Every finding on record at Perry County Nursing and Rehabilitation Center

Based on record review and interviews, the facility failed to report to the State Survey Agency a major injury of unknown origin for one (Resident #1) of three residents reviewed for accidents with major injuries. The findings include: A review of Resident #1's admission Record revealed the facility admitted Resident #1 on 06/10/2024, with diagnoses which included hemiplegia and hemiparesis following a cerebral infarction affecting the dominant right side, and gout. A review the discharge Minimum Data Set (MDS) with an Assessment Reference Date (ARD) dated on 07/04/2026 revealed a Staff Assessment of Mental Status (SAMS) code of 1, which indicated that Resident #1 had short term memory problems, and 3, which indicated their cognitive skills for daily decision making were severely impaired. The MDS revealed Resident #1 was dependent on staff for toileting hygiene, showering, upper and lower body dressing, personal hygiene, bed to chair transfer, and car transfers. The MDS also revealed Resident #1 was always incontinent with bowel and bladder. A review of the Care Plan initiated on 06/12/2024 indicated Resident #1 was at risk for falls. Interventions indicated to be sure Resident #1's call light was within reach and for Resident #1 to be encouraged to use for assistance as needed. The Care Plan also indicated Resident #1 required prompt response to all requests for assistance and required a mechanical lift with two staff for transfers. A review of a Release of Responsibility for Leave of Absence indicated that Resident #1 was signed out of the facility to attend a funeral on 06/02/2026 at 10:15 AM and returned to the facility on [DATE] at 3:30 PM. A review of a form titled Telemed Visit electronically signed by the APRN on 07/04/2026, revealed, [Resident #1], is evaluated for right lower extremity pain. Resident #1 was not able to participate in the telehealth visit related to cognitive impairment and not being able to speak (resident was non-verbal). Resident #1 complained of pain to the right lower extremity. An x-ray was obtained, revealing a fracture. Resident #1 was total care requiring a mechanical lift, family transferred the resident to a personal vehicle at max assist. On the return trip, the original vehicle broke down, requiring the family to transfer the resident from one vehicle to a smaller vehicle at max assist Resident #1 reports that the pain had been present since the funeral. Review of hospital records with an admission date of 07/04/2026, signed by the emergency room doctor indicated Resident #1 usually transfers from bed to wheelchair and back and had gone to a funeral and got moved around a lot. The ER doctor indicated that when he talked to Resident #1 most of the resident's answers were Nay Nay. Resident #1 was able to answer some questions with yes. The ER doctor indicated that Resident #1 answered Yes when asked if in pain, and if the resident had fallen. He indicated that there was no family or staff at bedside, and he couldn't understand what the resident's further response was. The ER doctor indicated that Resident #1 had a severe type of broken bone where the bone shatters or breaks into three or more pieces. The ER doctor indicated that Resident #1 had a fracture that was usually caused by high impact trauma such as a car crash, a heavy fall, or a severe sports injury. A review of an OLTC Witness Statement Form dated 07/08/2026 signed by Licensed Practical Nurse (LPN) #1, indicated that she was informed by CNA #2 that Resident #1 seemed off. LPN #1 indicated that Resident #1's face, right arm, abdomen, and right leg appeared swollen. LPN #1 assessed Resident #1 who had two plus pitting edema to the right leg, and non-pitting edema to their right arm. Resident #1 stated Ow when their arm, abdomen, and leg were palpated. A review of an OLTC Witness Statement Form dated 07/08/2026 signed by Certified Nurse Aide (CNA) #2 indicated, she noticed swelling to Resident #1's leg, and Resident #1 grabbing their leg. CNA #2 indicated that she reported the incident to LPN #1, and LPN #3. A review of an OLTC Witness Statement Form dated 07/08/2026 signed by Certified Nurse Aide (CNA) #4, revealed she worked with Resident #1 on 07/05/2026. CNA #4 indicated she reported it to the nurse and performed a stop and watch. CNA #4 did not indicate what she reported to the nurse. During an interview on 07/20/2026 at 12:10 PM the Administrator indicated that Resident #1's fracture was not observed by any person, and the resident was not able to inform staff of how they were injured. During an interview on 07/20/2026 at 4:00 PM, the Administrator indicated that an injury of unknown source was an injury where the source of how the fracture occurred was unknown. The Administrator indicated the Director of Nursing (DON) informed her of Resident #1's fracture when the X-rays came in. The Administrator indicated that an injury of unknown origin should be reported to the Office of Long-Term Care (OLTC) immediately. The Administrator indicated that she was responsible for reporting resident's injuries of unknown origin to OLTC. The Administrator indicated that OLTC was not notified of the fracture that Resident #1 sustained on 07/04/2025 because Resident #1 was having more stiffness when Resident #1 returned from the funeral, she could not recall the date of the funeral. She indicated Resident #1 was a total care patient and always had pain. The Administrator indicated she believed that Resident #1's history and medication caused the pathological fracture, and it was the reason OLTC was not notified. The Administrator indicated that she did not believe that anyone had abused Resident #1. Therefore, she did report the fracture to the police or the Medical Director. During an interview on 07/21/26 at 1:00 PM, LPN #5 indicated when she arrived for her shift the morning of 07/04/2026, Resident #1 had edema in the right hand and right knee. LPN #5 indicated that Resident #1 did not talk a lot and would say, Way way. LPN #5 indicated that she could tell that Resident #5 was in pain During an interview on 07/21/2026 at 2:23 PM, CNA #6 stated. Resident #1 was expressing pain in the right knee when I rolled [the resident] in bed on Friday morning (07/03/2026). CNA #6 indicated that Resident # was up in the dining room when she arrived at work on 7/04/2026. Resident #1 was put in bed around 8:30 AM and that's when their pain was noticed to be increasing. CNA #6 stated, [Resident #1] was fine until [staff] got [the resident] up for lunch, Resident #1 then expressed pain again. CNA #6 indicated that she had no idea how Resident #1 got the fracture, and accidents should be reported as soon as you see them. CNA #6 indicated that Resident #1 was non-verbal and would say Way way and use gestures. During an interview on 07/22/2026 at 6:43 AM, CNA #7 stated on 07/04/2026, when time to change Resident #1, the resident complained of pain. My partner, CNA # 2, was on the hall more than me. CNA #2 went to get LPN #3 and LPN #1, and they checked on Resident #1. CNA #7 indicated she did not remember the time Resident #1 was gotten up that day, but the resident was in bed when the nurse came. CNA #2 stated Resident #1 was a two-assist with a lift, and she had never transferred Resident #1 by herself. CNA #2 stated, Resident #1 could not tell us how they got the fracture. Resident #1 only used the words Way Way and Yeah. Resident #1 was able to use gestures and point to tell us if they were in pain. During an interview on 07/22/2026 at 6:50 AM, LPN #3 indicated that Resident #1's right leg was swollen. LPN #3 indicated that Resident #1 could not tell LPN #1 if they were in pain. LPN #3 indicated that all Resident #1 would say was Yeah and Way way. LPN #3 indicated she did not know how the resident got the fracture. LPN #3 indicated that Resident #1 transferred using a mechanical lift with two staff and there were always two people available to transfer Resident #1. LPN #3 indicated that accidents should be reported immediately. During an interview on 07/22/2026 at 7:08 AM, CNA #8 indicated Resident #1 was non-verbal and would only say Yeah and way on the days when the resident was very alert. CNA #8 indicated that Resident #1 required a two-person-assist with a mechanical lift only for transfers. CNA #8 indicated the last in-service on accidents was on 06/22/2026, and accidents were reported immediately to the nurse. During an interview on 07/22/2026 at 7:15 AM, CNA #2 indicated that she checked on Resident #1 with CNA #7 at approximately 4:00 AM on 07/04/2026. CNA #2 indicated Resident #1 looked really swollen all over. CNA #2 indicated she asked Resident #1 if and where they were hurting and the resident started fanning their right leg with their hand and saying, Way way. CNA #2 indicated that when she pulled the covers back, she noticed Resident #1's leg was swollen. CNA indicated that LPN #1 & #3 assessed Resident #1 and sent the resident to the emergency room. CNA #2 indicated that Resident #1 transferred with two people using a mechanical lift. CNA #2indicated that Resident #1 could not bear weight at all. CNA #2 indicated that her last in-service on accidents was 06/22/2026. CNA #2 indicated d that accidents were reported to the charge nurse immediately, and she did not have a clue how Resident #1 got the fracture. During an interview on 07/22/2026 at 7:31 AM, CNA #9 indicated Resident #1 transferred using a lift with two people. CNA #9 indicated that she did not know how Resident #1 got a fracture. During an interview on 07/22/2026 at 8:10 AM, the Administrator indicated that she completed an internal investigation although she thought Resident #1's fracture was pathological. The Administrator indicated the investigation started when the DON called her on 07/04/2026. During a follow up interview on 7/22/2026 at 8:55 AM, the Administrator indicated she determined the fracture was pathological based on Resident #1 being bed bound, did not walk, and took medications such as: steroids, anti-epileptics, diuretic, and an anti-depressant. The Administrator indicated she was not at the facility when she started the investigation but read Resident #1's chart and everything the DON sent to her. The Administrator indicated she returned to the facility from vacation on 07/07/26 and spent most of the day (07/08/2026) completing staff interviews. The Administrator indicated after she received the hospital records on 07/09/2026 it helped conclude her findings and gave confirmation that she was correct. The Administrator indicated she did not report the fracture to OLTC because she thought immediately the fracture was pathological after she received the phone call from the DON. During a phone interview on 07/22/2026 at 3:10 PM, the Medical Director (MD) indicated Resident #1 was losing bone mass, immobile, and a fracture was more likely. These factors made it much more likely to get a fracture. The MD indicated he did not see anything suspicious from his standpoints. As far as the fall , the MD indicated, he did not recall any bruising on the arms noted on records, and it looked like Resident #1 may have had some difficulty getting in and out of the car. The MD indicated he would not be surprised if the fracture had not come from Resident #1 getting in and out of the car when Resident #1 was out with family, but that he was not 100% sure how Resident #1 got the fracture. The MD indicated he was not sure of the rules with OLTC and when they should be contacted. The MD indicated it was hard to tell with a resident who has cognitive impairment when they are in pain. He indicated Resident #1 had a board that was used for communication, but even with the board Resident #1 did not give purposeful information. The MD indicated that it was hard to determine when the fractures were acquired, and how much pain Resident #1 was in at the facility. During a phone interview on 07/23/2026 at 4:30 PM, the Radiology Director indicated Resident #1's bone fracture could relate to Resident's #1 medical condition, and the fact that Resident #1 was immobile. The Radiology Director indicated he was not 100% sure if Resident #1's fracture was from their diagnosis, medical condition, transferring, or a fall. Review of the in-service training sheet indicated an Abuse In-service was conducted on 06/22/2026 by the administrator. Review of an Abuse Policy indicated that injuries of unknown source is when the injury was not observed by anyone, or the injury could not be explained by the resident. The injury is suspicious because of the extent and location of the injury.

