Every finding on record at Prairie Estates

Based on observation, interview and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 of 6 residents (Resident #1) reviewed for quality of care. The facility failed to ensure Resident #1, who sustained a mild nasal fracture from a fall on 07/11/26, followed up with an ENT in 7 days per hospital discharge orders. The resident was discharged from the hospital on [DATE] and the appointment was not made until 07/22/26. This failure could place residents at risk for worsening of condition which could lead to serious harm.Findings included:Record review of Resident #1's Quarterly MDS Assessment, dated 05/14/26, reflected the resident was an [AGE] year-old female who initially admitted to the facility on [DATE] and readmitted on [DATE]. The MDS Assessment under Section C-Cognitive Patterns reflected Resident #1's BIMS score was a 10, which indicated moderate cognitive impairment. The MDS Assessment under Section GG-Functional Abilities reflected Resident #1 required supervision to moderate assistance with most self-care ADLs. Resident #1 required supervision assistance and use of a walker for mobility. The MDS Assessment under Section I-Active Diagnoses reflected Resident #1's active diagnoses included: Alzheimer's Disease (brain disorder that causes loss of memory and thinking), quadriplegia (partial or total loss of use in all four limbs), osteoporosis (weak bones), and heart disease. Record review of Resident #1's Care Plan, revised 07/11/26, reflected Resident #1 was at risk for falls r/t gait and balance problems. Interventions included: keeping environment free from clutter, ensuring call light was within reach and encouraging resident to use it, educating resident and family about safety reminders, educating resident on walker safety, educating resident to wait for staff's assistance, encouraging resident to participate in activities that promote exercise, keeping fall identifiers in place, following the facility's fall protocol, and monitoring, documenting, and reporting changes in condition to the MD. This document also reflected that Resident #1 had impaired physical mobility. Interventions included: a consult with physical therapy, determining level of assistance needed based on ADLs, encouraging resident to increase activity as indicated, encouraging rest between care activities, encouraging use of prescribes assistive devices, evaluating ADLs and resident's ability to perform them, implementing measures to prevent further injury to spinal cord, monitoring for environmental barriers to mobility, observing resident's gait and posture, observing ROM in all joints, and performing a detailed neurological evaluation. Record review of Resident #1's hospital discharge records, dated 07/11/26, reflected in part the following: Patient Visit Information[Resident #1] was seen today for:Nasal fractureBack spasmHead injury Staff.Physician: [Hospital physician].Follow-upPlease contact the following to make an appointment for follow-up care:[ENT]Follow-up plan: 7 days.Radiology ResultsCT Head:No evidence of acute intracranial hemorrhage (brain bleed), midline shift (shift of brain), or hydrocephalus (fluid on brain).Age-related cerebral volume loss (shrinking of brain) and mild chronic small vessel changes. CT Cervical Spine (neck region of spine):No evidence of acute fracture or traumatic subluxation (partial dislocation of a joint) to the visualized cervical spine.Degenerative changes of the cervical spine (reduced cushioning and disc space that can lead to inflammation and pain) as described with moderate to severe spinal canal stenosis at C4-C5. CT Maxillofacial (jaw and face) bone:Acute mildly displaced fracture of the bilateral (both sides) nasal bones and nasal septum. CT thoracic spine (middle region of spine):No evidence of acute fracture or traumatic malalignment (not aligned or positioned correctly) to the visualized thoracic spine. CT lumbosacral spine (lower part of back/spine):No evidence of acute fracture or traumatic malalignment (not aligned or positioned correctly) to the visualized lumbosacral spine. Record review of Resident #1's progress notes, dated 07/11/26 at 8:37 p.m. by LVN A, reflected the following: Standing by the medication cart [LVN A] hard [sic] a loud noise, as [LVN A] looked to check where the noise was coming from [LVN A] observed [Resident #1] lying on the floor by the side of her bed face down, noted she was bleeding from the nose, 911 called, [MD] and [Resident #1's RP] notified, [Resident #1] was send [sic] to [local hospital]. Record review of Resident #1's progress notes, dated 07/11/26 at 9:41 p.m. by LVN A, reflected the following: [Resident #1] back from ER with DX: of acute mildly displaced fracture of the bilateral nasal bones and nasal septum. Noted new order of Robaxin (muscle relaxer) bid will continue to monitor. Record review of Resident #1's progress notes, dated 07/22/26 at 1:41 