVN D then corrected the tube feeding pump settings to deliver 40mL of water ever 1 hour. In an observation, interview on 04/26/22 at 11:33 AM, Resident #1 was lying in bed. She had a feeding pump on a pole next to her bed running and connected to her g-tube. The tube feeding hanging on the pole was a [MEDICATION(S)] 1.5 bottle dated 04/26/22 but was not labeled with the time or initials of the person who set up the bottle. The tubing used in the pump was a spike set with a connected bag that contained approximately 900mL of a clear liquid. The bag was not labeled with content, date, time, or initials of who set it up. The settings on the feeding pump displayed the pump set to deliver feeding at 45mL per hours; the flush was set to deliver 40mL every zero hours. HHSC Surveyor intervened, asked LVN A was asked to come to Resident #1's room and to review the 72-hour feeding pump history (maximum history). Resident #1's 72-hour feeding pump history from 04/23/22 to 04/26/22 with LVN A revealed Resident #1 had received 2442mL of feeding in the previous 72 hours zero mL of water in the previous 72 hours. LVN A stated he was the nurse assigned to Resident #1 that day, (04/26/22), for the 6 AM to 2PM shift. He stated he had not set up Resident #1's feeding on that day. LVN A stated he did not check pump settings during his shift, because that was the night nurses' responsibility. Upon observing Resident #1's flush was set to deliver 40mL every 0 hours, LVN A stated he did not know if that was the correct setting and said it depended on the doctor's orders. Upon observing Resident #1 had not received any water via the feeding pump in the previous 72-hours, LVN A stated he did not believe the flush setting was correct because the pump should have been set to deliver the feeding and water hourly. LVN A stated Resident #1 needed the hourly water flush for hydration and if she did not receive it, she might be somewhat dehydrated. LVN A said he did not know if Resident #1 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . In a telephone interview on 04/27/22 at 7:58 AM, LVN C stated she was the nurse who worked with Resident #1 overnight on 04/25/22 and into 04/26/22. LVN C stated she replaced Resident #1's formula bottle, but she did not replace the tubing or the water (flush) bag because there was still about 800mL of water in the bag. LVN C said she did not check the pump settings when setting up new feedings. She stated she would place the pump on hold while replacing the formula bottle and then hit continue to resume the pump administration at the previous settings. In an observation and interview on 04/26/22 at 12:45 PM, the DON verified Resident #1 had not receive any water via the pump in the previous 72-hours. The DON said there was a discrepancy, she had fixed the order, and would get a new pump. The DON stated she expected the nurses to check the feeding pump settings every shift. In a telephone interview on 04/26/22 at 12:51 PM, MD I said she had not been notified Resident #1 had not received her hourly water flush the previous 72-hours but said one of her two NPs (NP J and NP K) may have been called. She stated when the nurse notified her, she would order STAT labs and IV fluids. MD I said if Resident #1 did not receive her ordered hourly water flush for 72-hours, her greatest concern would be for dehydration and said Resident #1 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . In a telephone interview on 04/26/22 at 12:54 PM, NP J said if Resident #1 did not receive her ordered hourly water flush could affect her overall clinical status and could lead to dehydration or constipation. NP J said she did not know if Resident #1 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . In a telephone interview on 04/26/22 at 12:57 PM, NP K said the facility nurses had not called her to notify her Resident #1 had not received her ordered hourly water flushes. NP K said there should not be a reason Resident #1 was not receiving her ordered hourly water. NP K said Resident #1 had last been admitted to the hospital with an electrolyte imbalance and dehydration. NP K said nurses should be checking the feeding pump settings at least every shift, every time the pump is turned on or off, and said that's a facility protocol. NP K said labs for Resident #1 needed to be drawn right away to check if she's dehydrated. Review of Resident #1's lab report dated 04/06/22 reflected the following: 1. 02/07/22- Sodium 135 (normal 135-145), BUN 29 (normal 3-23) 2. 03/28/22- Sodium 138 (normal 135-145), BUN 21 (normal 3-23) Review of Resident #1's lab report dated 04/26/22 reflected the following: 1. 04/06/22- Sodium 135 (normal 135-145), BUN 16 (normal 3-23) 2. 04/26/22- Sodium 142 (normal 135-145), BUN 29 H (normal 3-23) In a telephone interview on 04/27/22 at 9:49 AM, MD I said Resident #1 received IV fluids overnight and she had been notified of the STAT lab results. MD I said Resident #1's BUN was increased and that could happen if the resident gets less water. MD I said Resident #1's electrolytes [were] ok, and IV fluids could take care of the water loss. MD I said she planned to re-check Resident #1's labs on 04/29/29. MD I said she ordered IV fluids for Resident #1 to prevent her from becoming significantly dehydrated, and she wanted her BUN down to or below lower level of 20. Review of MD I's progress note dated 04/27/22 reflected Chief Complaint/Reason for this Visit: Patient seen and examined in follow-up recent labs and also water pump malfunction yesterday which was later fixed during the day and patient has been receiving water per the dietitian recommendation, I had ordered stat labs and until the labs arrived patient received IV fluids at 100 cc an hour overnight, the IV stopped working this morning however the blood work when reviewed did not show significant dehydration, BUN was 29 which can be improved with increasing the water flushes through PEG tube and will repeat labs again tomorrow to reevaluate since water flushes has been increased per dietitian recommendation, patient has been getting her tube feedings at 45 mL/h and has been seen by dietitian every 2 weeks and adjusted based upon her recommendation as needed. Patient has been clinically stable no signs of distress noted, patient has been nonverbal so history obtained from nurse who is the nurse on duty this shift . Mild dehydration: Patient got IV fluids overnight, has increased water flushes now per RD commendations based upon lab results from yesterday, will repeat labs tomorrow and adjust the water flushes as needed . In an interview on 04/28/22 at 3:13 PM, RD X said when she completed a nutritional evaluation of residents with g-tube, she would go into the rooms and verify they are getting the right formula and rate. RD X said she could not think of a specific instance when she observed incorrect pump settings. RD X said she saw Resident #1 last week or the week before and she said many factors could cause an increase in BUN. RD X said Resident #1's water flush order was for 40mL/hr for 22 hours a day and said if Resident #1 did not receive the ordered water it could affect Resident #1's overall fluids status but said she was not qualified to say what it could cause. RD X said Resident #1 had so many other things going on and she's been in and out of the hospital several times. 2.Review of Resident #2's face sheet dated 04/28/22 reflected she was a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #2's care plan, dated with admitted [DATE], reflected she was NPO and a risk for nutritional problem due to impaired swallowing. Interventions included obtaining and monitoring lab/diagnostic work as ordered, RD to evaluate and make diet change recommendations PRN. Resident #2's care plans did not include a plan or interventions for management of her g-tube. Review of Resident #2's order report dated 04/28/22 reflected the following orders: -NPO (dated 03/01/22) -CBC and CMP labs (dated 04/26/22) -Check g-tube placement prior to feeding and/or medication administration (dated 03/01/22) -Document total intake Q shift to include formula and free water flushes (dated 03/01/22) -Flush g-tube with 35mL/hr every hour (dated 04/26/22) -[MEDICATION(S)] 1.5 50mL/hr via feeding pump for 22 hours (dated 04/11/22) -Change g-tube feeding tubing with each close system administered (start date 03/01/22) -Flush g-tube with 30mL of water before and after meds, flush with 10mL of water between meds (start date 03/01/22) Review of Resident #2's orders in the EHR on 04/28/22 reflected ADON M entered a physician's verbal order from MD I on 04/11/22 for water flush at 40mL every shift. Review of Resident #2's April 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Nurses signed the order as completed from 04/11/22 to 04/26/22. Further review reflected an order initiated on 04/26/22 for 35mL of water every hour. Review of Resident #2's lab reports reflected the following: -03/02/22: Sodium 135 (normal 135-145), BUN 21 (normal 3-23) -03/14/22: Sodium 134 L (normal 135-145), BUN 25 H (normal 3-23) -03/24/22: Sodium 137 (normal 135-145), BUN 22 (normal 3-23) -03/28/22: Sodium 138 (normal 135-145), BUN 26 H (normal 3-23) -04/11/22: Sodium 137 (normal 135-145), BUN 25 H (normal 3-23) -04/18/22: Sodium 136 (normal 135-145), BUN 26 H (normal 3-23) -04/25/22: Sodium 137 (normal 135-145), BUN 28 H (normal 3-23) -04/27/22: Sodium 137 (normal 135-145), BUN 28 H (normal 3-23) In an observation on 04/26/22 at 3:48 PM, LVN B replaced Resident #2's formula bottle but did not replace the tubing/water flush bag. The flush bag contained approximately 400mL of a clear liquid and was dated 04/24/22 but was not labeled with a time. LVN B cleared settings on Resident #2's pump and set the pump to deliver 50mL feeding every hour and he set the water flush to deliver 35mL every 0 hours. In an observation on 04/26/22 at 5:15 PM, Resident #2's pump was still set to deliver flush at 35mL every 0 hours. HHSC surveyor intervened and notified LVN B. LVN B stated he had reviewed Resident #2's doctor's order prior to setting the pump but said he did not go by the doctor's order, instead he set the pump by the RD's note which recommended 35mL per hour for feeding. He stated the RD made the recommendations for enteral feedings and that is what they usually went by. Upon observing Resident #2's feeding pump, LVN B said he did not know why the pump was set to deliver flush every 0 hours. LVN B said the pump must be broken because he set it correctly. LVN B then said he could not remember what he set Resident #2's pump at and said maybe he made a mistake in setting the pump. In an interview on 04/28/22 at 3:13 PM, RD X said she completed a nutritional assessment for Resident #2 on 04/25/22. She stated she found Resident #2's ordered water flush was for 40mL every shift (120mL per day) and said that was not what she had recommended when completed her previous nutritional assessment. RD X said that was not enough water and stated she recommended to increase the water to 35mL per hour for 22 hours (770mL per day). RD X said a facility nurse called her on 04/26/22 to clarify she had decreased the water flush form 40mL to 35 mL, but RD X explained to the nurse she had increased the interval from every shift (3 times per day) to hourly for 22 hours. RD X stated she completed a nutritional assessment on residents with g-tubes monthly, as needed, and if they went to the hospital. In a telephone interview on 04/28/22 at 3:40PM, MD I said she would not give a verbal order to cancel or alter RD X's recommended orders. MD I said when she gave the verbal order to ADON M on 04/11/22, she wanted the 40mL of water every shift in addition to the hourly water flushes recommended by RD X due to increase BUN, not in place of the hourly water flushes. MD I said a transcription error by ADON M led to a decrease in free water intake for Resident #2 and could cause Resident #2's trending increase in BUN. In an interview on 04/28/22 at 4:13 PM, ADON M said she entered MD I's verbal order on 04/11/22 for Resident #2 incorrectly and it should have been 40mL of water every hour instead of every shift. ADON M said she did not recall changing the order for Resident #2 and stated maybe she meant to enter an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . ADON M said she usually made a note when she put in a new doctor's order, but she had not on 04/11/22 for Resident #2 and she could not remember why she made the change to Resident #2's flush order. ADON M said the error could have dehydrated [Resident #2] for sure or could have caused issues with her kidney function. 3.Review of Resident #3's face sheet dated 04/28/22 reflected he was a [AGE] year-old male initially admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #3's care plan on dated with an admitted [DATE] reflected he required tube feeding due to comatose state. Interventions included administering tube feeding and flushes as ordered, checking for tube placement per protocol, and RD to evaluate quarterly and PRN. Review of Resident #3's hospital records dated 01/14/22 reflected he was admitted on [DATE]. His admission labs on 01/11/22 reflected: Sodium 155 H (normal 135-145), BUN 27 H (normal 3-23). His diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #3's hospital records dated 03/01/22 reflected he was admitted on [DATE]. His admission labs on 02/28/22 reflected: Sodium 153 H (normal 135-145), BUN 29 H (normal 3-23). His diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . In a telephone interview on 04/28/22 at 12:09 PM, RP #21 stated she was Resident #3's RP. She was not given a reason why Resident #3 was hospitalized with dehydration January 2022 and February 2022. RP #3 said she felt Resident #3 needed more water and he didn't receive it. RP #21 said the water Resident #3 was getting via his g-tube was adjusted. She said one of the nurses told MD Y she did not want to increase Resident #3's water but she had misunderstood her concern. RP #21 said she did not want Resident #3 to receive a large bolus of water because he could aspirate and get pneumonia. RP #21 wanted Resident #3's water to be increased hourly to avoid aspiration. RP #21 said she had a camera in Resident #3's room and she visited him daily. She said Resident #21 was on isolation precautions since he returned from his last hospitalization on [DATE] due to a bacterium in his [CONDITION(S)] and his room door would be kept closed. She said she would often need to call the facility to speak to a nurse because Resident #3's feeding pump would be beeping due to being empty for hours and no one would go in to replenish the feeding or water. RP #21 stated she had complained to the facility nurses about Resident #3 going to the hospital due to dehydration and had told them he was getting more water hourly at the hospital. In a telephone interview on 04/28/22 at 4:36 PM, MD Y stated she was Resident #3's primary physician. MD Y said Resident #3's family did not want him to receive boluses of water. MD Y said Resident #3 had gone to the hospital