Based on observations, interviews, record review and facility policy review, it was determined that the facility failed to develop and implement a comprehensive person-centered care plan for one (Resident #58) of five residents reviewed for comprehensive person center care plans. The findings include: Review of an admission Record indicated the facility admitted Resident #58 on 09/25/2025 with diagnoses that included degeneration of the brain, dementia with mood disturbances, depression, anxiety, wandering and repeated falls. Review of a quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/02/2026, revealed Resident #58 had a Brief Interview for Mental Status (BIMS) score of 4 which indicated the resident had severe cognitive impairment and was severely impaired for daily decision making. The MDS indicated Resident #58 was dependent on supervision of staff and touch assistance to walk 10 feet, to walk 50 feet with two turns and to walk 150 feet. Position changes from sitting to lying, lying or sitting on the side of the bed was supervision and touch assistance. The MDS indicated Resident #58's sit-to-stand motor skills required setup or clean up assistance and Resident #58 was frequently incontinent for bowels and bladder and falls with no injuries had occurred two or more times and one fall occurred with injury (except major). Review of Resident #58's Care Plan, initiated on 10/06/2025, revealed the resident required a secured/special care unit due to behaviors and the resident had a high risk for falls with actual falls documented. Interventions included placing Resident #58 on the memory unit of the facility. The Care Plan indicated Resident #58 exhibited behaviors such as wandering, verbal aggression, physical aggression, agitation, and confusion. Resident #58's Care Plan did not indicate the newly displayed behaviors of lying/sitting on the floor and the Care Plan did not indicate any interventions for this behavior. Review of Medication Administration Record and the Treatment Administration Record for March of 2026, revealed Resident #58 had the following medications administered: Allergy medication related to repeated falls, an antidepression medication, two antipsychotic medications for degeneration of the brain, two antianxiety medications, medication for dizziness, and a pain medication. Review of a Record for In-service Training dated 03/06/2026 and given by Licensed Practical Nurse (LPN) #1, indicated Resident #58 was lying on the floor sporadically throughout the day. The in-service encouraged staff to ensure Resident #58 was visible, location known and to encourage Resident #58 to sit in a chair or get in bed if tired. LPN#1 indicated to keep other residents safe from tripping or falling. A review of Resident #58's Custom Progress Notes, provided by LPN #1 on 03/19/2026 at 12:09 PM, indicated behaviors of crawling, sitting and lying on the floor throughout the unit began on 12-09-2026. The Custom Progress Notes indicated the following: -On 12/09/2025 Resident #58 was observed crawling on the floor. -On 12/10/2025 Resident #58 was observed lying on the floor.-On 12/18/2025 Resident #58 was observed crawling around on the floor in other residents' rooms.-On 12/24/2026 Resident #58 was observed laying on the floor beside the staff while charting.-On 01/20/2026 and 01/21/2026 Resident #58 was observed taking a seat on the floor. -On 01/27/2026 Resident #58 was assisted up from the floor by staff and the Resident #58 laid back down on the floor unassisted. -On 01/30/2026 Resident #58 was observed laying and sitting on the floor and it was reported to the nurse. -On 02/07/2026 Resident #58 was observed gently sitting on the floor. Staff offered a chair for Resident #58 to sit in. -On 02/18/2026 Resident #58 observed taking a seat on the floor while staff assisting other residents. On 03/16/2026 at 12:02 PM, a surveyor observed Resident #58 lying on the floor in the middle of the hall on the memory care unit. The surveyor was advised by Certified Nursing Assistant (CNA) #2, lying on the floor was a known behavior of Resident #58. CNA #2 reported being advised to document the behavior when it was observed. During an interview on 03/19/2026 at 10:55 AM, CNA #3 indicated CNAs enter a stop and watch in the computer when they needed to document and alert the nurses for increased behaviors for Resident #58. During an interview on 03/19/2026 at 11:01 AM, CNA #2 indicated Resident #58 liked to crawl, sit, and lay on the floor. CNA #2 indicated she had voiced her concerns to the Administrator and the Director of Nurses (DON) and CNA#2 was advised the team of all the department heads would meet and come up with interventions for the behavior. CNA #2 indicated this was a recent behavior Resident #58 had started within the last two to three months. CNA #2 indicated staff documented behaviors for Resident #58 under custom notes in the electronic record. CNA #2 stated Residents #58's behavior was a fall risk to the other residents because Resident #58 would lie down in front of the other residents' doorways. During an interview on 03/19/2026 at 11:25 AM, CNA #4 indicated Resident #58 had a new behavior of sitting on the floor. CNA #4 stated Resident #58 was observed by her lying on the floor in front of a resident's room and while she was ambulating the other residents to the shower. During an interview on 03/19/2026 at 12:09 PM, LPN #1 indicated that she created and conducted an in-service related to Resident #58's behavior of lying on the floor. LPN #1 stated all department heads were assigned a hall, and they were to review all new or changed behaviors for that day. LPN #1 stated a new or changed behavior should be Care Planned. LPN #1 confirmed CNA #2 had notified her of Resident #58's behaviors. During an interview on 03/19/2026 at 1:05 PM, LPN #5 indicated that she was responsible for updating Care Plans. LPN #5 stated she was aware of Resident #58's behavior of sitting on the floor and stated, yes that is something that should be care planned. LPN #5 indicated if the information was not included in the Care Plan, then staff would not know how to care for the residents, and the behavior is a fall risk for the other residents. During an interview on 03/19/2026 at 1:09 PM, the DON indicated Resident #58 started the new behaviors at the beginning of January. The DON stated CNAs were trained to enter custom alerts on residents and the nurses must do a follow-up note on the custom alert. The DON indicated the behaviors had been discussed and it was discussed to have the behaviors Care Planned. The DON indicated without the information listed in Resident #58's Care Plan, staff would not know how to care for the resident. The DON stated, the behaviors were a fall risk and caused mental anguish for the other residents. During an interview 03/19/2026 at 1:40 PM, the Administrator indicated Resident #58 had consistently been displaying the behaviors of lying and sitting on the floor since mid-December and it had not been consistently addressed. The Administrator stated that behaviors should be included in all Care Plans and that the Unit Coordinators and the Interdisciplinary Team (IDT) were responsible for making rounds every morning and checked for any changes with the residents and reviewed documentation for changes with the residents. The IDT consisted of all the department heads such as the Administrator, the DON, the MDS coordinator, the CNA Coordinator and the Treatment Nurse. The Administrator stated, the behavior was Care Planned now and that she updated the record herself. The Administrator reported that the nurses documented clinical alerts and the CNAs were trained to do stop and watch custom alerts. The Administrator stated once the alerts were received the information should be Care Planned then cleared and that apparently the staff had been clearing the alerts without the information being Care Planned. The Administrator was unsure which staff were assigned as Unit Coordinator for the hall Resident #58 resided on. During a follow-up interview on 03/19/2026 at 2:20 PM, the Administrator reported that she had spoken with the DON and was advised that LPN #1 was the nurse responsible for reviewing the hall Resident #58 resided on. The Administrator reported LPN #1 stated she was unaware that was her hall to cover for review. The Administrator also reported that the Unit Coordinators were responsible for making rounds every morning and checking for any changes with the residents and reviewing documentation for changes with the residents to discuss in the morning meetings. This surveyor requested a facility policy related to Care Plans. The Administrator stated the facility did not have a policy for Care Plans.

Based on observations, record review, interview, and review of the facility policy, the facility failed to ensure employees washed their hands between handling dirty equipment and clean equipment, food items stored on the freezer were covered or sealed to prevent the potential for foodborne illnesses, and hot food items were maintained of 135 degrees Fahrenheit or above on the steam table while awaiting service to prevent potential food borne illness for residents who received meals from 1 of 1 kitchen. The findings are: 1. On 9/3/24 at 9:20 AM, Dietary [NAME] (DC) #1 removed a bottle of coke and a glass containing coke from the counter and placed them on the window bar, contaminating her hands. DC #1 removed her gloves from the glove box and placed them on her hands, contaminating the gloves in the process. Without changing gloves and washing her hands. DC #1 then picked up a cucumber from the counter and peeled it. The cucumber slices were placed on top of the salad to be served to the residents who requested salad with their meals. 2. On 9/3/24 at 9:35 AM, the following observations were made on a shelf in the walk-in freezer: a. An opened box of biscuits, the box was not closed. b. An opened box of cheddar biscuits, the box was not closed. c. An opened box of sausage links, the box was not covered or sealed. d. An opened box of lima beans, the box was not covered or sealed. e. An open box of beef fritters, the box was not covered or sealed. f. An opened box of cookie dough, the box was not covered or sealed. Dietary Aide (DA) #2 was asked what would happen if food items were not completely covered or sealed. DA #2 stated it will cause freezer burn. 3. On 9/3/24 at 11:45 AM, DC #3 wore gloves on her hands when she picked up a spray bottle and sprayed inside a pan, contaminating her hands. Without changing gloves and washing her hands, she picked up a clean blade and attached it to the base of the blender. DC #3 was asked what she should have done after touching dirty objects and before handling clean equipment. DC #3 stated, I should have removed gloves and washed my hands. 4. On 9/03/24 at12:10 PM, DC #1 checked the temperatures of the hot food items that had been placed on the serving line on the steam table in preparation for the noon meal service. The temperatures were: a. Pureed pork chops - 120 degrees Fahrenheit. b. Ground pork chops - 119 degrees Fahrenheit. c. Fortified mashed potatoes - 119 degrees Fahrenheit. DC #1 stated it's stopping at 119 degrees Fahrenheit. The above food items were not reheated when served to the residents. 6. A review of a facility policy titled, Handwashing and Glove Usage in Food Service, not dated, and provided by the Dietary Manager on 9/3/2024, indicated, hands must be washed before starting work and when engaging in any activities that may contaminate hands.

Based on observations, record review, interview, and review of the facility policy, the facility failed to ensure pureed food items were blended to a smooth, lump free consistency to minimize the risk of choking or other complications for those residents who required pureed diets for 1 of 1 meal observed. The findings are: 1. On 9/03/24 at 11:50 AM, Dietary [NAME] (DC) #3 placed 6 servings of breaded fried pork chops into a blender, added a carton of whole milk and pureed. At 11:52 AM, DC #3 scraped pureed pork chops into a pan, covered the pan with foil and placed it in the oven. The consistency of the pureed fried chops was more of a ground texture and thick. 2. On 9/3/24 at 11:09 AM, DC #3 used a #8 scoop (1/2 cup) to portion 6 servings of turnip greens into a blender and pureed. At 11:11 AM, DC #3 poured the pureed greens into a pan, covered the pan with foil and placed it in the oven. The consistency of the pureed turnip greens was thick. 3. On 9/3/24 at 11:23 AM, DC #3 used a #8 scoop to portion 6 servings of black-eyed peas into a blender, added a carton of whole milk and pureed. At 11:25 AM, DC #3 scraped the pureed black-eyed peas into a pan, covered the pan with foil and placed it in the oven. The consistency was lumpy and thick. 4. On 9/3/24 at 12:58 PM, the Dietary Manager stated pureed meat had consistency of ground meat and was too thick. They did not put gravy on it. 5. On 9/3/24 at 1:04 PM, DC #3 who prepared the pureed food items stated the pureed turnip greens, pureed black-eyed peas and pureed fried pork chops were too dry. They were dry when I put them in the oven. I used a carton of milk when I pureed the pork chops and peas. 6. On 9/3/24 at 12:10 PM, the consistency of the pureed turnip greens remained as thick as it was when first pureed and placed in the oven and when taken out of the oven and placed on the steam table. Pureed black-eyed peas and pureed fried pork chops remained as thick and lumpy as they were when first pureed and placed in the oven and when taken out of the oven and placed on the steam table. This consistency persisted when they were served to the residents. 7. A review of a facility policy titled, Therapeutic and Modified Diets, initiated 8/24/20 and provided by the Dietary Manager on 9/4/2024, indicated to make sure residents received foods with the appropriate texture.

Based on observation, record review and interview, the facility failed to ensure meals were prepared and served according to the planned written menu to ensure that nutritionally balanced meals were provided for the residents for 1 of 1 meal observed. The findings are. 1. On 9/3/24 the noon meal menu indicated all residents on mechanical soft diets were to receive 2 ounces of gravy and for pureed diets, 2 ounces of gravy and one #10 (equivalent to 3 ounces) scoop of pureed bread. 2. On 9/3/24 at 12:23 PM, the residents on pureed diets were not served cornbread or regular bread. There were no substitutes served to the residents in place of bread. 3. On 9/3/24 at 12:50 PM, the residents on mechanical soft diets were not served gravy. 4. On 9/3/2024 at 1:06 PM, during an interview Dietary [NAME] (DC) #1 was asked about the texture of the pureed bread prepared to serve to the residents on pureed diets. DC #1 stated it looked like a dough ball when prepared, so it was not served to the residents. DC #1 confirmed she made gravy but forgot to serve it.

Based on observation, interview, and record review, the facility failed to ensure residents on the Dementia Unit were supervised at all times to prevent accidents and hazards for 1 (Resident #50) sampled resident. Findings are: On 9/3/2024 at 12:18 PM, Resident #50 was in the Observation Hall (a locked unit for residents with dementia) Dining Room sitting in a mobility device. Resident #50 self-propelled up to the trash can, located along the outside wall, lifted the lid and reached in with both hands. Resident #50 closed the lid and self-propelled out of the dining room. Staff was not in dining room during this time. On 9/3/2024 at 12:58 PM, Certified Nursing Assistant (CNA) #4 left seven dementia residents to eat in the Observation Hall Dining Room unattended (drink and meals were in front of residents). CNA #4 went to get an alternative meal for a resident. CNA #4 was gone from the dining room between 12:58 PM to 1:06 PM. On 9/5/2024 at 8:45 AM, CNA #4 stated it was unsanitary for Resident #50 to place both arms in the trash bin. You don't want the resident to pick anything up from inside the trash can and place the item in their mouth. CNA #4 confirmed there should always be an employee in the Observation Hall Dining Room in case a resident choked or needed something, fell or became combative or needed redirection. On 09/05/24 at 08:53 AM, Licensed Practicing Nurse (LPN) #5 confirmed Resident #50 arms should not be inside the trash can; it was not sanitary, and there is a concern of an item placed in the residents' mouth. There should always be a staff member in the Observation Hall Dining Room, during mealtimes, for resident safety due to choking hazards or behaviors. On 9/05/24 at 8:56 AM, the Director of Nursing (DON) confirmed there was a concern of infection control and safety of Resident #50 putting their arms inside the trash can. There should be staff in the Observation Hall Dining Room during mealtime, to ensure no one choked, and or had an altercation or fell . The Facility did not have an Observation Hall Dining Room policy/procedure.