p.m. (staff unknown), reflected an appointment was made for the resident to follow up with an ENT on 07/27/26 at 2:40 p.m. Further review of the progress notes reflected that there was no documentation for an appointment with the ENT made prior to 07/22/26. In an interview on 07/22/26 at 9:24 a.m. with the Administrator and DON, the DON stated Resident #1 had an unwitnessed fall in her room where she sustained a fractured nose. The DON stated Resident #1 was assessed by LVN A and transported to the local hospital, then returned to the facility on the same day. The DON stated Resident #1 had an order for pain medication and muscle relaxers and was being re-evaluated by therapy. The DON stated Resident #1 had a lot of yarn and craft supplies in her room, but staff helped keep it organized and out of the walkway, and the resident denied tripping over anything but could not state how she fell. The DON stated Resident #1 did not require much assistance and was able to walk using a walker. The DON stated Resident #1 did not always use the walker when walking short distances in the room, but she was encouraged to always use it. The Administrator stated following the incident staff were educated on the facility's policy and procedures regarding abuse and neglect and fall prevention. In an observation and interview on 07/22/26 at 10:21 a.m., Resident #1 was observed resting in her room with the bed in the lowest position as a fall precaution. Further observation of the room revealed the resident had a lot of personal belongings, including decor and art supplies that were not in the walkway. Resident #1 stated she was in slight pain but was receiving her medication. Resident #1 stated during the incident, she stood up from the bed to walk to the bathroom and just remembered falling to the floor. She stated she could not recall if she used her walker. Resident #1 stated she did not trip over anything and could have just been weak that day. Resident #1 stated she hit her face, so the facility sent her out to the hospital. Resident #1 stated she did not know if she followed up with a doctor. In an interview on 07/22/26 at 10:53 a.m., Resident #1's RP stated the facility notified her that the resident had a fall and sustained an injury. She stated the facility always notified her of all incidents, changes in the resident's condition, and doctor appointments. Resident 1's RP stated she was unaware that Resident #1 needed to follow up with an ENT because the facility had not informed her. Also, she stated Resident #1 would have told her if she went on an appointment outside of the facility. Resident #1's RP stated she did not have any concerns that the resident was being abused or neglected, but she was now concerned that Resident #1 had not followed up with an ENT if it was needed. In an interview on 07/22/26 at 1:27 p.m., the Unit Clerk stated that after a resident returned to the facility from the hospital, the nurses reviewed the discharge records and if there was an order for a follow-up appointment it was his responsibility to schedule and document the appointment. The Unit Clerk stated he was aware that Resident #1 needed to follow-up with an ENT regarding her fractured nose, and since the incident happened over the weekend, he scheduled the appointment on the next business day. The Unit Clerk stated he did not document the appointment in Resident #1's EHR and just wrote it on his calendar. The Unit Clerk stated appointments were supposed to be documented in the residents' clinical chart, but he must have gotten busy and forgot to do so. In an interview on 07/22/26 at 1:39 p.m., the ENT's office representative stated the facility contacted them on 07/22/26 at 1:15 p.m. and scheduled an appointment for 07/27/26. In an interview on 07/22/26 at 2:17 p.m., the DON stated when a resident returned to the facility from the hospital, the charge nurse received the discharge summary and checked for any new orders, including follow-up appointments. The DON stated if there was a referral for a follow-up appointment, the unit managers or clerks would schedule the appointments. The DON stated once the appointment was made, the expectation was for it to be documented in the resident's clinical chart for everyone to be aware. The DON stated it was important to ensure that residents followed up on appointments for continuation of care, and not doing so could place them at risk of worsening conditions. In an interview on 07/22/26 at 3:01 p.m., LVN A stated she worked with Resident #1 on the day of the incident. LVN A stated she was at the medication cart when she heard a loud noise. LVN A stated she rushed to Resident #1's room and found her on the floor face down with her nose bleeding. LVN A stated she yelled for help and assessed Resident #1 on the floor while 911 was called. LVN A stated Resident #1 was transported to the hospital, and she notified the MD, DON, and Resident #1's RP, then completed