Every finding on record at Powder Springs Center for Nursing & Healing

Based on observations, staff interviews, record review, and review of the facility's policies titled, Food Receiving and Storage and Appendix 14: Emergency Water Supply, the facility failed to ensure emergency drinking water was stored in safe and sanitary manner for residents in the facility. This deficient practice had the potential to cause contamination and compromise all facility resident's safety. The facility census was 195 residents. Findings include:Review of the facility's policy titled Food Receiving and Storage revised 4/1/2024 section; 1.150 revealed foods shall be received and stored in manner that complies with safe food handling practices.Review of the facility's policy titled Appendix 14: Emergency Water Supply dated/ revised 8/17/2022, further review of Emergency Preparedness Binder page 117 number 4 revealed, Primary water storage emergency water is stored away from kitchen in alternative location in AU (Alzheimer's unit) unit.Observation and Interview on 1/7/2026 at 10:09 am revealed multiple brown boxes stacked on top of each other up against the building outside behind the kitchen where the dumpster and grease trap were located. There was a broom on top of the boxes. Some were moistened and others were opened where gallons were missing and debris such as sticks and dirt was present. The boxes were next to a non-operating freezer. The Dietary Supervisor (DS) revealed that it was their emergency water. She stated they did not have room to fit all in the closet on the AU, so it was put outside. Observation with the Dietary Supervisor and the Registered Dietitian (RD) for the facility of the AU revealed the remaining emergency water and the closet where emergency water was stored was cluttered with boxes in the closet with no order. They counted 66 boxes of emergency water on hand which they stated was enough for each resident for three days.Observation on 1/7/2026 at 11:32 am revealed a portion of emergency water remained outside. The Administrator, the Dietary Supervisor, and the Regional Registered Dietitian went outside where the emergency water was located, and all confirmed that this was some of their emergency water. The Administrator stated that the water was placed outside because of renovations and they were moving from one area to AU and just did not have room for it. The Regional Registered Dietitian stated that they would not use the emergency water outside and that it would be poured out and more would be purchased.

Based on observations, staff interviews, and review of the facility policy titled, Smoking Debris Protocol/Procedures, the facility failed to dispose of cigarette butts in the appropriate receptacle in the outdoor designated smoking area. This deficiency had the potential to cause a fire. The sample size was five residents reviewed for smoking.Findings include:Review of the undated facility policy titled, Smoking Debris Protocol/Procedures, revealed the following: Activities' staff is responsible for the general clean up and cleanliness of the assigned smoking areaActivities' staff to empty the individual smoking ash containers when smoking the session is overAsh containers are emptied into the step on red containerShould the red container be found full, activities is to contact maintenance immediately.After the last smoking session of the day, the maintenance department executes the following protocols:Maintenance will remove the red container from the smoking areaMaintenance floods the container with water or sand to ensure there are no red or smoking embers.Maintenance will then empty the container into a trash bag. Maintenance will then place the trash bag into the applicable refuse container.Observation of the smoking session on 1/7/26 at 11:03 AM revealed a red step-on container which was empty, but a trash receptacle which contained trash and more than 50 cigarette butts. In an observation and interview with Activities Assistant (AA) HH on 1/7/2026 at 11:10 am, she confirmed the presence of cigarette butts in the trash only receptacle. She stated she was a recent hire to the Activities Department and received instruction on the smoking supervision task during orientation where she was instructed to empty ash containers (trays) into the red step-on container and to call the Maintenance Department when it was full. She also stated this current smoking session was the first one she monitored today and she did not know who discarded cigarette butts into the trash receptacle. In a joint observation and interview with the Administrator and the Assistant Administrator on 1/7/26 at 11:15 am, they each confirmed the presence of cigarette butts in the trash only receptacle and acknowledged they should not be emptied into the trash only receptacle. The Administrator stated the Maintenance Director was responsible for disposal of cigarette butts from the red step-on container after the last smoking break of the day. In an observation and interview with the Activities Director on 1/7/2026 at 11:20 am, she stated she trained her staff to empty cigarette butts into the red step-on container and to only place trash in the trash only receptacle. She confirmed that AA GG did not supervise the previous smoking break. In an observation and interview with the Maintenance Director (MD) on 1/7/2026 at 11:25 am, he stated at the end of his day he took the red step-on container away from the smoking area, flooded it with water, then dumped the cigarette butts into a trash bag for disposal. In an interview with the Administrator on 1/7/2026 at 4:15 pm, he stated he removed the trash only receptacle from the smoking area and will only leave the smoking ash container and the red step-on container. He stated he re-educated the activities and maintenance staff regarding the proper disposal of cigarette butts.

Based on staff interviews, record review and review of the facility's policy titled, Binding Arbitration Agreements, the facility failed to ensure the arbitration agreement specifically provided for the selection of a convenient venue: a location in which to carry out arbitration proceedings which should be agreed upon and was convenient and suitable to both parties for three of three residents (R) R246, R140 and R251 reviewed for arbitration.Findings include: Review of the facility's policy titled Binding Arbitration Agreements reviewed 9/12/2025 documented under Policy Explanation and Compliance Guidelines: . 2. The agreement must: . b. Provide for selection of a venue that is convenient for both parties.Review of the facility's arbitration agreement document revealed there was no mention of a venue nor specifically provided for the selection of a venue should be agreed upon and suitable to both parties.Interview on 1/8/2026 at 4:46 pm with the facility's Concierge II revealed she confirmed the venue was not documented on the arbitration agreement. She further stated that she was responsible for informing residents and their family of arbitration, and she did not inform any residents or family members including R246, R140 and R251 of a venue. She stated she did not know the information of where the arbitration venue would be, and there was nothing in the arbitration agreement that stated there should be a mutual venue.Interview on 1/8/2026 at 5:35 pm with the Administrator revealed he confirmed the facility's arbitration agreement did not specifically state a venue for the arbitration. He stated he could not say for sure that the agreement was required to state the venue.Interview on 1/9/2026 at 1:30 pm with the Assistant Administrator revealed she confirmed there was no mention of a mutual venue in the facility's arbitration agreement.

Based on observations, staff interviews, record review, and review of the facility policy titled, Personal Protective Equipment (PPE), the facility failed to follow infection control protocol related to disposal of PPE in two out of five rooms with residents on Droplet Precautions (infection control measures used to prevent the spread of respiratory infections). The census was 183. Findings include: 1. Review of the facility policy titled Personal Protective Equipment date reviewed/revised January 2024, revealed under Policy: This facility promotes appropriate use of personal protective equipment to prevent the transmission of pathogens to residents, visitors, and other staff. Under the section Policy Explanation and Guidelines revealed: Wear a mask to protect the face from contamination with blood, body fluids, and other potentially infectious materials during tasks that generate splashes or sprays. Do not reuse. Under the section Respiratory Protection: Wear a NIOSH [National Institute for Occupational Safety and Health]-approved N95 or higher-level respirator to prevent inhalation of pathogens transmitted by the airborne route. Do not reuse single-use-only respirators. Review of the education roster revealed the in-service on 6/17/2024 titled, Symptoms of COVID-19, Activities Director BB attended the class. The class was taught by Registered Nurse (RN) AA. The overview of the class included to provide a review of COVID-19 symptoms, report change in condition, and Employees - Stay home away from others if symptomatic. During an observation on 6/25/2024 at 12:15 pm, Activities Director BB entered a room where the Residents were on Droplet Precautions. The Activities Director put on a gown, gloves, and face shield; she already had on a KN95 mask. When Activity Director BB exited the room, she discarded the gown and gloves in the room. She came out in the hall with the mask and face shield on. She took the face shield off, cleaned it, and took it with her off the floor. She did not take off her mask and she began passing trays to other residents. During an interview on 6/26/2024 at 2:15 pm with Registered Nurse (RN) AA revealed staff would put on a gown, gloves, mask, and face shield, before entering a resident's room who was on Droplet Precautions. She stated the mask and face shield can be re-used. If the face shield was re-used, it would be cleaned with sanitizer and put in a clean bag. The staff could re-use the N95 mask and would keep it in a clean bag. During an interview on 6/27/2024 at 10:28 am with Activities Director BB revealed they had recent in-services on COVID-19. When she goes into a room and the resident has COVID, she will put on a face mask, gloves, gown, and face shield. Once finished in the room, she will take off the face shield, gown, and gloves, sanitize the face shield, and re-use it. She keeps the face shield in her office. She stated she can keep using the KN95 and discard it at the end of the day. If she uses an N95 mask she will not throw it away but keep it in a bag and use for a few days, unless she starts to sweat and it is soiled. During an interview on 6/27/2024 at 11:20 am with Certified Nursing Assistant (CNA), the CNA stated she will wear a gown, gloves, face mask, and face shield in the room with residents who have COVID-19. Once finished in the room, she will discard all PPE before leaving the room. She stated the PPE cannot be re-used. She believes there was enough PPE for staff. During an interview on 6/27/2024 at 11:42 am with Licensed Practical Nurse (LPN) DD revealed if taking care of a resident with COVID-19 or who was on Droplet Precautions, she would wear a gown, gloves, mask, and face shield into the room. Once she completed care, LPN DD would discard the PPE in the room. She does not re-use any of the PPE. She believes there was enough PPE to take care of the residents. During an interview on 6/27/2024 at 12:45 pm with Central Supply EE revealed she replenishes the PPE on the floor about three times a week. She stated there was enough PPE for the staff to take care of the residents. During an interview on 6/27/2024 at 1:14 pm with the Director of Nursing (DON) revealed the staff would wear a mask, gown, gloves, and face shield into an isolation room. Once finished in the room, they would doff (remove) all PPE and dispose of it in the room. They would not re-use any of the PPE. She stated there was enough PPE for staff to use. 49396 2. During an observation on 6/27/2024 at 11:24 am, Housekeeper FF was observed entering a room where the residents were on Droplet Precautions. She was wearing a gown, gloves, and a KN95 mask, but did not use a face shield. Upon exiting the room, Housekeeper FF failed to discard her gown and gloves inside the room as required. Instead, she removed them in the hallway, discarding them into a trash bin on her cart outside the room. During an interview on 6/27/2024 at 2:37 pm with the DON the proper protocol for PPE disposal was discussed. The DON stated that the behavior observed was unacceptable and confirmed that under no circumstances should staff exit a room without properly discarding their PPE in the designated trash receptacles inside the room.