Based on observation, record review, and interview, the facility failed to ensure foods stored in the storage area, freezer, and refrigerator were covered, sealed and dated to minimize the potential for food borne illness for residents who received meals from 1 of 1 kitchen; and expired food items were promptly removed from stock to prevent potential food borne illness for residents who received meal trays from I of I kitchen; dietary staff washed their hands and changed gloves before handling food items to prevent the potential for cross contamination for residents who received meals from 1 of 1 kitchen. and hot food items on the steamtable were maintained at a temperature at or above 135 degrees Fahrenheit while awaiting service, to prevent potential food borne illness for residents who received meals from 1 of 1 kitchen. These failed practices had the potential to affect 52 residents who received meals from the Kitchen (Total Census: 54), according to the list provided by the Dietary Supervisor on [DATE] PM The findings are: 1. On [DATE] at 10:28 AM An opened bag of bread was on the bread rack in the kitchen. The bag was not sealed. 2. On [DATE] at 10:32 AM, the following observations were made on a shelf in the walk-in freezer. a. An opened box of French toast sticks was not covered or sealed. They had freezer burn. The Dietary Supervisor stated, they have freezer burn. I will throw them away. b. An opened box of Salisbury steak was not covered or sealed. c. An opened box of chicken was not covered or sealed. 3. On [DATE] at 10:35 AM. A container of cucumber with onion was on a shelf in the walk-in refrigerator with an expiration date of [DATE]. 4. On [DATE] at 11:38 AM Dietary Employee (DE)#2 opened a bag of mix whip topping and emptied it into a pan. Without washing her hands, she placed a glove on her hand, contaminated the glove, and used the same gloved hand to push mixed fruits into a pan that contained coconut flakes to be used in making ambrosia deluxe for the supper meal. 5. On [DATE] at 11:56 AM DE #3 took the temperature of the food items on the steam table with the following results. a. Pureed dinner roll with milk 118 degrees Fahrenheit. b. gravy 113 degrees Fahrenheit. The above items were not reheated before being served to the residents. 6. On [DATE] at 12:16 PM DE #3 turned on the 3-compartment sink faucet and rinsed tomatoes. After rinsing the tomatoes, she turned off the faucet, contaminating her hands. She used the same hand to hold the tomatoes from falling out of the container while draining the water. DE #3 then placed the container with the tomatoes on the counter. At 12:21 PM she turned on the hand washing sink faucet and washed her hands. After washing her hands, she pushed down on the handle of the paper tissue dispenser to release tissue and dried her hands. At 12:23 PM She removed gloves from the glove box and placed them on her hands, contaminating the gloves. Without changing gloves and washing her hands, she picked up a tomato from the container and placed it on the cutting board to slice. The surveyor immediately stopped her and asked what should you do after touching dirty objects and before handling food items and clean equipment? She stated, I should have rewashed my hands. 7. The facility policy titled, hand washing provided by the Dietary Supervisor on [DATE] at 4:33 PM documented, Staff will wash hands and exposed portions of their arms to remove contamination: a. After entering the kitchen. b. After handling soiled utensils. c. During food preparation. d. Before donning gloves for working with food. e. After engaging in their activities that contaminates the hands. 2. Procedure: a. Rinse hands under clean, warm running water. b. Apply soap. c. Rub together vigorously for approximately 20 seconds. d. Rinse thoroughly under clean, running warm water. e. Shut off the water faucet without contaminating clean hands (i.e., by using a paper towel).

Based on observation and interview, the facility failed to ensure medication was stored in a safe manner and failed to ensure expired medications were removed from one of one medication rooms, to prevent potential administration of an expired medication to a resident. The failed practices had the potential to affect all 54 residents who reside in the facility. The findings are: 1. On 07/11/2023 at 10:39 AM observed Resident #25 in a recliner in their room. On the over bed table, within reach of the resident, were two medications with the resident's name on the label. One was a Breo Ellipta Inhaler the other was an Ipratropium Bromide Solution nasal spray. Resident #25 stated, I am supposed to take it back to her (meaning the nurse) after I give it to myself. I always do it that way. a. On 07/16/2023 at 10:40 AM interview with Licensed Practical Nurse (LPN) #2 who stated, she left the inhaler in the room, and stated he thought the resident had a self-administration assessment. b. Review of the policy, Medication, Self-Administration of, last updated on 5/1/15 noted, .storage of medications in the resident's room must be such that it will prevent access by other residents . 2. On 07/18/2023 at 2:53 PM during inspection of the medication storage room the following observations were made: a. One open vial of Tubersol Tuberculosis testing serum, located on the top compartment of the refrigerator door, did not have an open date documented on the vial. b. Two open vials of pneumonia vaccine, located in the top compartment of the refrigerator door, had an expiration date of 07/17/23 and did not have an open date documented on the vial. c. One unopened 30 ml (milliliter) bottle of Lorazepam oral concentrate, a controlled substance, was in a blue bin that was not secured by a second lock, the bin was under the locking mechanism resting on the refrigerator shelf. d. Two bottles of open Nitroglycerin tablets, were in a storage cabinet with an expiration date of 06/2023 and did not have an open date on the bottle. e. One 20 ml open vial of Lidocaine 1% was in a storage cabinet and did not have an open date on the vial. f. On 07/18/2023 at 2:20 PM interview with LPN #4 who stated one resident self-administers Gas X and stated other than that, no other medications are left in the rooms. She stated the resident that has medication stays in the room and does not have a roommate. LPN #4 was asked, How do you ensure that no other resident takes the medication? LPN #4 responded, Her door stays closed, and she has no roommate at this time. g. On 07/18/2023 at 2:33 PM interview with LPN #1 who stated only one resident in the facility self-administers medications, and the medication is kept at the bedside and further stated the resident does not have a roommate and does not leave the room. h. On 07/18/2023 at 2:38 PM interview with the Director of Nurses (DON)who stated, there are two residents who self-administer medications and stated the Gas X is kept in the resident's room. She stated that resident does not have a roommate. i. On 07/20/2023 at 08:55 AM the surveyor asked LPN #5, why is it important to add an open date to the medication? LPN #5 responded, To make sure it is not expired. The surveyor asked LPN #5, how many locks should a controlled substances be behind and why is this important? LPN #5 replied, Two locks, because they are controlled and only prescribed to one person. The surveyor asked LPN #5, what could be the outcome of administering expired drugs? LPN #5 responded, It would be a medication error and it's not going to work correctly. j. On 07/20/2023 at 09:00 AM the surveyor asked LPN #3, why is it important to add an open date to the medication? LPN #3 responded, they will expire, and they are only good for a certain number of days The surveyor asked, what could be the result of administering medication without knowing an open date? LPN #3 replied, you won't know when it expires. LPN #3 stated controlled substances are kept under, two locks for safety. k. On 07/20/2023 at 09:03 AM interview with the Director of Nurses (DON) who stated, medication vials are dated when opened so you will know when to discard the medication. She stated without dating the medication, there is a risk of administering expired medication. She confirmed the controlled substances are required to be under two locks to keep unauthorized people from taking it. l. The policy for Medication Storage in the Facility, obtained from the Administrator on 07/20/23 at 9:30 AM documented, .When the original seal of a manufacturer's container or vial is initially broken, the container or vial will be dated the nurse shall place a date opened sticker on the medication and enter the date opened and the new date of expiration .the nurse will check the expiration date of each medication before administering it .all expired medications will be removed from the active supply .Controlled-substances that require refrigeration are stored within a locked box within the refrigerator. This box must be attached to the inside of the refrigerator .

Based on observation, record review, and interview, the facility failed to ensure meals were prepared and served according to the planned written menu to meet the nutritional needs of the residents for 1 of 1 meal observed. This failed practice had the potential to affect 44 residents who received regular diets,10 residents who received mechanical soft diets, and 8 residents who received pureed diets from the kitchen according to a list provided by the Assistant Dietary Supervisor on 07/16/2023. The findings are: 1. The facility menu for lunch provided by the Assistant Dietary Supervisor on 07/16/23 at 1:37 PM, noted each resident who received regular diets were to receive 4 ounces of fried chicken, each resident on mechanical soft were to receive 4 ounces of ground fried chicken and each resident on pureed diets were to receive a #8 scoop (4-ounces) of pureed fried chicken. 2. The following observations were made during the noon meal preparation and meal observation. a. On 07/16/23 at 10:59 AM Dietary Employee (DE) #1 used a #16 (Blue) scoop (2 ounce) to place 18 servings of leftover pulled turkey roast into a blender, a total of 36 ounces. At 11:02 AM DE #1 poured it into a pan and placed it in the oven to be served to 10 residents on mechanical soft diets. The menu noted the residents were to receive 4 ounces, which would require a total of 40 ounces. At 12:10 PM, DE #1 used an #8 scoop (4 ounces). Although DE #1 used the correct scoop, she still served half of the resident's smaller portions of ground pulled roast turkey to the residents on mechanical soft diets, instead of full servings of a #8 scoop as specified on the menu. 3. 07/16/23 at 11:06 AM, when DE #1 was about to put small sizes of regular chicken breasts into the blender to puree, the surveyor asked for the chicken to be weighed. DE#1 weighed it as 2.5 ounces. At 11:09 AM she placed 11 servings of chicken breast into a blender for a total of 27.5 ounces. At 11:11 AM, DE #1 added 4 cups of gravy and pureed it. At 11:12 AM she poured the pureed meat into a pan and placed it in the oven to be served to 8 residents on pureed diets. The written menu called for 4 ounces per resident which would require 32 ounces of chicken. 4. On 07/16/23 at 1:00 PM 33 residents on regular diets were served one chicken leg each. At 1:04 PM the surveyor asked the Assistant Dietary Supervisor to weigh the same amount of fried chicken served to the residents for lunch. She did so, and stated, It weighed 2.5 ounces. At 1:08 PM the surveyor asked DE #4 the reason the residents on mechanical soft diets and residents on pureed diets received different types of meat. She stated, I used the leftover roasted turkey for the mechanical soft diets and grilled chicken breast from the freezer for the pureed diets.

Based on observation, interview, and record review the facility failed to prevent a resident from self-administering medications without being assessed for self-administration of medication for 1 (resident #25) of 15 sampled residents. On 07/11/2023 at 10:39 AM observed Resident #25 in a recliner in their room. On the over bed table, within reach of the resident, were two medications with the resident's name on the label. One was a Breo Ellipta Inhaler the other was an Ipratropium Bromide Solution nasal spray. Resident #25 stated, I am supposed to take it back to her (meaning the nurse) after I give it to myself. I always do it that way. Review of the physician orders dated 08/09/2022 revealed an order for Breo Ellipta Aerosol Powder inhalation one time a day and Ipratropium Bromide Solution nasal spray two times a day. There was no order for the resident to self-administer the medications. A review of Resident #25 medical record failed to reveal a medication self-administration assessment. A review of Resident #25 care plan revealed a care plan for allergies, last updated on 4/14/20, with an intervention to give medications as ordered, and lists Ipratropium Bromide, but does not indicate the resident can self-administer the medication. A care plan with an initiated date of 3/14/22 for altered respiratory status with an intervention to administer medication/puffers as ordered. Breo Ellipta inhaler was listed but does not indicate the resident can self-administer the medication. On 07/16/2023 at 10:40 AM, Licensed Practical Nurse, (LPN) #2 confirmed, she left the inhaler in the room, and stated she thought the resident had a self-administration assessment. On 07/18/2023 at 2:20 PM LPN #4 stated one resident self-administers Gas X and stated other than that, no other medications are left in the rooms. She stated the resident that keeps medication in the room stays in the room and does not have a roommate. LPN #4 was asked, How do you ensure that no other resident takes the medication? LPN #4 responded, Her door stays closed, and she has no roommate at this time. On 07/18/2023 at 2:33 PM interview with LPN #1 who stated only one resident in the facility self-administers medications, and the medication is kept at the bedside. LPN #1 stated the resident does not have a roommate and does not leave the room. On 07/18/2023 at 2:38 PM interview with the Director of Nurses (DON) who stated, there are two residents who self-administer medications and stated the Gas X is kept in the resident's room. She stated that resident does not have a roommate. Review of the policy, Medication, Self-Administration of, last updated on 5/1/16 noted, A resident may be permitted to administer or retain medication in his/her room under the following conditions: a. Assessment and approval by the interdisciplinary team. Suggested assessments: 1. Assessment for self-administration of medication 2. BIMS (Brief Interview for Mental Status) .b. order is obtained from the resident's physician . storage of medications in the resident's room must be such that it will prevent access by other residents .