her documentation. LVN A stated Resident #1 had a history of falling but had never sustained a serious injury. LVN A stated Resident #1 was able to walk fine as long as she used her walker. LVN A stated that when a resident returned to the facility from the hospital, the nurses were responsible for assessing the resident, orienting them back to their room, and reviewing the discharge records for new orders or appointments. LVN A stated if there was a referral for a follow-up appointment, the nurses would inform the unit managers for the appointment to be scheduled. In an interview on 07/22/26 at 3:25 p.m., the MD stated he was notified that Resident #1 had an unwitnessed fall and sustained an injury. The MD stated the expectation was for the facility to follow up on all discharge orders and he was made aware that Resident #1 had an appointment with the ENT on 07/27/26. The MD stated with a mild fracture, there was probably not much an ENT could do for Resident #1. The MD stated the facility was still expected to schedule the follow-up appointment per hospital discharge orders, unless otherwise advised by him. The MD stated Resident #1 was a long-term care resident and was seen by him at least quarterly; however, the NP visited weekly and usually saw residents after an incident. The MD stated he would check his notes to see if the NP documented anything. Record review of the facility's policy titled, Provision of Physician Ordered Services, revised 12/0125, reflected in part the following: Policy: The purpose of this policy is to provide a reliable process for the proper and consistent provision of physician ordered services according to professional standards of quality. Definition: Professional Standards of Quality means that care and all services are provided according to acceptedstandards of clinical practice. Standards may apply to care provided by a particular clinical discipline [NAME] a specific clinical situation or setting. Policy Explanation and Compliance Guidelines:.Qualified nursing personnel will submit timely requests for physician ordered services (laboratory,radiology, consultations) to the appropriate entity.4. Documentation of consultations, diagnostic tests, the results, and date/time of physician notification will be maintained in the resident's clinical record.

Based on observation, interview and record review the facility failed to ensure the resident had the right to a safe, clean, comfortable and homelike environment, including but not limited to Housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior for 1 of 5 residents (Resident #14) reviewed for environmental conditions. The facility failed to ensure Resident #14's toilet seat was in good condition and was not broken. This failure could place residents at risk for injury and a decreased quality of life.Findings included: Observation and interview on 03/24/26 at 10:58 AM with Resident #14 stated his toilet seat had been broken for about a week. Observation of Resident #14's toilet seat in his bathroom revealed it was broken and the left side was not connected to the toilet. Resident #14 said he had told the aide and nurse about it being broken and was told someone would be by to fix it, but they never did. Resident #14 said he was scared to sit on the toilet because he did not want to fall and hurt himself. Resident #14 said he had not fallen off the toilet seat or injured himself in any way. Observation and interview on 03/26/26 at 11:47 AM, both LVN B and CNA C stated Resident #14 took himself to the bathroom and did not need assistance . LVN B and CNA C said Resident #14 never mentioned to them that his toilet seat was broken. LVN B and CNA C said they would have added the maintenance request to the maintenance log that was located at the nurse's station had they known about Resident #14's toilet seat being broken. LVN B and CNA C went to Resident #14's bathroom and confirmed the toilet seat was broken. Observation of Resident #14's toilet seat in his bathroom revealed the toilet seat was broken. Review of the Maintenance Log for the month of March 2026 did not reflect a request for Resident #14's toilet seat to be fixed due to it being broken. Interview on 03/26/26 at 1:33 PM, the Maintenance Director said he had not heard Resident #14's toilet seat was broken. The Maintenance Director said when staff were aware of something that needed to be repaired, they were supposed to put it in the maintenance book that was at the nurse's station. The Maintenance Director said he and his assistant checked the book every day and one of them normally handled small requests like that quickly. The Maintenance Director said he would normally be responsible for taking care of maintenance requests immediately. The Maintenance Director said if a resident's toilet seat was broken, that would put them at risk for falling off of it. Interview on 03/26/26 at 1:55 PM, the Maintenance Assistant said he