Based on record review, interviews, and review of the facility policy titled Urinary Tract Infections/Bacteriuria-Clinical Protocol, the facility failed to provide appropriate treatment and services to prevent a catheter associated urinary tract infection from worsening for one of 57 sampled residents (R) (R10). The failure caused R10 to be sent to an acute care hospital with the diagnosis of shock, sepsis, and metabolic crisis (including acute kidney injury and acute renal failure). R10 expired in the hospital on [DATE]. On [DATE], a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation caused or had the likelihood to cause serious injury, harm, impairment, or death to residents. The facility's Administrator was informed of the Immediate Jeopardy (IJ) for F690 and F770 on [DATE] at 10:08 a.m. The noncompliance related to the Immediate Jeopardy was identified to have existed on [DATE]. An Acceptable IJ Removal Plan was received on [DATE] related to 483.25(e)(2) Bowel/Bladder Incontinence, Catheter, UTI (F690) and 483.50(a), Laboratory Services (F770). Findings included: A review of the facility's policy titled Urinary Tract Infections/Bacteriuria-Clinical Protocol/ Assessment and Recognition dated [DATE] revealed the staff and practitioner will identify individuals with signs and symptoms suggesting a possible UTI (urinary tract infection); and nurses should observe, document, and report signs and symptoms in detail. A review of the Electronic Medical Record (EMR) revealed that R10 was admitted to the facility on [DATE] with diagnosis including cerebral infarction, cerebrovascular disease, dementia, benign prostatic hypertrophy with lower urinary tract symptoms, neuromuscular dysfunction of bladder, and cystostomy. A review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed that R10 presented with a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact, and had a urinary catheter. A record review of the Physician Orders dated [DATE] instructed the facility to document output from the urinary catheter every shift related to neuromuscular dysfunction. A review of the Nursing Progress Notes dated [DATE] at 4:22 pm, revealed that the Nurse Practitioner CC documented the chief complaint for R10 was increased confusion and ordered an UA and CS to rule out acute urinary tract infection. A review of the Medication Administration Record (MAR)/Treatment Administration Records (TAR) for [DATE] revealed that R10's urine output ranged from 250 cubic capacity (cc) (on [DATE]) to 600 cc (on [DATE]) per shift. There was no method to monitor if urine output was greater or lesser than normal to see if the catheter was draining properly, and there was no documentation in the medical record of urine color or odor. A review of Nursing Progress Notes dated [DATE] at 12:03 pm, revealed R10 was found to be lethargic, was not eating, and expressed complaints of headache. The notes revealed that the resident's family was worried, and the physician was made aware. A new order was received by the physician to transfer R10 to the emergency room for further evaluation and treatment. A review of the Nurse Practitioner encounter notes dated [DATE] at 3:55 pm, Nurse Practitioner CC noted R10 presented with altered mental status and lethargy. A review of the hospital emergency department provider note dated [DATE] at 12:56 pm, revealed that critical care was necessary to treat or prevent imminent or life-threatening deterioration of the following conditions: shock (sudden drop in blood flow through the body), sepsis, and metabolic crisis (severe hyperkalemia, acute kidney injury/acute renal failure). Purulent (containing pus) urine, very little urine in the bag despite two liters of intervenous fluid bolus. On further assessment, [R10] was found to have so much purulent sediment in the bladder that the indwelling urinary catheter was not draining; the indwelling urinary catheter was not wide enough to drain pus. Removed the urinary catheter, copious drainage of thick green malodorous (odor) pus from the bladder via the urinary catheter site. [R10] was placed in hospice on [DATE] for sepsis. A record review of R10's death certificate revealed R10 died in the hospital on [DATE]. During an interview on [DATE] at 2:16 pm, Licensed Practical Nurse (LPN) AA stated she went to assess R10 on [DATE] and he wasn't looking good. She stated that the resident was too sleepy, so she called Nurse Practitioner CC and informed him that R10 was not how he usually looks. LPN CC further stated that she looked at R10's urinary catheter and it was cloudy. She confirmed the observation of cloudy urine was not documented in R10's medical record. During an interview on [DATE] at 5:25 pm, Nurse Practitioner CC stated that he left the facility in [DATE] and refused to answer questions related to R10. During an interview on [DATE] at 1:43 pm, Physician PPPP remembered R10. He stated, He was the guy who had a UTI and went to the hospital and died . He stated that had the facility done good catheter care and prevented the infection, there may have been a different outcome for R10 and that R10 might not have died . He revealed that he was the Medical Director at the facility at that time R10 was sent out to the hospital, but he left the facility in [DATE]. The facility implemented the following actions to remove the IJ: R10 no longer resides at the facility. On [DATE], the Regional Director of Operations, Regional Director of Clinical Services, and the Administrator reviewed the center policy Catheter Care, Urinary. No policy changes or recommendations were made because of this review. On [DATE], the facility's Director of Nursing (DON) identified one resident with catheters on the center resident roster. On [DATE], the facility's DON reviewed orders for residents with catheters to validate that no lab had been missed. On [DATE], licensed nurses to include MDS Nurse and nurse managers were educated by the DON on the importance of reviewing and addressing residents with catheters for lab orders on [DATE]. Employees on leave of absence, vacation, and agency staff will be re-educated prior to returning to duty and will not be given an assignment until they are given additional on-site education (87 percent (%)). The DON will review orders for lab reports from the previous day during daily clinical meetings and will verify care plans are developed and revised as needed, to address interventions to prevent urinary tract infections. The Administrator reviewed the results of the audits and shared the findings with the Ad Hoc Quality Assurance Performance Improvement (QAPI) Committee on [DATE]. The State Survey Agency (SSA) validated the facility's written IJ Removal Plan as follows: A review of the census list revealed R10 was discharged to the hospital on [DATE] and did not return. During an interview on [DATE] at 10:16 am, the Administrator confirmed R10 was no longer residing in the facility. A review of the policy titled Catheter: Urinary - Justification for Use and signed as reviewed on [DATE] by the Regional Director of Operations, Regional Director of Clinical Services, and Administrator. An interview on [DATE] at 1:30 pm with the DON revealed she reviewed the residents' orders and labs from the previous day and addressed them in the daily clinical meetings. A review of the facility's catheter list dated [DATE] revealed one resident (R49) with an indwelling catheter. On [DATE] at 12:53 pm, a sample of four residents were selected to review their lab orders and subsequent results. All labs were ordered, and results were received. A review of the in-service titled Lab/Diagnostic Orders and Other Orders dated [DATE], revealed that 76 staff members were educated and in-service on labs, diagnostic orders, and other orders. To certify that staff were educated, the survey team interviewed a sample of staff within each department and all shifts. Interviews were conducted on [DATE] through [DATE] with following employees revealed they received and understood the education: [DATE] at 6:26 am LPN UU; [DATE] 6:39 am LPN VV; [DATE] at 6:51 am Registered Nurse (RN) ZZ and MM; [DATE] at 6:55 am LPN YY; [DATE] at 7:14 am Certified Nursing Assistant (CNA) WW; [DATE] at 7:22 am CNA XX; [DATE] at 8:18 am LPN AAA; [DATE] at 9:39 am LPN BBB; [DATE] at 8:17 am Lead Housekeeper CCC; [DATE] at 8:37 am Housekeeping DDD; [DATE] at 8:48 am Housekeeping EEE; [DATE] at 3:32 pm Cook FFF; [DATE] at 3:39 pm Cook GGG; [DATE] at 3:47 pm Cook HHH, [DATE] at 3:57 pm Business Office Manager III; [DATE] at 4:09 pm Receptionist JJJ; [DATE] at 4:37 pm Assistant Administrator KKK; [DATE] at 10:44 am Director of Maintenance; [DATE] at 9:25 am MDS Coordinator/LPN MMM; [DATE] at 9:54 am MDS Coordinator/LPN NNN; [DATE] at 10:15 am Physical Therapy Assistant OOO; [DATE] at 10:31 am Speech Language Pathologist PPP; [DATE] at 10:54 am Maintenance Assistant RRR; [DATE] at 11:18 am with Social Service Assistant SSS; [DATE] at 12:04 pm CNA TTT; [DATE] at 12:19 pm CNA NN; [DATE] at 12:40 pm CNA UUU; [DATE] at 12:45 pm Certified Medication Assistant (CMA) QQ; and [DATE] at 1:04 pm CNA VVV. A review of the facility Plan of Correction book revealed the center reviewed the lab orders, (for residents with catheters) and verified no other labs were missing. A review on [DATE] of the QAPI Committee minutes revealed the minutes were prepared by the Administrator and dated [DATE]. The QAPI topics reviewed were physicians orders, lab requisitions, catheter care, and neglect reporting. The QAPI minutes revealed catheter care education would be conducted by the Staff Development Coordinator and would be on-going. It was verified that the facility demonstrated that the immediate jeopardy was removed on [DATE].

Based on record review, interviews, and review of the facility's policy titled Laboratory Services and Reporting, the facility failed to provide critical laboratory tests for one of 57 sampled residents (R) (R10). The Nurse Practitioner ordered urine culture sensitivity (UA and CS) tests on [DATE]. The failure caused R10 to be sent to an acute care hospital with the diagnosis of shock, sepsis, and metabolic crisis (including acute kidney injury and acute renal failure). R10 expired in the hospital on [DATE]. On [DATE], a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation caused or had the likelihood to cause serious injury, harm, impairment, or death to residents. The facility's administrator was informed of the Immediate Jeopardy (IJ) for F690 and F770 on [DATE] at 10:08 a.m. The noncompliance related to the Immediate Jeopardy was identified to have existed on [DATE]. An Acceptable IJ Removal Plan was received on [DATE] related to 483.25(e)(2) Bowel/Bladder Incontinence, Catheter, UTI (F690) and 483.50(a), Laboratory Services (F770). Findings included: A review of the undated facility's policy titled Laboratory Services and Reporting revealed that the facility must provide or obtain laboratory services when ordered by a physician, physician assistant, nurse practitioner, or clinical nurse specialist in accordance with state law. The Policy Explanation and Compliance Guidelines revealed that the facility must provide or obtain laboratory services to meet the needs of its residents; and the facility is responsible for the timeliness of the services. On [DATE] at 3:07 pm, the Administrator said they did not have a policy for laboratory collections. A review of the Electronic Medical Record (EMR) revealed R10 was admitted to the facility on [DATE] with diagnosis including benign prostatic hypertrophy with lower urinary tract symptoms, neuromuscular dysfunction of bladder, and cystostomy. A review of the nurse practitioner encounter note dated [DATE] identified R10 as having the chief complaint of increased confusion (a common sign/symptom of a urinary tract infection). Nurse Practitioner CC ordered UA and CS tests to rule out an acute urinary tract infection. There was no documentation in the medical record that this laboratory specimen was collected or that staff acted on the order for R10 written by Nurse Practitioner CC. A review of the EMR revealed that a second order for UA and CS tests and an order for a comprehensive metabolic panel (CMP) test was written on [DATE]. There was no documentation in the medical record that this second laboratory specimen was collected or that staff acted on the second order written for R10. A review of the nurse practitioner encounter notes dated [DATE] at 3:55 pm, Nurse Practitioner CC noted R10 presented with altered mental status and lethargy. A review of the hospital emergency department provider note dated [DATE] at 12:56 pm, revealed that critical care was necessary to treat or prevent imminent or life-threatening deterioration of the following conditions: shock (sudden drop in blood flow through the body), sepsis, and metabolic crisis (severe hyperkalemia, acute kidney injury/acute renal failure). Purulent (containing pus) urine, very little urine in the bag despite two liters of intervenous fluid bolus. On further assessment, [R10] was found to have so much purulent sediment in the bladder that the indwelling urinary catheter was not draining; the indwelling urinary catheter was not wide enough to drain pus. Removed the urinary catheter, copious drainage of thick green malodorous (odor) pus from the bladder via the urinary catheter site. [R10] was placed in hospice on [DATE] for sepsis. A record review of R10's death certificate revealed R10 died in the hospital on [DATE]. During an interview on [DATE] at 5:25 pm, Nurse Practitioner CC stated that he left the facility in [DATE] and refused to answer questions related to R10. During an interview on [DATE] at 1:43 pm, Physician PPPP remembered R10. He stated, He was the guy who had a UTI and went to the hospital and died . He stated that had the facility done good catheter care and prevented the infection, there may have been a different outcome for R10 and that R10 might not have died . He revealed that he was the Medical Director at the facility at that time R10 was sent out to the hospital, but he left the facility in [DATE]. During an interview on [DATE] at 5:56 pm, Medical Director QQQQ confirmed that when he came on as the Medical Director in 2022, he was aware the facility was having problems getting physicians orders and lab orders transferred and completed timely. He said his expectation was that laboratory orders be acted upon within 24 hours of the order date. The facility implemented the following actions to remove the IJ: R10 no longer resides at the facility. On [DATE], the facility's Director of Nursing (DON) identified one resident with catheters on the facility's resident roster. On [DATE], the facility's DON reviewed orders for residents with catheters to validate if any UA and CS lab had been missed. On [DATE], all licensed nurses were educated by the DON on the importance of reviewing and addressing residents with catheters for UA and CS lab orders. Employees on leave of absence, vacation, and agency staff will be re-educated prior to returning to duty and will not be given an assignment until they are given additional on-site education (87 percent (%)). The DON will review orders for lab requests and 24 hour reports from the previous day during daily clinical meetings and will verify that labs orders were drawn as ordered by the nurse practitioner or physician to prevent urinary tract infections. The Administrator reviewed the results of the audits and shared the findings with the Ad Hoc Quality Assurance Performance Improvement (QAPI) Committee on [DATE]. The State Survey Agency (SSA) validated the facility's written IJ Removal Plan as follows: A review of the census list revealed R10 was discharged ot to the hospital on [DATE] and did not return. During an interview on [DATE] at 10:16 am, the Administrator confirmed R10 was no longer residing in the facility. A review of the facility's catheter list dated [DATE] revealed one resident with an indwelling catheter. On [DATE] at 12:53 pm, a sample of four residents were selected to review their lab orders and subsequent results. All labs were ordered, and results were received. Interviews were conducted on [DATE] through [DATE] with following employees revealed they received and understood the education: [DATE] at 6:26 am with Licensed Practical Nurse (LPN) UU; [DATE] at 6:39 am with LPN VV; [DATE] at 6:51 am with Registered Nurse (RN) ZZ; [DATE] at 6:55 am LPN YY; [DATE] at 8:18 am LPN AAA; [DATE] at 9:39 am LPN BBB; [DATE] at 9:57 am LPN LL; [DATE] at 11:38 am LPN EE; [DATE] at 12:08 pm LPN BB; [DATE] at 9:25 am MDS Coordinator LPN MMM; and [DATE] at 9:54 am MDS Coordinator LPN NNN. The facility conducted an audit of residents that had lab orders. A total of 29 labs were audited. On [DATE] at 12:53 pm, a sample of five labs for four residents were selected to review their lab orders and subsequent results. All labs were ordered, and results were received. A review of the sign in sheet dated [DATE] revealed that a QAPI monthly meeting was held. It was verified that the facility demonstrated that the immediate jeopardy was removed on [DATE].

Based on observation, interviews, and review of the facility's policy titled, Food Receiving and Storage, the facility failed to ensure the vents directly over the steam table were free from dirt and debris, a fan used in the kitchen area was clean, the frozen food items are kept off the freezer floor, and that hair nets were worn in the kitchen. The census was 178 residents. Findings included: A review of the undated facility's policy titled, Food Receiving and Storage documented that the refrigerated foods will be stored in such a way that promotes adequate air circulation around food storage containers. Refrigerators/walk-ins will not be overcrowded. During an observation on 3/18/2024 at 6:41 pm, the Dietary Manager was observed in the kitchen and was not wearing a hair net. During an interview on 3/19/2024 at 7:50 am, the Dietary Manager confirmed not wearing a hair net during the dinner service on 3/18/2024. The Dietary Manager stated that her hair net was on their desk in the office. During an observation on 3/19/2024 at 8:01 am, there were three vents over the steam table, where meals were being actively plated for residents. The vents were filled with dirt and debris and a fan by the kitchen sink was filled with dirt and debris. During an interview on 3/19/2024 at 9:33 am, the morning cook, Cook KKKK stated that when the kitchen gets hot, the staff does turn on the fan. Cook KKKK confirmed that they were uncertain about the last time the fan was cleaned. During an interview on 4/11/2024 at 2:18 pm, the Dietary Manager stated that the maintenance department is responsible for cleaning the air conditioning vents but the kitchen staff needed to notify the receptionist in order to put in a work order. During an observation on 3/19/2024 at 7:36 am, the freezer was observed to have one box of frozen shrimp and two boxes of frozen bacon on the freezer floor. The Dietary Manager confirmed leaving one box of frozen shrimp and two boxes of frozen bacon on the floor.

Based on observation, interviews, and review of the facility policy titled, Food-Related Garbage and Rubbish Disposal, the facility failed to ensure that the facility's outside garbage disposal area was free from trash and debris. The census was 178 residents. Findings included: A review of the undated facility's policy titled Food-Related Garbage and Rubbish Disposal, documented that all garbage and rubbish containing food waste should be kept in containers; all garbage and rubbish containers shall be provided with tight-fitting lids or covers and must be kept covered when stored or not in continuous use; and outside dumpsters provided by garbage pickup services will be kept closed and free of surrounding litter. On 3/19/2024 at 7:46 am, a kitchen tour was conducted with the Dietary Manager. Two trash compactors were observed outside and had several bags of trash on the ground, including gloves and several plastic bags of trash. The lid of one of the trash compactors was opened. The Dietary Manager confirmed that the lids should have been closed and stated that the cleaning of the garbage dumpster was a joint effort between the dietary staff and housekeeping staff to keep the trash areas clean. The Dietary Manager stated that the outside garbage area should have been kept clean, that the staff was informed that all trash goes in the bin, and they must pick up anything that is dropped.