Based on observation, interview, and record review the facility failed to follow the physicians order to change oxygen tubing for 1 (resident #32) of eight (Resident #2, #4, #13, #25, #26, #32, #39, and #41) sampled residents who received supplemental oxygen. The findings are: On 07/16/2023 at 11:02 AM observed Resident #32 lying in bed with oxygen in place. An oxygen concentrator was at the bedside, with a humidifier bottle and oxygen tubing connected both were dated 07/06/23. Review of the physician orders dated 06/21/2023 noted, change oxygen tubing, clean filter and oxygen cabinet, date all tubing every Thursday on the 7 am-7 pm shift. On 07/18/2023 at 2:20 PM the surveyor asked Licensed Practical Nurse (LPN) #4 who is responsible for taking care of the residents' oxygen, who is responsible for changing the oxygen tubing and when is it changed? LPN #4 stated the nurses monitor the oxygen, and the treatment nurse changes the tubing every Thursday. On 07/18/2023 at 2:30 PM the surveyor asked LPN #3 who is responsible for taking care of the residents' oxygen, who is responsible for changing the oxygen tubing and when is it changed? LPN #3 stated, she usually takes care of the resident's oxygen, and changes the tubing and it is required to be changed weekly. On 07/18/2023 at 2:33 PM the surveyor asked LPN #1 Who is responsible for taking care of the residents' oxygen, who changes the tubing and how often is the tubing changed? LPN #1 stated the treatment nurse is responsible for taking care of the resident's oxygen and changes the tubing and stated it should be changed weekly. On 07/18/2023 at 2:43 PM the surveyor asked the Director of Nurses (DON) who is responsible for taking care of the residents' oxygen, who is responsible for changing the tubing and when is the tubing changed? The DON stated, the treatment nurse takes care of the oxygen and changes the tubing every Wednesday. The surveyor asked the DON, How do you ensure this task is complete? The DON responded, its charted on the electronic health record, and they spot check the tubing to ensure it is dated properly. On 07/18/2023 at 2:44 PM the DON stated they did not have a policy on oxygen care.

Based on observation, record review and interview, the facility failed to ensure oxygen tubing, [CONDITION(S)] (Continuous Positive Airway Pressure) equipment, and nebulizer equipment was properly dated and stored when not in use to prevent potential cross contamination and respiratory infections for 2 (Residents #7 and #42) of 2 sampled residents who had physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] 1. Resident #7 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Significant Change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/30/22 documented the resident scored 15 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status and did not receive oxygen therapy. a. The Care Plan with a revision date of 02/09/22 documented, . The resident has altered respiratory status/difficulty breathing . Administer medication/puffers as ordered . [MEDICATION(S)]-[MEDICATION(S)] updraft TID [three times daily] X [times] 3D [days] for wheezing . OXYGEN SETTINGS: O2 via nasal prongs/mask @ [at] 2-4 L/M (Keep Pulse ox above 89%) PRN. Humidified . b. The April 2022 physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] > [greater than] 89 % [percent] as needed for O2 below 90% . Order Date 09/25/21 . Change o2 tubing weekly while in use. every day shift every Thu [Thursday] for maintenance . Order Date 10/21/21 . [MEDICATION(S)]-[MEDICATION(S)] Solution 0.5-2.5 (3) MG/3ML [milligrams per milliliters] 3 ml [milliliters] inhale orally every 6 hours as needed for shortness of breath or cough . Order date 04/28/22 . c. The April 2022 MAR (Medication Administration Record) documented, .May use O2 at 2-4 LPM via NC PRN to keep O2 > 89% as needed for O2 below 90% . The April MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . d. The April 2022 Treatment Administration Record (TAR) documented .Change O2 tubing weekly while in use every day shift every Thu for maintenance . The TAR documented the O2 tubing was last changed on 04/21/22 (Thursday). e. On 04/25/22 at 11:21 AM, Resident #7 was lying in bed. His O2 tubing was lying on the bed not dated. Resident #7 asked for the oxygen to be put back on, staff was located, and the nasal cannula was placed on Resident #7. There was no bag for storage of the oxygen tubing when not in use. f. On 04/27/22 at 1:00 pm, Licensed Practical Nurse (LPN) #1 was asked, What is the process for care and storage of respiratory equipment and who is responsible for it? LPN #1 stated, They are changed out weekly, dated, and stored in a bag when not in use. It is done by the Treatment Nurse and documented on the TAR. 2. Resident #42 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Significant Change MDS with an ARD of 3/8/22 documented the resident was moderately impaired in cognitive skills for daily decision making per a staff Assessment for Mental Status and received oxygen and [CONDITION(S)] therapy. a. On 04/25/22 at 11:09 AM, Resident #42 was lying in bed with oxygen at 3 LPM via NC. There was no date on the oxygen tubing, no humidity, nasal cannula for the portable oxygen was lying in a wheelchair and not in a bag. The [CONDITION(S)] nosepiece was lying on bedside table not in bag and a nebulizer mask was in a bag dated 03/17/22. b. On 04/26/22 at 10:00 am, Resident #42 was in her room, her oxygen tubing did not have a date on it. The [CONDITION(S)] nosepiece was lying on the bedside table not in a bag and a nebulizer mask was in a bag dated 03/17/22. c. On 04/27/22 at 12:30 pm, Resident #42 was in her room with LPN #1. The nosepiece of the [CONDITION(S)] was lying on the bedside table and not in a bag. The oxygen mask dated 04/26/22 was lying on top of [CONDITION(S)] machine and was not in a bag. d. On 04/25/22 at 11:09 am, Resident #42 was lying in bed with O2 at 3 LPM via NC. The O2 tubing was not dated and there was no humidity. The nasal cannula for the portable oxygen was lying in a wheelchair, not in a bag. The nosepiece for the [CONDITION(S)] lying on the bedside table not in a bag and a nebulizer mask was in a bag dated 03/17/22. e. On 04/26/22 at 10:00 am, Resident #42 was in 's O2 tubing was not dated. The nosepiece for the [CONDITION(S)] was lying on the bedside table not in a bag and a nebulizer mask was in a bag dated 03/17/22. f. On 04/27/22 at 12:30 pm, Resident #42 was her room with LPN #1. The nosepiece for the [CONDITION(S)] was lying on the bedside table not in bag. An oxygen mask was lying on top of the [CONDITION(S)] machine and was not in a bag. LPN #1 was asked what the facility policy on changing and storing respiratory supplies was. LPN #1 stated, They are changed weekly, dated and I assume the bags should be changed weekly too . 3. On 04/28/22 at 2:30 pm, LPN #2 was asked, What is the process for care and storage of respiratory equipment? LPN #2 stated, They are changed out weekly, dated and stored in a bag when not in use. I may have missed it. 4. On 04/28/22 at 2:45 pm, the DON was asked if [Resident #7's] oxygen tubing should have a date on it and how it should be stored when not in use. The DON stated, It should have a date on it, stored in a bag with a date when not in use. The DON was asked if it was acceptable for [Resident #42's] nebulizer kit, observed by surveyor on 04/26/22, to be stored in a bag dated 03/17/22, the portable oxygen tubing to be lying in the wheelchair seat and not stored in a bag, and the [CONDITION(S)] nose piece to be lying on the bedside table? The DON stated, No, that isn't acceptable, the nurses change out oxygen tubing, nebulizers, and storage bags weekly. They should all be dated, and initialed. The DON was asked why it is completed each week. The DON stated, That is what we have always done, by manufacturer's guidelines.

Based on observation, interview and record review the facility failed to ensure physical restraints were used only after an initial assessment was completed prior to use for 2 (Residents #20 and 49) of 3 (Residents #20, 42 and 49) sampled residents who had devices that restricted movement by use of chair/bed alarms. This failed practice had the potential to affect 4 residents with physical restraints according to a list provided by the Administrator on 2/4/21. The findings are: 1. Resident #20 had [DIAGNOSES REDACTED]. A Quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of 11/30/2020 documented the resident was severely impaired in cognitive skills for daily decision making per a staff assessment for mental status (SAMS) and had no documented physical restraints but used bed and chair alarms daily. a. The February 2021 physician's orders [REDACTED]. b. A Care Plan with a review date of 11/30/2020 documented .falls, self-release seat belt alarm, wc (wheelchair) lowered, and padded assist rails on bed . Impaired safety awareness . The resident has had an actual fall with potential for injury . The resident uses chair self-release belt and bed electronic alarm . c. On 02/01/21 at 10:49 AM, the seatbelt was in place on the wheelchair, velcro with wheelchair alarm device. d. On 02/02/21 at 08:30 AM, the resident was up in the wheelchair with a seatbelt in place with a wheelchair alarm device. e. On 02/02/21 at 01:52 PM, Certified Nursing Assistant (CNA) #1 made several attempts in directing the resident to remove the seat belt. The resident was unable to remove the seat belt on command. CNA #1 stated the resident had been up since right before lunch, might be tired. f. On 2/2/2021 at 2:20 PM, the resident was resting quietly in bed with the bed alarm device blinking. g. On 2/03/2021 at 2:40 PM, the Director of Nursing (DON) was asked for the restraint assessment for Resident #20 and #49. She stated, They don't have one because they aren't restraints. She was asked, If you don't complete a restraint assessment, how do you know they aren't considered restraints? She stated, According to the regulations, they aren't restraints. She was asked, Was a restraint assessment completed for either of these residents? She stated, No, they aren't restraints. h. On 2/3/2021 at 2:45 PM, the Administrator was asked, How does your staff know a positioning device isn't a restraint if there isn't a restraint assessment complete to make that determination? She stated, I don't know the answer to that, I'll have to get back with you. 2. Resident (R) #49 had [DIAGNOSES REDACTED]. An Annual MDS with an ARD of 1/21/2021 documented the resident was severally impaired in cognitive skills for daily decision making per the SAMS, documented no physical restraints and had daily use of bed and chair alarms. a. A Care Plan with a review date of 1/04/2021 documented, .The resident has an ADL (activity of daily living) self-care performance deficit r/t (related to) Alzheimer's with dementia . Wheelchair pad alarm Date Initiated: 08/28/2019 . Wheelchair seat tilted . MERI-WALKER FOR AMBULATION SAFETY-observe for safety/proper use of device Meri-walker PRN (as needed) for locomotion . Wheelchair pad alarm . Bed pressure alarm changed out for new one. Date Initiated: 09/28/2020 . Meri-walker w/seat d/t (due to) weakness and falls. Fidget sleeve on meri-walker for activity. Date Initiated: 2/29/2020 . b. On 02/01/21 at 11:13 AM, the resident was up in her room, sitting inside the merry walker unit, with the bar closed. c. On 02/02/21 at 08:30 AM, the resident was sitting in the merry walker unit, eating breakfast, with the bar closed. d. On 02/02/21 at 01:49 PM, the resident was sitting up in the merry walker unit. CNA #2 stated the resident was able to let staff know when she needs to go to bathroom sometimes, and the walker helped with residents' mobility. e. On 02/02/21 at 02:01 PM, the resident was ambulating with the merry walker. CNA #2 was asked about the resident ability to remove the bar on the merry walker and she stated the resident was unable to remove the bar on command and was unable to ambulate without assist of 2 staff. f. On 2/4/21 at 2:09 PM, CNA #3 was asked, When is a seatbelt considered a restraint? She stated, When not able to undo themselves, when not able to move freely within merry walker. She was asked, When the restraint is released, who releases the restraint, for how long, and how often? She stated, Every 2 hours. She was asked, Is there a position change alarm in use? She stated, Yes, Resident #20 both bed and chair. She was asked, Why is this device being used for this resident? She stated, R #20 seat belt, behaviors, will try to stand, scoot, or fall out of her chair. She was asked, Have you had any training on the use of device? She stated, Yes, it's been a little bit. She was asked, When did the use of the device begin? For R #20, more than5 years, and R #49 about a year. She was asked, How often is the device applied, for how long, and under what circumstances is it to be used? She stated, R #49 daily and R #20 daily. She was asked, How often is the device removed? She stated, R#20 every 2 hours when checked, R #49 released every 2 hours for toileting She was asked, How do you respond to the resident's request to remove the device? She stated, R #49 a few times has asked to get out, we assist her to go to bed or sit up in a w/c and R #20 when tries to get out, we redirect her and if continues, then get nurse direction. g. On 2/4/2021 at 10:37 AM, A Restraint, Use of Policy was received from the Administrator. It documented, .Residents have the right to be free from restraint or seclusion, of any form, used as a means of coercion, discipline, convenience or retaliation. All facility residents will be free from seclusion, unless required pursuant to the facility's infection control policies and procedures. All facility residents will be free from, any physical restraints except those which may be required per physician's orders [REDACTED]. 1. Restraints will only be used for the safety and well-being of the resident and only after other alternatives have been unsuccessfully tried and documented. 2. A Pre-restraining assessment will be completed on all residents prior to the application of a restraint. 3. Restraints will be used upon written order of a physician. physician's orders [REDACTED]. type of restraint: b. Reason for restraint: and Period of time and circumstances under which the restraint may be applied . 6. Care Plans which include the use of physical restraints . 7. Reassessment for restraint reduction/elimination will be performed at least quarterly and PRN (as needed) using the restraint elimination assessment. 8. Restraints will be checked every thirty (30) minutes and released ever two (2) hours for range of motion, repositioning, and toileting as necessary .