was told about Resident #14's toilet seat being broken earlier in the day after the nurse told him about it. The Maintenance Assistant said he did not see the entry for it in the maintenance book at the nurse's station which he checked daily. The Maintenance Assistant said today was the first time he heard about Resident #14's toilet seat being broken. Interview on 03/26/26 at 3:33 PM, the Administrator said when something needed to be repaired in a resident's room, staff should put it in the maintenance book at the nurse's station. The Administrator said he expected staff to put things that needed repairing in the maintenance book as soon as they were aware of it. The Administrator said if something is broken in a resident's room it could potentially cause an injury. The Administrator said the maintenance department staff should go into resident rooms to check and make sure things are in good repair. The Administrator said he expected all things in resident's rooms to be in good repair. Review of the facility's Safe and Homelike Environment policy, dated 10/01/25, reflected the following: .3. Housekeeping and maintenance services will be provided as necessary to maintain a sanitary, orderly, and comfortable environment.

Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs that were identified in the comprehensive assessment for 1 of 31 residents (Resident #24) reviewed for care plans. The facility failed to develop a care plan with measurable objectives and timeframes to address Resident #39's colostomy (an opening in the abdominal wall that allows waste to pass into a removeable pouch). This failure could place residents at risk of receiving inadequate interventions not individualized to their care needs. Findings included:Review of Resident #24's quarterly MDS assessment dated [DATE] reflected the resident was a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included paraplegia (impairment or loss of motor sensory function in the lower half of the body), multiple sclerosis (chronic autoimmune disease where the immune system attacks the central nervous system causing nerve damage), and encounter for attention to colostomy. Resident #24 had a BIMS of 15 which indicated her cognition was intact and the MDS further reflected the resident had a colostomy. Review of Resident #24's care plan initiated on 10/30/24 did not reflect the resident had a colostomy. Review of Resident #24's Order Summary Report for March 2026 reflected the following: Colostomy - Check Placement and Empty Contents every shift to ensure it is secured. Empty Contents qshift and more often as necessary.Observation and interview on 03/26/26 at 12:03 PM, Resident #24 was observed sitting in her wheelchair alert and pleasant. Observation of the colostomy site revealed it was clean, no redness and free of infection. During an interview RN G stated they had never had any issues or concerns regarding the resident's colostomy site. Interview on 03/31/26 at 3:40 PM, the MDS Nurse stated care plans were initiated by the ADONs or the nursing staff and she was not aware that Resident #24's colostomy status was not in her care plan. The MDS Nurse said her colostomy status was on the previous computer system, and they switched to a new system in November 2025, and it appeared that her colostomy status has not transferred over. The MDS Nurse stated it was the responsibility of the nursing management, herself included, to ensure care plans were not missed. Interview on 03/26/26 at 4:18 PM, the ADON stated the MDS Nurse and nursing staff were responsible for implementing care plans. The ADON stated she did not know why Resident #24's colostomy status was not in the current system and thought that when the facility changed computer systems in November 2025, the colostomy status might have been dropped. The ADON said the MDS Nurses and other nursing staff were responsible for overseeing resident care plans to ensure they were accurate. The ADON stated it was important to make sure care plans were accurate, so the staff knew how to take care of the residents and were updated on any changes. Interview on 03/26/26 at 4:37 PM, the DON stated care plans were implemented by the nursing staff which included the MDS Nurse and the MDS Nurse was responsible for overseeing they were accurate. The DON said he was not aware Resident #24's colostomy status was not on the current plan, and it appeared it might have dropped off when they switched to the new computer system in November 2025. The DON said it was important to ensure resident care plans were accurate, so the staff knew how to take care of the residents. Review of the facility's policy titled Comprehensive Care Plans dated 10/01/25 reflected the following: PolicyIt is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental psychosocial needs and ALL services that are identified in the resident's comprehensive assessment and meet professional standards of quality.