Based on record review, policy review, and interviews, the facility failed to maintain the tracking and trending of the Infection Control Program. The census was 178 residents. Findings included: A review of the policy entitled, Infection Prevention and Control Program with a reviewed/revision date of May 2023 revealed that the designated Infection Preventionist is responsible for oversight of the program and serves as a consultant to our staff on infectious diseases, resident room placement, implementing isolation precautions, staff and resident exposures, surveillance, and epidemiological investigations of exposures of infectious diseases; a system of surveillance is utilized for prevention, identifying, reporting, investigating, and controlling infections and communicable disease for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon a facility assessment and accepted national standards; and the Infection Preventionist serves as the leader in surveillance activities, maintains documentation of incidents, findings, and any corrective actions made by the facility and reports surveillance findings to the facility's Quality Assessment and Assurance Committee. A review of the Infection Control Program from October 2023 thru March 2024 revealed during the month of October 2023 the facility's tracking and trending for the facility for Upper Respiratory Infection (URI) tracked only one infection for the month, but nine infections were documented. In the area of Urinary Tract Infection (UTI) the facility had tracked no UTIs, but thirteen infections were documented. Under Gastrointestinal Infections (GI), there were no infections tracked, but one was documented for the month. Under skin conditions, no skin issues were tracked, but four skin conditions were documented for the month. A review of the November 2023 tracking and trending revealed under URIs, one infection was tracked, but eight infections were documented. Under UTIs, there were three tracked for the month, but 15 were documented for the month. Under skin conditions, there were no skin conditions tracked for the month, but seven were documented for the month. A review of the December 2023 tracking and trending revealed that URIs, the facility tracked only one, but 12 were documented. Under UTIs for the month, there was no UTI tracked, but 12 were documented. Under GIs for the month there were no GI issues tracked, but one was documented. Under skin conditions only three were tracked, but six were documented. A review of the January 2024 tracking and trending revealed that in the area of URIs, one issue was tracked but 10 were documented. Under the area of UTIs only one was tracked, but 11 were documented. Under the area of skin conditions only four skin conditions were tracked, but nine were documented. A review of the February 2024 tracking and trending revealed that under URIs only five were tracked, but six URIs were documented. Under UTIs only nine were tracked, but 11 were documented. Under skin conditions only three were tracked, but four were documented. A review of the Infection Control Program for the month of March 2024 to present revealed no documentation for the month of March or April. An attempt was made to interview Infection Preventionist (IP) NNNN, but there was no answer, a voice mail message was left, but there was no call back. During an interview on 3/14/2024 at 11:27 am with DON/IP confirmed that she was the designated IP for the facility. During an interview on 4/8/2024 at 11:02 am, the Administrator stated that IP NNNN is staff as an Infection Preventionist, but she works as needed. During an interview on 4/11/2024 at 1:37 pm with the DON who confirmed that she had not done any work with the infection control program for the past few weeks. She stated that other staff had been spending from 16 to 20 hours per week on the program. She confirmed that the person who was designated to work with the program had not done any work with the program since January 2024. The DON stated that her expectation of the tracking and trending for the previous month should be that it be completed by the 15th of the current month.

Based on record review, policy review, and interviews, the facility failed to ensure that residents were offered and/or consented to the pneumoccal vaccination for three of six residents (R) (R25, R44, and R46) reviewed for immunizations. Findings included: A review of the Pneumococcal Vaccine (Series) Policy with a date of reviewed/revised of December 2023 revealed that it is the facility's policy to offer residents and staff immunization against pneumococcal disease in accordance with current (infection control) guidelines and recommendations. Further review of the Pneumococcal policy under the Policy Explanation and Compliance Guidelines revealed that, Each resident will be assessed for pneumococcal immunization upon admission. Self-report of immunization shall be accepted; the resident/representative retains the right to refuse the immunization. The facility will document in the clinical record the reason for refusal or the medical contraindication of the immunization. 1. A review of the clinical record revealed that R25 was admitted to the facility on [DATE] with diagnoses of peripheral vascular disease, pressure ulcer of sacral region, osteomyelitis of vertebra, sacral and sacrococcygeal region, other spondylosis, sacral and sacrococcygeal region, heart failure, cognitive communication deficit, muscle weakness, cirrhosis of liver, asthma with (acute) exacerbation, atrial fibrillation, acquired absence of right leg below knee, acquired absence of left leg below knee, insomnia, and gastro-esophageal reflux disease without esophagitis. A review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed that R25 presented with a Brief Interview for Mental Status (BIMS) score of 14, indicating that resident was cognitively intact. A review of the immunization records for R25 revealed under the tab Pneumovax was a date of 11/2/2018. There was no other documentation related to Pneumovax being offered or refused. A review of the Immunization Audit Report for R25 revealed that Pneumovax was administered on 11/2/2018. There was no other documentation related to Pneumovax being offered or refused. A review of the Medication Administration Record (MAR) for R25 dated September 2022 through March 2023 revealed no vaccination of the Pneumococcal vaccination. A review of the MAR for R25 dated September 2023 through March 2024 revealed no vaccination of the Pneumococcal vaccination. A review of the progress notes for R25 dated September 2022 through March 2024 revealed no vaccination of the Pneumococcal vaccination. 2. A review of the clinical record revealed that R44 was originally admitted to the facility on [DATE] with diagnoses of chronic systolic (congestive) heart failure, cardiomyopathy, hypertension, long-term use of anticoagulants, personal history of pulmonary embolism, and presence of artificial knee joint. A review of the quarterly MDS assessment dated [DATE] for R44 revealed that the resident presented with a BIMS score of 10, indicating moderate cognitive impairment. A review of the Pneumococcal Vaccine Consent Form dated 10/23/2023 revealed that the family representative signed consent for the Pneumococcal vaccination. A review of the progress notes for R44 dated 10/23/2023 revealed no documentation of the Pneumococcal vaccination being administered. Further review of the progress notes dated September 2022 through March 2023 revealed no documentation of Pneumococcal vaccination being administered. A review of the Immunization Audit Report for R44 revealed that the resident refused to give consent to receive the Pneumococcal vaccination on 5/11/2017. There was no other documentation that the Pneumococcal vaccination was offered or refused after 5/11/2017. A review of the MAR for R44 dated September 2022 through March 2023 revealed no documentation that the Pneumococcal vaccination was administered. A review of the MAR for R44 dated September 2023 through March 2024 revealed no documentation that the Pneumococcal vaccination was administered. 3. A review of the clinical record revealed that R46 was admitted to the facility on [DATE] with diagnoses of cerebral infarction due to embolism of unspecified cerebral artery, acquired absence of right leg above knee, complete traumatic amputation at knee level, left lower leg, hyperlipidemia, essential (primary) hypertension, polyneuropathy, specified peripheral vascular diseases, atherosclerosis of native arteries of extremities with gangrene left leg, seizures, retention of urine, muscle weakness, and abnormal posture. A review of the quarterly MDS assessment dated [DATE] revealed that R46 presented with a BIMS score of 13, indicating that resident was cognitively intact. A review of the immunization records for R46 revealed that the Pneumococcal vaccination was refused. There was no refusal date documented. A review of the Immunization Audit Report for R46 revealed that the resident's family refused the Pneumococcal vaccination on 6/7/2018. There was no documentation if the vaccine was offered or refused after 6/7/2018. A review of the MAR for R46 dated September 2022 through March 2023 revealed no documentation that the Pneumococcal vaccination was administered. A review of the MAR for R46 dated September 2023 through March 2024 revealed no documentation that the Pneumococcal vaccination was administered. A review of the progress notes for R46 dated September 2022 through March 2024 revealed no vaccination of the Pneumococcal vaccination. During an interview on 4/3/24 at 2:33 pm, the Director of Nursing (DON) stated that the primary care doctor or the DON/Infection Preventionist (IPC) is responsible for making sure the vaccinations are offered and/or provided. She stated that Influenza and Pneumococcal vaccinations are offered to the residents every five years, and this should be documented in the clinical record.

Based on observations, staff interviews, record review, and review of the facility policies titled, Medication Storage and Medication Administration, the facility failed to ensure medications securely stored and ensure expired medications were discarded appropriately on two of three Units (East Unit and Secured Memory Unit). Findings included: A review of the facility policy titled Medication Administration last updated January 2024 revealed that medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. The policy explanation and compliance guidelines noted to identify expiration date and if expired, notify nurse manager. A review of the facility policy titled Medication Storage last updated June 2023 revealed that it is the policy of this facility to ensure all medications housed on our premises will be stored in the pharmacy and/or medication rooms according to the manufacture's recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control segregation, and security. During a medication pass, medications must be under the direct observation of the person administering medications or locked in the medication storage area/cart. 1. During an observation on the East Unit on 3/18/2024 at 10:00 am, Licensed Practical Nurse (LPN) DD was observed to administer medication to Resident (R)2. LPN DD was observed to pull R2's medications and placed them in a cup, locked the medication cart, and left the medication blister packets on top of the medication cart. LPN DD entered the R2's room with the cup of medications and had her back turned away from the medication cart. The medication that was left on top of the medication cart was Atorvastatin Calcium 40 milligrams (mg), Empagliflozin 10 mg, Metoprolol Succinate extended release (ER) 25 mg, Propranolol hydrochloric acid (HCI) 10 mg, Sertraline HCl 25 mg, Vitamin D3 125 micrograms (mcg), Keppra 500 mg, Torsemide 10 mg, and Gabapentin 300 mg. During an interview on 3/18/2024 at 10:22 am, LPN DD stated there had not been any problem with leaving the medication packets on top of the cart and that the packets were able to be left on top of the cart while she was in the resident's room. During an interview on 3/18/2024 at 6:16 pm, LPN EE stated that medication packets were never to be left unattended. LPN EE stated she would not leave any kind of medication on top of the cart, while in the cart was unattended. She stated the medication should always be secured in the medication cart with the cart locked whenever the nurse stepped away. During an interview on 3/26/2024 at 9:02 am, the Director of Nursing (DON) stated that during medication administration, after the medications have been pulled, the nurse should place the medication blister packets back in the cart and locked the cart. The DON stated that all medications are required to be secured under lock and key. The DON further stated that it had never been the facility's practice to leave the medication blister packets on top of the medication cart. 2. During an observation with the DON of the Secure Memory Unit's Medication Room on 3/26/2024 at 9:09 am, the DON confirmed that the following medications were expired: Vitamin D 10 mg had an expiration date of February 2024 and Aspirin 325 mg had an expiration date of January 2024. During an interview on 3/26/2024 at 9:20 am, LPN PP stated that the medications had been checked for expiration dates, but the Vitamin D 10 mg and the Aspirin 325 mg must have been overlooked.

49687 Based on record reviews, staff interviews, and a review of the facility policy titled Resident and Family Grievances the facility failed to resolve a grievance related to missing glass for one of six sampled residents (R) (R17). Findings included: The facility's policy titled, Resident and Family Grievances documented that prompt efforts to resolve' include facility acknowledgement of a complaint/grievance and actively working toward resolution of that complaint/grievance and that the staff member receiving the grievance will record the nature and specifics of the grievance on the designated grievance form or assist the resident or family member to complete the form. A review of the Electronic Medical Record (EMR) for R17 revealed an original admitted [DATE]. A review of the Admission Minimum Data Set (MDS) assessment dated [DATE], revealed R17 had a Brief Interview for Mental Status (BIMS) score of three, indicating severely impaired cognition. A review of facility documents revealed that it was reported that R17 was missing a pair of glasses and that Licensed Practical Nurse (LPN) KK, who was also the [NAME] Wing Unit Manager, had notified R17's responsible party (RP) about the missing glasses on 8/16/2023. A review of the facility's filed grievances for the period of August 2023 revealed that there were no grievances filed on behalf of the R17 to locate the missing glasses. During an interview on 4/1/2024 at 3:29 pm, LPN KK revealed s/he did remember the R17 but did not remember being told about any missing glasses. LPN KK stated that if R17's RP reported missing glasses to LPN KK, it would have been reported to the Administrator. LPN KK revealed that when a resident or their family member reports an item missing, the staff would first search for it in the resident's room and then search in the facility's laundry. If the item wasn't found, then the staff would report it to the Administrator and file a grievance. If someone else found the glasses later, the staff would give the item to the Administrator or take it to the front desk. After reviewing the documentation dated 8/16/2023, LPN KK confirmed s/he wrote that statement and that a lot was going on with R17 the night they were sent to the hospital. S/he confirmed that they didn't file a grievance to locate R17's glasses.