Based on record review and interview, the facility failed to ensure documentation of the provision of written information regarding the right to formulate an advanced directive was readily available for review in the clinical record, to protect resident rights for 2 (Residents #19 and 31) of 15 (Residents #19, 31, 40, 32, 30, 47, 49, 28, 39, 14, 27, 18, 23, 25, and 20) sampled residents whose clinical records were reviewed for advanced directive information. This failed practice had the potential to affect 21 residents who did not have an Advanced Directive, as documented on a list provided by the Administrator on 2/4/21 at 1:50 p.m. The findings are: 1. Resident #19 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of 11/29/2020 documented the resident was severely impaired in cognitive skills for daily decision making per a staff assessment for mental status. a. A Do Not Resuscitate (DNR) order was dated 2/19/19. b. The advance care plan (provided on 2/19/19) which is part of the admission paperwork contained the resident's name but had no signatures for the family or facility representative regarding the resident's quality of life concerns. c. On 2/03/21 at 9:57 a.m., the Administrator was asked for an advance directive for this resident. At 10:15 a.m., the Social Worker provided a Durable Power of Attorney, a copy of the DNR and a capacity verification documenting waxing and waning capacity and is able to make decisions some of the time. Cause of incapacity is Dementia. Surveyor explained we needed documentation on where the resident and or family were provided a choice regarding advance directives? The Social Worker stated, I see your side, but I was trained if the BIMS is less than 8 the resident cannot sign the Advance Care Plan unless they have a family member present. She was asked, Why didn't the family sign the advance directive section of the admission paperwork? She stated, I'll have to look into that. 2. Resident #31 had [DIAGNOSES REDACTED]. A Quarterly MDS with an ARD of 12/09/2020 documented the resident was severely impaired in cognitive skills for daily decision making on a SAMS. a. The Plan of Care with a review date of 12/14/2020 did not address the Advance Directive. b. As of 02/03/21 at 02:27 PM, the facility had not provided documentation on the advance directive or family refusal of the advance directive. c. On 02/03/21 at 02:30 AM, Social Worker stated she had been instructed to not allow a resident to sign papers if their BIMS was less than 8 (08-12 indicated moderately impaired) The Durable power of Attorney notes documented specifically, .This power of attorney does not authorize your agent to make health-care decisions for you . She stated after reviewing the document, .I see, I didn't realize it said that. I'll have to contact his wife . d. On 2/5/2021 at 8:29 am, the Advance Directives Policy was received from the DON and documented, .The facility will review existing advance directives upon admission. The facility will also provide residents with no advance directive in place with an opportunity to formulate an advance directive, if desired, and will follow those directives in accordance with applicable state law 1. Prior to, or upon admission, a representative of the social services department or designee will provide resident with written information concerning the resident's right under state law to accept or refuse medical or surgical treatment and the resident's right to prepare an advance directive .

Based on observation and interview, the facility failed to ensure foods stored in the refrigerator and freezer were sealed and dated; expired baking agent was promptly removed / discarded on or before the expiration or use by dates; leftover food items were used within 48 hours, used only as an alternative for disliked foods; and frozen or refrigerated with 30 minutes after the final meal service to prevent potential food borne illness; and the ice scoop holder and ice machines were maintained in a clean and sanitary condition to prevent potential contamination of residents' food or beverages for residents who received meal trays from 1 of 1 kitchen. These failed practices had the potential to affect 65 residents who received food from the kitchen, according to the diet list provided by the Dietary Employee #1 dated [DATE] at 11:24 a.m., (total census: 66). The findings are: 1. On [DATE] at 11:25 a.m., the following observations were made in the kitchen: a. 2 (24 oz. (ounce)) classic baking soda documented a best by date of [DATE]. b. 2 (10 lb. (pound)) beef steak fritters were unsealed. c. 1 (16.4 oz.) home style pancakes were in the walk-in refrigerator. The food item label documented keep frozen. d. A box of elbow noodles was open, with no open date documented on it. e. A clear bin containing approximately 30 onions did not have a date. f. A white storage container containing approximately 70 potatoes did not have a date on it. g. 1 (,[DATE] gal) (gallon) chocolate milk did not have an open date on it. h. Yeast rolls in a clear bag did not have an open date on it. i. 2 (5 lb.) ground meat tubes did not have a date on it. 2. On [DATE] at 9:25 a.m., the interior surfaces of the ice machine and the panel where the ice shoots down to the ice collector had an accumulation of brown / black wet residue on them. Dietary Employee #1 was asked to wipe the brown / black residue on the interior surfaces and the panel of the ice machine. She did so, and the brown / black substance easily transferred to the tissue. The ice scoop holders on the counter by the ice machine in the dining room had a grayish substance at the bottom of the scoop. Dietary Employee #1 stated, It was dust from the ice machine vent blowing on it. The back of the ice machine vent had dust on it. The ice scoop holders were on the counter by the ice machine. The second ice scoop holder had brown residue on the spout. The ice scoop was stored in the scoop holder in direct contact with the residue. Dietary Employee #1 was asked to wipe the brown residue on the spout of the ice scoop holder. She did so, and the brown substance easily transferred to the tissue. She was asked, Who uses the ice from the ice machine and how often do you clean the ice machine and the ice scoop holder. She stated, Every Monday, but doesn't look like it. But we were occupied this week. We use it in the kitchen to fill beverages served to the residents at meal. That's the ice the CNAs (Certified Nursing Assistants) use for the water pitchers in the residents' rooms. 3. On [DATE] at 9:58 a.m., the following leftover foods were stored in the freezer to be used for alternate, and pureed and blended diets: a) Two containers of white bean dated [DATE]. b) Two containers of BBQ chicken dated [DATE]. c) Container of ground beef dated [DATE]. d) Container of spaghetti sauce dated [DATE]. e) Container of meat loaf dated [DATE]. f) Container of meat loaf dated [DATE]. g) Container of ham and beans dated [DATE]. h) Container of lima beans dated [DATE]. i) Container of beef tips dated [DATE]. j) Container of cat fish dated [DATE]. k) Container of pork roast dated [DATE]. l) Container of white beans dated [DATE]. m) Container of BBQ pork dated [DATE]. n) Container of corn dated [DATE]. All food items we stored in deep containers. 4. The Facility policy for Storage of Frozen and Refrigerated Foods dated (MONTH) 2001 received from Dietary Employee #1 on [DATE] at 3:56 p.m., documented Procedure #7 Freeze leftover food in small, airtight packages for quick freezing. On [DATE] at 9:10 a.m., Dietary Employee #1 was asked, How do you use the frozen leftover food items and what do you use them for? She stated, If we are preparing food items listed on the menu and we have the same food items in the freezer as leftovers. We pull leftover freezer food from the freezer, thaw them out and used them for the pureed diets and mechanical soft diets. We served fresh prepared meals for the residents on regular food. Dietary Employee #1 was asked, How do you cool leftover food items before you store them. She stated, We put it in a container on a batch of ice and leave them on the counter for about 15 to 20 minutes until it cools down. We put it in a cooler, the next day we put it in the freezer, with soup it will take longer time for about 25 to 30 minutes. 5. On [DATE] at 10:09 a.m., an open bag of frozen chicken was on a box on the lower shelf in the freezer. The bag was not completely sealed. 6. The Facility policy on Use of Left overs received from the Food Service Supervisor on [DATE] documented, Excess leftovers should be avoided. Leftovers will be properly handled and used. Leftovers are NOT used for pureed diets . 2.) Leftovers should be covered, labeled and dated; then stored appropriately (refrigerated or frozen if necessary with ,[DATE] hour. 3.) Do not serve leftovers that have not been properly stored. (When in doubt, throw it out.) 4.) Any food that is leftover (food served for a meal but was not all served), shall be used as follows: A. Desserts may be given as nourishments as allowed by diet order. B. Leftovers can be substituted for food dislike if used within 48 hours. C. Leftovers are not to be used as pureed food.

Based on observation, record review, and interview, the facility failed to ensure direct care staff changed gloves and washed their hands when gloves were contaminated and the labia was separated to allow proper cleaning of the urethral meatus and surrounding area to prevent the potential for development of urinary tract infections for 1 (Resident # 4) of 3 (Resident #4, #18, and #51) sampled residents who were dependent on staff for indwelling catheter care. This failed practice had the potential to affect 4 residents who had indwelling Foley catheters and were dependent on staff for catheter care according to a list provided by The Director of Nursing on 8/22/19 at 11:08 a.m. The findings are: Resident #4 had [DIAGNOSES REDACTED]. A Significant Change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/11/19 documented the resident was severely impaired in cognitive skills for daily decision making on a Staff Assessment for Mental Status (SAMS); totally dependent two plus persons for bed mobility, transfers, toileting, and bathing; required extensive assistance of 2 persons for dressing, and personal hygiene; had an indwelling urinary catheter, and was always incontinent of bowel. a. The Care Plan dated 7/1/19 documented, .The resident has Indwelling Catheter . The resident will show no Signs or Symptoms (s/sx) of Urinary infection . The resident has History (HX) of Urinary Tract Infection . Resident / caregiver teaching should include: Good hygiene practices: Females to wipe and cleanse from front to back, Clean Perineum (peri) area well after bowel movement (BM) in order to help prevent bacteria in urinary tract . b. A physician's orders [REDACTED]. c. On 8/21/19 at 9:15 a.m., Certified Nursing Assistant (CNA) #1 and CNA #2 put on Personal Protective Equipment (PPE) gown and gloves and entered the resident's room. The resident had an indwelling Foley Catheter, secured with a stat lock. The CNAs removed the blankets from the resident and discovered they did not have any disposable wipes to start catheter care. CNA #2 removed her gown and gloves and placed them in a barrel in the room labeled trash. She washed her hands and left the room. CNA #2 put on the PPE, (gown and gloves) in the hallway before entering the room with a bag of incontinent adult briefs and package of disposable wipes. CNA #1 and CNA #2 unfastened the resident's adult incontinent brief. Using the disposable wipes, CNA #2 wiped across the resident's abdomen from right to left, then CNA #2 wiped down both thighs using one wipe per each swipe. Without changing gloves, CNA #2 held the catheter approximately 2 inches from the insertion site and wiped down the catheter towards the catheter tubing for 2 inches. CNA #2 did not open the resident's labia and clean from the insertion site. CNA#2 asked the resident to turn over on her left side. The resident's buttocks was covered with a thick white paste. CNA #2 wiped downward on the right buttocks 4 times using 4 separate wipes. The resident was then asked to turn to the right side and the brief was removed. CNA #1 did not wipe the resident's buttocks on the left side. CNA #2 took off her gloves and placed them in a plastic bag at the foot of the residents' bed and put on a clean pair of gloves. CNA #1 placed a clean brief under the resident and both CNAs assisted the resident to turn to her right side and pulled the brief in place. CNA #2 took off the gown and gloves, opened the trash lid barrel with the same gloves on, and put the PPE gown inside. Using the same gloves CNA #2 then picked up the lid still wearing the same gloves and put the lid back on the barrel. CNA#2 removed her gloves and put them inside the barrel through an opening in the top of the lid. d. On 8/21/19 at 10:00 a.m., CNA #1 and CNA #2 were asked, When should you wash or sanitize your hands for peri care or catheter care? CNA#2 stated, Before you go into the room, when you change your gloves, and before you go out of the room. They were asked, Did you wash or sanitize your hands between glove changes? CNA #2 stated, No. I did not. When I was by her bed and I changed my gloves. They were asked, Should you touch or remove the trash lid with your dirty contaminated gloves? CNA #2 stated, No. The CNAs were asked, Did you complete catheter care? CNA #1 stated, No. Neither one of us wiped her left side because she was laying on it before we rolled her over. She was asked, Should you have completed the care and cleaned the resident on her left side? CNA #1 stated, Yes. e. A Policy and Procedure titled Perineal / Catheter Care received from the Director of Nursing on 8/22/19 at 8:46 a.m. documented, .Females: with gloved hands gently open labia with one hand using the other hand to gently cleanse. Repeat until complete cleansing is achieved .Assist resident over to one side and cleanse the anus and coccyx area .Repeat once you have assisted the resident to the other side .Change gloves .clean insertion site (urethra) .When the entire insertion site has been cleansed, proceed to cleansing the insertion tubing in the direction of the catheter bag . f. On 8/22/19 at 10:32 a.m., CNA #1 was asked, When should you change your gloves while doing catheter care? She stated, You should change your gloves after you do peri care. Then change your gloves, then do catheter care, and change them when you finished. She was asked, How far from the body should you begin catheter care? She stated, From the insertion site where the tubing goes into the body then down the tubing. She was asked, How far down the catheter should you clean? She stated, Three inches down the catheter. g. On 8/22/19 at 10:28 a.m., the Director of Nursing was asked, When should you change your gloves while doing catheter care? She stated, When they get visibility soiled, and when you are finished. She was asked, Should the labia be opened and cleaned during catheter care? She stated, Yes. She was asked, How far from the body should you begin catheter care? She stated, From the insertion site of the catheter tubing. She was asked, How far down the catheter should you clean? She stated, All the way from the catheter insertion site to where the catheter connects to the catheter tubing.