Based on observation, interview and record review, the facility failed to ensure parenteral fluids were administered consistent with professional standards of practice and in accordance with physician orders, the comprehensive person-centered care plan, and the resident's goals and preferences for 1 of 8 residents (Resident #137) reviewed for intravenous medication. The facility failed to ensure Resident #137's intravenous medication bag and tubing were labeled with the date, time, and initials.These failures could place residents at risk for medication error, delay in medication administration, infections and cross-contamination. Findings include:Findings include:Record review of Resident #137's annual MDS Assessment, dated [DATE], reflected an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #137's diagnoses included chronic respiratory failure with hypoxia (lungs cannot adequately transfer oxygen into the blood), hyperlipidemia (high cholesterol), Non-Alzheimer's Dementia (brain disorders causing cognitive decline), and anxiety disorder. Resident #137's BIMS score was 13, which indicated her cognition was intact. Record review of Resident #137's care plan, dated [DATE], reflected: Focus: The resident is on antibiotic therapy (Ceftriaxone 1gm qd x 7 days) r/t infection UTI/Elevated WBC End date -[DATE]. Goal: The resident will be free of any discomfort or adverse side effects of antibiotic therapy through the review date. Interventions: Administer ANTIBIOTIC medications as ordered by physician. Monitor/document side effects and effectiveness Q-SHIFT.Record review of Resident #137's [DATE] physician orders reflected the following: Ceftriaxone Sodium Solution Reconstituted 1GM. Use 1 gram intravenously one time a day related to Urinary Track Infection for 7 Days. Order date [DATE]. Observation and interview on [DATE] at 2:38 PM, revealed Resident #137 in her room, sitting in her wheelchair watching television. She was observed to have a PICC line on her left arm; it had a dressing with a date of [DATE]. No signs of redness or drainage were observed. Resident #137 stated she received her antibiotics at nighttime. The intravenous medication bag was observed hanging on the pole and the IV tubing was not labeled with the date, time, and initials.Interview on [DATE] at 3:20 PM, LVN A stated she was the 2PM-10PM nurse assigned to Resident #137. She stated Resident #137 was on antibiotics, and she received the antibiotics during the second shift. LVN A stated she was the nurse who provided the antibiotics on [DATE]. LVN A entered Resident #137's room and observed the intravenous medication bag hanging on the pole and stated the medication bag was missing the time, date and initial. She stated she got busy and forgot to label the medication with the date and time when she hung it up. She stated it was important to date, time and initial the medication bag and tubing so that next staff knows whether the tubing was good to be used. She stated the tubing should be disposed after 24 hours. She stated the potential risk of not dating and labeling the medication bag and tubing would be infection. Interview on [DATE] at 2:37 PM, ADON stated she expected staff to date and initial the medication bag and tubing when administering the medications. She stated staff should make sure they followed the 6 rights, right resident, right medication, right dosage, right route, right time, and right documentation. She stated the potential risk of not dating and labeling the medication bag and tubing would be not knowing when it was administered. Interview on [DATE] at 4:38 PM, the DON stated the expectation when administering IV medication, staff should check to make sure it was the correct medication, right patient, right time and ensure the medication was not expired. He stated staff should label the medication bag and tubing with the time and date. The DON stated it should be labeled with the time and date so that the staff were aware of how long the medication had been infusing and know the duration of when the medication was hanged. He stated the potential risk would be staff not knowing when it was administered. The DON stated he had done training with staff on labeling and putting initials on bags and tubing and had done skill checks with the nurse. Record review of the facility's Intravenous Therapy policy, revised [DATE], reflected the following: The facility will adhere to accepted standards of practice regarding infusion practices.5. All IV tubing is to be labeled with date, time and initials.