49687 Based on record review, interviews, and review of the facility's policies titled, Fall Prevention Program and High Risk Medications- Anticoagulants, the facility failed to ensure that residents were supervised, fall incidents were documented, and neuro checks were completed for unwitnessed fall incidents for two of four sampled residents (R) (R4, and R17). Findings included: A review of the undated facility's policy titled, Fall Prevention Program documented that when any resident experiences a fall, the facility will assess the resident; complete a post - fall assessment; complete an incident report; notify physician and family; review the resident's care plan and update as indicted; document all assessment and actions and obtain witness statements in the case of injury. A review of the facility's policy titled High Risk Medications- Anticoagulants documented that anticoagulants refers to a class of medication that are used to prevent clot extension and formation. Examples include warfarin, heparin, Lovenox, Xarelto, Pradaxa and Eliquis. 1. A review of the Electronic Medical Record (EMR) revealed R4 was originally admitted to the facility on [DATE] and was discharged on [DATE] with diagnoses including, but not limited to unspecified sequelae of cerebral infarction, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, dysphagia following cerebral infarction, moderate protein-calorie malnutrition, [NAME] Syndrome, Ileus, history of falling, and difficulty walking. A review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed that R4 had a Brief Interview for Mental Status (BIMS) score of 15, indicating no cognitive impairment. A review of the Medication Administration Record (MAR) dated April 2022 showed that resident was ordered and administered Plavix at 75 milligrams (mg) at 9:00 am daily beginning on 4/23/2022. A review of the progress note dated 4/23/2022 at 1:00 am revealed that R4 was found on the floor on 4/22/2022 at 11:30 pm. The note stated that R4 climbed out of bed to the floor. It was documented that R4 denied any injury or pain and was returned to bed by a transfer lift. A review of the EMR revealed no documentation that neurological checks were completed. During an interview on 4/9/2024 at 1:08 pm, the Director of Nursing (DON) confirmed that there was no documentation of any neurological checks completed after the fall on 4/22/2022. She confirmed that the incident was not witnessed, but R4 was alert and was able to tell how he got on the floor, and no neuro checks were completed because R4 was able to give details. During an interview on 4/9/2024 at 4:58 pm, Registered Nurse (RN) RRRR stated that if there were no neurological checks documented, then that meant that there were no neurological checks done. RN RRRR stated that the protocol is if a resident falls and hits their head, then n neurological checks would be completed, but since the resident was able to tell her that he did not hit his head, then there was no need for neurological checks. 2. A review of the EMR revealed R17 was originally admitted to the facility on [DATE] with diagnosis of but not limited malignant neoplasm of the brain, hydrocephalus, dysphagia, hypo-osmolality and hypernatremia, gastroesophageal reflux disease without esophagitis, and Anemia. A review of the Admission MDS assessment dated [DATE] revealed R17 had a BIMS of three, indicating severe cognitive impairment. A review of R17's MAR indicated that R17 received heparin sodium injection solution 10000 unit/milliliters (ml). Inject 0.5 ml subcutaneously every eight hours for deep vein thrombosis (DVT). The medication start date was 6/26/2023 and discontinued on 8/15/2023. R17 was then ordered heparin sodium (porcine) injection solution 10000 unit/ml inject 0.5 ml subcutaneously every eight hours for DVT. The start date was 8/15/2023 with a discontinued date of 9/7/2023. A review of R17's progress notes revealed R17 fell on [DATE], 8/3/2023, 8/14/2023, and 8/16/2023. The progress note dated 8/16/2023 at 1:28 pm documented that R17 was noted sitting up in his wheelchair at the nursing station; attempting to stand without assistance; the nurse asked the resident not to stand without assistance; and the resident still stood up by himself and fell to the floor before the nurse could get to him. It was documented that no visible injuries were noted, no bruising noted, resident did not hit his head he fell on to his left side. There were no documented assessments found in the residents clinical record. During an interview on 3/27/2024 at 12:23 pm, the DON stated that all interventions should be time stamped in the resident's care plan. The DON confirmed that there were no documented incident reports or post fall intervention found for R17. The DON stated there should have been an incident report completed after a fall, and unwitnessed falls require that neurological checks be completed and documented. During an interview on 3/27/2024 at 3:00 pm, the Licensed Practical Nurse (LPN) MMMM stated when a fall occurs a visual check on the resident is completed. LPN MMMM stated that the staff would perform a skin assessment, pain assessment, change of condition, notify the doctor, DON, Administrator, and family member. LPN MMMM stated s/he had only been at the facility a month prior to R17's fall that occurred on 8/16/2023. LPN MMMM stated s/he had not been familiar with the process until the DON notified them about the missing incident report. LPN MMMM did not know that R17 was on blood thinners.

Based on interviews and record review, the facility failed to keep accurate medical record of health status for one of 57 sampled residents (R) (R17). Findings included: A review of the Electronic Medical Record (EMR) for R17 revealed an original admitted [DATE] with diagnosis of, but not limited to, malignant neoplasm of the brain, hydrocephalus, dysphagia, hypo-osmolality and hypernatremia, gastroesophageal reflux disease without esophagitis and anemia. A review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed R17 had a Brief Interview for Mental Status (BIMS) score of three, indicating severely impaired cognition. A review of R17's comprehensive progress notes which includes their Medication Administration Record (MAR) indicated the following events: A nursing note dated [DATE] documented that R17 was out of the building and was unable to receive intervenous (IV) hydration. An administration note documented by Licensed Practical Nurse (LPN) HH and dated [DATE] documented that R17 was deceased . An administration note dated [DATE] documented that R17 was hospitalized . An administration note documented by LPN JJJJ and dated [DATE] documented that R17 was deceased . An administration note dated [DATE] documented that R17 was hospitalized . An administration note dated [DATE] documented that R17 was out. An administration note dated [DATE] documented that R17 was at the hospital. An administration note dated [DATE] documented that R17 was at the hospital. An administration note dated [DATE] documented that R17 remained on LOA (leave of absence). An administration note dated [DATE] documented that R17 remained on LOA during that shift. During an interview on [DATE] at 5:38 pm, the Administrator revealed that R17 was not deceased until [DATE]. The Administrator stated R17 was at the hospital until [DATE] and did not return to the facility. A review of R17's death certificate revealed that R17 was deceased on [DATE]. During an interview on [DATE] at 3:29 pm, LPN HH revealed that s/he received the health status of R17 from another nurse. She confirmed that the documentation error wasn't corrected using a strikethrough after finding out that R17 was not deceased because s/he couldn't do anything due to R17 already being discharged from the facility. During an interview on [DATE] at 3:55 pm, the Director of Nursing (DON) stated upon review of R17's progress notes on [DATE], the DON noted that R17 progress note documented that s/he was deceased on [DATE] and [DATE], then the notes afterwards document R17 was still at the hospital, not deceased . The DON stated s/he is unsure why staff did not do a follow-up note. The DON stated that LPN HH didn't know if R17 was deceased or in the hospital and that LPN JJJJ made the documentation error because s/he was PRN and rarely at the facility.

Based on observations, interviews, and record review, the facility failed to ensure that the nursing call system was functional for one of three sampled residents (R) (R37). Findings included: 1. A review of the Electronic Medical Record (EMR) for R37 revealed the resident was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis of, but not limited to, multiple fractures of ribs, end stage renal disease, dependence on renal dialysis, muscle weakness, anemia, and diplopia. A review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed R37 had a Brief Interview for Mental Status (BIMS) score of 15; indicating that R37 was cognitively intact. 2. A review of the EMR for R30 revealed the resident was originally admitted to the facility on [DATE] with diagnosis of, but not limited to, end stage renal disease, type 1 diabetes, dependence on renal dialysis, morbid obesity, hyperlipidemia, hypertension, hypoxia, acquired absence of the right [NAME] below the knee, and visual loss. A review of the admission MDS assessment dated [DATE] revealed R30 had a BIMS score of 14; indicating that R30 was cognitively intact. During an interview on 3/18/2024 at 3:48 pm, R30 stated that her roommate's (R37) call light was not working. R30 stated that R37 moved into her room in March 2024 and the call light was not working then. R30 stated when R37 would attempt to use the call light to call for staff assistance, they could not hear that sound to alert staff that the resident needed assistance. R30 stated she was blind, but her hearing was more sensitive due to the loss of vision. At this time, R37's call light was tested and was found to not be functioning when pressed. R30's was observed to press her call light, which was functional and Certified Nursing Assistant (CNA) GGGG entered the room. CNA GGGG was asked if she knew that R37's call light wasn't working. CNA GGGG stated, Oh, I don't normally work this side of the unit. CNA GGGG was observed to press the call light on R37's side of the room and noted there was no audible sound. She further confirmed that the light outside the resident's room did not turn on. R37 was out of the building at an appointment during these interviews and observations. During an interview on 3/18/2024 at 4:05 pm, the Administrator revealed that when a new resident is admitted , the room readiness steps are initiated by the Housekeeping Department, Nursing Department, and Maintenance Department. She stated that each department has a working checklist to complete prior to a resident being admitted to the facility and subsequently, placed in that room. The Administrator provided a blank checklist that each department was responsible for completing. When asked for a copy of R37's completed checklist, the Administrator stated the checklists are not kept once they are completed. The Administrator stated the checklists are merely a guide to complete the room check. A review of the black check list revealed that it is the responsibility of the Maintenance Department to ensure that the call light is attached and functioning. During an observation on 3/18/2024 at 5:22 pm, the Director of Nursing (DON) tested R37's call light and confirmed that it was not working. During an interview on 3/20/2024 at 3:25 pm, the Maintenance Assistant RRR revealed that s/he did not recall any issues with R37's call light while performing the room readiness checklist. During an interview on 3/21/2024 at 10:39 am, Licensed Practical Nurse (LPN) LL confirmed that CNA GGGG did not report to her that the call light was not working. She stated that overheard the conversation and notified Maintenance that the call light was not functioning. During an interview on 3/26/2024 at 9:01 am, the DON stated it was the expectation that the staff notify someone and/or put the work order if the call light is found to not be functional. She stated that all staff have access to put in a work order and that in the interim, the facility had bells that can be used until maintenance can fix the call light.

Based on record reviews, observations, staff and resident interviews, and a review of the facility's policy titled Activities of Daily Living (ADLs), the facility failed to promote dignity and independence for one of ten sampled residents (R) (R20) related to providing incontinence pull ups. Findings included: A review of the Activities of Daily Living (ADLs) policy with a date reviewed/revised of January 2024 revealed that the policy stated, The facility will, based on the resident's comprehensive assessment and consistent with the resident's needs for choices, ensure a resident's abilities in ADLs do not deteriorate unless deterioration is unavoidable. A review of the admission records for R20 revealed that the resident was originally admitted to the facility on [DATE] with diagnoses of gastrointestinal hemorrhage, unspecified, Rhabdomyolysis, unilateral inguinal hernia, repeated falls, personal history of other diseases of the nervous system and sense organs, and cerebral palsy. A review of the care plan for R20 revealed that the resident had an Activities of Daily Living (ADL) self-care performance and mobility deficit related to cerebral palsy. An intervention included that R20 required one person staff limited assistance for toileting. The plan of care related to R20's diagnosis of cerebral palsy included interventions of encouraging the resident to do as much for self as possible, checking resident for bowel and bladder incontinence, and assisting with toileting as needed. A review of the most recent comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed that R20 had a Brief Interview for Mental Status (BIMS) score of 15, indicating that the resident has no cognitive impairment. A review of the quarterly MDS assessment dated [DATE] revealed that R20 required limited assistance of one staff for toileting. During an interview on 3/12/2024 at 10:32 pm, R20 stated that the facility stopped supplying the pull-ups a few months before and now only provided the residents with briefs. He also stated that the briefs are too hard for him to manage. R20 stated that he could change himself without staff if he had the pull-ups and that having to wear a brief takes away his independence when he is not able to change himself. He stated that he now must wait on staff if he wears briefs, and it is not a good feeling, so he started purchasing his own briefs with the $70 he gets a month. R20 stated that it takes all his money to purchase the pull-ups monthly. During an interview on 4/11/2024 at 3:13 pm, the Administrator revealed that the facility stopped ordering pull-ups before she started working at this facility. The Administrator stated she was not here when the current corporation took over. The Administrator further stated that each time the Ombudsman tells the residents that the facility provides pull-ups, she must go back and tell them that the facility does not provide them. The Administrator stated that the family members of the residents who would prefer pull-ups, have provided pull-ups. The Administrator further stated that residents who used to change their own pull-up, now must wait for staff to do it, and they may be left wet/soiled, but they have options to buy their own.

Based on observation, staff interviews, record review, and a review of the facility's policy titled, Care Plans, Comprehensive Person-Centered, the facility failed to develop and implement comprehensive care plans for one of six sampled residents (R) (R42). Findings included: A record review of the facility's policy titled Care Plans, Comprehensive Person-Centered, last updated December 2022, revealed a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychological and functional needs is developed and implemented for each resident. The comprehensive, person-centered care plan will include measurable objectives and timeframes; incorporate identified problem areas; incorporate risk factors associated with identified problems; reflect treatment goals, timetables, and objectives in measurable outcomes; aid in preventing or reducing decline in the resident's functional status and/or functional levels; and reflect currently recognized standards of practice for problems areas and conditions. Areas of concern that are identified during the resident assessment will be evaluated before interventions are added to the care plan. The comprehensive, person-centered care plan is developed within seven days of completion of the required comprehensive assessment (MDS). Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. A review of the Electronic Medical Record (EMR) revealed R42 was admitted to the facility on [DATE] with a diagnosis including, but not limited to, neuromuscular dysfunction of bladder, and unstageable pressure ulcer of sacral region. A review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed R42 was diabetic and diagnosed with an unstageable pressure ulcer to the sacral region; R42 required substantial maximal staff assistance for personal hygiene, and toileting; and that R42 was always incontinent of bowel and had an indwelling catheter. A review of R42's physician's orders dated March 2024, included but not limited to: May change 'indwelling' catheter when occluded, leaking, or to obtain urine specimen, as needed for catheter care. Clean around 'indwelling'/suprapubic catheter with soap and water every shift .' Indwelling' catheter 16 FR (French) with 10 mL (milliliters) balloon to bedside straight drainage for diagnosis and history of neurogenic bladder. A review of the comprehensive care plan dated 2/14/2024 revealed that R42's indwelling catheter was not addressed. There was no documentation related to interventions for person-centered comprehensive care plan for R42's indwelling catheter management. During an observation on 4/5/2024 at 8:19 am R42's was observed in bed. The resident was observed to have an indwelling catheter. During an interview on 4/5/2024 at 8:50 am with the (Licensed Practical Nurse) LPN BB, revealed all residents with an indwelling catheter must be cared for and should have been care planned. During an interview on 4/8/2024 at 2:45 pm with the Director of Nursing (DON) revealed all indwelling catheters must be care planned and that R42's indwelling catheter should have been care planned. An interview on 4/9/2024 at 4:37 pm with LPN KKK revealed residents with indwelling catheters must be care planned. Further, LPN KKK stated the care plan for an indwelling catheter should have included keeping the catheter and tubing free from kinks and obstruction and replacing catheters and catheters bags per the physician's orders.