with [CONDITION(S)] (high sodium level), he was on continuous [water] flushes with the pump. He's on [MEDICATION(S)] and gets 40mL/hr. He's getting continuous fluids. MD Y said she could not say whether Resident #3 was getting his hourly water flushes or not. MD Y said she wanted to do more bolus fluids, but his family was concerned, so she instead ordered IV fluids to compensate for the g-tube deficits. MD Y said an elevated BUN depended on the person's baseline because some people's baseline was high. She said dehydration was a clinical picture which included Sodium, the BUN, and the urine output. In an interview on 04/27/22 at 10:00AM, the ADM said they could not locate the annual enteral feeding trainings for nurses which were requested by HHSC Surveyor on 04/6/22. The annual trainings for facility nurses were not provided by the facility by the time of exit on 04/29/22. Review of the facility's policy titled Enteral Nutrition dated November 2011 reflected, . Adequate nutritional support through enteral feeding will be provided to residents as ordered . A dietician will assess residents who are receiving enteral feedings and will make appropriate recommendations for interventions to enhance tolerance and nutritional adequacy of enteral feedings . Enteral feeding orders will be written to ensure consistent volume infusion. The following information will be included to ensure that the full volume will be infused, regardless of interruption of feeding: Pump Feeding: 1. Product name; 2. Type of tube; 3. Rate of infusion (number of mL per hour); 4. Total calories per day; 5. Start time; and 6. Total daily volume to be infused (number of mL per day) . Fluids to be provided (beyond free fluid in product) will be calculated by the Dietitian and referred to the Physician for an order . The policy did not address the expectation of nurses to verify physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The ADM, DON, and Regional Nurse were notified on 4/27/22 at 3:20 PM an identified IJ situation was identified due to the above failures and an IJ template was provided. The facility's Plan of Removal (POR) was accepted on 04/28/22 at 6:57 PM and included: [Facility Name] Plan of Removal [Facility Name] submits the following Plan of Removal for the alleged failure to ensure resident received appropriate treatment to prevent complications of incorrect enteral feeding pump settings. By submitting this plan of removal [Facility Name] does not admit to the accuracy of the alleged deficient practice. What corrective actions have been implemented for the identified residents? Resident #1 A. Resident #1 enteral orders were verified for feeding and flush settings on 4/26/2022 by [the DON] and [LVN D]. B. Resident #1 head to toe assessment completed on 4/26/2022 and recorded in [electronic record] progress note by [LVN D] and [the DON] with no adverse effects noted from alleged incorrect Kangaroo pump settings. C. C. Attending physician notified on 4/26/2022 at 1537 [3:37 PM] of alleged discrepancy water flush of Kangaroo pump settings. Physician gave stat orders for CBC, CMP and IV fluids normal saline at 100cc per hour q 72 hours. D. CBC and CMP results were obtained on 4/27/2022 and reviewed with attending physician with new order to discontinue IV fluids. E. Daughter was notified of lab results and orders by physician for resident # 1 and daughter was satisfied with outcome. F. [RD X] conducted a nutritional assessment for resident #1 on 4/26/2022 with no new recommendations made. Resident #2 A. Resident #2 enteral orders were verified for feeding and flush settings by the [DON] and [ADON N] and [LVN D] on 4/26/2022. B. Resident #2 head to toe assessment completed on 4/26/2022 and recorded in [electronic record] progress note by [LVN D] and [the DON] with no adverse effects noted from alleged incorrect Kangaroo pump settings. C. [RD X] assessed resident #2 on 4/26/2022 and recommendations provided to increase free water flush at 35cc per hour times 22 hours per day. How were other residents at risk to be affected by this deficient practice identified? All residents receiving enteral feeding have the potential to be affected by this alleged deficient practice. What does the facility need to change immediately to keep residents safe and ensure it does not happen again? A. All residents who are dependent on G Tubes for nutrition and hydration had their settings checked and pumps verified with physicians' orders by [the DON] and [ADONs N and M] on 4/26/2022 to verify settings and functionality. There were no discrepancies noted between the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The audit was recorded on facility census sheet. The facility RD, [RD X], completed a nutritional assessment for all residents with enteral nutrition on 4/25 and 4/26. B. A nurse's skills checklist with return demonstration on administering enteral feeding and monitoring pump settings against physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . This will be completed by 4/28/2022 with any nurses that were not captured will be completed prior to start of their shift going forward. This training will be completed by [the DON] and [ADONs N and M] or designee. C. All newly hired nurses will be in-serviced on verifying physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . D. Nurses will receive annual enteral skills checklist competency. E. Bedside shift to shift report to verify pump settings and function per physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Bedside shift to shift is located in Narcotic count binder. This will be completed by 4/28/2022 with any nurses that were not captured will be completed prior to start of their shift going forward. This training will be completed by [the DON] and [ADONs N and M] and or designee. F. On 4/26/2022 and 4/27/2022 all residents receiving enteral feedings had their settings checked and pumps were verified per physicians' orders by [the DONs] and [ADONs N and M] and Regional Clinical Nurse. No discrepancies noted and audit was recorded on facility census sheet. G. DON, ADON's and Regional Nurse immediately began in-servicing on verifying physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The in-services began on 4/26/2022 and continued on 4/27/2022 and 4/28/2022. The DON was trained by [Regional Nurse] on 4/26/2022. H. A skills checklist for enteral feeding to include settings and function was implemented by [the DON] and [ADONs N and M] for nurses on 4/26/2022 and 4/27/2022 and 4/28/2022. Return demonstration was completed to ensure understanding of education provided. I. A Performance Improvement Plan (PIP) and ADHOC QAPI were developed and implemented on 4/27/2022. The IDT and Medical Director reviewed and approved PIP and QAPI. How will the system be monitored to ensure compliance? A. [The DON] and [ADONs N and M] immediately visually began inspecting enteral pumps on 4/26/2022 and again on 4/27/2022 and 4/28/2022. Monitoring will be conducted by [the DON] and [ADONs N and M] and or designee will continue daily X 4 weeks (to include weekends) and then at least 5x weekly for the 8 weeks following. This is to ensure settings match physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . B. [The DON] and [ADONs N and M] verified shift to shift report compliance on 4/26/2022, 4/27/2022 and 4/28/2022. Monitoring will be conducted by [the DON] and [ADONs N and M] and or designee will continue daily X 4 weeks (to include weekends) and then at least 5x weekly for the 8 weeks following. This is to ensure settings match physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] C. Bedside shift to shift report will be reviewed during morning clinical meeting to ensure compliance. The nurse management team and administrator will review findings of visual inspections of enteral pumps working properly and ensuring following physician orders. D. [ADM] will have overall monitoring of the plan and will submit findings to the IDT during monthly QAPI. Quality Assurance A Performance Improvement Plan (PIP) and ADHOC QAPI were developed and implemented on 4/27/2022. The IDT and Medical Director reviewed and approved PIP and QAPI. Monitoring of the POR included: Observation of Resident #1's, #2, and #3's feeding pump settings on 04/27/22 at 9:31 AM reflected the feeding pumps settings for feeding and flush were set according to the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] Observation of Resident #1's, #2, and #3's feeding pump settings on 04/28/22 at 12:29 PM reflected the feeding pumps settings for feeding and flush were set according to the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] Observation of Resident #1's, #2, and #3's feeding pump settings on 04/20/22 at 10:40 AM reflected the feeding pumps settings for feeding and flush were set according to the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] In an interview on 04/29/22 at 1:35 PM, RN W said he was an agency nurse who had been at the facility since March 2022. He said he worked 6AM to 2PM shift, 2PM to 10PM shifts, and weekends. RN W said he was trained on the kind of feeding the resident is receiving, the kangaroo pump setting and verifying every shift. RN W said pump setting monitoring would be documented on the nurse to nurse feeding check list. RN W said he also received training on how to set up the feeding and the flush. RN W said signs of dehydration included a [CONDITION(S)], and creatinine/Sodium/BUN

Based on observation, interview and record review, the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for one (Resident #23) of 16 residents reviewed for quality of care. Resident #23 did not have an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #23 was hospitalized from [DATE] until [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident received a blood transfusion while hospitalized and was at risk for death An Immediate Jeopardy (IJ) situation was identified on [DATE] at 4:42 PM. The ADM, DON, and the Regional Nurse were notified and a POR was requested. While the IJ was removed on [DATE] 4:55 PM, the facility remained out of compliance at a scope of isolated at the severity level of actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. These failures could affect residents with foley catheters or on anti-coagulants by placing them at risk for infections, bleeding, hospitalization , or death. Findings Included: Review of Resident #23's face sheet reflected he was an [AGE] year-old male admitted to the facility on [DATE]. His diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #23's MDS dated [DATE] reflected he had a BIMS score of 8 and indicated a moderately impaired cognitive status. His functional status reflected he required extensive assistance with bed mobility, transfers, eating, toilet use, personal hygiene, and he had an indwelling catheter. Review of Resident #23's care plans in the EHR on [DATE] reflected the Regional Nurse had created the following care plans on [DATE]: a. [Resident #23] has altered cardiovascular status related to [CONDITION(S)] b. [Resident #23] is on Anticoagulant therapy related to [CONDITION(S)] c. [Resident #23] is on diuretic therapy related to [CONDITION(S)] d. [Resident #23] has Essential tremors e. [Resident #23] has impaired circulation related to [CONDITION(S)] f. [Resident #23] has fluid overload or potential fluid volume overload r/t Disease process g. [Resident #23] has an ADL Self Care Performance Deficit r/t Impaired balance, Limited Mobility, tremors, cognitive impairment h. [Resident #23] has a code status of Full Code/CPR Review of Resident #23's progress notes from [DATE] until [DATE] in the EHR on [DATE] reflected the following: a. LVN HH documented on [DATE] at 8:18 PM: At around [7:22 PM], patient was admitted under the care of [MD I] , via a stretcher by EMS from [hospital]. Patient was [alert and oriented x 3] and was able to answer all questions . Foley catheter in situ [in its original place], patent and draining a yellow colored urine . b. LVN II documented on [DATE] at 3:31 AM: new admit alert x 3, able to verbalize needs know to staff, [respirations] even and [non-labored] no [shortness of breath] noted, bowel sound active in all 4 quad, denied pain, call light within reach, assist x 1 with ADLS needs. c. LVN D documented on [DATE] 7:53 PM: new admit day 2 under the care of [MD I] . very poor appetite need assistance with feeding . dressing and reposition . reposition every 2 [hour] . incontinence of care urine and stool . alert and oriented x1 . refused food this evening shift . nurse notified wife and she stated to this nurse to always encourage food and drink because resident will continue to refused and stated that resident need to sit on his [wheelchair]. d. LVN D documented on [DATE] at 9:49 PM: Resident hand shaking when eat Resident need Assistance with feeding all meals hand unable to drink water or eat on his own , hand shaking . e. LVN D documented on [DATE] at 10:35 PM: lab result back send to [MD I] no new order noted cbc cmp sent f. LVN BB documented on [DATE] at 3:52 PM: resident is stable and continues on antibiotic . dark colored urine in catheter . MD has been notified of urine color. g. LVN JJ documented on [DATE] at 2:55 PM: writer observed blood in patients foley catheter bag. patient has no complaints of pain or any recent trauma to private from what he remembers . [NP J] notified and will see patient today regarding so. h. LVN D documented on [DATE] at 10:40 PM: Order from [NP J] to start on [MEDICATION(S)] ,d+[DATE] bid and collect urine for a [urine analysis and culture and sensitivity] incoming nurse notify about urine. i. LVN JJ documented on [DATE] at 4:00 AM: Writer observed patient laying on right shoulder and back and legs on the bed, patient does not complain of any pain, no bruising noted, range of motion to upper extremities normal. when asked patient what happened he said he was reaching for his phone and accidently fell . MD notified of incident, DON notified, spouse also called but no answer, voicemail left regarding event. j. LVN BB documented on [DATE] at 9:46 AM: bruised found on right upper arm on the side of arm. Resident denies any pain . resident denies hitting his head. foley clean and w/o signs of tugging or infection . NP called with new orders and order for x ray. NP asked to be notified if urine is still the same after ordered normal saline IV given . k. LVN BB documented on [DATE] at 1:07 PM: Midline inserted per MD orders Administration of normal saline via IV has began at 75 ml/hr per MD orders . l. LVN BB documented on [DATE] at 2:35 PM: Resident continues on [oral] antibiotic for [CONDITION(S)] . per NP orders resident was given Potassium 40 mEq [oral] one time at 12 pm .Nurse reported NP orders to oncoming nurse. 