Based on record review and interview, the facility failed to ensure the Minimum Date Set (MDS) accurately reflected the resident was receiving hospice services to facilitate appropriate care planning for 1 (Resident #49) of 4 (Resident #27, 38, 47, and 49) sampled residents who received hospice services. This failed practice had the potential to affect 4 residents who are currently receiving Hospice services, as identified on a list provided by Director of Nursing (DON) on 8/22/19 at 10:05 a.m. The findings are: Resident #49 had a [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 7/13/19 documented the resident was severely impaired in cognitive skills for daily decision making per a Staff Assessment for Mental Status (SAMS). The resident required limited assistance of 1 staff member for bed mobility, transfers, and dressing, extensive assistance of 2 staff members for toilet use and personal hygiene, and did not document hospice services. a. The (MONTH) physician's orders [REDACTED]. b. An updated Care Plan dated 7/25/19 documented, .Focus: Hospice Care; Goal: Resident is to receive services from (hospice) services; Interventions / Task: See the Handbook for hospice care plan for any changes or updates to the initial hospice care plan and Support family members, provide education, allow family to vent, cry or express feelings. Date initiated: 4/18/2018 . c. On 8/22/19 at 8:53 a.m., the MDS Coordinator was asked, Are you familiar with (Resident #49)? The MDS Coordinator stated, Yes Ma'am. The MDS Coordinator was asked, Is he on hospice? The MDS Coordinator stated, Yes he is. The MDS Coordinator was asked, On the resident Annual MDS completed on 4-12-19, states, Special treatments, procedures, and programs, Hospice Care while a resident was checked yes. On the Quarterly MDS completed on 7-13-19, Special treatment, procedures, and programs, Hospice Care while a resident was checked No. Was he discharged from Hospice between the Annual and Quarterly MDS? The MDS Coordinator stated, No. He is still on Hospice. That was just human error. The MDS coordinator was asked, Was the Hospice Care supposed to be checked? The MDS Coordinator stated, Yes.

Based on record review and interview, the facility failed to ensure that the Minimum Data Sets (MDS) accurately reflected the use of anticoagulant medications to facilitate appropriate care planning and monitoring for 2 (Residents #39 and #58) of 9 (Residents #4, 6, 16, 35, 39, 40, 43, 57 and 58) sampled residents who had physician orders [REDACTED]. The findings are: The Centers for Medicare and Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual documented, .Coding Instructions . N0410A-H: Code medications according to the pharmacological classification, not how they are being used . N0410E, Anticoagulant e.g. (for example) [MEDICATION NAME], or low- molecular weight [MEDICATION NAME]: Record the number of days an anticoagulant medication was received by the resident at any time during the 7-day look-back period (or since admission/entry or reentry if less than 7 days). Do not code antiplatelet medications such as aspirin/extended release, [MEDICATION NAME], or [MEDICATION NAME] here . Resident #39 had [DIAGNOSES REDACTED]. a. A Physicians order dated 7/28/16 documented, Aspirin Tablet 81 mg (milligram) give 1 tablet by mouth one time per day related to [MEDICAL CONDITIONS] of Native Coronary Artery without [MEDICAL CONDITION] Pectoris, with food. b. The Annual MDS with an assessment reference date of 8/13/18 documented the resident received an anticoagulant medication on 7 of the past 7 days. 2. Resident #58 had [DIAGNOSES REDACTED]. a. A Physicians order dated 8/28/17 documented, Aspirin Tablet chewable 81 mg give 1 tablet by mouth one time a day related to Dementia in Other Diseases Classified Elsewhere with Behaviors .give with food. b. The Annual MDS with an ARD of 9/1018 documented the resident received an anticoagulant medication on 7 of the past 7 days. 3. On 10/04/18 at 12:40 p.m., the Director of Nursing (DON) was asked, should [MEDICATION NAME] be coded on the MDS as an anticoagulant? The DON stated, It would depend on a case by case basis. Yes, [MEDICATION NAME] should be coded under anticoagulant on the MDS . 4. On 10/04/18 at 12:43 p.m., Licensed Practical Nurse (LPN) #2 was asked, should [MEDICATION NAME] be coded on the MDS as an anticoagulant? The LPN stated, Yes, [MEDICATION NAME] and aspirin are anticoagulants and should be coded as such on the MDS. 5. On 10/04/18 at 12:20 p.m., the MDS Coordinator was asked, should [MEDICATION NAME] be coded on the MDS as an anticoagulant? The MDS Coordinator stated, No, [MEDICATION NAME] or Aspirin should not be coded as an anticoagulant. 6. The Nursing (YEAR) Drug Handbook, Wolters Kluwer, page 359, documented, [MEDICATION NAME] Bisulfate ([MEDICATION NAME]) therapeutic class: Antiplatelet drugs. Pharmacologic class: Platelet aggregation inhibitors . 7. The Nursing (YEAR) Drug Handbook, Wolters Kluwer, page 359, documented, Aspirin . Therapeutic class: NSAIDs (Nonsteroidal Anti-[MEDICAL CONDITION] Drugs) . Pharmacologic class: [MEDICATION NAME] .

Based on observation, record review and interview, the facility failed to ensure the care plan identified and addressed a problem with excessive oral secretions, to ensure staff were aware of how to appropriately intervene for 1 of 1 (Resident #48) sampled resident who had copious oral secretions. The failed practice had a potential to affect 1 resident who had excessive oral secretions, according to the Administrator on 10/16/18. The findings are: Resident #48 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set with an Assessment Reference Date of 7/5/18 documented the resident scored 3 (0- 7 indicates severely impaired) on a Brief Interview for Mental Status and required limited assistance of 1 person for dressing and personal hygiene. a. A physician's orders [REDACTED].[MEDICATION NAME] 1% solution give 2 drops sublingual every 2 hours as needed for excessive secretions . b. The Care Plan dated 10/6/18 documented, Focus .Ancillary social services are indicated due to aggressive periodontal disease .initiated 10/06/18 .Social services ancillary .routinely assess for changes .The care plan did not address how staff should address the excessive oral secretions (such as the consistent use of clothing protectors or frequent oral care). c. On 10/1/18 at 11:23 a.m., the resident was sitting in a wheelchair in the dining room on the secure unit. Her eyes were closed, her head was leaning forward, and her chin was tilted downward toward her chest. There were thick oral secretions draining from her lower lip, down her blouse. The resident's blouse was wet from top to bottom from the secretions. There was no adult clothing protector in place. d. On 10/2/28 at 11:00 a.m., the resident was in a wheel chair and had oral secretions draining from her mouth down to the top of her blouse. e. On 10/4/18 at 9:45 a.m., Certified Nurse Assistant (CNA) #1 was asked about the resident's oral secretions and stated, She's had quite a bit of teeth pulled, and she does have a lot of secretions; some days, she has to have medication. Sometimes, the oral secretions are so much, we have to put one of those things around her, so she won't stay wet. f. On 10/4/18 at 9:53 a.m., Registered Nurse (RN) #1 was asked about the resident's oral secretions and stated, .She does have copious amounts of oral secretions. Today is a good day; sometimes she is so saturated, her clothes have to be changed and a washcloth to cleanse her face. She is offered a clothing protector, and she will wear one . She was asked if this could be a dignity issue and stated, .Yes, it could be a dignity issue if the oral secretions are dripping onto her and she does not have a clothing protector on. g. On 10/4/18 at 10:00 a.m., the DON was asked about the resident's oral secretions and stated, Yes, I know (Resident #48), and she does drool a lot. We use clothing protectors, of course; she is on swallowing precautions. We use the brown clothing protectors during meal times. I believe she is on meds for oral secretions . She was asked about potential outcomes to the resident from the excessive drooling and stated, Skin and dignity could be issues if adult clothing protectors are not provided.

Based on observation and interview, the facility failed to ensure 2 of 2 clothes dryers remained free of excessive lint build-up to decrease the potential for fire in 1 of 1 laundry room located on the Cedar hall. This failed practice had the potential to affect 8 residents who resided on the Cedar hall due to the proximity of the laundry room as identified by the Administrator on 10/16/18. The findings are: 1. On Thursday, 10/4/18 at 8:03 a.m., during a tour of the laundry room with the Maintenance Supervisor, the following observations were made: a. There were 2 electrical dryers in the clean area of the laundry room. The Maintenance Supervisor opened the bottom drawer to Dryer #1. When the lint trap was pulled out, he stated, That's hot. There were 3 dryer sheets and an accumulation of lint in the lint trap. The Maintenance Supervisor pulled out a handful of lint from the lint trap, then used a hand held broom and swept out another handful of lint and discarded the lint in the trash. b. The Maintenance Supervisor then opened the lint trap for Dryer #2. The Maintenance Supervisor removed 2 handfuls of lint from the lint trap. He stated, I just cleaned them out Monday (10/1/18). The Environmental Supervisor was asked, how often are the lint traps cleaned? She stated, Three times a day; they have a sensor that tells you when to change them. The Environmental Supervisor was asked, do you think they needed cleaning? She stated, (We will) start cleaning them out after every load. 2. On 10/4/18 at 9:30 a.m., the Administrator was asked, do you have a policy for how often to clean the dryer lint traps? She stated, No, we do not; I have looked. She was asked, Do you know how often the dryer lint traps should be cleaned out? She stated, I have been here for over 5 years, and I'm used to them being cleaned out every load.