Based on record review, staff interview, and review of the facility's policy titled Medication Administration, the facility failed to follow the physician orders to administer medications for one of three sampled residents (R) (R41). Findings included: A review of the facility policy titled Medication Administration with a review date of January 2024 revealed that medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. Policy Explanation and Compliance Guidelines included obtaining and recording vital signs, when applicable or per physician orders; when applicable, hold medication for those vital signs outside the physician's prescribed parameters. A review of R41's quarterly Minimum Set Data (MDS) assessment dated [DATE] revealed the resident was admitted to the facility on [DATE] with diagnoses, including but not limited to, hypertension, cardiomyopathy, and congestive heart failure. The MDS further revealed R41 that had a Brief Interview for Mental Status (BIMS) score of 12 (moderately impaired). A review of the Medication Administration Record (MAR) dated March 2024 for R41 revealed the following: * R41 was ordered carvedilol 6.25 milligrams (mg) twice per day and hold if the blood pressure is less than 110/60. * R41 was administered carvedilol 6.25 mg on 3/17/2024; her blood pressure was documented as 103/75 by Licensed Practical Nurse (LPN) CCCC. * R41 was administered carvedilol 6.25 mg on 3/31/3024; her blood pressure was documented as 108/79 by LPN EEEE. A review of the MAR dated February 2024 for R41 revealed the following: * R41 was ordered carvedilol 6.25 mg twice per day and hold if the blood pressure is less than 110/60. * R41 was administered carvedilol 6.25 mg on 2/3/2024; her blood pressure was documented as 101/72. * R41 was administered carvedilol 6.25 mg on 2/7/2024; her blood pressure was documented as 109/56 by LPN EEEE. * R41 was administered carvedilol 6.25 mg on 2/8/2024 on the day shift; her blood pressure was documented as 108/66 by LPN CCCC. * R41 was administered carvedilol 6.25 mg on 2/8/2024 on the evening shift; her blood pressure was documented as 108/66 by LPN DDDD. * R41 was ordered lisinopril 10 mg once per day and hold if the blood pressure is less than 110/60. * R41 was administered lisinopril 10 mg on 2/3/2024; her blood pressure was documented as 101/72 by LPN DDDD. * R41 was administered lisinopril 10 mg on 2/7/2024; her blood pressure was documented as 109/62 by LPN EEEE * R41 was administered lisinopril 10 mg on 2/8/2024; her blood pressure was documented as 108/66 by LPN CCCC. * R41 was administered lisinopril 10 mg on 2/11/2024; her blood pressure was documented as 109/62 by LPN HHHH. A review of the December 2023 MAR revealed: * R41 was ordered lisinopril 10 mg once per day and hold if the blood pressure is less than 110/60. * R41 was administered lisinopril 10 mg on 12/1/2023; her blood pressure was documented as 108/67 by LPN CCCC. * R41 was ordered carvedilol 6.25 mg twice per day and hold if the blood pressure is less than 110/60. * R41 was administered carvedilol 6.25 mg on 12/1/2023; her blood pressure was documented as 108/67 by LPN CCCC. A review of the clinical records for R41 revealed the facility had not reported the medication errors to the physician. During an interview on 4/11/2024 at 11:22 am, the Director of Nursing (DON) revealed nurses are to administer blood pressure medication according to the physician's order.

Based on a review of the facility policy titled, Empire Care Centers Testing Plan/Policy, facility policy titled, Facility Testing Requirements for Staff and Residents, testing records and interviews, the facility failed to ensure consistent testing throughout the facility for residents and staff as required by the Center for Medicare and Medicaid (CMS) while the facility was experiencing an outbreak of COVID-19. Findings include: Review of the facility policy titled, Empire Care Centers Testing Plan/Policy Reviewed/revised 6/24/21, revealed Empire Care Centers monitor the local county positivity rates, and best testing frequency on the thresholds set forth, Further Empire Care Centers test associates and/or residents in the event of an identified outbreak, meaning one positive tested associate and/or one positive tested resident in the center. At which time, the center will test 100% of the residents' and/or associates who have not tested positive within the last 90 days of the outbreak. The center will continue to follow guidance of breakout testing as recommended by CDC and supported by DPH. Review of the facility policy titled, Facility testing Requirements for Staff and Residents Revised February 2022 revealed under the section Testing of Staff and Residents During an Outbreak Investigation A new COVID-19 infection in any staff or residents triggers an outbreak investigation. In an outbreak investigation, rapid identification and isolation of new cases is critical in stopping further [CONDITION(S)] transmission. Upon identification of a single new case of COVID-19 infection in any staff or residents testing should begin immediately. The Facility was unable to produce a testing log for the dates of the last outbreak or a log of testing through the date of the Survey. The lack of testing logs or proof testing had been conducted was verified by the Infection Control Preventionist (ICP), Director of Nursing (DON) and Administrator. The DON and Administrator could not provide documentation that the facility implemented outbreak testing of all residents and staff when a staff member who had worked in the facility within week of testing positive for COVID-19 on 2/17/22. The only documentation presented were forms identified as COVID-19 testing Verification Form and Results. Interviews with DON and ICP confirmed this was the only documentation that could be found. Only seven staff were tested and approx. One-third of the residents, according to the documentation, presented during the last outbreak and verified by the ICP. The staff were unable to present documents to verify all the residents and staff were tested and confirmed that the results of testing were not entered into the resident Electronic Medical Records. (EMR). An interview with the Administrator on 4/19/22 at 11:00 a.m. revealed that there are no confirmed COVID-19 positive residents in the building and the facility has had no positive COVID-19 cases since an 2/18/22 when an employee was positive, and they are no longer in Outbreak Status. An interview with the ICP and DON on 4/19/22 at 12:00 p.m. revealed the last outbreak occurred on 2/18/22 when an employee from housekeeping called the DON and notified her that he had tested positive on 2/17/22 at a physician's office. Further interview revealed the employee never returned to the facility after the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] An interview on 4/19/22 at 1:00 p.m. with the ICP revealed she has been employed at the facility less than one month. Further interview revealed during the week of 2/18/22 the county transmission rate was in the red which is high risk for transmission and the previous report was red as well. Further interview revealed at that time testing should have been conducted two times weekly but there was no evidence it had been being performed. An interview on 4/21/22 at 10:35 a.m. with the Administrator, DON, ICP and Regional Vice -President of Empire Clinical Services revealed the last outbreak was on 2/18/22 when an employee of the housekeeping department tested positive outside the facility. The DON revealed she was notified the evening of Friday 2/18/22 of the positive result by the employee but had not documented the conversation. Further interview of the DON revealed she questioned the employee about the last time he worked in the facility and in what areas, the employee revealed he was symptomatic. The DON revealed she notified the facility of the outbreak 2/18/22 at approximately 8:00 p.m. and told them to begin testing. The DON revealed outbreak testing did not start until the following day 2/19/22 when a total of seven staff were tested . No evidence of additional staff testing could be produced by the facility. Continued interview and review of documentation revealed the testing of residents did not start until 2/26/22, eight days after the outbreak started. The ICP revealed the results of the test were not entered into the residents' electronic medical records and she was unaware they needed to be. The DON revealed no other staff or residents experienced symptoms or tested positive as a result of the last outbreak in the facility. The DON revealed there was no line listing of testing, or a log maintained. The only documentation of staff and resident testing of the outbreak was on individual paper forms kept in notebooks in the DON's office. There was no documentation of any further testing of staff or residents after one initial test. The Administrator, DON and ICP all revealed the definition of an outbreak was one positive resident or staff member and that outbreak testing should begin immediately of all staff and residents. At the conclusion of the interview The ICP and DON revealed they were unaware a testing log or line listing including positive and negative results should be completed and maintained.

Based on record review, interviews and review of policy titled, Antibiotic Stewardship Program, the facility failed to provide evidence of a monitoring system to track and trend antibiotic use for seven months (September 2021 through March 2022) or the past 12 months reviewed. Findings include: Review of the facility policy titled Antibiotic Stewardship Program dated August 19, 2019, revised March 2020 revealed the Antibiotic Stewardship Program's (ASP) action is to improve antibiotic use adverse events, prevent emergence of resistance, and lead to better outcomes for patients and residents in this setting. The ASP is based on The Core Elements of Antibiotic Stewardship for nursing Homes, which include Leadership, Accountability, Drug Expertise, Action, Tracking, Reporting and Education. Core element 5. Tracking-monitor measures of antibiotic use by auditing available reports and patient medical records for adherence to: Clinical. Evaluation documentation, i.e., signs / symptoms., vital signs physical exam findings. Prescribing documentation (dose, duration, indication). Genesis-specific algorithms for assessing and treating patients, including optimizing diagnostic tests for specific infections. Monitor if cultures obtained before antibiotics initiated, if indicated, and if antibiotics changed during course of treatment, monitor rates of new antibiotic starts/1,000 resident-days through use of EOM and/or pharmacy reports or line lists, monitor antibiotic days of therapy/1,000 resident-days through use of pharmacy reports, monitoring outcomes of antibiotic use, monitor rates of [CONDITION(S)] infection through use of line listings and monthly infection control report, monitor rates of antibiotic-resistant organisms through use of monthly infection control report and multi-drug resistant organisms ([CONDITION(S)]) specific line listings and monitor rates of adverse drug events due to antibiotics, through use of RMS. Further review of the facility policy titled Antibiotic Stewardship Program revealed the Infection Preventionist monitors and supports antibiotic stewardship activities through rounds, review of provider orders, PCC documentation and available PCC/ Pharmacy /Lab reports tracks antibiotic starts through the use of line listing and pharmacy reports. Reviews antibiotic resistant patterns. Monitors HAI. MDROs on monthly line listing and infection control report looking for increased rates and our trends compares with center algorithm to look for commonalities monitors cohorting immunization status for COVID. A review of the policy titled, Infection Control Policy and Procedure revised September 2020 indicated Procedure including Infection Prevention and Control Program. The Facility shall establish an IPCP that will follow national standards and guidelines and will include, at a minimum, the following elements one of which is an antibiotic stewardship program that includes antibiotic protocols and a system to monitor antibiotic use. Review of the facility's Infection Control Tracking log/book dated January 2021 through September 2021 revealed the facility did not have evidence that the ASP usage, tracking, or reporting had been completed. An Interview on 4/19/2022 at 10:03 a.m. with the Infection Control Preventionist (ICP), she stated she has been employed at the facility for one month. Continued interview revealed she was the ICP for two and a half months in the fall but resigned in November. Further interview revealed the former Assistant Director of Nursing had been assigned the role of ICP from September 2021 until March 2022. The ICP provided documentation for the antibiotic stewardship program from January 2021 through September 2021 and stated she was unable to locate any documentation regarding the antibiotic stewardship program for September to the current date. She also revealed she was not in the process of preparing the report of antibiotic usage, trending or tracking for this month. Interview on 4/21/2022 at 2:30 p.m. with the Regional Registered Nurse Consultant and Director of Nursing revealed the facility had no additional information to provide regarding their antibiotic stewardship program.