20 Meq potassium will be given 2hr after . m. LVN JJ documented on [DATE] at 5:55 AM: patient on IV NS for hydration related to recent U/A , midline to right arm. resident has increased confusion, MD notified n. LVN JJ documented on [DATE] at 6:40 AM: patient has increased confusion, MD notified. IV NS running as ordered. midline to right arm o. ADON M documented on [DATE] at 8:17 AM: [MD I] notified of negative shoulder x ray. Wife also notified p. LVN BB documented on [DATE] 2:31 PM: resident is stable. currently continuing antibiotic [oral] . Resident midline is clean and free of signs of infection. Resident denies any pain to midline at this time. IV normal saline is being continued at 75 ml/hr for 72hr. first administration was ,d+[DATE]. Resident is tolerating fluids well. urine results and xray result from previous fall sent to Dr. Dr. sent over new orders for [MEDICATION(S)] [antibiotic] 500 [oral] daily for 7 days and Lactobacillus [probiotic] one tablet [oral] daily for 7 days . q. NP K documented on[DATE] at 8:29 PM: . [CONDITION(S)]/ Elevated WBC . referred by [MD I] for positive UA and elevated WBC . on [MEDICATION(S)] for DVT and was reported to have hematuria . Foley with mild hematuria . [CONDITION(S)]- UA positive, culture pending . started on [MEDICATION(S)] 500 mg po daily with probiotics for 7 days . Elevated WBC- WBC on [DATE] was 12.3, WBC on [DATE] is 8.0 . r. LVN D documented on [DATE] at 11:15 PM: Resident in bed continue with normal saline iv @75ml hr midline to right upper arm , no redness noted . no sign of infection noted at this time order from [MD I] to HOLD [MEDICATION(S)] x2 day. s. LVN C documented on [DATE] at 5:05 AM: . IV to right arm patent infusing NS@75cc/hour . [foley catheter] patent draining coffee-colored urine noted . t. ADON M documented on [DATE] at 5:55 AM: .noted with generalized weakness and requires assistance with feeding and adls. u. LVN KK documented on [DATE] at 10:55 PM: .noted with generalized weakness and requires assistance with feeding and adls. v. ADON M documented on [DATE] at 5:55 AM: .noted with generalized weakness and requires assistance with feeding and adls. Has Midline to L arm with NS running @ 75cc/hr. Residnt remains confused. [MD I] called and updated on resident's condition and no improvement w. ADON M documented on [DATE] at 6:07 PM: New orders received from [MD I] 20 meq of K+ now and 10 meq daily, NS @ 100ml/hr x 3 days, [foley catheter] flush for hematuria @ 200 cc BID. [MD I] has spoken to wife and son in regards to current treatment and plans, She has also started the palliative care conversation with them . x. LVN D documented on [DATE] at 10:43 PM: resident continue with IV normal saline 100ml/hr iv site to left arm clean. Foley cath flush as order . y. LVN II documented on [DATE] at 1:44 AM: resident continue IV normal saline @ 100ml/hr x 3days . z. ADON M documented on [DATE] at 12:02 PM: Resident ate less than 50% of meal MD aware labs ordered and fluids are being encouraged. Wife and son are discussing palliative care aa. ADON M documented on [DATE] at 1:43 PM: Resident noted to have further decline. [NP J] in house and is evaluating resident at this time. bb. ADON M documented on [DATE] at 2:31 PM: Spoke to wife about decline and to let her know resident did not eat breakfast or lunch. Resident is getting IV fluids @ 100ml/hr for hydration. Wife provided Son's contact info and asked that resident be sent to hospital. [MD I] notified and [NP J] for [MD I] in house is aware as well. cc. LVN BB documented on [DATE] at 2:35 PM: resident has increased confusion. He is not eating nor drinking. Resident is alert x 1 only can state his name. his urine is dark red. He continues IV NS 75ml for 72hr. Resident continues to ramble and he is very lethargic. [vital signs within normal limits] and he is unable to communicate to the staff. Doctor, family and ADON has been has been notified dd. ADON M documented on [DATE] at 3:17 PM: Resident was sent to [hospital] Wife followed. [MD I] called to find out which hospital resident went to. She states she will follow up with son ee. LVN BB documented on [DATE] at 10:39 PM: Resident sent to [hospital] via ambulance per doctor's order @ [2PM] today. Adon was notified and assist in the transfer of the resident. Family member has been notified. Review of Resident #23's hospital records dated [DATE] reflected he was hospitalized from [DATE] to [DATE]. He was diagnosed with gross hematuria, dehydration, acute blood [CONDITION(S)], acute GI bleed, lumbar spine infection, essential tremors, and [CONDITION(S)]. On admission his labs were: WBC 8.2 (normal), RBC 2.8 (low), hemoglobin 8.3(low), and hematocrit 25.3 (low). He was given one blood transfusion and IV iron supplements. Discharge instructions included a dose decrease of [MEDICATION(S)] from 5mg twice a day to 2.5mg twice a day. An interview and observation on [DATE] at 2:40 PM revealed Resident #23 was lying in bed. He said he was hospitalized last month but did not recall the events leading to his hospitalization s. Resident #23 said he had a foley catheter prior to his hospitalization but did not recall what his urine looked like. He said the facility staff were giving him a lot of fluids to drink and also inserted an IV for fluids. In an interview on [DATE] at 12PM, LVN BB stated she had not worked with Resident #23 since his re-admission from the hospital on [DATE], but said he was eating much better, I see him out in the hallway, and he talks to me and we have conversations. LVN BB said Resident #23 was no longer confused. LVN BB said Resident #23 was admitted from the hospital on [DATE] with blood in his urine and she did not know if that was a regular thing for him. LVN BB said she was the nurse who got [Resident #23] sent out [to the hospital] on [DATE]. She said she was concerned because his urine color was not changing despite interventions including flushing his foley catheter, antibiotics, and IV fluids. She stated he had increased confusion and he wasn't looking. His demeanor, he just seemed off. He was more tired than normal; he was eating less. [ADON M] got the order from the doctor to send him. In an interview on [DATE] at 12:23 PM, ADON M said nurses should have followed-up and documented on Resident #23's hematuria [blood in urine] and eating every shift until it resolved. ADON M said she notified MD I on [DATE] that Resident #23 was declining, and she knew MD I was going to visit [Resident #23]. She stated she did not believe MD I gave any orders, just continue to monitor. In a telephone interview on [DATE] at 11:30 AM, LVN JJ said he was an agency nurse who started working at the facility around [DATE], and only worked a few times before he was hired on as a staff nurse at the facility in [DATE]. He said recalled on [DATE] one of the CNAs or therapy told him Resident #23 had dark, coffee colored blood in his urine. LVN JJ said Resident #23 was stable at the time and right away I notified the NP about it. LVN JJ said he could not recall how he notified the NP, if it was via phone or the tablet messaging system and he stated he could not recall what instructions she gave him. LVN JJ stated he could not recall assessing Resident #23's urine when he worked with him on [DATE] and [DATE]. In a telephone interview on [DATE] at 3:58PM, LVN C said she did not call the provider when she noted Resident #23 had coffee colored urine on [DATE] at 5:05 AM because she was told by another nurse that his urine had looked like that since he was admitted . In an interview on [DATE] at 12:11 PM, RN V said she had worked at the facility since [DATE]. RN V said she would consider blood in urine a change in condition. In an interview on [DATE] at 12:45 PM, LVN BB said she had worked at the facility for one month. She stated she became concerned about Resident #23 when his urine color was not changing from red. LVN BB said ADON M just got the orders to keep flushing [the foley catheter] and he was not supposed to be pissing blood. It was rust colored. LVN BB said it was LVN JJ who initially discovered the hematuria, and she was told about it from him in report. LVN BB said she could not recall assessing Resident #23's urine when she worked with him on [DATE] because she was more concerned about his fall, does not recall what the urine looked. LVN BB said she went to ADON M on [DATE] and asked her why Resident #23 was still at the facility and asked, what are we doing. LVN BB said it was early in the day when she spoke to ADON M and she had reached out to ADON M more than once regarding Resident #23 and his decline. In an interview on [DATE] at 3PM, the Regional Nurse stated it was her expectation the nurse notifies a NP or MD if a Resident had a change in condition and notification could be made anytime during their shift. The Regional Nurse stated she could not say she would expect nurses to document the change in Resident #23's cognition and the change from admission as oriented x 3 (person, place, time) to oriented x 1 (person) in subsequent assessments. The Regional Nurse said nurses charted by exception and if a change in cognition, hematuria, or decrease in meal intake was noted one shift, the following nurse was not expected to document a follow-up if her assessment was normal. The Regional Nurse then stated the facility's policy was for a nurse to follow-up, assess, and document on a resident every shift when a change is noted until the resident returned to baseline or the issue was resolved. In a telephone interview on [DATE] at 1PM, MD I, who was also the facility's medical director, stated it was reasonable that a provider be notified there was a significant change in the resident's physical status or a need to alter treatment significantly within 24 hours. MD I said she spoke with Resident #23's son and wife prior to his hospitalization on [DATE] and they were debating on considering hospice services or aggressive treatment. MD I said she believed she was notified of the change in Resident #23's urine color, but an existing [CONDITION(S)] could cause bloody urine. MD I said she did not recall when she was notified of the blood in Resident #23's urine because when she was called by the facility nurses, she did not take notes. MD I said if she had been notified of the blood in Resident #23's urine on [DATE], she would have given the order to hold [MEDICATION(S)]. In a telephone interview on [DATE] at 2:50PM, MD I said she could not recall if Resident #23 had hematuria. MD I said she typically ordered 3 things when hematuria was reported: hold anti-coagulants, monitor urine, and order a UA. MD I said if a resident was on blood thinners, she would like the nurse to report that information since they are in front of the computer and then I can help the patient better. When they call me, I may be out an about, and I don't take notes. If the nurses give me helpful and all the information, I can help the patients better. In an interview on [DATE] at 11:07 AM, the ADM said he was not obligated to provide the 24-hours nursing reports or the tablet records of communication between the providers and the nurses. He said those records were internal documents were not a part of the residents' EHR. The ADM said he expected any conversations that occurred in the tablet communication system between a nurse and a provider a nurse would then transcribe into the residents' progress notes in their EHR. He stated he expected any documentation on the 24-hour nursing report a nurse would then transcribe into the residents' progress notes in the EHR. Record review of NP J's note on [DATE] revealed she documented, .Patient presents with Foley catheter today is having some hematuria. Is awake and alert but appears tired Admit labs [DATE]: WBC 12.3, Hgb 8.4, NA 131, BUN 9, CR 0.65 . [DATE] Ordered stat CBC CMP and UA . ASSESSMENT AND PLAN hematuria: Flush Foley catheter, hold [MEDICATION(S)] for 2 days, follow-up labs to review CBC-UA order . Record review of Resident #23's current, discontinued, and completed orders in the EHR on [DATE] reflected NP J's order to hold [MEDICATION(S)] was not entered into the system on [DATE]. The [MEDICATION(S)] was not held until [DATE] when Resident #23 was seen by MD I. Further review reflected Resident #23 did not have an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #23's [DATE] MARs reflected he received [MEDICATION(S)] 5mg once on [DATE] and twice from [DATE] to [DATE]. It was held on [DATE] and [DATE] and given twice on [DATE]. In a telephone interview on [DATE] at 10:39 AM, NP J said she did not place orders into the EHR herself. She stated her orders were entered into the EHR two ways, she have a direct verbal order to the floor nurse or more recently they had been having issues with the order system so she would communicate her orders to ADON M. NP J stated when she gave a verbal order to the floor nurse or ADON M, she expected them to enter the order into the EHR immediately. NP J said because Resident #23's [MEDICATION(S)] was not held when she ordered on [DATE], it could contribute to the blood loss. NP J said when she saw Resident #23 on [DATE] he was pretty lethargic, he was weaker. Clinically not looking as great. He didn't look any better, he looked worse. NP J said she had seen Resident #23 since his return from the hospital on [DATE] and said, he's looks much much better, he looks great. NP J said she would expect the nurses to contact her to get an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . NP J said she would expect nurses to monitor a resident's foley catheter output at minimum, every shift and report any changes in urine appearance or output. NP J stated not routinely monitoring Resident #23's urine output could have contributed to his overall decline. In an interview on [DATE] at 11:07 AM, ADON M said she did not recall NP J giving her the order to hold the [MEDICATION(S)] on [DATE]. In an interview on [DATE] at 11:56 PM, the DON said providers did not enters their orders into the EHR. She said the providers would get with floor nurse or get with the ADONs and the ADON with put the orders into the EHR. The DON said NP J would usually come to her or the ADONs and say she gave a specific order to the floor nurse and would ask them to follow-up to ensure it was entered into the EHR. The DON said she recalled NP J speaking with ADON M on [DATE] because at that time, they were all officing together in a big office. The DON said NP J gave ADON M the order for Resident #23 for CBC, UA, and hold the [MEDICATION(S)]. In a telephone interview on [DATE] at 3:10PM, the Pharmacist stated [MEDICATION(S)] was contraindicated if a patient had elevated platelets, issues with clotting, on a lot of other anti-coagulants, and nurses needed to make sure the MD was aware. The Pharmacist said [MEDICATION(S)] was contraindicated if they have elevated platelets because it could cause bleeding. The Pharmacist stated the main side effects of [MEDICATION(S)] were clotting issues or bleeding, and the resident should be monitored every shift for of bruising or bleeding. The Pharmacist said it would take a day and a half to two days for [MEDICATION(S)] to get out of the resident's system after being held or discontinued. The Pharmacist said [MEDICATION(S)] would have caused Resident #23's hemoglobin to be low or lower because it was an anti-coagulant. The Pharmacist