Complaint # (AR 876) was substantiated (all or in part) with these findings: Based on record review and interview, the facility failed to ensure necessary care and services were provided to address a change in condition, as evidenced by failure to ensure the physician was immediately consulted for treatment and diagnostic procedure orders to address an acute decline in respiratory status, failure to conduct and document a thorough respiratory assessment and provide regular ongoing monitoring of the resident's condition, to include vital signs and oxygen saturation levels, in order to provide the physician with necessary information to make treatment decisions for 1 (Resident #6) of 1 (Resident #6) case mix resident who had a change of condition in the past 60 days. The failed practice resulted in immediate jeopardy, which caused or could have caused serious harm, injury or death to Resident #6, who had a respiratory change of condition, and had the potential to cause more than minimal harm to 5 residents who had a significant change of condition and were hospitalized in the past 60 days, as documented on a list provided by the Administrator on 4/21/17. The facility removed the immediate jeopardy on 3/13/17 prior to the survey, when Licensed Practical Nurse (LPN) #1 was terminated; however, the underlying failed practices were not corrected as of the survey date. The Administrator was notified of the removed immediate jeopardy condition on 5/1/17. The findings are: Resident #6 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set with an assessment reference date of 3/7/17 documented the resident scored 5 (0-7 indicates severely impaired) on a Brief Interview for Mental Status (BIMS), shortness of breath/trouble breathing with exertion and required oxygen therapy. a. The Overall Plan of Care dated 2/8/17 documented, Resident at risk for shortness of breath due to congested heart failure. Resident will have no episodes of shortness of breath next 90 days 1. Monitor resident for congestion . and notify physician promptly . 3. Monitor resident for episodes of shortness of breath and implement interventions as ordered . b. A Physician's Telephone Order dated 3/2/17 at 10:20 p.m., written by Licensed Practical Nurse (LPN) #1, documented, N.O. (new order) chest x-ray d/t (due to) rubs on exhalation left and right upper lobes. c. A Nurses Note dated 3/2/17 and signed by LPN #1 at 10:30 p.m. documented, Earlier in shift, resident was complaining of not being able to catch own breath. Nurse elevated HOB (head of bed) about 90 degrees. Respirations were fast and deep. Nurse gave PRN (as needed) inhaler 3 puffs at that time. Shortly after PRN inhaler, resident was still having a hard time breathing. Nurse Adm (administered) updraft. Resident stated that it had helped and was fine at the moment. Around 10:15 p.m., staff came to nurse reporting that resident was having a hard time breathing again. Nurse went down to resident's room, HOB elevated about 45 degrees. Lung sounds had rubs upon exhalation in the upper right and left lobes. Very little rubs auscultated in the lower lobes. Nurse adm PRN 2-4 L (liters) O2 (oxygen) via NC (nasal cannula) D/T (due to) SOB (shortness of breath). Resident's SpO2 (oxygen saturation) was 99% after adm of oxygen. Resident stated, 'I feel like I can breathe now' when nurse gave PRN O2. Will continue to monitor resident's respirations and O2 status. N.O. (new order) Chest x-ray D/T rubs on exhalation to left and right upper lobes . There was no documentation of vital signs at this time, and no documentation of what the resident's oxygen saturation was, prior to initiating the PRN oxygen therapy. d. A Nurses Note dated 3/2/17 at 10:39 p.m. documented, MAR (Medication Administration Record) 2239 (10:39 p.m.): [MEDICATION NAME] 0.83% - Per Neb (nebulizer) Q (every) 4H (hours) PRN (as needed) SOB . Late entry. Gave PRN D/T SOB. A Nurses Note dated 3/2/17 at 10:40 p.m. documented, MAR - PRN - 2240 (10:40 p.m.): [MEDICATION NAME] HFA (hydrofluoroalkane) 2-4 puffs . Q 4 hrs PRN wheezing . Late entry. Gave PRN inhaler D/T SOB. A Nurses Note dated 3/3/17 at 1:07 a.m. documented, MAR - PRN . [MEDICATION NAME] . 2-4 puffs .Q4H PRN wheezing . C/O (complains of) SOB wheezing noted. Gave 3 puff of [MEDICATION NAME]. There was no documentation O2 saturation or vital signs were assessed. A Nurses Note dated 3/3/17 at 1:08 a.m. documented, MAR - PRN . C/O SOB. Congestion noted. Gave an updraft of Albu ([MEDICATION NAME]). A Nurses Note dated 3/3/17 at 7:24 a.m. and signed by Registered Nurse (RN) #2 documented, X-ray that was ordered on 3-11 (3:00 p.m. to 11:00 p.m. shift) on 3/2/17 has still not arrived for pt (patient), called onsite to see when they would be here and no answer. Will call again if not arrived after med (medication) pass. A Nurses Note dated 3/3/17 at 9:34 p.m. and signed by RN #1 documented, .Late entry: 11-7 Last night. Resident with SOB. HOB up. O2 on (at) 2L/min (liters per minute) via N/C (nasal cannula). Gave PRN updraft and inhaler. Resident encouraged to cough and deep breathe .Audible congestion noted upon expiration. Pulse ox ranged from 97-82. Monitored closely entire shift. A Nurses Note dated 3/3/17 at 10:23 a.m. and signed by RN #2 documented, During report R (Resident) pulse ox was in 80s not consistent, 11-7 nurse raised HOB about 45 degrees and admin prn inh (inhaler) and updraft with no improvement. Updraft machine sitting on BST (bedside table), machine fell on to R (resident) bed and hit R FA (right forearm) when nurse was assessing, pulled back skin sleeves to assess and found that machine had sheared skin causing ST (skin tear) to R FA. NO (new order) clean with sea clens, app (apply) DAO (double antibiotic ointment), cover qd (every day) and PRN. Cleaned and app (applied) bandage. Moved NEB (nebulizer) to nightstand to prevent this from happening again. LS (lung sounds) also have crackles bilat (bilateral) lobes, audible without stethoscope. R moaning and turning head side to side verbalizing that she does not feel good at all. 11-7 nurse called family to give update and to tell about ST. X-ray had still not arrived at this time, called at 730 (7:30 a.m.) to see when they would arrive and no answer. Family came to see R and asked nurse to send R out via ambulance. Nurse went to assess R again. LS still have crackles audible with and without stethoscope, congestion that does not improve after having R cough. Pulse ox at 75% on 2 LPM (liters per minute) of O2, increased to 4 LPM and pulse ox increased to 86%. Kept at 4LPM, CNAs (Certified Nursing Assistants) came to check VS (vital signs), BP in R arm 98/42, L (left) wrist 88/42, Nurse checked in L arm 98/52. P (pulse) 65, SPO2 now at 97% on 4 LPM. Notified family of this condition, Dr (physician name) notified of condition and everything nurse has done for improvement. Dr gave order to send to ER for [MEDICAL CONDITION], Notified family . Called ambulance at 850 (8:50 a.m.), arrived to facility at 9 a.m., left building with patient on stretcher at 908 (9:08 a.m.), called report to (hospital) charge nurse at 950 (9:50 a.m.). e. The Emergency Department (ED) Triage Notes dated 3/3/17 documented, .Reason for Visit - Respiratory Distress . Triage: Description of Symptoms: .reports pt started having SOB (shortness of breath) yesterday reports decreased CPOX (oxygen saturation) at the nursing home .breath sounds coarse to auscultation . 1.) The Emergency Department Laboratory Report dated 3/3/17 at 10:00 a.m. documented the resident's red blood cell count (RBC) was 1.74 (normal range: 3.78 - 5.33); the hemoglobin was 4.8 (normal range: 11.5 - 16.0); and the hematocrit was 18 (normal range: 35.0 - 47.0). 2.) The hospital Physician Exam notes dated 3/3/17 documented, .Respiratory: Distant breath sounds in the bases with rhonchi . Radiology Imaging: Chest x-ray shows [MEDICAL CONDITIONS] and cardiomegaly . Clinical Impression: .[MEDICAL CONDITION] . ED Course / Procedures: 3/3/17 10:46 (a.m.) . Patient's H&H (hemoglobin and hematocrit) is low and [MEDICATION NAME], blood will be started at this time . We will start the second unit of blood in transport (to larger metropolitan hospital) . 3.) The Radiology Report dated 3/3/17 documented, .Procedure: .Chest . Shortness of breath . Findings: Compared with prior exam 8/1/2016, there is marked increased perihilar opacity, small left pleural effusion and heterogeneous (diverse in character) [MEDICAL CONDITION] opacity bilaterally. This is most consistent with moderate to severe [MEDICAL CONDITIONS] . 4.) A Radiology Report dated 3/3/17 at 11:43 a.m. documented, .Procedure: Portable chest film . Indication: Shortness of breath . Findings: Lung fields show perihilar [MEDICAL CONDITIONS] consistent with acute heart failure as noted on the prior examination of the same date . Impression: 1. Heart failure . f. On 4/2/17 at 1:35 p.m., LPN #1 was asked what occurred with the resident on 3/2/17 and stated, I really do not know; she was having complications that night, having complications later in the shift. The LPN was asked what was done for the resident and stated, I gave her an updraft, I gave her inhaler, I gave her an inhaler first, then the updraft. The LPN was asked if these measures gave the resident any relief and stated, She didn't get any relief at all. All I know is, she wasn't getting any relief, so I tried different measures. She said she was short of breath. I think she got 2 puffs - she was fine - then she said she didn't get any relief. The LPN was asked how long the resident was relieved and stated, Probably minutes. The LPN was asked if the updraft gave the resident any relief and stated, She said she was better and then she said she couldn't get her breath, and the floor tech told me she couldn't get her breath. The LPN was asked what the oxygen saturation was, when the resident initially began to complain of shortness of breath, if it was checked at that time, and stated, I don't remember. The LPN was asked when the oxygen was initiated for the resident and stated, I think the oxygen around 10:30 (p.m.). The LPN was asked what the oxygen flow rate was at that time and stated, I don't remember; I think probably 3 liters at the most. I don't remember. The LPN was asked what the oxygen saturation was, prior to the oxygen being applied and stated, I do not remember. The LPN was asked if the oxygen saturation was checked prior to the initiation of oxygen and stated, Yes. The LPN was asked if this was documented and stated, Probably not. The LPN was asked what else was done for the resident and stated, I just checked on her till shift change. The LPN was asked what the resident's vital signs were and stated, I don't really think I got her vital signs. The LPN was asked if the vital signs should have been checked and stated, Yes. The LPN was asked if vital signs were an important part of the assessment process and stated, Yes. The LPN was asked if she had monitored and checked the resident's respiratory rate and stated, No I didn't. The LPN was asked why the respiratory rate was not checked and stated, I honestly didn't think to. The LPN was asked if the physician was notified of the change in the resident's condition and stated, I did not. The LPN was asked how the chest x-ray order was obtained if the physician was not notified. LPN #1 stated, We are able to do orders like that if it's necessary. The LPN was asked if it was important to notify the physician when a resident had a change of condition such as shortness of breath and stated, Yes, it is. The LPN was asked to verify that she did not consult the physician on the night shift of 3/2/17 and stated, Correct, I just ordered the x-ray. LPN #1 was asked if a nurse can order x-rays without calling a doctor, especially when a resident is experiencing a change of condition, and stated, Our procedures are, they told me x-rays can be ordered. The LPN was asked who they consisted of and stated, They, the bosses . the people who trained me. The LPN was then asked if, at any time, on the 11:00 p.m. to 7:00 a.m. shift on 3/2/17, the physician was consulted regarding the resident's condition. The LPN stated, No, I just passed it on, and other than doing different measures, I just told them (next shift) about the problems she was having. The LPN was asked if the physician should have been consulted regarding the resident's respiratory difficulty and stated, Yes, I should have. g. On 4/21/17 at 2:15 p.m., RN #2 was asked how she knew what had been done for the resident and the resident's condition on the night of 3/2/17 and stated, The 11 to 7 (11:00 p.m. to 7:00 a.m. shift) nurse, when we made walking rounds at about 6:45 a.m. or 6:50 a.m., gave that updraft, and I was in there with her, and while I was in there, she (resident) was real congested and made me think of [MEDICAL CONDITIONS], and she had crackles and you could hear without a stethoscope, and I still listened with a stethoscope. She had crackles. The RN was asked what was done for the resident at that time and stated, When I was calling x-ray - when I called them at 7:20ish - it just rang. The RN was asked if she notified the physician at that time and what time the oxygen saturation of 75% was obtained. RN #2 reviewed the notes and stated, Probably 8:20 a.m., after the family came. Increased the oxygen. The RN was asked why the oxygen flow rate was increased and stated, In hopes she would get relief . it brought it (oxygen saturation) up to 86%, and that was just the immediate response. The RN was asked when the physician was made aware of the resident's condition before the shift and stated, I don't know what happened the night before, but normally, when we have a chest x-ray order, Dr. (Physician name) is notified. So, I notified him that her condition was worsening and hadn't gotten any better. I let him know. The RN was asked if the physician had been consulted prior to when the resident was seen receiving treatment from the 11 to 7 nurse (LPN #1). The RN stated, .I was under the impression he knew, since there was a chest x-ray ordered. h. On 4/21/17 at 3:12 p.m., RN #1 was asked if she had notified the physician and stated No I didn't have to call the doctor, because he ordered a chest x-ray, and we had to get that. i. On 4/21/17 at 3:55 p.m., the Director of Nursing (DON) was asked what was to be done when a resident had a change of condition and stated, They do an assessment and then they call the doctor. The DON was asked if the physician should be notified if the resident is having respiratory difficulty, such as congestion / shortness of breath and stated, For respiratory difficulty, yes. The DON was asked who could order a chest x-ray and stated, The physician. The DON was asked if a nurse could order a chest x-ray without notifying the physician and stated, The physician has to be notified. j. The facility's Change of Condition or Status policy, received from the DON on 4/21/17 at 6:20 p.m., documented, .Change of Condition or Status . this facility will promptly notify . the physician . of changes in the patient's condition or status .Physician Notification 1. The Charge Nurse will notify the patient's attending physician when: .b. There is a significant change in the patient's physical .status as defined as: A major decline . in the patient's status that will not normally resolve itself without further intervention . or A deterioration in health . status in either life-threatening conditions or clinical complications c. There is need to alter the patient's treatment significantly . 9. Acute Medical Change . a. An acute medical change is any sudden or serious change in a resident's condition, manifested by marked change in physical . behavior. b. The change will be communicated to the physician (alternate physician or Medical Director) in a timely manner . k. The following information, collected during a partial extended survey from 5/1/17 through 5/3/17, indicated the facility removed the immediate jeopardy to Resident #6, and reduced the scope / severity to H (based on length of time / number of shifts involved), on 3/13/17 when LPN #1 was terminated, but had not corrected the underlying failed practices as of the survey date: 1.) A Social Services Progress Note dated 3/6/17 documented the resident remained in the hospital and would not be returning to this facility upon discharge from the hospital, as her family and healthcare agent had agreed to move her to a different facility. 2.) A Payroll and Insurance Change Form dated 3/13/17 documented LPN #1 was terminated from employment with the facility on 3/13/17, because she did not pass her State board exam. The Arkansas State Board of Nursing's online license verification system indicated LPN #1 continued to hold a Temporary Licensed Practical Nurse Permit as of 5/1/17. 2.) The Employee Timecard Report for LPN #1 documented her last day worked was 3/12/17 from 2:25 p.m. to 11:15 p.m. 3.) On 5/1/17 at 12:30 p.m., the DON was asked, When did you become aware that (LPN #1) did not notify the physician of the resident's change of condition and that she wrote an order for [REDACTED].#1) on 4/21/17). The DON was asked, What did you do when you became aware of this? The DON stated, .I texted all my nurses and told them there would be a meeting on Monday (4/24/17) at 2:00 p.m . We went over everything, assessments, x-ray (mobile radiology service) not showing up . (Resident #6) had chronic shortness of breath, this wasn't an unusual occurrence. The 11 to 7 (11:00 p.m. to 7:00 a.m.) nurse went into the resident's room [ROOM NUMBER] times and checked her O2 sat (oxygen saturation) throughout the night. The DON was asked, So, this actually started on the 3 to 11 (3:00 p.m. to 11:00 p.m.) shift with (LPN #1), went over into the 11 to 7 shift, and the resident was sent to the hospital on the 7 to 3 (7:00 a.m. to 3:00 p.m.) shift because the family requested it? The DON was asked, Since (LPN #1) had a temporary license, what kind of orientation did she get prior to being in charge of resident halls? The DON stated, She worked at least 2 weeks with another nurse and she was orientated to everything, and on 3 to 11 shift, we have 2 nurses all the time. The DON was asked, Do you know if she consulted the other nurse on duty during her shift on 3/2/17? The DON stated, I don't remember that. 4.) A Class Attendance Record dated 4/24/17 documented the DON provided training to the facility's licensed nursing staff from 2:00 p.m. to 3:00 p.m. The record documented the signatures of 12 licensed nurses who attended this training. The attached in-service information documented the topics discussed during this training were assessments, vital signs, lung sounds, initiation of immediate care and notification of the physician for changes in condition, following up with outside service providers (such as mobile radiology service) to ensure ordered services are carried out, the need to contact the physician to order diagnostic services such as x-rays, and to, .be alert for possible changes in condition . know your resident, be aware of anything different about them, listen to CNAs (Certified Nursing Assistants). If they think something is going on, listen and check it out . As of 5/1/17, the facility's documentation of the corrective actions and training conducted in response to the failed practices identified on 4/21/17, did not include documentation of any monitoring that was conducted prior to 4/24/17, to prevent potential recurrence.