Based on record review and interviews it was determined that Administration failed to ensure that the facility was administered in a manner that enabled it to use its resources effectively and efficiently to ensure each resident attained or maintained the highest possible level of physical, mental and psychological well-being. The Administration failed to investigate an employee actions until [DATE] when the resident was given the wrong diet tray on [DATE] and expired on the same day. On [DATE], a determination was made that a situation in which the facility's non-compliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents. Immediate Jeopardy was related to the facility's non-compliance with the program requirements as follows: CFR 483.21(b)(2) Comprehensive Person-Centered Care Plans (F 657 Scope and Severity (S/S): J) The facility failed to follow the care plan put in place for one resident (R#11) for a therapeutic diet. CFR 483.25(d) Quality of Care (F 808 S/S: J) The facility failed to ensure R#11 received and consumed foods in the appropriate form and/or the appropriate nutritive content as prescribed by a physician. CFR 483.70 Administration (F 835 S/S: J) The Administrator failed to oversee the management to ensure care plans and diet orders were followed, and that a system was in place to ensure the proper diets were served in accordance with physicians orders. The facility's Administrator was informed of the Immediate Jeopardy on [DATE] at 12:00 p.m. The non-compliance related to the Immediate Jeopardy was identified to have existed as of [DATE] when R#11 was served the wrong diet tray and expired on the same day at 9:52 a.m. The Immediate Jeopardy continued through [DATE],and was removed on [DATE]. On [DATE] the facility provided a Credible Allegation of Compliance (A[NAME]) of Jeopardy Removal alleging that interventions had been put into place to remove the immediacy on [DATE]. Based on validation of the A[NAME], the State Survey Agency (SSA) determined the Immediate Jeopardy was removed on [DATE]. The Scope and Severity were lowered to a D level while the facility develops and implements a Plan of Correction (P[NAME]) and the facility's Quality Assurance Committee monitors the effectiveness of the systematic changes. The immediate jeopardy is outlined as follows: The IJ was determined to exist as of [DATE], when R#11 became unresponsive in his room and could not be resuscitated, after being served a mechanically soft diet that included chopped eggs and chopped sausage. Review of the Medical Examiner's (ME) report [DATE] revealed a limited autopsy was performed on R#11 on [DATE] at 1400 (military time) hours. The report lists the cause of death asphyxia due to aspiration of food bolus, manner of death accident and how injury occurred; choked on food bolus. The limited autopsy report further revealed, a lump of food was found above the vocal cords, in the larynx. Residual food was found within the mouth and within the endotracheal tube, the food bolus is consistent with pieces of egg and meat product. The facility failed to ensure the care plan and therapeutic diet orders were followed to ensure the correct diet was provided to R#11 who was at risk for aspiration. This caused R#11 to aspirate on a food bolus and he expired as a result. Findings include: Review of the face sheet, undated, revealed resident (R) #11 was admitted to the facility on [DATE] and was an [AGE] year-old male. Review of the [DIAGNOSES REDACTED]. Review of the physician orders, dated [DATE], revealed R#11 was on a reduced concentrated sweets diet and pureed consistency with honey thickened liquids. Further review of an undated physician order [REDACTED].#11 required limited or extensive assistance for nearly all activities of daily living (ADLs), except for eating, for which he required supervision. Further review of R#11's physician orders, dated [DATE], revealed an order for [REDACTED]. Review of R#11's care plan, dated [DATE], revealed planning for an Activity of Daily Living (ADL) self-care deficit. Interventions for this plan included the certified nursing assistant would provide assistance with eating. Review of the care plan also revealed planning for altered nutritional potential related to dysphagia. Interventions included to monitor/document/report to the Medical Doctor (MD) as needed (PRN) for signs or symptoms of dysphagia, including choking, coughing, holding food in mouth, several attempts at swallowing, refusing to eat, and to provide and serve diet as ordered. Review the progress notes, dated [DATE] at 9:15 a.m. revealed R#11 was found in his room unresponsive and his skin was warm to touch. Further review revealed cardiopulmonary resuscitation (CPR) was started, the responsible party (RP) and medical doctor (MD) were contacted, as was emergency medical services (EMS). Review of a progress note, dated [DATE] at 9:25 a.m., revealed that EMS arrived and took over the code. Review of a progress note, dated [DATE] at 9:52 a.m., revealed EMS was unsuccessful at reviving R#11, so they called their medical director who advised that the code be stopped and a registered nurse (RN) should pronounce the resident dead. Review of a progress note dated [DATE] at 12:00 p.m. revealed R#11's remains were released to the medical examiner. Review of the autopsy report, dated [DATE], revealed the ME found R#11 died of asphyxiation due to food bolus in the airway (choked to death on food blocking airway). Review of the intake information document, dated [DATE], revealed a detective from the local police department stated she spoke with Administrator VV on [DATE] while investigating the R#11 incident, as a suspicious death, in the facility. Further review of this document revealed the detective stated she thought it odd when Administrator VV stated the ambulance took R#11 away, but she subsequently found R#11's body in his room. This document also revealed the detective stated a police sergeant witnessed this conversation between the detective and Administrator VV. On [DATE] at 4:30 p.m. Administrator VV was interviewed in the conference room. He stated he was the Administrator at the facility for 5 years. He stated he was not aware of the incident involving R#11 choking to death until [DATE] at 8:57 a.m. and reported it to the State Agency (SA) 90 minutes later. He also stated he was aware on [DATE] that R#11 had died and that the police and medical examiner (ME) were in the facility investigating the death, but he did not think it unusual or out of the ordinary, because the police came frequently and the ME two or three times a year. He stated he did not speak to the police on the day of the incident. He stated he did not typically investigate when the police were in the building. He stated he contacted the facility's regional nurse consultant and started educating the staff on the night of [DATE]. Administrator VV stated he personally was unaware of R#11's dysphagia and had not realized it was a problem until this incident occurred. Administrator VV stated the Certified Nursing Assistant (CNA) that served the wrong tray was terminated on [DATE]. He stated the certified nursing assistant CNA involved stated freely she went to the kitchen and asked for a mechanical soft diet for R#11 when the actual diet order was for a pureed diet. He stated he took her statement on [DATE] or [DATE], then offered education. He stated he waited to terminate her until he got the cause of death from the medical examiner because he had no way of knowing for sure if her actions were the cause of death. He stated he was not sure if the involved CNA (AA) was monitored feeding residents after [DATE]. He stated he did not know if the CNA was supervised feeding residents between [DATE] and [DATE]. Administrator VV stated further R#11 ate always ate alone. Review of the separation notice, dated [DATE], revealed that CNA AA was terminated on that date for failure to maintain job performance conduct that was detrimental to facility operations and failure to maintain acceptable standards in circumstances warranting immediate termination. On [DATE] 2:00 p.m. Administrator UU was interviewed in her office. She stated she was a Registered Nurse (RN) and a Licensed Nursing Home Administrator (LNHA). She stated she had been an LNHA since 2002. She stated Administrator VV had been fired for cause that morning ([DATE]). She stated she was here to take his place as Administrator. She stated she had reviewed the incident regarding R#11. She stated Administrator VV should have known about this event and should have started to investigate this incident on [DATE]. She stated the ten-day delay was unacceptable. She stated Administrator VV should have suspended or terminated the involved CNA on [DATE]. She stated it was unacceptable that Administrator VV did not think the incident involving R#11's death on [DATE] should have been investigated. She stated an emergency quality assurance and performance improvement meeting (QAPI) should have been called immediately, and not delayed until [DATE]. Review of the Administrator job description, dated ,[DATE], revealed the duties and responsibilities as the facility administrator, including: o Plan, develop, and implement facility programs o Develop and maintain written policies o Assist department directors in the development, use, and implementation of departmental policies and procedures and standards of practice. o Ensure that all employees follow policy Further review of the Administrator job description, page 8, revealed Administrator VV's signature, dated [DATE]. The facility implemented the following actions to remove the Immediate Jeopardy: Administrator was terminated [DATE] Director of Nursing was terminated [DATE] An Ad Hoc QAPI committee reviewed the complaint from the surveyor that was given to the Administrator on (MONTH) 10, 18. Attendees were Administrator, Assistant Director of Nursing (ADON), Medical Director, Business Office Manager, Dietary Manager, Medical Records, Social Services, Activities Director, Rehab Director, CNA's and MDS to review findings of the investigation related to resident O.M's event. Immediate actions initiated on [DATE] (YEAR). Immediate actions consisted of in-services that began on the 3;00 p.m -11:00 p.m. shift conducted by Licensed Practical Nurse (LPN) LPN 3.-11. Supervisor with CNA, (100%) LPNs (100%) and (100%) Registered Nurses (RN's) in attendance for the 3pm-11pm shift on [DATE]. In-services were continued by LPN ,[DATE]. Supervisor with CNAs (100%), Licensed Practical Nurses (100%), and Registered Nurses (100%) in attendance for the staff assigned on ,[DATE] shift on [DATE]. All in-services consisted of instruction to utilize a binder on each nursing station with diet listings for new / readmitted residents. Procedures on how to confirm diets on meal trays, how to access information for interim care plans, how to review diets on the Kiosk and procedures to report change of conditions to nurses. In-services began before the surveyor exited the facility on 6/ 918. Residents on modified diets in the facility on (MONTH) 9, (YEAR) were reassessed for safe dining and care plan revisions were discussed with the resident and/or resident representative as needed. New residents prescribed modified diets will be assessed for restorative dining and/or encouraged to take their meals in the dining room to provide supervision. In-services continued for the remained of staff on (MONTH) 10th , 12th and 23rd and were conducted by RN, ADON , LNHA, Dietary Manager, LPN staff development and House Keeping Manager . As of this submission of Allegation of Compliance, the following departments have completed in-service attendance requirements. CNAs-79 employees/ 73 completed LPNs-29 employees / 25 completed RNs-12 employees / 12 completed Dietary-22 employees / 22 completed Rehabilitation 14 employees / 14 completed Employees that have not completed the required in-services will not to return to work duty until in-services are completed. The COO reviewed the Administrator job description with the interim Administrator on [DATE]. The COO reviewed the Director of Nursing job description with the interim Director of Nursing on [DATE]. The State Survey Agency (SSA) validated the facility ' s Credible Allegation of Immediate Jeopardy Removal as follows: On [DATE], beginning on or around 2:30 p.m., each line and bullet point of the document entitled Powder Springs A[NAME] Version 6 Final was reviewed. Observation, interview, inservices,record review, and return demonstration review revealed no concerns with this document. The facility provided two binders, one entitled A[NAME] Book, and the other Audits, each containing documentation pertinent to and supporting the A[NAME]. No concerns were noted. Review of the Separation Notice, dated [DATE], revealed that Administrator VV was terminated. Review of the Separation Notice, dated [DATE], revealed the DON was terminated. Review of the quality improvement program committee sign-in sheet, dated ,[DATE] at 10:30 a.m. revealed the following signatures on the sign-in sheet: Administrator VV, DON, Medical Director, ADON, Infection Control, Maintenance/Safety, Business Office Manager, Human resources, Dietary Services, Housekeeping/Laundry, Social Service , Activity Director, Therapy Director, CNAs, Minimum Date Set Coordinator, and a Unit Manager. Further review of this document revealed the meeting topics to include psych medications, diet orders, tray audits, Kiosk training, and abuse reporting training. Review of the DON job description, dated [DATE], revealed the DON was responsible for Quality Assurance Process Improvement ( QAPI.) The Administrator's and the DON's signatures were on this document. Review of the Dietary Director's job description, dated [DATE], revealed the Dietary Manager was responsible for process improvement (QAPI) reporting on matters pertinent to her review.

Based on observation, record review, resident and staff interview, the facility failed to implement the care plan related to a therapeutic diet for one resident (R) (R #11) identified at risk for aspiration. The sample size was 14 residents. On [DATE], a determination was made that a situation in which the facility's non-compliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents. Immediate Jeopardy was related to the facility's non-compliance with the program requirements as follows: CFR 483.21(b)(2) Comprehensive Person-Centered Care Plans (F 657 Scope and Severity (S/S): J) The facility failed to follow the care plan put in place for one resident (R#11) for a therapeutic diet. CFR 483.25(d) Quality of Care (F 808 S/S: J) The facility failed to ensure R#11 received and consumed foods in the appropriate form and/or the appropriate nutritive content as prescribed by a physician. CFR 483.70 Administration (F 835 S/S: J) The Administrator failed to oversee the management to ensure care plans and diet orders were followed, and that a system was in place to ensure the proper diets were server in accordance with physicians orders. The facility's Administrator was informed of the Immediate Jeopardy on [DATE] at 12:00 p.m. The non-compliance related to the Immediate Jeopardy was identified to have existed as of [DATE] when R#11 was served the wrong diet tray and expired on the same day at 9:52 a.m. The Immediate Jeopardy continued through [DATE] , and was removed on [DATE]. On [DATE] the facility provided a Credible Allegation of Compliance (A[NAME]) of Jeopardy Removal alleging that interventions had been put into place to remove the immediacy on [DATE]. Based on validation of the A[NAME], the State Survey Agency (SSA) determined the Immediate Jeopardy was removed on [DATE]. The Scope and Severity were lowered to a D level while the facility develops and implements a Plan of Correction (P[NAME]) and the facility's Quality Assurance Committee monitors the effectiveness of the systematic changes. The immediate jeopardy is outlined as follows: The IJ was determined to exist as of [DATE], when R#11 became unresponsive in his room and could not be resuscitated, after being served a mechanically soft diet that included chopped eggs and chopped sausage. Review of the Medical Examiner's (ME) report [DATE] revealed a limited autopsy was performed on R#11 on [DATE] at 1400 hours (military time). The report lists the cause of death asphyxia due to aspiration of food bolus, manner of death accident and how injury occurred; choked on food bolus. The limited autopsy report further revealed, a lump of food was found above the vocal cords, in the larynx. Residual food was found within the mouth and within the endotracheal tube, the food bolus is consistent with pieces of egg and meat product. The facility failed to ensure the care plan and therapeutic diet orders were followed to ensure the correct diet was provided to R#11 who was at risk for aspiration. This caused R#11 to aspirate on a food bolus and he expired as a result. Findings include: Review of R #11's Quarterly Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) summary score of 10, indicating mild cognitive impairment, Section G-functional status assessed the resident as requiring setup assistance for meals, Section K-swallowing/dental status assessed the resident as required a mechanically altered diet/therapeutic diet. His [DIAGNOSES REDACTED]. Review of R#11's Nursing Baseline Initial 48-hour care plan dated [DATE] revealed specialty interventions related to resident's health condition that included;Thickened liquid order-honey thickened liquid and Diet order-pureed. Review of R#11's Comprehensive Care Plan, revised on [DATE] revealed R#11 had altered nutritional potential related to a therapeutic diet. Interventions listed included; monitor/document/report to Medical Director (MD ) PRN (as necessary) for s/sx (signs/and symptoms) of dysphagia; pocketing, choking, coughing, drooling, holding food in mouth, several attempts at swallowing, refusing to eat, appears concerned at meal. Provide, serve diet as ordered. Review of the Facility Reported Incident dated [DATE] revealed that on [DATE], R#11 fed himself breakfast in his room. His prescribed diet order was pureed; however, the Certified Nursing Assistant (CNA) gave him a mechanical soft diet for breakfast. During an interview on [DATE] at 11:45 a.m. with CAN AA revealed [DATE] was R#11's first day on the Alzheimer's Unit. (AU). Certified Nursing Assistant (CNA) AA revealed, she went to the kitchen to get R#11 a breakfast tray because he did not have one on the cart that delivers meal trays to the AU. She revealed, when she went to the kitchen, she gave the kitchen staff the resident's name, asked for a tray and was given the tray that she served R#11. CNA AA described the food on the tray as soft eggs and meat chopped to a size between the size of an M&M and Life Saver with toast cut in the shape of a triangle. CNA AA stated she finds out what residents can eat by asking other employees, she does not have access to resident care plans, and she thinks the kitchen staff did not know R#11's diet because he recently returned to the facility. During an interview on Interview on [DATE] at 6:10 p.m. Assistant Director of Nursing (ADON) MM revealed, upon return to the facility, R#11's diet order should have been verified by kitchen staff before a tray was given. R#11 was evaluated and it is not safe for him to receive a mechanical diet. ADON MM further added, it is her expectation for the nurse to know the resident's diet and to contact the physician for clarification when needed. Cross-refer to F 808 The facility implemented the following actions to remove the Immediate Jeopardy: The policy and procedure for Assistance with Meals was reviewed and revised by the administrator, DON, ADON, Rehab Director, VP of Clinical and MDS Director to include adding personal -centered care plans for resident's with modified diets to identify safety risks and add appropriate interventions on [DATE]. [DATE] The RN conducted an in-service with MDS department, DON, ADON, Rehab Director, Speech Therapist on [DATE] to review policy revision of the Assistance with Meals. The policies and procedures for Assistance with Meals, Diet Process, Resident Rights and Abuse Prevention Policy were reviewed by the interim Administrator on [DATE]. [DATE] A total of 26 residents who prefer to eat in non-group settings out of 61 residents with modified diets were assessed by Speech Therapy. Care Plans were updated with appropriate interventions and goals. Residents and/or resident representatives were notified of care updates. 21 residents-Mechanical soft diet 4 residents-Puree diet 1 resident-Regular diet The Director of Nursing and Dietary manager will be responsible for the QAPI process. The Director of Nursing and designees (Unit Manager/Nursing Supervisor) will monitor the safety of residents who require modified diets and prefer to eat in non-group environments by conducting random audits at meal times every day Sunday thru Saturday. A Unit Manager/Nursing Supervisor will conduct audits in the absence of the Director of Nursing. Findings of audits will be reported to facility QAPI committee monthly and stored in the Administrator's binder in that office. The State Survey Agency (SSA) validated the facility ' s Credible Allegation of Immediate Jeopardy Removal as follows: The Assistance with Meals Policy, dated [DATE], revealed standards of practice for dining room residents, residents confined to bed, Residents requiring full assistance, and residents with feeding tubes. Interventions included residents would be encouraged to eat in the dining room, facility staff will serve trays and would help residents requiring assistance, approaches addressing safety, comfort and dignity, avoiding the use of labels such as feeders, minimizing staff-to-staff interactions during meals, and avoiding the use of clothing protectors instead of napkins, unless the resident requests it. Review of the In-service report document, dated [DATE], revealed an inservice including training on policy review of assistance with meals attended by Minimum Data Set (MDS) Nurse, Nursing, Rehab, Speech Therapy, and Dietary. Review of the inservice report, dated [DATE] at 2:30 p.m. revealed the MDS coordinator, nursing, rehab, speech therapy and dietary leadership attended a meeting concerning the F656 citation, development of and implementing comprehensive care plans. A policy review of assistance with meals, person-centered care plans for residents on special diets, speech therapy role in assessment to identify safety risk, and to add appropriate interventions. Review of the Annual Policy and Procedure Review document, dated [DATE], revealed a review of the assistance with meals policy signed by the Administrator, the Director of Nursing (DON), and the Medical Director. On [DATE] at 2:10 p.m. the Rehab Director was interviewed in the conference room. She stated her speech therapy team assessed 26 residents out of 61 on modified diets. These 26 chose to eat in their room. The speech therapists decided which of the 26 were safe to eat on their own. This data was given to the DON and MDS director to disseminate. Three care plans from the group of 26 residents were sampled at random and each care plan was found to have been modified appropriately. These care plans included encouragement for each resident to eat in the dining room vs. being supervised in their rooms. Review of the Rehab Services Screening forms, each dated [DATE], revealed 26 screenings for intake safety. Review of the tray and meal audits in each area for [DATE], [DATE], and [DATE] were reviewed. No concerns identified.