said if Resident #23 was on [MEDICATION(S)], I'm sure that's what contributed to his hospitalization with acute blood loss [CONDITION(S)]. On [DATE] at 4:42 PM the ADM, DON, and the Regional Nurse were notified an IJ situation was identified due to the above failures. On [DATE] 12:30 PM, the POR was accepted and included the following: [Facility Name] Plan of Removal [Facility Name] submits the following Plan of Removal for Quality of Care related to the alleged failure to ensure resident received treatment and care in accordance with professional standards of practice, comprehensive centered person care plan and resident choices. By submitting this plan of removal [Facility Name] does not admit to the accuracy of the alleged deficient practice. What corrective actions have been implemented for the identified residents? A. Resident # 23 catheter status/condition was assessed by Director of Nursing on [DATE] at the time the concern was received, and it was noted the resident's catheter was removed on [DATE]. No adverse effects were noted on this assessment. B. Resident #23 chart was reviewed on [DATE] by Clinical Services Director and identified that on [DATE] the attending physician, was contacted by charge nurse, of change in coloration of urine in catheter as per nurse's progress note. On [DATE] the nurse practitioner was notified by charge nurse of observation of blood in catheter as per the progress notes. Nurse practitioner returned call to facility on [DATE] and gave an order to charge nurse to obtain urinalysis as per progress note and orders. Urinalysis was obtained on [DATE] and sent to the lab. On [DATE] the nurse practitioner followed up with the patient at bedside and reviewed urinalysis results per progress notes and started patient on [MEDICATION(S)] 500mg for seven days per progress note and medication orders. Attending Physician saw patient at bedside on [DATE] per H&P in progress notes and Attending Physician gave order to hold [MEDICATION(S)] for two days on [DATE] per medication orders. [MEDICATION(S)] was held per medication administration review after receiving the order to hold on [DATE] for two days. Medication was held on [DATE] and [DATE] and started back on [DATE]. C. Residents currently residing in the facility were audited by the DON and ADON on [DATE] to ensure no other resident has a catheter without appropriate monitoring orders and are not on an anticoagulant. The audit revealed no further discrepancies and no residents with foley catheters are on anticoagulants. D. An audit was completed on [DATE] by the Clinical Services Director the for 8 residents on anticoagulants to ensure there are no signs of bleeding and proper monitoring order is in place. The 1 resident with a foley catheter is not on anticoagulants at the current time. The audit revealed no further discrepancies. How were other residents at risk to be affected by this deficient practice identified? An audit was completed on [DATE] by the Clinical Services Director and revealed there were no residents on concurrent anticoagulants and catheter use. There were 9 residents at risk for this potential deficient practice. There are 8 residents on anticoagulants and 1 resident with foley catheter care. What does the facility need to change immediately to keep residents safe and ensure it does not happen again? A. On [DATE] Corporate Clinical Services Director in-serviced the DON and nurse managers on identify, monitor for change of condition, using the E Interact tool (resident assessment tool to use when notifying attending physician), and notifying attending physician regarding change of conditions and appropriate orders are in place for foley catheters. DON and nurse managers verbalized teach back of education provided to them. B. An in-service was completed on [DATE] by Director of Nursing and nurse managers, with the licensed nursing staff including contract staff on identifying, monitor for change of condition, using the E Interact tool (resident assessment tool to use in assessing the patient when notifying attending physician), and notifying attending physician regarding change of conditions and appropriate orders are in place for foley catheters. Licensed staff verbalized teach back of education provided to them. C. Newly hired nurses and contract staff will be in-serviced by the Director of Nursing, or an Assistant Director of Nursing/designee on identifying monitor for change of condition, using the E Interact tool (resident assessment tool to use in assessing the patient when notifying attending physician), and notifying attending physician regarding change of conditions and appropriate orders are in place for foley catheters. Licensed staff will verbalized teach back of education provided to them. D. On [DATE] Corporate Clinical Services Director in-serviced the DON and nurse managers on signs and symptoms of side effects of residents on anticoagulants and proper monitoring orders are in place and if there are signs and symptoms identified the attending physician needs to be notified of the patient being on an anticoagulant and what the signs and symptoms are. DON and nurse managers verbalized teach back of education provided to them. E. An in-service was completed on [DATE] by the DON and nurse managers with all licensed nurses including contract nurses on signs and symptoms of side effects of residents on anticoagulants and proper monitoring orders are in place and if there are signs and symptoms identified the attending physician needs to be notified of the patient being on an anticoagulant and what the signs and symptoms are. Licensed nurses verbalized teach back of education provided to them. F. Newly hired nurses and contract staff will be in-serviced by the Director of Nursing, or an Assistant Director of Nursing/designee on signs and symptoms of side effects of residents on anticoagulants and proper monitoring orders are in place and if there are signs and symptoms identified the attending physician needs to be notified of the patient being on an anticoagulant and what the signs and symptoms are. Licensed nurses will verbalize teach back of education provided to them. G. On [DATE] an in-service will be completed by DON and Clinical Services Director with licensed nurses on all orders needing to be transcribe all orders through PCC by the attending physician or nurse practitioner and no longer utilize verbal or telephone orders to impute a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Licensed nurses completed return demonstrate and verbalized understanding of education provided to them. H. All new nurses and contract nurses will be in-serviced on all orders needing to be transcribe all orders through PCC by the attending physician or nurse practitioner and no longer utilize verbal or telephone orders to impute a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Licensed nurses will complete return demonstrate and verbalized understanding of education provided to them prior to start of their shift. I. On [DATE] an in-service will be completed by DON and Clinical Services Director with all attending physicians and nurse practitioners were contacted and educated on all orders needing to be transcribe all orders through PCC themselves and no longer utilize verbal or telephone orders to a charge nurse. Attending physicians and NPs will complete a return demonstration to the trainee to demonstrate understanding. J. Any new hired physicians or NPs will be in-serviced by the Director of Nursing or Clinical Services Director on transcribing all physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Attending physicians and NPs will complete a return demonstration to the trainee to demonstrate understanding prior to being credentialed. K. Effective [DATE] all orders will be transcribed by the physician or NP into Point Click Care (PCC). How will the system be monitored to ensure compliance? A. 24-hour report will be reviewed daily in point click care by the Director of Nursing, Assistant Director of Nursing or designee to audit residents with change of condition, E Interact tool (resident assessment tool to use when notifying attending physician) completed and physician notification. If resident has foley catheter will ensure all monitoring and care orders are in place. B. 24-hour report will be reviewed by the Director of Nursing, Assistant Director of Nursing or designee to audit nurse documentation in progress notes notifying attending physician of patient change of conditions. Discrepancies noted during reviews will be immediately by contacting attending physician of change of condition and completing documentation in the patient's progress note. Further training will be provided as identified by nurse manager who identified the discrepancy when and if necessary. C. Order listing report will be reviewed by Director of nursing or nurse manager daily for any new anticoagulant orders to ensure proper monitoring orders are in place. Order listing report will be reviewed to ensure that all physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . If a discrepancy is identified then the individual completing the audit will obtain and input the appropriate monitoring orders. D. 24-hour report will be reviewed by Director of Nursing or nurse manager to identify any signs and symptoms of side effects related to anticoagulant medications and that there is documentation of notification to the attending physician of the patient being on an anticoagulant medication showing signs and symptoms of side effects. If a discrepancy is identified then the individual completing the audit will contact the attending physician to ensure notification has occurred and document notification to physician of the patient showing signs and symptoms of side effects of the resident being on anticoagulant medication. E. The DON/designee will review 24-hour report to ensure nurses document timely notification to the attending physician of resident changes of condition and signs of symptoms of side effects related to residents on anticoagulant medications has been communicated with the physician and documented 2x week X 6 weeks. Review will be documented on [TRUNCATED]

Based on observation, interview, and record review, the facility failed to store, prepare, and distribute food under sanitary conditions in one of one kitchen. 1. Dietary staff failed to remove the ankle-deep waste water, from the backed-up drain which covered the dish room floor and contained chunks of food debris. Dietary staff walked through the waste water, tracking throughout the kitchen, including the food preparation area and where the clean dishes were stacked, while preparing the residents' lunch. After surveyor intervention, the facility did not serve the food prepared in the kitchen to the residents. Instead they had the residents' meals catered. An IJ was identified on 01/27/13. While the IJ was removed on 01/29/13, the facility remained out of compliance at a scope of "widespread" and a severity level of "potential for more than minimal harm, that is not immediate jeopardy," because the facility was still monitoring the effectiveness of the POR. 2. Dietary staff failed to put the residents' meal trays on carts, which did not have dried on food spills. 3. Dietary staff failed to clean the production table drawers, which had food spills in the interior of the drawers. 4. Dietary staff failed to store the ice scoop in a holder that was free of coffee-ground like substances. 5. Dietary staff failed to clean the tables, walls, and floors, which had a grease film. 6. Dietary staff failed to clean the five food bin tops. One top had a pool of red liquid, which the DM said was probably meat juice. Another top had rodent droppings. 7. Dietary staff failed to put paper towels in the holder at the handwashing sink. 8. Dietary staff failed to clean the floor in the paper products store room. 9. Dietary staff failed to store the sugar and flour scoops outside the bins. Staff also failed to clean the handles. Insect casings were in the flour bin. Staff also failed to store an opened box of cocoa and two opened boxes of spaghetti with tight fitting lids. 10. Staff failed to clean the shelf below the steam table, which had dried on food particles, and an employee's beverage without a lid. These failures could affect the 87 residents, who received meals from the kitchen, at risk for airborne and foodborne illnesses. Findings included: 1. On 01/27/13 at 11:22 AM observation of the kitchen revealed lunch was on the steam table. Dishwasher L, whose shoes and bottoms of her pant legs half-way up to her knees were saturated with the waste water, was setting up food carts with trays, beverages, silverware and condiments for the noon meal. An observation on 01/27/13 at 11:30 AM revealed the DM wiping down a production counter using a cloth from a sanitizing bucket. At this time, the DM stated the drain in the dish room backed up and waste water was all over the dish room floor. An observation on 01/27/13 at 11:50 AM revealed Cook M walked from the food production area to the dish room, through the waste water and back to the food production area where lunch was being prepared, which tracked waste water throughout the kitchen. An observation on 01/27/13 at 11:58 AM revealed Cook M measured the concentration of the sanitizing agent in the three-compartment sink and in the container used to sanitize counter tops. No sanitizing solution registered on the chemical strip (Note: This was the same bucket from the observation on 01/27/13 at 11:30 AM that the DM was using to wipe down the counter.) During an observation on 01/27/13 at 12:00 PM, Dishwasher L was standing in a large area of waste water approximately ankle deep at the drain area, which contained numerous chunks of food debris. Both of her shoes and the bottom of her pant legs half-way up to her knees were saturated with the waste water. Interview with Dishwasher L at this time revealed the floor drain in front of the dish machine backed up and the waste water back flowed out onto the floor, while she washed dishes. She stated she thought the drain was snaked earlier this past week. She further revealed the garbage disposal was not working. Observation of the dish room floor on 01/27/13 at 12:00 PM revealed the waste water covered approximately the length and width of the room. The waste water was the deepest at the area around the floor drain. The water was brown, murky and contained chunks of food debris and particles of food. The waste water spread to the clean side of the dish machine, where clean plates were stacked on the clean side of the dish machine. The waste water extended to the floor in front of the three-compartment sink and around to the clean dish room. The waste water continued to overflow to the area where all the clean dishes were stored on carts. During an observation on 01/27/13 at 12:00 PM, Dishwasher L was standing in a large area of waste water approximately ankle deep at the drain area, which contained numerous chunks of food debris. Both of her