Based on observation, interview, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the drugs and biologicals used in the facility must be labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable) to meet the needs of each resident for 2 of 5 medication carts (Halls 100 medication Aide medication cart and Hall 900 nurses' medication cart) reviewed for medication storage .1. The facility failed to ensure expired medications were removed from the Hall 100 medication aide cart and Hall 900 nurses' medication cart. This failure could place residents at risk of not receiving the therapeutic benefit of medication or an adverse drug reaction.Observation on 03/25/2026 at 1:19 PM, Hall 100 medication aide cart revealed one bottle of Calcium 500mg/Vitamin D 400unit (used as dietary supplement designed to support bone health and improve calcium absorption with an expiry date of December 2025.Interview on 03/25/2026 1:30 PM, LVN E stated Medication Aide F was responsible for checking the cart for expired medications. She stated failing to remove the expired medication could result in the medications being administered which could cause reactions, or the residents would not get the required therapy.Interview on 03/25/2026 1:40 PM, MA F revealed she was responsible for checking the cart for expired medications. She stated she had not checked her cart on 03/25/26, she only checked every couple of days, and she was not specific on which days. She stated failing to remove the expired medication could result in the medications being administered which could make residents sick. She stated she could not recall training, but she had been instructed verbally to be checking the carts for expired medications. Observation on 03/25/2026 at 1:57 PM, of the Hall 900 nurses' medication cart with RN G revealed, one bubble pack of Clonidine 0.1milligrams (used to treat high blood pressure) with an expiry date of 02/24/26 and one bottle of Tums (used to provide rapid relief for heartburn, acid indigestion, sour stomach, and upset stomach) with no expiry date. Interview on 03/25/2026 1:57 PM, RN G stated she was responsible for checking the cart for expired medications. She stated she had checked her cart for expired medications that morning , and she had missed the expired medication. RN G stated she checked her cart daily for expired medication and expiry dates. RN G said failing to remove the expired medication and having medications with no expiry dates could result in the medications being administered which could cause the residents not to get the required therapy. She stated the risk of having expired medication if administered it will not be effective. She stated she had done training on cart audit, but she could not recall when.Interview on 03/26/2026 at 2:46 PM, the ADON revealed her expectation was for nurses to check their cart for expired medications every week. She stated the ADON's were responsible for checking behind the nurses weekly. She stated she last audited the carts on 03/23/25 and she also missed the expired medications. She stated the risk of having expired medications on the cart was being administered, and they would not be effective.Interview on 03/26/2026 at 4:37 PM, the DON stated his expectation was all nurses were responsible for checking the carts weekly, to ensure expired medications were removed from the carts. He stated it was the responsibility of ADON to go behind the nurses weekly and ensure expired medications were being removed from the carts. He stated if expired medications get administered could place residents at risk of having side effects.Review of facility training records on 03/26/25 revealed facility training on carts audit and RN G was in attendance. Record review of facility's Medication Administration policy dated 02/01/25 reflected: . 13. Identify expiration date. If expired, notify nurse manager.