Based on review of clinical records review, physician's orders, review of the Medical Examiner's limited autopsy dated [DATE], review of the Georgia Nutrition Consulting, Inc. Modified Textures policy dated [DATE], review of the facility Incident report findings, dated [DATE] and staff interviews, the facility failed to follow physician's orders for a therapeutic diet, thus resulting in aspiration and death for one (1) resident (R) #11 from a sample of fourteen 14 residents. On [DATE], a determination was made that a situation in which the facility's non-compliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents. Immediate Jeopardy was related to the facility's non-compliance with the program requirements as follows: CFR 483.21(b)(2) Comprehensive Person-Centered Care Plans (F 657 Scope and Severity (S/S): J) The facility failed to follow the care plan put in place for one resident (R#11) for a therapeutic diet. CFR 483.25(d) Quality of Care (F 808 S/S: J) The facility failed to ensure a resident received and consumed foods in the appropriate form and/or the appropriate nutritive content as prescribed by a physician. CFR 483.70 Administration (F 835 S/S: J) The Administrator failed to oversee the management to ensure care plans and diet orders were followed, and that a system was in place to ensure the proper diets were served in accordance with physicians orders. The facility's Administrator was informed of the Immediate Jeopardy on [DATE] at 12:00 p.m. The non-compliance related to the Immediate Jeopardy was identified to have existed as of [DATE] when R#11 was served the wrong diet tray and expired on the same day at 9:52 a.m. The Immediate Jeopardy continued through [DATE] , and was removed on [DATE]. The IJ was determined to exist as of [DATE], when R#11 became unresponsive in his room and could not be resuscitated, after being served a mechanically soft diet that included eggs and sausage. Review of the Medical Examiner's (ME) report [DATE] revealed a limited autopsy was performed on R#11 on [DATE] at 1400 hours(military time). The report lists the cause of death asphyxia due to aspiration of food bolus, manner of death accident and how injury occurred; choked on food bolus. The limited autopsy report further revealed, a lump of food was found above the vocal cords, in the larynx. Residual food was found within the mouth and within the endotracheal tube, the food bolus is consistent with pieces of egg and meat product. The facility failed to ensure the care plan and therapeutic diet orders were followed to ensure the correct diet was provided to the R#11 who was at risk for aspiration. This caused R#11 to aspirate on a food bolus and he expired as a result. On [DATE] the facility provided a Credible Allegation of Compliance (A[NAME]) of Jeopardy Removal alleging that interventions had been put into place to remove the immediacy on [DATE]. Based on validation of the A[NAME], the State Survey Agency (SSA) determined the Immediate Jeopardy was removed on [DATE]. The Scope and Severity were lowered to a D level while the facility develops and implements a Plan of Correction (P[NAME]) and the facility's Quality Assurance Committee monitors the effectiveness of the systematic changes. Findings include: Record review for R#11 revealed 5-day scheduled Minimum Data Set (MDS) assessment dated [DATE] which documented the resident's [DATE] reentry to the facility. The MDS documented in the Section C-Cognitive Patterns a score of 10 for the resident's Brief Interview for Mental Status (BIMS) score, indicating mild cognitive impairment. Section G-Functional Status assessed the resident required setup assistance for meals, Section K-Swallowing/Dental Status assessed the resident required a mechanically altered diet/therapeutic diet. His [DIAGNOSES REDACTED]. Review of the breakfast menu for [DATE] revealed scrambled eggs, sausage patty, toast, juice of choice, cream of wheat, whole milk and coffee. Review of the Medical Examiner's (ME) report dated [DATE] revealed a limited autopsy was performed on R#11 on [DATE] at 1400 hours. The report lists the cause of death asphyxia due to aspiration of food bolus, manner of death accident and how injury occurred; choked on food bolus. The limited autopsy report further revealed, a lump of food was found above the vocal cords, in the larynx. Residual food was found within the mouth and within the endotracheal tube, the food bolus is consistent with pieces of egg and meat product. Further review of the ME's report revealed R#11 was found unresponsive at the facility where he had been transferred to after surgery for [REDACTED]. He was discovered with a blank stare approximately an hour later. The EMS evaluation revealed R#11 to be unresponsive, in asystole, and without a radial or carotid pulse. He was pronounced dead at the scene. Review of the Pronouncement of Death dated [DATE] revealed R#11's date of death [DATE] and time of death was 9:52 a.m. and his remains were released to the Medical Examiner on [DATE] at 12:00 p.m. Review of progress notes dated [DATE] at 22:26 (military time) revealed R#11 was re-admitted to the facility on [DATE]. Family member requested for resident to be moved to the Alzheimer's unit (AU) due to altered mental status. Review of speech therapy notes, encounter date [DATE] revealed R#11 was seen for bedside swallow re-evaluation. Patient remains unsafe for diet initiation at this time. Recommend NPO (nothing by mouth), ice after oral care and medications crushed in puree. If nutritional status a concern (pt NPO x 2 days), patient may benefit from short term alternative means. Barriers: Oral dysphagia; Pharyngeal dysphagia; impaired cognition; impaired safety, impaired judgement; aspiration Review of the hospital discharge summary dated [DATE] revealed hospital course by problems including; dysphagia, speech evaluation-swallowing well when calm, as well as orders to continue pureed diet when patient is not agitated. Review of progress notes dated [DATE] at 9:15 a.m. revealed writer summoned in room by Certified Nursing Assistant (CNA). Resident noted unresponsive, skin warm to touch, no rise and fall of chest, and unable to obtain apical pulse. Therefore, CPR (Cardio [MEDICAL CONDITION] Resuscitation) was initiated, 911 called and family notified. Further review of progress notes date [DATE] at 9:25 a.m. revealed Emergency Medical Services (EMS) arrived and took over code. Record review of progress notes dated [DATE] at 9:52 a.m. revealed EMS was unsuccessful with reversing resident's condition; therefore, EMS contacted their medical director and was instructed to stop CPR and for Registered Nurse (RN) staff to pronounce resident. Record review revealed physicians orders with a start date of [DATE] with no end date, for an Reduced Concentrated Sweet diet, pureed texture and honey thick liquids. Record review revealed physicians orders to release R#11's remains to the medical examiner on [DATE]. Review of the Facility Reported Incident dated [DATE] revealed that on [DATE], R#11 fed himself breakfast in his room. His prescribed diet order was pureed; however, the CNA gave him a mechanical soft diet for breakfast. Review the Georgia Nutrition Consulting, Inc. Modified Textures policy dated [DATE] and provided by the facility on [DATE] revealed the following considerations: 1.Read each tray card carefully to ensure all food and liquid textures are served to the resident accurately. Failure to do so may place the resident in a harmful situation. 2.Notify the Dietary Manager and Director of Nursing if you notice a resident having a difficult time chewing foods, choking, or coughing on foods or liquids. Further review of the Georgia Nutrition Consulting, Inc. Modified Textures policy dated [DATE] and provided by the facility on [DATE] revealed residents with dysphagia may choke on foods or liquids. Review of an undated policy titled Admission of the Resident-Licensed Nurse Policy-Standard of Practice revealed when a resident is admitted to the facility, the licensed nurse is to initiate an Immediate Plan of care and notify dietary as appropriate. During an interview on [DATE] at 11:45 a.m., Certified Nursing Assistant (CNA) AA revealed [DATE] was R#11's first day on the Alzheimer's Unit. (AU). CNA AA further revealed she set-up R#11's breakfast tray and left him alone to eat in his room. She added that she went to the kitchen to get R#11 a breakfast tray because he did not have one on the cart that delivers meal trays to the AU. She revealed, when she went to the kitchen, she gave the kitchen staff the resident's name, asked for a tray and was given the tray that she served R#11. CNA AA described the breakfast served to R#11 as eggs and toast and pureed meat and thickened liquids, water and cranberry juice. She then acknowledged, the meat was chopped sausage on his tray and the eggs were regular, soft eggs, with two liquids. She described the food on the tray as soft eggs and meat chopped to a size between the size of an M&M and Life Saver with toast cut in the shape of a triangle. She revealed that she asked R#11 if he could feed himself. He said yes, she set the tray up and left. She then revealed, R#11 probably choked on the first thing he ate because she had just sat his tray down and went to feed another resident when Activities Assistant BB came down the hall and told her R#11 was choking. CNA AA added, she finds out what residents can eat by asking other employees, she does not have access to resident care plans, and she thinks the kitchen staff did not know R#11's diet because he recently returned to the facility. She further added, after she and Licensed Practical Nurse (LPN), D1 went into the room to check on the resident, the Unit Manager (UM) CC entered the room with the crash cart. She told UM CC that R#11 was choking, he was making a noise like coughing or clearing his throat. During an interview on [DATE] at 11:52 a.m., Dietary Manager (DM) DD revealed R#11 has been on a puree diet for a long time and the dietary staff all know his diet. She added, I don't know how he would have received chopped food. With a pureed diet, everything is puree, including the meat and eggs. DM DD further added that on [DATE], R#11 had not been put in the system and dietary staff did not have a slip from nursing that they usually get the night before. He would not have had a diet listed in dietary because he had just returned to the building the night before. We have not received any orders for him after he came back from the hospital. I remember that day when he died , by the time I found out he was back in the building, he was already deceased . I never received the order or instructions to resume the order. During an interview on [DATE] at 12:20 p.m., Activities Assistant BB revealed that on [DATE], she went into R#11's room and he wasn't saying anything, he was motioning with his hand for her to come to him. She told him, I think you need a CNA, and she left to get CNA AA. Activities Assistant further revealed, she could tell something was wrong with R#11 and she thinks it was something with his food. She does not know what he had eaten, only that CNA AA had left food for him to eat and he was in his room alone. He called for her and she went and got CNA AA and Licensed Practical Nurse D1 who went to get the unit manager. Activities Assistant BB then left the area and went back to Activities. During an interview on [DATE] at 1:12 p.m., Registered Dietician (RD) EE revealed, R#11 had just got back from the hospital on [DATE] and was ordered a pureed diet with honey thick liquid. She had not done an assessment on R#11 since his return. He had a quarterly assessment on [DATE] that indicated he required a Puree diet with honey think liquids. RD EE added, R#11 was high-risk for choking and that's why he had to be on thickened liquids. Mechanically chopped food would have been unsafe for him to eat. He needed help with setup for meals. He would eat in his room and could feed himself. During an interview on [DATE] at 1:22 p.m., Speech Language Pathologist (SLP) FF revealed, R#11 had a severe oropharyngeal dysphagia which in layman's terms means, a choking hazard he coughed a lot and was on a puree honey thick diet. She added, you are only put on that diet if you are a high aspiration risk. She then revealed, she would never give him a mechanically chopped meal. It would pose a high aspiration risk for him. She added, all I know is the tray was not puree. I was in the facility when all this happened. I don't know if he was choking. SLP FF then revealed, when the incident occurred, she was at a table; in the dining unity on the Alzheimer's Unit (AU). Her patient was there eating and suddenly, she saw everyone running into that room with the crash cart. She added, it was mentioned that R#11 had some sort of food given other than his prescribed diet. This was not a new diet he was puree/honey thick for a while now. He was just put back there in the AU. The staff in the AU probably didn't know his proper diet. There should have been a ticket, someone should have checked. During an interview on [DATE] at 1:52 p.m., Licensed Practical Nurse (LPN) HH revealed, he was one of the first people to respond when the code was called for R#11 on [DATE]. He further revealed, he entered the room, it looked like the resident was already deceased and a CNA said he choked on his food, she said he was coughing but not holding his throat. She told the nurse he was choking but the nurse said he was coughing. LPN HH then added, I noticed that when they bagged the resident, his stomach was rising but not his chest which tells me something was blocking the air. We looked in his mouth and throat and didn't see anything blocking. We kept adjusting the bag but only the stomach would move. During an interview on [DATE] at 2:20 p.m. with UM CC revealed when she responded to R#11's room, he was seated upright on the bed. She and Licensed Practical Nurse (LPN) D1 got him flat in bed. UM CC added, she conducted an assessment and noticed he was doing Cheyne-stokes respirations. She ran and got the crash cart and they started doing compressions and giving him oxygen. When she went out to call 911, Licensed Practical Nurse D1 told her from the resident's room door that he wasn't breathing. She further revealed she had no idea he was given the wrong tray and has no recollection of any tray or discussion of a tray. Further interview on [DATE] at 3:53 p.m. with UM CC revealed she checked R#11's throat for blockage when he was breathing funny and she swept his mouth and didn't find any blockage. She added, no one attempted the [MEDICATION NAME] Maneuver that she is aware of and her concentration was on CPR, not the [MEDICATION NAME] Maneuver. During an interview on [DATE] at 6:02 p.m., Nurse Practitioner (NP) LL revealed she is familiar with R#11's dysphasia and knows he was a risk for choking. She then added, I was in the building that morning. He was not responsive when I got there, he was yellow, warm and had a fixed look. He was not purple, blue or ashen. It looked like a catastrophic event. When I got there, I started compressions. They had called the code and the cart was coming. He was flat on the bed and there was a board underneath him. I don't know if anyone attempted the [MEDICATION NAME] Maneuver, it did not occur while I was there. He was post-op, his behaviors had changed, he was post anesthesia. In the past I would say he could handle chopped sausage. I don't know if he could the way he was. Post operatively and given in the report from the hospital, mechanically chopped food could have been a choking hazard for him. During an interview on [DATE] at 6:10 