shoes and the bottom of her pant legs half way up to her knees were saturated with the waste water. Interview with Dishwasher L at this time revealed the floor drain in front of the dish machine backed up and the waste water back flowed out onto the floor, while she washed dishes. She stated she thought the drain was snaked earlier this past week. She further revealed the garbage disposal was not working. Observation of the dish room floor on 01/27/13 at 12:00 PM revealed the waste water covered approximately the length and width of the room. The waste water was the deepest at the area around the floor drain. The water was brown, murky and contained chunks of food debris and particles of food. The waste water spread to the clean side of the dish machine, where clean plates were stacked on the clean side of the dish machine. The waste water extended to the floor in front of the three compartment sink and around to the clean dish room. The waste water continued to over flow to the area where all the clean dishes were stored on carts. On 01/27/13 at 12:00 PM observation of the dish room floor revealed dish racks (used to to run dishes through the dishmachine) were on the floor in the waste water on the clean side of the dishmachine, which put the clean dishes at risk for being splashed with waste water. During this same observation, 13 "clean" plates on the clean side of the dishmachine had dried-on food debris. On 01/27/13 at 12:40 PM the DM was informed he could not serve food out of the kitchen because the drainage problem could cause cross-contamination from the dirty waste water to the clean dishes and food preparation with the potential to cause foodborne illness. An observation on 01/27/13 at 12:50 PM revealed Maintenance Director I using a wet vacuum in the dish room to remove the waste water. Interview with Maintenance Director I at this time revealed he snaked the drain on 01/22/13 when the drain backed up. On 01/27/13 at 12:50 PM, interview with the Administrator revealed he had been informed a week or two ago that one of the drains in the kitchen was slow, but he did not recall which drain. He further stated either Maintenance Director I or the DM was supposed to be putting chemicals down the drain. The Administrator stated he did not recall if he followed up on the slow drain problem. The Administrator was informed the facility could not serve the food that had been prepared. When asked about the plans to feed the residents, the Administrator replied the facility would cater the residents' meals until the problem was resolved. http://www.fda.gov/Food/ResourcesForYou/Consumers/Seniors/ucm 9.htm reflected on 02/14/13, "Why Some People Face Special Risks: Some people are more likely to get sick from harmful bacteria that can be found in food. And once they are sick, they face the risk of more serious health problems, even death. A variety of people may face these special risks...people with chronic illnesses and weakened immune systems and older adults, including people over 65. Why are older adults more susceptible to foodborne illness? Everyone's health is different, including his or her ability to fight off disease. But immune systems weaken as we age. In addition, stomach acid also decreases as we get older -- and stomach acid plays an important role in reducing the number of bacteria in our intestinal tracts -- and the risk of illness. Plus underlying illnesses such as diabetes, [MEDICAL CONDITION] treatments, and kidney disease may increase a person's risk of foodborne illness...." On 01/27/13 an IJ was identified. The Administrator was notified of the IJ on 01/27/13 at 3:30 PM. A POR was requested at that time. On 01/28/13 at 11:40 AM, interview with the Maintenance Assistant revealed he snaked the drain in the dish room on 01/23/13, when the drain backed up. The facility's Plan of Removal was accepted on 01/29/13 at 2:00 PM and included: (1) Facility department heads informed residents of the kitchen auxiliary drain issue, necessary menu changes, and service delays. (2) Kitchen was closed and prepared food was discarded. (3) Emergency food arrangements were made for lunch and dinner on 01/27/13 and breakfast and lunch on 01/28/13. (4) Maintenance Director I unclogged auxiliary drain by snaking the drain on 01/27/13. (5) Plumber provided preventative maintenance to ensure drain was fully operational on 01/27/13. (6) Electrician connected garbage disposal on 01/27/13. (7) Professional Sanitation Company will disinfect and sanitize the walls, floors, and equipment of the entire kitchen by 01/28/13. (8) Pest Control Services will provide additional treatment to the kitchen following the deep sanitation by 01/28/13. (9) All dietary trays, dishes, glasses, cups, utensils, and carts will be cleaned and sanitized by 01/28/13 by the kitchen staff with the Dietitian oversight. (10) Medical Director was notified via Physician Assistant on 01/27/13 and the DON discussed occurrences and corrective actions with the Medical Director on 01/28/13. Medical Director did not have further recommendations. (11) All direct care staff will be educated by ADON/Designee about signs and symptoms of food-borne illness. If signs or symptoms are present, the primary care physician of the resident will be notified immediately. (12) Once the issue was identified on 01/27/13, the members of the QA Committee formulated the plan of resolution, which included the Administrator, DON, Maintenance Director I, Assistant Food Service Supervisor, ADON, Dietitian, and Corporate Nurse. A follow-up QA meeting with Medical Director attending was conducted on 01/28/13, to again review the plan of correction and to discuss any other action needed. The plumber's invoice dated 01/27/13 reflected they cleared the floor drains of debris with a small machine and in front of dishwasher, ran hydrant jet machine from clean out to under the building to prevent further problems. The electrician's invoice dated 01/27/13 reflected a new solenoid was wired for the new garbage disposal. An observation on 01/27/13 at 2:00 PM of meal service revealed disposable dishes and silverware, which were not stored in the dishroom were used. Observations on 01/27/13 the noon and evening meals and on 01/28/13 the breakfast meal and noon meals revealed the residents' meals were catered by local restaurants and served out of the activity room kitchen. The facility's In-Service Records, dated 01/29/13 and 01/30/13, reflected the Corporate Dietitian in-serviced all dietary staff on kitchen sanitation issues. They were to be alert of any slow drains and report to the Maintenance Director I or administration. If there was any standing water, immediately stop dishwashing and pot sink washing and notify the Administrator and Maintenance Director I. Halt food preparation until drain was flowing. Do not place the dish racks or dirty pans on the floor. Gloves do not replace hand washing. No food may be touched during tray lines. Clean gloves should be used after hand washing to handle raw foods. Dishes, utensils, and pans should be checked for cleanliness before storing. Silverware must go through the dish machine twice and turned eating end down during last cycle. Pellet system must be used on all hall trays. Organization of tray line and timeliness of meal service were discussed. All dietary staff was in-serviced on the above dates. Observation on 01/2813 at 2:00 PM of the completed cleaning of the kitchen by the contracted company revealed: nonfood-contact surfaces: floors, walls, ceilings, cleaned in place equipment, deep fat fryer, can openers ventilation hood systems and filters, all surfaces in refrigeration and freezers and removable equipment , such as food carts,dishes and flatware were free of the heavy build- up of grease, dirt and dust. On 01/28/13 at 2:45 PM interviews with DM, Cook M and Cook N revealed they knew what to do with the slow drain or if drains had standing water. An interview on 01/29/13 at 1:00 PM with the consultant dietitian revealed in-services for dietary staff on procedures for the slow drains and/or not draining were on -going until all staff were inserviced. The facility's "After Service Follow-up Report," dated 01/27/13, reflected the facility hired a company to deep clean the kitchen on 01/27/13. Their time in was at 7:00 PM and their time out was at 3:45 AM. They cleaned three dietary carts, food bins, stainless steel food racks, and meat racks. They deep cleaned the vent hood, dish machine exhaust, dish room floors and walls. The service to follow up reflected a deep cleaning dated 01/27/13. All chemicals used for cleaning purposes were completely removed during the process. Food prep transport equipment provided by client were deep cleaned, disinfected, and deodorized. The kitchen contained both missing and cracked tiles. The service was provided in the kitchen in seven steps. A degreasing chemical was applied to the floors and walls, and agitated to remove the surface buildup of dirt and grime. All food prep transfer equipment had degreaser applied only. Next, a tile and grout cleanser was applied to remove tough stains, as well as dirt and grime that accumulated in the pores of the tile and grout. After agitating and removing, the second chemical pressure and heat were applied to remove any remaining stains. Based on the conditions of tile and grout, the service provider decided to reduce water pressure to eliminate the possibility of any damage to loose or damaged tiles. The fourth step of the service process was the application of a hospital grade disinfectant for the walls, drains, and floor. The next step was the treatment of [REDACTED]. once the drains were treated, the walls were wiped down, as well as tables, sinks, paper dispensers, etc. To finish, the on-sight supervisor for the provider company makes a final walk through once the floor was dry to ensure the job was completed properly accompanied by the maintenance director for the facility. On 01/29/13 at 2:20 PM, the Administrator, Corporate Nurse, and Regional Director of Operations were informed the IJ was removed. While the IJ was removed, the facility remained out of compliance at a scope of "widespread" and a severity level of "potential for more than minimal harm, that is not immediate jeopardy," because the facility was still monitoring the effectiveness of the POR. Non-IJ Findings Observations on 01/27/13 at 11:22 AM in the kitchen revealed the following: 2. The shelf below the production table had five (5) food bins, whose lids were heavily coated with food spills and grease. One bin lid had a red liquid substance, which the DM confirmed, at that time, was probably meat juice. Another bin lid had what appeared to be rodent droppings. 3. Food on the steam table was ready for lunch. The shelf below the steam table had dried-on food particles, and an employee beverage without a lid was on the same shelf. 4. Five food carts set up for the noon meal had dried-on food spills. 5. The production table's two drawers had dried food spills and crumbs in them, and a "clean" spatula and scraper were in one drawer and both had dried food on them. 6. The ice scoop holder had black coffee ground-like substances on the bottom of the holder and was in need of cleaning. 7. There was a fine film of grease throughout the kitchen, on the tables, walls and floors. The grease on the floors made it difficult to walk. 8. The stove top burners had a heavy amount of burned-on food carbon. The grease catch pan was full and dripping onto the floor. 9. The handwashing sink contained no paper towels in the holder. 10. The large mixer was covered with a trash bag (not approved for food use). The mixer was rusty and on the top of where the blade attached had flour debris. Interview with the DM, at this time, revealed the mixer had not been used recently and had been repaired. 11. The store room for paper products had a large box of napkins directly on the floor. The floor in the store room had a dark grease and dirt mixture. 12. The scoop for the sugar bin, stored in the dry goods store room, was submerged in the product and on the handle. The flour bin's scoop was covered with flour. An opened box of powdered cocoa and two opened boxes of pasta were stored there. 13. An observation on 01/27/13 at 11:59 AM of the walk-in refrigerator revealed a container of something, which the DM identified as gravy, was unlabeled and undated. There was pork thawing with no date on it, and a three-bean salad also did not have a date. Three pounds of ground beef were on a shelf without a pan and the juice had pooled onto a sheet where beef tips had been thawing with no date. 14. An observation on 01/28/13 at 8:35 AM of the flour bin, stored in the dry good store room, revealed small particles appearing to be bug casings. When asked what she planned to do with the flour, the Corporate Dietitian replied, "Toss it out." 15. The Consultant Dietitian Dietary Recommendations, dated 12/12/12, reflected the following: Dish storage area: organize; discard any items not used, store dishes inverted on trays. Janitor room: deep clean; discard any items not needed. Handwashing sinks: ensure paper towel, soap and step on trash can in each area. Stove top/ovens: deep clean Beverage area inside kitchen: deep clean, organize, clean and sanitize daily. Pot and pan sink: clean walls and shelf, clean and sanitize after each meal. Production counter/drawers: deep clean, organize scoops, then clean weekly. 16. On 01/28/13 at 1:00 PM interview with the Corporate Dietitian revealed when she first entered the facility approximately two weeks ago, there was no cleaning schedule. She stated she provided the DM with an example of a cleaning schedule. The DM provided a cleaning schedule, dated 01/17/13, which was incomplete and inconsistently initialed with job duties completed. 17. On 01/29/13 at 8:40 AM, observation of the nourishment room on Nurse's Station B revealed a sign on the front of the refrigerator, which reflected, "Resident refrigerator." An observation of the inside of the refrigerator revealed dried food spills on the floor of the refrigerator and in the bins. Two lunches were observed, one for a [MEDICAL TREATMENT] resident and one of an employee. The counters, in the nourishment room, had a mix of dirty pitchers next to clean pitchers. Under the counter, there was a cleaning product container labeled hazardous to humans and domestic animals. Three of the four drawers had multiple food spills in them. 18. On 01/29/13 at 9:00 AM, Nurse's Station A was observed with one box of standard sterile tongue depressors underneath the sink. There were multiple souffle cups on the floor under the sink next to an orange tool chest. 19. The facility's contracted pest control service's invoice dated 01/28/13 at 3:40 AM - 4:40 AM reflected they treated for [REDACTED]." No problems were found. 20. The facility's Form CMS-672, Resident Census and Conditions of Residents, dated 01/27/13 signed by the DON, reflected a census of 93 residents, with six residents receiving nutrition via a [DEVICE].