Based on record review and interview, the facility failed to ensure Resident #14's right to have cardiopulmonary resuscitation (CPR) per the resident's choice. The facility failed to ensure CPR (Cardio-Pulmonary Resuscitation) was initiated for 1 of 1 (Resident #14) case mix resident who had chosen to have CPR initiated in the event of cardiac or respiratory arrest. This failed practice resulted in immediate jeopardy which caused or could have caused serious harm, death, or impairment to Resident #14, who was found without vital signs and did not have CPR initiated, and was likely to affect 19 residents who had chosen to have CPR initiated per a list provided by the Administrator on [DATE] at 1:58 p.m. The facility was notified of the Immediate Jeopardy on [DATE] at 5:12 p.m.. The findings are: 1. Resident #14 had [DIAGNOSES REDACTED]. a. Physician's Directions (Orders) dated [DATE] documented, "Admit to PCNC (Perry County Nursing Home) (with) dx (diagnoses) of [MEDICAL CONDITION], esoph ([MEDICAL CONDITION]) cancer... Full code." b. The admission nurses note dated [DATE] and untimed documented, "... resident arrives via (by way of) ambulance alert and oriented x (times) 3..." c. A Capacity Verification form signed by the resident and dated [DATE] had a check mark in the space that documented, "...Capacity. Has the capacity to understand the nature of his or her medical condition and the consequences of treatment decisions and I do not choose to formulate or issue a Power of Attorney of Healthcare decisions at this time." d. A DNR (Do Not Resuscitate)/CPR (Cardio-Pulmonary Resuscitation) Instructions form was signed by the resident on [DATE] and had a check mark in the box next to "I want CPR..." e. A nurses note dated [DATE] on the 3:00 p.m. - to 11:00 p.m. shift and signed by Licensed Practical Nurse (LPN) #2 documented, "...A (Alert) & (and) O (oriented) x 1, confused (decreased) loc (level of consciousness). Resp (Respirations) shallow/labored... (Physician) visited no new orders... c/o (complains of) pain at 4:50 p.m... [MEDICATION NAME] 0.25 mg (milligrams) given..." On [DATE] at 3:00 p.m., Licensed Practical Nurse (LPN) #2, who worked the evening of [DATE] stated, "I called the doctor the evening of [DATE] due to the resident bleeding from his PEG tube. The doctor came to the facility and went down to the patient and spoke to him for a few minutes and listened to him (his abdomen and heart). The resident did not respond when the doctor was talking to him. He talked to the family outside of the room... He did not talk in the room directly to the resident. I knew he was a full code, that is why I called the doctor." f. A nurses note dated [DATE] ([DATE]) at 12:10 a.m. documented, "(resident) c/o pain and freq (frequently) yells out help... 1:10 a.m., skin pale, fingers/toes/knees blue in color." A nurses note dated 6:10 a.m. documented, "(Resident) resting well (no) s/s (signs and symptoms) of discomfort. resp (respirations) shallow & labored... skin pale cool to touch blue in color in fingers toes & knees... " g. The Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE] documented the resident was severely impaired in cognitive skills for daily decision making per the Staff Assessment for Mental Status. h. A nurses notes dated [DATE] at 2:30 p.m. documented, "Resp. shallow @ (at) 10 per min (minute), unable to obtain pulse, B/P (blood pressure) @ ,[DATE], temp (temperature) 95.2... mottling to bil (bilateral) ft (feet)/hands." A nurses note dated [DATE] at 3:10 p.m. documented, "Pt. (patient) breathless and pulseless (no) response to tactile stimuli Dr. (doctor) notified." Another nurses note dated [DATE] documented, "...3:10 p.m.... (no) pulse found (physician) called. pronounced pt (patient) dead... (Resident) DNR." i. A DNR/CPR Instructions form signed by a family member of the resident was dated [DATE] and had a check mark in the box next to "I do not want CPR ..." j. On [DATE] at 3:30 p.m., the Administrator stated, "I understand, we didn't do what we were suppose to. We didn't honor the resident's wishes of a full code." 2. The facility removed the Immediate Jeopardy on [DATE] at 7:12 p.m. and the scope/severity was reduced to a G, when the facility implemented the following plan of removal: a. The Director of Nursing (DON) compiled a list of resident Code Status Report. On [DATE] at 5:20 p.m., 19 Full Code residents were identified. b. The DON assessed each Full Code resident to determine if guidelines for CPR need or aggressive decline in condition has been recognized. If there were any, the physician would be notified and/or emergency medical treatment would be sought immediately. On [DATE] no residents were found to be at risk at this time. c. The Registered Nursing Supervisor compared list of Code Status Residents to Residents on census to ensure all residents are included. All were identified on [DATE] at 5:30 p.m. d. The Certified Nursing Aide Supervisor checked that all CPR status Magnets were intact in rooms on [DATE] at 5:30 p.m. e. The Administrator compiled the inservice sheet for the CPR Protocol and Code Status on [DATE] at 5:30 p.m.. Inservice included appropriate nursing response to Emergency change in condition. f. Charge Nurses reviewed charts to ensure Code Status available and current on MARs (Medication Administration Records) and in the chart available for nursing staff on [DATE] at 5:30 p.m. g. All current Nursing Staff here will be inserviced at 5:40 p.m. on [DATE] by DON. Each oncoming shift will be inserviced prior to next scheduled shift by DON or designee. This will continue until each nursing staff is inserviced prior to next scheduled shift by DON. or designee. h. Quality Assurance (QA) form for monitoring has been implemented for charge nurse to monitor for Code Status residents each shift. Any change in condition will be taken care of by contacting physician and or seeking emergency medical treatment immediately. Monitoring will be checked by DON on 24 hour report with any negative findings re-inserviced. This monitoring will continue until compliance met.

Based on record review and interview, the facility failed to provide the necessary care and services in accordance with Resident #14's decision regarding the performance of Cardio-Pulmonary Resuscitation. The facility failed to ensure CPR (Cardio-Pulmonary Resuscitation) was initiated for 1 of 1 (Resident #14) case mix resident who had chosen to have CPR initiated in the event of cardiac or respiratory arrest. This failed practice resulted in immediate jeopardy which caused or could have caused serious harm, death, or impairment to Resident #14, who was found without vital signs and did not have CPR initiated, and was likely and was likely to affect 19 residents who had chosen to have CPR initiated per a list provided by the Administrator on [DATE] at 1:58 p.m. The facility was notified of the Immediate Jeopardy on [DATE] at 5:12 p.m. The findings are: 1. Resident #14 had [DIAGNOSES REDACTED]. a. Physician's Directions (Orders) dated [DATE] documented, "Admit to PCNC (Perry County Nursing Home) (with) dx (diagnoses) of [MEDICAL CONDITION], esoph ([MEDICAL CONDITION]) cancer... Full code." b. The admission nurses note dated [DATE] and untimed documented, "... resident arrives via (by way of) ambulance alert and oriented x (times) 3..." c. A Capacity Verification form signed by the resident and dated [DATE] had a check mark in the space that documented, "...Capacity. Has the capacity to understand the nature of his or her medical condition and the consequences of treatment decisions and I do not choose to formulate or issue a Power of Attorney of Healthcare decisions at this time." d. A DNR (Do Not Resuscitate)/CPR (Cardio-Pulmonary Resuscitation) Instructions form was signed by the resident on [DATE] and had a check mark in the box next to "I want CPR..." e. A nurses note dated [DATE] on the 3:00 p.m. - to 11:00 p.m. shift and signed by Licensed Practical Nurse (LPN) #2 documented, "...A (Alert) & (and) O (oriented) x 1, confused (decreased) loc (level of consciousness). Resp (Respirations) shallow/labored... (Physician) visited no new orders... c/o (complains of) pain at 4:50 p.m... [MEDICATION NAME] 0.25 mg (milligrams) given..." On [DATE] at 3:00 p.m., Licensed Practical Nurse (LPN) #2, who worked the evening of [DATE] stated, "I called the doctor the evening of [DATE] due to the resident bleeding from his PEG tube. The doctor came to the facility and went down to the patient and spoke to him for a few minutes and listened to him (his abdomen and heart). The resident did not respond when the doctor was talking to him. He talked to the family outside of the room... He did not talk in the room directly to the resident. I knew he was a full code, that is why I called the doctor." f. A nurses note dated [DATE] ([DATE]) at 12:10 a.m. documented, "(resident) c/o pain and freq (frequently) yells out help... 1:10 a.m., skin pale, fingers/toes/knees blue in color." A nurses note dated 6:10 a.m. documented, "(Resident) resting well (no) s/s (signs and symptoms) of discomfort. resp (respirations) shallow & labored... skin pale cool to touch blue in color in fingers toes & knees... " g. The Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE] documented the resident was severely impaired in cognitive skills for daily decision making per the Staff Assessment for Mental Status. h. A nurses notes dated [DATE] at 2:30 p.m. documented, "Resp. shallow @ (at) 10 per min (minute), unable to obtain pulse, B/P (blood pressure) @ ,[DATE], temp (temperature) 95.2... mottling to bil (bilateral) ft (feet)/hands." A nurses note dated [DATE] at 3:10 p.m. documented, "Pt. (patient) breathless and pulseless (no) response to tactile stimuli Dr. (doctor) notified." Another nurses note dated [DATE] documented, "...3:10 p.m.... (no) pulse found (physician) called. pronounced pt (patient) dead... (Resident) DNR." i. A DNR/CPR Instructions form signed by a family member of the resident was dated [DATE] and had a check mark in the box next to "I do not want CPR ..." j. On [DATE] at 3:30 p.m., the Administrator stated, "I understand, we didn't do what we were suppose to. We didn't honor the resident's wishes of a full code." 2. The facility removed the Immediate Jeopardy on [DATE] at 7:12 p.m. and the scope/severity was reduced to a G, when the facility implemented the following plan of removal: a. The Director of Nursing (DON) compiled a list of resident Code Status Report. On [DATE] at 5:20 p.m., 19 Full Code residents were identified. b. The DON assessed each Full Code resident to determine if guidelines for CPR need or aggressive decline in condition has been recognized. If there were any, the physician would be notified and/or emergency medical treatment would be sought immediately. On [DATE] no residents were found to be at risk at this time. c. The Registered Nursing Supervisor compared list of Code Status Residents to Residents on census to ensure all residents are included. All were identified on [DATE] at 5:30 p.m. d. The Certified Nursing Aide Supervisor checked that all CPR status Magnets were intact in rooms on [DATE] at 5:30 p.m. e. The Administrator compiled the inservice sheet for the CPR Protocol and Code Status on [DATE] at 5:30 p.m.. Inservice included appropriate nursing response to Emergency change in condition. f. Charge Nurses reviewed charts to ensure Code Status available and current on MARs (Medication Administration Records) and in the chart available for nursing staff on [DATE] at 5:30 p.m. g. All current Nursing Staff here will be inserviced at 5:40 p.m. on [DATE] by DON. Each oncoming shift will be inserviced prior to next scheduled shift by DON or designee. This will continue until each nursing staff is inserviced prior to next scheduled shift by DON. or designee. h. Quality Assurance (QA) form for monitoring has been implemented for charge nurse to monitor for Code Status residents each shift. Any change in condition will be taken care of by contacting physician and or seeking emergency medical treatment immediately. Monitoring will be checked by DON on 24 hour report with any negative findings re-inserviced. This monitoring will continue until compliance met.