p.m., Assistant Director of Nursing (ADON) MM revealed when R#11 returned from the hospital on [DATE], the diet slip was supposed to be completed and taken to dietary and that staff have been unable to locate the diet order that was to be entered. She further added, the CNA should have verified the tray slip with the electronic documenting system, and the nurse. She further added, my expectation is for the residents to receive the correct diet order. If there is no diet order, the CNA should go to the nurse or the electronic documenting system and get the diet order. If the nurse didn't have the diet order, she should have called the doctor and clarified. The kitchen should have verified the diet before giving the tray. I do understand that a Doctor gives an order for [REDACTED]. During an interview on [DATE] at 7:49 p.m., Licensed Practical Nurse (LPN) D2 revealed, she completed the diet order form and walked it to the kitchen and gave a guy the form when R#11 was readmitted to the facility on [DATE]. She further added, I cannot recall the name of the person I gave it to, there are new faces in the kitchen. I gave him the top copy and put the yellow copy in the pendeflex file at the nurse's station. If there was no communication, he would have no tray. I do remember he was on a puree diet. I personally took the diet communication to the kitchen that evening. I was on the ,[DATE] p.m. shift. During an interview [DATE] at 8:43 p.m., the Administrator revealed he did not know anything about an incorrect tray and would have done an initial report and investigated the incident, if he had known. He further stated had he been made aware of the incident, the facility would have done the necessary teaching, training, terminating if necessary. During an interview on [DATE] at 12:22 p.m., Medical Examiner (ME) revealed, R#11's cause of death was asphyxia due to aspiration of food bolus. The ME further added, her office is waiting for the histology report that will take a while, likely more than a week. The ME agreed to forward the autopsy report upon completion. During an additional interview on [DATE] at 4:05 p.m. with the ME revealed, she participated in an autopsy on R#11 and the examiners opened his neck, went down the airway and saw a food bolus. The food bolus was consistent with egg and meat product. The facility implemented the following actions to remove the Immediate Jeopardy: The policy and procedure for diet ordering processes from ,[DATE] reviewed on [DATE] with no revisions necessary by the Administrator, DON, RD, ADON, VP of Clinical. The policy and procedure for diet ordering processes reviewed again on [DATE] by the Interim Administrator, Interim Director of Nursing and VP Clinical. Work flow was edited within the dietary software program with modifications made to allow the data to show that a resident diet order is discontinued when the resident is a discharge return anticipated. Receiving nurse will transcribe and communicate the diet order to dietary by utilizing a dietary communication form. Dietary will enter the order into the dietary software program. Dietary will review resident diet orders twice a day and monitor food tray preparation to ensure it matches the diet order , audit recorded and maintained in binder in administrator's office Unit nurses will verify physician diet orders prior to food delivery to residents by reconciling diet orders to diet tray cards, this will be maintained in the diet manuals on each nursing station The Director of Nursing will be responsible for the QAPI process. The Director of Nursing will monitor the transcription of dietary orders, communication of dietary changes to the kitchen, staff performance with return demonstrations, and the safety of residents who require modified diets and prefer to eat in non-group environments every day Sunday thru Saturday. This will be maintained on an audit tool in the administrators binder in the office The Director of Dietary will monitor the process of communicating diet orders between nursing and dietary, the data entry of orders in the dietary software by auditing the orders and the software, and the provision of correct meals to residents with physician orders for modified diets every day Sunday thru Saturday utilizing audit too and maintained in the administrators binder. Audits will be reviewed with facility QAPI monthly meetings. Audits will be maintained in the Administrator's binder in that office. Immediate actions initiated on (MONTH) 9, (YEAR) into (MONTH) 10, (YEAR). Immediate actions consisted of in-services that began on the 3:00 p.m.-11pm shift conducted by the LPN ,[DATE] Supervisor with CNA, (100%) LPNs (100%) and (100%) RNs in attendance for the 3pm-11pm shift on (MONTH) 9, (YEAR). In-services were continued by the LPN ,[DATE] Supervisor with CNAs (100%), LPNs (100%), and RNs (100%) in attendance for the staff assigned on ,[DATE] shift on (MONTH) 9, (YEAR). All in-services consisted of instruction to utilize a binder on each nursing station with diet listings for new / readmitted residents. Procedures on how to confirm diets on meal trays, how to access information for interim care plans, how to review diets on the KIOSK and procedures to report change of conditions to nurses. In-services began before surveyor exited the facility on (MONTH) 9, (YEAR). (57) Residents on modified diet orders in the facility on (MONTH) 9, (YEAR) were reassessed by the DON, ADON, Unit Manager, Staff Development Nurse, Dietary Manager for safe dining risks any care plan revisions were discussed by the IDT with the resident and/or resident representative as needed. (MONTH) 9, total census 147 New residents on modified diets will be assessed by the Interdisciplinary team for restorative dining and/or encouraged to take their meals in the dining room to provide supervision. In-services continued for the remained of staff on (MONTH) 10th , 12th and 23rd and were conducted by RN, ADON , LNHA, Dietary Manager, LPN staff development and House Keeping Manager . As of this submission of allegation of compliance, the following departments have completed in-service attendance requirements. CNAs-79 employees/ 75 completed LPNs-29 employees / 26 completed RNs-2 employees / 12 completed Dietary-22 employees / 22 completed Rehabilitation 14 employees / 14 completed Employees that have not completed the required in-services will not to return to work duty until in-services are completed. New hire employees for dietary and nursing will be in-serviced during orientation by the staff development director and dietary manager regarding dietary instruction to utilize a binder on each nursing station with diet listings for new / readmitted residents. Procedures on how to confirm diets on meal trays, how to access information for interim care plans, how to review diets on the KIOSK and procedures to report change of conditions to nurses The RD, reviewed and participated in the preparation of this A[NAME] on [DATE] & [DATE]. She has actively conducted in-services with the Dietary Manager and Assistant Dietary Manger regarding diet order verification. She has conducted audits for physician orders, diet orders in the Point Click Care clinical software, and the dietary computer software program- these audits and in-service records are maintained in the Administrators Binder. The State Survey Agency (SSA) validated the facility ' s Credible Allegation of Immediate Jeopardy Removal as follows: INSERVICES, AUDITS, AND RETURN DEMONSTRATION REVIEWED Review of the Powder Springs Transitional Care and Rehab document, dated [DATE], revealed the Administrator's signature on a statement that affirmed the review of the diet ordering process on [DATE]. Review of the Diet Process document, dated ,[DATE], revealed a flow process for diets including newly admitted or bed-hold residents, diet order entry, and how the electronic documenting system would push diet orders to software meal tracker, which would print out dietary tickets in the kitchen for each resident. A dietary communication form is taken to the kitchen as back up. Review of the quality improvement program committee sign-in sheet, dated [DATE] at 10:30 a.m. revealed the following signatures on the sign-in sheet: Administrator, DON, Medical Director, ADON, Infection Control, Maintenance/Safety, Business Office Manager, Human resources, Dietary Services, Housekeeping/Laundry, Social Service, Activity Director, Therapy Director, CNAs, MDS coordinator, and a Unit Manager. Further review of this document revealed the meeting topics to include psych meds, diet orders, tray audits,Kiosk training, and abuse reporting training. Review of the inservice report, dated [DATE], revealed training on the following: diet orders will be kept on every unit in a binder at the nurses station. The CNAs must confirm diet on all new and re-admit residents with the nurse. Nurse/CNA must confirm diets on all trays match dietary order. CNA must report change in condition to the nurse. Review interim care plan and review diet on Kiosk. Review of the sign-in sheet revealed 127 signatures. Another inservice of the same kind was given on [DATE], with 9 rehab department signatures on the sign-in sheet. On [DATE] at 4:00 p.m. Speech Therapist YY was interviewed in the 300-hall. She stated she was a speech therapist and had worked at the facility for two years. She stated she recalled working with R#11 two or three times and he was a severe aspiration risk. She stated the facility did not have standard aspiration risk precautions. She stated she thought it would be very helpful if a risk precaution protocol for aspiration risk was developed. She stated if she currently assessed a resident as an aspiration risk, she would change the diet, either pureed or mechanical soft, and would change the liquid intake. She stated she would then hand-write the diet order on an old-fashioned carbon copy sheet, which would go to the kitchen. She stated she would educate the staff on steps to take for the at-risk resident. She stated she did frequent face-to-face education with the CNAs. On [DATE] at 1:00 p.m. the diet books at the 200-hall, the 300-hall, the dining room, and the Alzheimer's Unit were reviewed and revealed to be up-to-date, were easy to access, and had diet information for each resident in the area. On [DATE] at 1:15 p.m. CNA ZZ was interviewed in the dining room. He stated he had worked for the facility for three years. He stated he had to be sure the meal ticket matched the resident. He stated he knew the residents well. He stated if he was not sure if the tray contained the right diet for the resident he could always check the electronic documenting system computer Kiosk on the wall and get the diet order. He stated there had been a recent inservice on dietary delivery. He demonstrated the Kiosk for the surveyor. On [DATE] at 1:20 p.m. LPN OO was interviewed in the hall near the dining room. She stated she had worked for the facility for one year. She stated she had to make sure the resident and the meal ticket on the tray matched. She stated if she was suspicious about the tray contents, she could check the order in the electronic documenting system and the electronic medical record (EMR), the diet book, or she could ask the Dietary Manager, if she was assisting in the dining room. She stated there was an inservice on this matter in (MONTH) (YEAR) after a resident choked. On [DATE] at 1:25 p.m. LPN A1 was interviewed on the 200 hall. He stated he worked for the facility for one year. He stated he would wash his hands, check the meal ticket, and check the resident's identity before he let them have a tray. He stated it was easy to check the diet order in the diet book or the EMR. He stated the diet book at the nursing station was updated every day. Review of another inservice report, dated [DATE] at 3:15 p.m. revealed an inservice that included diet orders at that time. Further review revealed each unit had a book with diets for new admissions, re-admissions, and current residents. The diet was to be checked before giving any resident food or drink. Review of the sign-in sheet for this inservice revealed 96 signatures. Review of an inservice document, dated [DATE], revealed an inservice teaching that all items on the resident's ticket should be on their tray, and, if the nursing staff asks for a new resident tray a diet order and communication slip should be given to the kitchen staff before a tray could be dispensed, and there was always a print-out of each resident's diet in the office door. If the resident was not on the print-out a tray could not be provided. Review of the sign-in sheet revealed 15 dietary worker signatures. On [DATE] at 2:25 p.m. Assistant Dietary Manager B1 was interviewed in the kitchen. He stated if a staff member requested a tray he would require a meal ticket with the diet order before he would give the tray. He stated he could check the diet order by checking the diet print-out before he gave the tray. He showed the Dietary Director's door to the surveyor and there was no diet print out in the folder holder on the door. B1 then went into the Dietary Director's office and found the print-out on the desk. The dietary print-out was dated [DATE]. B1 then stated he would not give out a tray unless he had the diet order and it was easy to print out. He stated there had been an inservice on this matter a few days ago. On [DATE] at 4:30 p.m. Assistant Dietary Manager B1 was interviewed in the kitchen. He stated dietary audits are done at each and every meal. He stated the dietary status of each resident was pulled from the electronic documenting system two times a day. He stated he absolutely would not give a tray if a CNA requested a mechanical soft tray but could not name the resident. He stated each tray was checked at each meal. The dietary audits, dated [DATE], were noted in a holder in the dietary director's door. Review of the Georgia Nutrition Consulting, Inc.'s hand-out, entitled Modified Textures, dated [DATE], revealed inservice training was provided for the dietary staff on that date. This training offered information on mechanical soft diets, pureed diets, full liquid diets, clear liquid diets, nectar liquids, honey thick liquids, and pudding or spoon thick liquids. Considerations in this inservice included to read tray cards (meal tickets) carefully. The sign-in sheet for this inservice revealed 18 signatures. Another inservice of this type was provided on [DATE] and had 11 signatures on it. Another Modified Textures inservice sign-in sheet, dated [DATE], had two signatures on it, including B1's. Review of an inservice report, dated [DATE], revealed training was provided on diet locations on that date, including use of the P[NAME] Kiosk, diet book at nurses' stations, and using the diet slip. Review of the sign-in sheet for the inservice revealed 82 signatures. Review of an inservice report, dated [DATE], revealed an inservice was held for the rehab department on that day, including a review of importance of diet adherence and location of diet information, including diet books and the electronic documenting system. Review of the sign-in sheet for this inservice revealed 18 signatures. Review of a Diet Order Verification inservice, dated [DATE], revealed training given by a Registered Dietician (RD), including view the dashboard in electronic documenting system twice a day to obtain the list of new admissions and discharges, and to audit the physician diet orders at least monthly against the tray card system. Review of the Dietary Manager Skills check List, dated [DATE], revealed an RD will check the dietary managers skills in diet order verification, electronic do