Based on observation, interview, and record review, the facility failed to maintain an Infection Control Program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease for four (Residents #11, #16, #14, and #22) of four residents observed for care and for one of one kitchen. 1. Dietary staff failed to remove the ankle-deep waste water, from the backed-up drain which covered the dish room floor and contained chunks of food debris. Dietary staff walked through the waste water, tracking throughout the kitchen, including the food preparation area and where the clean dishes were stacked, while preparing the residents' lunch. After surveyor intervention, the facility did not serve the food prepared in the kitchen to the residents. Instead they had the residents' meals catered. An IJ was identified on 01/27/13. While the IJ was removed on 01/29/13, the facility remained out of compliance at a scope of "widespread" and a severity level of "potential for more than minimal harm, that is not immediate jeopardy," because the facility was still monitoring the effectiveness of the POR. 2. LVN C failed to change her gloves and perform hand hygiene multiple times during wound care for Resident #11. RN D failed to perform hand hygiene before exiting Resident #11's room. RN D also failed to put Resident #11's soiled boot on an appropriate surface at the Nurse's Station. 3. LVN A failed to put Resident #16's soiled dressing in a red medical waste bag. CNA F failed to perform hand hygiene before exiting Resident #16's room, after assisting with wound care. 4. CNA E failed to change her gloves and perform hand hygiene, while providing incontinent care to Resident #14. 5. LVN A failed to place Resident #22's soiled dressing in a red medical waste bag. These failures could affect all 93 residents by placing them at risk for food-borne illness, cross-contamination, infections and diseases. Findings included: 1. On 01/27/13 at 11:22 AM observation of the kitchen revealed lunch was on the steam table. Dishwasher L, whose shoes and bottoms of her pant legs half-way up to her knees were saturated with the waste water, was setting up food carts with trays, beverages, silverware and condiments for the noon meal. An observation on 01/27/13 at 11:30 AM revealed the DM wiping down a production counter using a cloth from a sanitizing bucket. At this time, the DM stated the drain in the dish room backed up and waste water was all over the dish room floor. An observation on 01/27/13 at 11:50 AM revealed Cook M walked from the food production area to the dish room, through the waste water and back to the food production area where lunch was being prepared, which tracked waste water throughout the kitchen. An observation on 01/27/13 at 11:58 AM revealed Cook M measured the concentration of the sanitizing agent in the three-compartment sink and in the container used to sanitize counter tops. No sanitizing solution registered on the chemical strip (Note: This was the same bucket from the observation on 01/27/13 at 11:30 AM that the DM was using to wipe down the counter.) During an observation on 01/27/13 at 12:00 PM, Dishwasher L was standing in a large area of waste water approximately ankle deep at the drain area, which contained numerous chunks of food debris. Both of her shoes and the bottom of her pant legs half-way up to her knees were saturated with the waste water. Interview with Dishwasher L at this time revealed the floor drain in front of the dish machine backed up and the waste water back flowed out onto the floor, while she washed dishes. She stated she thought the drain was snaked earlier this past week. She further revealed the garbage disposal was not working. Observation of the dish room floor on 01/27/13 at 12:00 PM revealed the waste water covered approximately the length and width of the room. The waste water was the deepest at the area around the floor drain. The water was brown, murky and contained chunks of food debris and particles of food. The waste water spread to the clean side of the dish machine, where clean plates were stacked on the clean side of the dish machine. The waste water extended to the floor in front of the three-compartment sink and around to the clean dish room. The waste water continued to overflow to the area where all the clean dishes were stored on carts. During an observation on 01/27/13 at 12:00 PM, Dishwasher L was standing in a large area of waste water approximately ankle deep at the drain area, which contained numerous chunks of food debris. Both of her shoes and the bottom of her pant legs half way up to her knees were saturated with the waste water. Interview with Dishwasher L at this time revealed the floor drain in front of the dish machine backed up and the waste water back flowed out onto the floor, while she washed dishes. She stated she thought the drain was snaked earlier this past week. She further revealed the garbage disposal was not working. Observation of the dish room floor on 01/27/13 at 12:00 PM revealed the waste water covered approximately the length and width of the room. The waste water was the deepest at the area around the floor drain. The water was brown, murky and contained chunks of food debris and particles of food. The waste water spread to the clean side of the dish machine, where clean plates were stacked on the clean side of the dish machine. The waste water extended to the floor in front of the three compartment sink and around to the clean dish room. The waste water continued to over flow to the area where all the clean dishes were stored on carts. On 01/27/13 at 12:00 PM observation of the dish room floor revealed dish racks (used to to run dishes through the dishmachine) were on the floor in the waste water on the clean side of the dishmachine, which put the clean dishes at risk for being splashed with waste water. During this same observation, 13 "clean" plates on the clean side of the dishmachine had dried-on food debris. On 01/27/13 at 12:40 PM the DM was informed he could not serve food out of the kitchen because the drainage problem could cause cross-contamination from the dirty waste water to the clean dishes and food preparation with the potential to cause foodborne illness. An observation on 01/27/13 at 12:50 PM revealed Maintenance Director I using a wet vacuum in the dish room to remove the waste water. Interview with Maintenance Director I at this time revealed he snaked the drain on 01/22/13 when the drain backed up. On 01/27/13 at 12:50 PM, interview with the Administrator revealed he had been informed a week or two ago that one of the drains in the kitchen was slow, but he did not recall which drain. He further stated either Maintenance Director I or the DM was supposed to be putting chemicals down the drain. The Administrator stated he did not recall if he followed up on the slow drain problem. The Administrator was informed the facility could not serve the food that had been prepared. When asked about the plans to feed the residents, the Administrator replied the facility would cater the residents' meals until the problem was resolved. http://www.fda.gov/Food/ResourcesForYou/Consumers/Seniors/ucm 9.htm reflected on 02/14/13, "Why Some People Face Special Risks: Some people are more likely to get sick from harmful bacteria that can be found in food. And once they are sick, they face the risk of more serious health problems, even death. A variety of people may face these special risks...people with chronic illnesses and weakened immune systems and older adults, including people over 65. Why are older adults more susceptible to foodborne illness? Everyone's health is different, including his or her ability to fight off disease. But immune systems weaken as we age. In addition, stomach acid also decreases as we get older -- and stomach acid plays an important role in reducing the number of bacteria in our intestinal tracts -- and the risk of illness. Plus underlying illnesses such as diabetes, some cancer treatments, and kidney disease may increase a person's risk of foodborne illness...." On 01/27/13 an IJ was identified. The Administrator was notified of the IJ on 01/27/13 at 3:30 PM. A POR was requested at that time. On 01/28/13 at 11:40 AM, interview with the Maintenance Assistant revealed he snaked the drain in the dish room on 01/23/13, when the drain backed up. The facility's Plan of Removal was accepted on 01/29/13 at 2:00 PM and included: (1) Facility department heads informed residents of the kitchen auxiliary drain issue, necessary menu changes, and service delays. (2) Kitchen was closed and prepared food was discarded. (3) Emergency food arrangements were made for lunch and dinner on 01/27/13 and breakfast and lunch on 01/28/13. (4) Maintenance Director I unclogged auxiliary drain by snaking the drain on 01/27/13. (5) Plumber provided preventative maintenance to ensure drain was fully operational on 01/27/13. (6) Electrician connected garbage disposal on 01/27/13. (7) Professional Sanitation Company will disinfect and sanitize the walls, floors, and equipment of the entire kitchen by 01/28/13. (8) Pest Control Services will provide additional treatment to the kitchen following the deep sanitation by 01/28/13. (9) All dietary trays, dishes, glasses, cups, utensils, and carts will be cleaned and sanitized by 01/28/13 by the kitchen staff with the Dietitian oversight. (10) Medical Director was notified via Physician Assistant on 01/27/13 and the DON discussed occurrences and corrective actions with the Medical Director on 01/28/13. Medical Director did not have further recommendations. (11) All direct care staff will be educated by ADON/Designee about signs and symptoms of food-borne illness. If signs or symptoms are present, the primary care physician of the resident will be notified immediately. (12) Once the issue was identified on 01/27/13, the members of the QA Committee formulated the plan of resolution, which included the Administrator, DON, Maintenance Director I, Assistant Food Service Supervisor, ADON, Dietitian, and Corporate Nurse. A follow-up QA meeting with Medical Director attending was conducted on 01/28/13, to again review the plan of correction and to discuss any other action needed. The plumber's invoice dated 01/27/13 reflected they cleared the floor drains of debris with a small machine and in front of dishwasher, ran hydrant jet machine from clean out to under the building to prevent further problems. The electrician's invoice dated 01/27/13 reflected a new solenoid was wired for the new garbage disposal. An observation on 01/27/13 at 2:00 PM of meal service revealed disposable dishes and silverware, which were not stored in the dishroom were used. Observations on 01/27/13 the noon and evening meals and on 01/28/13 the breakfast meal and noon meals revealed the residents' meals were catered by local restaurants and served out of the activity room kitchen. The facility's In-Service Records, dated 01/29/13 and 01/30/13, reflected the Corporate Dietitian in-serviced all dietary staff on kitchen sanitation issues. They were to be alert of any slow drains and report to the Maintenance Director I or administration. If there was any standing water, immediately stop dishwashing and pot sink washing and notify the Administrator and Maintenance Director I. Halt food preparation until drain was flowing. Do not place the dish racks or dirty pans on the floor. Gloves do not replace hand washing. No food may be touched during tray lines. Clean gloves should be used after hand washing to handle raw foods. Dishes, utensils, and pans should be checked for cleanliness before storing. Silverware must go through the dish machine twice and turned eating end down during last cycle. Pellet system must be used on all hall trays. Organization of tray line and timeliness of meal service were discussed. All dietary staff was in-serviced on the above dates. Observation on 01/2813 at 2:00 PM of the completed cleaning of the kitchen by the contracted company revealed: nonfood-contact surfaces: floors, walls, ceilings, cleaned in place equipment, deep fat fryer, can openers ventilation hood systems and filters, all surfaces in refrigeration and freezers and removable equipment , such as food carts,dishes and flatware were free of the heavy build- up of grease, dirt and dust. On 01/28/13 at 2:45 PM interviews with DM, Cook M and Cook N revealed they knew what to do with the slow drain or if drains had standing water. An interview on 01/29/13 at 1:00 PM with the consultant dietitian revealed in-services for dietary staff on procedures for the slow drains and/or not draining were on -going until all staff were inserviced. The facility's "After Service Follow-up Report," dated 01/27/13, reflected the facility hired a company to deep clean the kitchen on 01/27/13. Their time in was at 7:00 PM and their time out was at 3:45 AM. They cleaned three dietary carts, food bins, stainless steel food racks, and meat racks. They deep cleaned the vent hood, dish machine exhaust, dish room floors and walls. The service to follow up reflected a deep cleaning dated 01/27/13. All chemicals used for cleaning purposes were completely removed during the process. Food prep transport equipment provided by client were deep cleaned, disinfected, and deodorized. The kitchen contained both missing and cracked tiles. The service was provided in the kitchen in seven steps. A degreasing