Based on observation, interview, and record review the facility failed to ensure the storage of all drugs and biologicals were in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys for 1 of 1 resident (Resident #19) reviewed for storage of medications.The facility failed to ensure Resident #19's Oxycodone-Acetaminophen tablet was not left on his over-bed table in his room by staff.This failure could affect residents by placing residents at risk of consuming unsafe medications left at bedside unattended.Findings included:Findings included:Record review of Resident #19's face-sheet revealed a [AGE] year-old male initially admitted to facility on 10/09/2023 and readmitted on [DATE]. His diagnosis included: Unspecified Dementia, Mild Without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance, and Anxiety (excessive and persistent fears or worries that interfere with daily life); Chronic Ischemic Heart Disease, Unspecified (long-term condition caused by reduced blood flow to the heart muscle, primarily due to narrowed or blocked coronary arteries); Schizoaffective Disorder, Recurrent, Unspecified (a mental health condition that is marked by a mix of schizophrenia symptoms, such as hallucinations and delusions, and mood disorder symptoms such as depression). Record review of Resident #19's quarterly MDS dated [DATE] revealed BIMS score to be 15 with memory intact. Resident #19 able to make decisions r/t her care. Resident #19 requires set-up, supervision, and independent with ADL care. Record review of Resident #19's care plan revealed that there was no documentation r/t self-administration of medication.Record review of Resident #19's physician orders revealed no orders for self-administration of medication. Record review of Resident #19's Medication Administration Record dated 03/26/2026 noted the following medication was initialed by LVN D.Orders as noted:Oxycodone-Acetaminophen Tablet 10-325 mgGive 1 tablet by mouth 3 times a day for chronic pain Observation on 03/36/3026 at 03:20 p.m. revealed LVN D set a medicine cup with a pill in the cup on the over-bed table in front of Resident #19 and walked out of the room. LVN D did not stay and ensured Resident 19 took his pill. In an interview on 03/26/2026 at 3:25 p.m., Resident #19 revealed that he was aware the pill was his pain medication. Resident stated the nurses have left his medication at bedside before because they know he will take it. Resident #16 states that this occurs on different shifts, but not often. Resident #16 revealed he receives his medications on time, and the nurses inform him what he is being given. In an interview on 03/26/2026 at 3:40 p.m., LVN D stated she is aware of the policy for providing medication to residents at the bedside. LVN D stated the policy was to observe residents take their medications before leaving the room. LVN D stated she could not explain why she left Resident #19's medication on his over-bed table and walked out of the room. She stated Resident #16 told her he would take his medication. LVN D stated that Resident #16 was provided a pain pill. LVN D stated the risk of not observing Resident #16 taking his medication could be he may not take the medication or another resident may take the medication by mistake if resident left medication unattended. LVN D stated that it was not her normal practice to leave medication at the bedside. In an interview on 03/26/2026 at 4:00 p.m., the DON stated the policy and procedures of the facility was no medications are to be left at the resident's bedside. The DON stated the risk of nurses not observing the resident taking medications could be the resident may not take the medication or another with dementia could wander into the room and take the medication not knowing the medication does not belong to them causing harm to that resident.In an interview on 03/26/2026 at 5:10 p.m., the ADM stated his expectations r/t resident's medications are staff are to follow the medication administration policy. The ADM stated that there was not a risk for Resident #16 to self-administer his own medication. The ADM stated the possible risk may be another resident could take the medication if left unattended by Resident #16. Review of the facility's Medication Administration policy, revised 12/01/25 reflected the following: .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 standards of practice, in manner to prevent contamination or infection.