chemical was applied to the floors and walls, and agitated to remove the surface buildup of dirt and grime. All food prep transfer equipment had degreaser applied only. Next, a tile and grout cleanser was applied to remove tough stains, as well as dirt and grime that accumulated in the pores of the tile and grout. After agitating and removing, the second chemical pressure and heat were applied to remove any remaining stains. Based on the conditions of tile and grout, the service provider decided to reduce water pressure to eliminate the possibility of any damage to loose or damaged tiles. The fourth step of the service process was the application of a hospital grade disinfectant for the walls, drains, and floor. The next step was the treatment of [REDACTED]. once the drains were treated, the walls were wiped down, as well as tables, sinks, paper dispensers, etc. To finish, the on-sight supervisor for the provider company makes a final walk through once the floor was dry to ensure the job was completed properly accompanied by the maintenance director for the facility. On 01/29/13 at 2:20 PM, the Administrator, Corporate Nurse, and Regional Director of Operations were informed the IJ was removed. While the IJ was removed, the facility remained out of compliance at a scope of "widespread" and a severity level of "potential for more than minimal harm, that is not immediate jeopardy," because the facility was still monitoring the effectiveness of the POR. Non-IJ Findings 2. Resident #11's Face Sheet dated 01/29/13 at 9:15 AM reflected the resident was an [AGE] year-old female, admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Observation on 01/28/13 at 11:20 AM revealed LVN C entered Resident #11's room without performing hand hygiene, donned gloves, then removed her gloves and exited the room to the treatment cart in the hallway. Following the removal of her gloves, she did not perform hand hygiene. LVN C next removed gauze squares from a drawer in the treatment cart with her un-sanitized hand, and without using them, returned the gauze squares to their original package. LVN C stated she was a recent hire. Returning at 11:30 AM to Resident #11's bedside, LVN C performed hand hygiene, donned gloves, pulled the room's privacy curtain closed with her gloved hands, and then pulled the trash can, towards the resident's bed, by its inner liner with the same gloved hands. Without changing her gloves, LVN C provided wound care to Resident #11. After cleansing the pressure ulcer on the resident's left heel, LVN C placed the soiled gauze dressing into a clear trash can liner. LVN C did not place the trash can liner in a red medical waste bag on the treatment cart. After completing the dressing change, LVN C was about to place Resident #11's heel, with the uncovered pressure ulcer, back into an inflatable boot that had a brown substance in the heel area. LVN C then went and consulted with RN D. Observation on 01/28/13 at 11:45 AM revealed RN D assessed Resident #11's boot with the brown substance in the heel area, determined it could not be cleaned in the resident's room, elevated Resident #11's heels on pillows, then exited the resident's room with the soiled boot, without first performing hand hygiene. She laid the soiled boot on the counter at the Nurse's Station for Resident #11's hall, before washing her hands. After an unsuccessful attempt to clean the boot, she disposed of it in a red medical waste bag. Interview on 01/31/13 at 9:00 AM with LVN C, regarding wound care and dressing changes, revealed she would: Consult the treatment order; gather garbage bags; don gloves; identify herself to the resident; explain the procedure; wash her hands; put on new gloves; remove the dressing and put it in a red bag, or a regular waste basket liner to later take out to the red bag; cleanse the wound; pat it dry; apply the treatment using Q-Tips for each area requiring treatment; apply the ordered dressing; and date and initial the dressing tape before applying it to the resident. She also stated she would put supplies on wax paper prior to administering the treatment. Regarding hand hygiene, she stated she would clean her hands when she first went into a resident's room, again when she took off a dressing, and then upon leaving the resident's room. Interview on 01/31/13 at 9:25 AM with RN D regarding hand hygiene revealed, "I don't wash hands before I enter a room," or sanitize them. She stated, "If I don't touch the resident, I use hand sanitizer. I don't wash hands unless I've touched the resident," upon leaving the room. RN D revealed she would wash her hands before touching a resident and putting on gloves. She also stated she would wash her hands again after throwing away the gloves. Regarding medical waste, such as soiled dressings, she would wrap it in a glove, throw it in a regular trash can liner, place this liner in a red medical waste bag, and wash her hands. She stated she had received an in-service on hand washing the previous week. 3. Resident #16's Face Sheet dated 02/08/13 reflected the resident was an [AGE] year-old female, admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. Observation on 01/29/13 at 10:10 AM of Resident #16 revealed she had a pressure ulcer on the outer aspect of her right ankle. After changing the resident's dressing, LVN A placed the soiled dressing in a clear trash can liner located in a trash can under the sink in the resident's room. She did not place the clear liner into a red medical waste bag located on the treatment cart. LVN A left the liner in the resident's room. After assisting LVN A by holding Resident #16's leg during the wound care and dressing change procedures, CNA F exited the resident's room without performing hand hygiene. Interview on 01/31/13 at 8:25 AM with CNA F regarding hand hygiene revealed she would wash her hands before coming to work, before entering a resident's room, before leaving the resident's room, if she touched anything, and after breaks. She further stated she received a handwashing in-service on 01/30/13. She had also received training through the computerized in-service system utilized by the facility, on the topic of handwashing. Interview on 01/31/13 at 8:30 AM with LVN A regarding wound care revealed the steps she would follow were: Confirm the resident is in their room, wash her hands, lay out wax paper for supplies, explain the procedure to the resident, remove the old dressing, and place it in a "little red bag." She stated if the soiled dressing was put in a clear trash can liner, she would remove the liner and place it in the red bag on the treatment cart, then wash her hands, put on fresh gloves, clean the wound, assess the wound for redness or drainage, apply the treatment, apply the dressing, and then initial and date the dressing. 4. Resident #14's Face Sheet, dated 02/08/13, reflected the resident was an [AGE] year-old female, admitted to the facility on [DATE], and readmitted on [DATE] with [DIAGNOSES REDACTED]. An observation on 01/29/13 at 9:25 AM revealed CNA E, with gloved hands, wiped Resident #14's anal area and between her buttocks using perineal skin cleanser. Without changing her gloves, she applied [MEDICATION NAME] Skin Protectant between the resident's buttocks and to her lower back. Interview on 01/31/13 at 8:40 AM with CNA E, regarding incontinent care, revealed CNA E would collect supplies, including skin protectant, wash her hands, and remove the soiled brief or pad. Then starting from the front, clean the resident towards the back, clean the resident's "behind," put on the fresh brief or pad, and reposition the resident. CNA E stated she would change gloves after applying the skin protectant and before the brief change. She further stated she should also change gloves after cleaning the resident and before applying skin protectant. CNA E revealed she could not recall the date of her last in-service on incontinent care. 5. Resident #22's Face Sheet dated 01/31/13 reflected the resident was a [AGE] year-old male, admitted on [DATE], and readmitted on [DATE] with [DIAGNOSES REDACTED]. Observation on 01/28/13 at 9:05 AM revealed LVN A providing [DEVICE] care to Resident #22, who had a small amount of serosanguineous (composed of blood and clear serum) drainage around his [DEVICE] site. LVN A gathered her supplies prior to entering Resident #22's room. With gloved hands, LVN A cleansed the site with "dermal wash" then placed the soiled dressing in the bedside trash can without a liner. LVN A then transferred the soiled dressing from the trash can to a clear trash can liner, tied the liner and removed it from the resident's room to a storage area down the hall. LVN A returned to the medication cart, removed her gloves, but did not perform hand hygiene. 6. The facility's current Policy Statement dated June 2010 and entitled Handwashing/Hand Hygiene reflected the following: "5. Employees must wash their hands for at least fifteen (15) seconds using antimicrobial or non-antimicrobial soap and water under the following conditions: ...c. Before and after direct resident contact (for which hand hygiene is indicated by acceptable professional practice) ...k. Before and after changing a dressing ...s. After handling soiled equipment or utensils ...6. In most situations, the preferred method of hand hygiene is with an alcohol-based hand rub. If hands are not visibly soiled, use an alcohol-based hand rub containing 60-95% [MEDICATION NAME] or [MEDICATION NAME] for all the following situations: a. Before and after direct contact with residents; ...f. Before moving from a contaminated body site to a clean body site during resident care; g. After contact with a resident's intact skin; ...j. After removing gloves. 7. Hand hygiene is always the final step after removing and disposing of personal protective equipment ...." The facility's current Policy Statement dated June 2010 and entitled Medical Waste Handling reflected the following: "1. For the purpose of this policy, medical waste includes human blood and blood-soiled articles, contaminated items (i.e., soiled dressings), ... ...4. Disposable items, which are contaminated with excretions or secretions from residents believed to be infectious, must be placed in plastic bags and sealed, and either decontaminated with bleach..., incinerated, or stored in appropriate container until removal from the premises." The facility's current Policy Statement dated October 2010 and entitled Wound Care reflected the following: "The following equipment and supplies will be necessary when performing this procedure.... ...6. Put on exam glove. Loosen tape and remove dressing. 7. Pull glove over dressing and discard into appropriate receptacle. Wash and dry your hands thoroughly...." The facility's undated training curriculum, "An Introduction to Infection Control," reflected, "You should also wash your hands in the following situations...Before and after assisting a resident with personal care and meals...Before and after you use gloves...You should also wash your hands after touching a resident's intact skin to take his pulse or blood pressure and after you help lift a resident...Change your gloves between tasks and procedures involving the same resident...If resident care equipment is soiled with blood or OPIM (other potentially infectious material), do not let it touch your skin, mucous membranes, clothing, or other items in the environment...Dispose of all potentially infectious waste material by placing it in a color-coded or biohazard-labeled container." The facility's Education Report by Course dated 01/30/13 reflected the following employees completed the "An Introduction to Infection Control" curriculum on the following dates: LVN A: 05/14/12 RN D: 06/02/12 CNA E: 10/01/12 CNA F: 10/05/12 The Centers for Disease Control and Prevention (CDC)'s Morbidity and Mortality Weekly Report (MMWR) published 10/25/05, reflected Recommendations for Hand Hygiene including: 1. Indications for handwashing and hand antisepsis A. When hands are visibly dirty or contaminated with proteinaceous material or are visibly soiled with blood or other body fluids, wash hands with either a nonantimicrobial soap and water or an antimicrobial soap and water (IA) (66).B. If hands are not visibly soiled, use an alcohol-based hand rub for routinely decontaminating hands in all other clinical situations described in items 1C-J(IA) (74,93,166,169,283,294,312,398). Alternatively, wash hands with an antimicrobial soap and water in all clinical situations described in items 1C-J (IB) (69-71,74). C. Decontaminate hands before having direct contact with patients (IB) (68,400)...F. Decontaminate hands after contact with a patient's intact skin (e.g., when taking a pulse or blood pressure, and lifting a patient) (IB) (25,45,48,68)...G. Decontaminate hands after contact with body fluids or excretions, mucous membranes, nonintact skin, and wound dressings if hands are not visibly soiled (IA) (400)...H. Decontaminate hands if moving from a contaminated-body site to a clean-body site during patient care (II) (25,53).I. Decontaminate hands after contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient (II) (46,53,54). J. Decontaminate hands after removing gloves (IB)(50,58,321)." 7. The facility's Form CMS-672, Resident Census and Conditions of Residents, dated 01/27/13 and signed by the DON, reflected a census of 93 residents.

Based on observation, interview, and record review, the Administrator and Dietary Manager failed to use resources effectively and efficiently to attain or maintain the highest physical, mental and psychosocial well-being of each resident in 1 of 1 facility. 1. The Administrator failed to follow-up, when he was informed of a slow drain in the Dietary Department. There was ankle-deep waste water, from the backed-up drain which covered the dish room floor and contained chunks of food debris. 2. The DM failed to remove the ankle-deep waste water in the dish room. 3. The DM failed to supervise and instruct his staff to not walk through the waste water and track the waste water through the kitchen. 4. The DM failed to stop food preparation when the drain backed up and back flowed, until after surveyor intervention. An IJ was identified on 01/27/13. While the IJ was removed on 01/29/13, the facility remained out of compliance at a scope of "widespread" and a severity level of "potential for more than minimal harm, that is not immediate jeopardy," because the facility was still monitoring the effectiveness of the POR. These failures could affect the 87 residents who received meals from the facility's only kitchen by placing them at risk for cross-contamination and food-borne illness. Findings included: On 01/27/13 at 11:22 AM observation of the kitchen revealed lunch was on the steam table. Dishwasher L, whose shoes and bottoms of her pant legs half-way up to her knees were saturated with the waste water, was setting up food carts with trays, beverages, silverware and condiments for the noon meal. An observation on 01/27/13 at 11:30 AM revealed the DM wiping down a production counter using a cloth from a sanitizing bucket. At this time, the DM stated the drain in the dish room backed up and waste water was all over the dish room floor. An observation on 01/27/13 at 11:50 AM revealed Cook M walked from the food production area to the dish room, through the waste water and back to the food production area where lunch was being prepared, which tracked waste water throughout the kitchen. An observation on 01/27/13 at 11:58 AM revealed Cook M measured the concentration of the sanitizing agent in the three-compartment sink and in the container used to sanitize counter tops. No sanitizing solution registered on the chemical strip (Note: This was the same bucket from the observation on 01/27/13 at 11:30 AM that the DM was using to wipe down the counter.) During an observation on 01/27/13 at 12:00 PM, Dishwasher L was standing in a large area of waste water approximately ankle deep at the drain area, which contained numerous chunks of food debris. Both of her shoes and the bottom of her pant legs half-way up to her knees were saturated with the waste water. Interview with Dishwasher L at this time revealed the floor drain in front of the dish machine backed up and the waste water back flowed out onto the floor, while she washed dishes. She stated she thought the drain was snaked earlier this past week. She further revealed the garbage disposal was not working. Observation of the dish room floor on 01/27/13 at 12:00 PM revealed the waste water covered approximately the length and width of the room. The waste water was the deepest at the area around the floor drain. The water was brown, murky and contained chunks of food debris and particles of food. The waste water spread to the clean side of the dish machine, where clean plates were stacked on the clean side of the dish machine. The waste water extended to the floor in front of the three-compartment sink and around to the clean dish room. The waste water continued to overflow to the area where all the clean dishes were stored on carts. During an observation on 01/27/13 at 12:00 PM, Dishwasher L was standing in a large area of waste water approximately ankle deep at the drain area, which contained numerous chunks of food debris. Both of her shoes and the bottom of her pant legs half way up to her knees were saturated with the waste water. Interview with Dishwasher L at this time revealed the floor drain in front of the dish machine backed up and the waste water back flowed out onto the floor, while she washed dishes. She stated she thought the drain was snaked earlier this past week. She further revealed the garbage disposal was not working. Observation of the dish room floor on 01/27/13 at 12:00 PM revealed the waste water covered approximately the length and width of the room. The waste water was the deepest at the area around the floor drain. The water was brown, murky and contained chunks of food debris and particles of food. The waste water spread to the clean side of the dish machine, where clean plates were stacked on the clean side of the dish machine. The waste water extended to the floor in front of the three compartment sink and around to the clean dish room. The waste water continued to over flow to the area where all the clean dishes were stored on carts. On 01/27/13 at 12:00 PM observation of the dish room floor revealed dish racks (used to to run dishes through the dishmachine) were on the floor in the waste water on the clean side of the dishmachine, which put the clean dishes at risk for being splashed with waste water. During this same observation, 13 "clean" plates on the clean side of the dishmachine had dried-on food debris. On 01/27/13 at 12:40 PM the DM was informed he could not serve food out of the kitchen because the drainage problem could cause cross-contamination from the dirty waste water to the clean dishes and food preparation with the potential to cause foodborne illness. An observation on 01/27/13 at 12:50 PM revealed Maintenance Director I using a wet vacuum in the dish room to remove the waste water. Interview with Maintenance Director I at this time revealed he snaked the drain on 01/22/13 when the drain backed up. On 01/27/13 at 12:50 PM, interview with the Administrator revealed he had been informed a week or two ago that one of the drains in the kitchen was slow, but he did not recall which drain. He further stated either Maintenance Director I or the DM was supposed to be putting chemicals down the drain. The Administrator stated he did not recall if he followed up on the slow drain problem. The Administrator was informed the facility could not serve the food that had been prepared. When asked about the plans to feed the residents, the Administrator replied the facility would cater the residents' meals until the problem was resolved. http://www.fda.gov/Food/ResourcesForYou/Consumers/Seniors/ucm 9.htm reflected on 02/14/13, "Why Some People Face Special Risks: Some people are more likely to get sick from harmful bacteria that can be found in food. And once they are sick, they face the risk of more serious health problems, even death. A variety of people may face these special risks...people with chronic illnesses and weakened immune systems and older adults, including people over 65. Why are older adults more susceptible to foodborne illness? Everyone's health is different, including his or her ability to fight off disease. But immune systems weaken as we age. In addition, stomach acid also decreases as we get older -- and stomach acid plays an important role in reducing the number of bacteria in our intestinal tracts -- and the risk of illness. Plus underlying illnesses such as diabetes, [MEDICAL CONDITION] treatments, and kidney disease may increase a person's risk of foodborne illness...." On 01/27/13 an IJ was identified. The Administrator was notified of the IJ on 01/27/13 at 3:30 PM. A POR was requested at that time. On 01/28/13 at 11:40 AM, interview with the Maintenance Assistant revealed he snaked the drain in the dish room on 01/23/13, when the drain backed up. The facility's Plan of Removal was accepted on 01/29/13 at 2:00 PM and included: (1) Facility department heads informed residents of the kitchen auxiliary drain issue, necessary menu changes, and service delays. (2) Kitchen was closed and prepared food was discarded. (3) Emergency food arrangements were made for lunch and dinner on 01/27/13 and breakfast and lunch on 01/28/13. (4) Maintenance Director I unclogged auxiliary drain by snaking the drain on 01/27/13. (5) Plumber provided preventative maintenance to ensure drain was fully operational on 01/27/13. (6) Electrician connected garbage disposal on 01/27/13. (7) Professional Sanitation Company will disinfect and sanitize the walls, floors, and equipment of the entire kitchen by 01/28/13. (8) Pest Control Services will provide additional treatment to the kitchen following the deep sanitation by 01/28/13. (9) All dietary trays, dishes, glasses, cups, utensils, and carts will be cleaned and sanitized by 01/28/13 by the kitchen staff with the Dietitian oversight. (10) Medical Director was notified via Physician Assistant on 01/27/13 and the DON discussed occurrences and corrective actions with the Medical Director on 01/28/13. Medical Director did not have further recommendations. (11) All direct care staff will be educated by ADON/Designee about signs and symptoms of food-borne illness. If signs or symptoms are present, the primary care physician of the resident will be notified immediately. (12) Once the issue was identified on 01/27/13, the members of the QA Committee formulated the plan of resolution, which included the Administrator, DON, Maintenance Director I, Assistant Food Service Supervisor, ADON, Dietitian, and Corporate Nurse. A follow-up QA meeting with Medical Director attending was conducted on 01/28/13, to again review the plan of correction and to discuss any other action needed. The plumber's invoice dated 01/27/13 reflected they cleared the floor drains of debris with a small machine and in front of dishwasher, ran hydrant jet machine from clean out to under the building to prevent further problems. The electrician's invoice dated 01/27/13 reflected a new solenoid was wired for the new garbage disposal. An observation on 01/27/13 at 2:00 PM of meal service revealed disposable dishes and silverware, which were not stored in the dishroom were used. Observations on 01/27/13 the noon and evening meals and on 01/28/13 the breakfast meal and noon meals revealed the residents' meals were catered by local restaurants and served out of the activity room kitchen. The facility's In-Service Records, dated 01/29/13 and 01/30/13, reflected the Corporate Dietitian in-serviced all dietary staff on kitchen sanitation issues. They were to be alert of any slow drains and report to the Maintenance Director I or administration. If there was any standing water, immediately stop dishwashing and pot sink washing and notify the Administrator and Maintenance Director I. Halt food preparation until drain was flowing. Do not place the dish racks or dirty pans on the floor. Gloves do not replace hand washing. No food may be touched during tray lines. Clean gloves should be used after hand washing to handle raw foods. Dishes, utensils, and pans should be checked for cleanliness before storing. Silverware must go through the dish machine twice and turned eating end down during last cycle. Pellet system must be used on all hall trays. Organization of tray line and timeliness of meal service were discussed. All dietary staff was in-serviced on the above dates. Observation on 01/2813 at 2:00 PM of the completed cleaning of the kitchen by the contracted company revealed: nonfood-contact surfaces: floors, walls, ceilings, cleaned in place equipment, deep fat fryer, can openers ventilation hood systems and filters, all surfaces in refrigeration and freezers and removable equipment , such as food carts,dishes and flatware were free of the heavy build- up of grease, dirt and dust. On 01/28/13 at 2:45 PM interviews with DM, Cook M and Cook N revealed they knew what to do with the slow drain or if drains had standing water. An interview on 01/29/13 at 1:00 PM with the consultant dietitian revealed in-services for dietary staff on procedures for the slow drains and/or not draining were on -going until all staff were inserviced. The facility's "After Service Follow-up Report," dated 01/27/13, reflected the facility hired a company to deep clean the kitchen on 01/27/13. Their time in was at 7:00 PM and their time out was at 3:45 AM. They cleaned three dietary carts, food bins, stainless steel food racks, and meat racks. They deep cleaned the vent hood, dish machine exhaust, dish room floors and walls. The service to follow up reflected a deep cleaning dated 01/27/13. All chemicals used for cleaning purposes were completely removed during the process. Food prep transport equipment provided by client were deep cleaned, disinfected, and deodorized. The kitchen contained both missing and cracked tiles. The service was provided in the kitchen in seven steps. A degreasing chemical was applied to the floors and walls, and agitated to remove the surface buildup of dirt and grime. All food prep transfer equipment had degreaser applied only. Next, a tile and grout cleanser was applied to remove tough stains, as well as dirt and grime that accumulated in the pores of the tile and grout. After agitating and removing, the second chemical pressure and heat were applied to remove any remaining stains. Based on the conditions of tile and grout, the service provider decided to reduce water pressure to eliminate the possibility of any damage to loose or damaged tiles. The fourth step of the service process was the application of a hospital grade disinfectant for the walls, drains, and floor. The next step was the treatment of [REDACTED]. once the drains were treated, the walls were wiped down, as well as tables, sinks, paper dispensers, etc. To finish, the on-sight supervisor for the provider company makes a final walk through once the floor was dry to ensure the job was completed properly accompanied by the maintenance director for the facility. On 01/29/13 at 2:20 PM, the Administrator, Corporate Nurse, and Regional Director of Operations were informed the IJ was removed. While the IJ was removed, the facility remained out of compliance at a scope of "widespread" and a severity level of "potential for more than minimal harm, that is not immediate jeopardy," because the facility was still monitoring the effectiveness of the POR. The facility's Form CMS-672, Resident Census and Conditions of Residents, dated 01/27/13 signed by the DON, reflected a census of 93 residents, with six residents receiving nutrition via a [DEVICE].