Based on interview and record review the facility failed to develop and implement a comprehensive, person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing and mental and psychological needs that were identified in the comprehensive assessment for one of five residents (Resident #1) reviewed for care planning.1. The facility failed to ensure Resident #1's care plan had a person-centered approach to address her evolving medical and dietary needs.2. The facility failed develop a care plan to address a hospitalization for pneumonia and a return the facility with continued textured diet orders, aspiration precautions and additional antibiotic treatment.These failures could place residents at risk of being inconsistently monitored, possible delayed identification of swallowing difficulty, and lack of coordinated food/dietary interventions during meals.Findings included:Record review of Resident #1's Face Sheet, dated 01/30/26, reflected an [AGE] year-old female who was admitted to the facility on [DATE] and re-admitted on [DATE]. Resident #1 had diagnoses with an onset date of 12/13/24 which included: lobar pneumonia (primary diagnosis-a type of lung infection that affects one or more lobes of the lungs, primarily caused by bacterial infections, leading to inflammation and fluid buildup), acute kidney failure (when the kidneys suddenly stop functioning and cannot filter waste and toxins from the blood), gout (painful form of inflammatory arthritis), mononeuropathy (pain, tingling, numbness, or muscle weakness in specific body areas), diabetes (a chronic condition characterized by high blood sugar [glucose] levels resulting from the body's inability to produce or properly use insulin) and malignant neoplasm (a cancerous tumor formed by rapid, uncontrolled cell growth that can invade nearby tissue and spread to other parts of the body via the blood or lymph systems). Additional diagnoses were added through Resident #1's stay, which included: metabolic encephalopathy (added 01/08/25-a reversible, non-traumatic brain dysfunction caused by systemic illness, organ failure or chemical imbalances), anemia (added 01/14/25-not having enough healthy red blood cells or hemoglobin to carry oxygen to the body's tissues), chronic kidney disease-stage 4-severe (added 01/14/25-kidneys are moderately or severely damaged and are not properly filtering waste from the blood), pneumonia due to MRSA (added 1/14/25-a severe, often necrotizing lung infection caused by Methicillin-resistant Staphylococcus aureus, carrying a high mortality rate) and malnutrition (added 01/27/25-a serious condition resulting from an imbalance between the nutrients the body needs and what it receives). Record review of Resident #1's 5-day admission MDS, dated [DATE], reflected she had a BIMS score of 05, which indicated severe cognitive impairment. Resident #1 had range of motion impairment on the side of her lower extremity and used a wheelchair for ambulation. She required supervision or touching assistance when eating. Resident #1 had a mechanically altered and therapeutic diet and was administered three high-risk medications-an antidepressant, anticonvulsant and diuretic. She had occupational and physical therapies provided during the assessment period. Record review of Resident #1's speech therapy order, dated 12/20/24, reflected a need for skilled speech therapy for cognitive-linguistics deficits and dysphagia (difficulty swallowing) management five times a week for four weeks. Record review of Resident #1's SLP Cognitive and Nutrition Screening, dated 01/15/25, reflected Resident #1 had signs consistent with swallowing impairment, which included loss of liquids/solids from the mouth, holding food in the mouth or cheeks, and she required a mechanically altered diet. Record review of Resident #1's nephrology progress note, dated 01/23/25, reflected she was status-post hospitalization for right lower lung pneumonia and was treated with antibiotics and had an ordered textured diet. On 01/11/25, she was readmitted to the hospital due to altered mental status, was given intravenous fluids and sent back to the facility for skilled services on 01/14/25. Record review of Resident #1's physician orders, dated 01/31/25, reflected she had a LCS/NAS diet with ground texture and regular/thin consistency (start date 12/13/24). Record review of Resident #1's care plan reflected only two identified focus areas: pressure ulcer risk (initiated 12/17/2024) and antibiotic therapy (12/16/2024). The care plan did not address any concerns related to dysphagia, aspiration risk, supervision during meals or any respiratory issues and treatments related to pneumonia. An interview with the RNC and DON on 01/30/26 at 12:10 PM revealed the MDS nurse was responsible for the initial development of the care plan, but the issue with Resident #1 was she had never been at the facility continuously for 21-days to trigger the comprehensive care plan to be completed due to the resident being in and out of the hospital. The RNC and DON stated when a resident re-admitted from the hospital with any new conditions or concerns, an acute care plan had to be completed immediately. They stated both the charge nurses and ADONs could complete them. The RNC stated an acute care plan was a concern that needed attention immediately for the staff to know how to manage a situation. The RNC stated he expected the MDS nurses to complete any updates and revisions to residents' care plans, but around January/February 2025 when Resident #1 was at the facility, there was no MDS nurse. As a result, the facility went a month without one. The RNC stated there were some corporate staff who helped with the MDS and care planning but there remained a backlog. An interview with LVN A on 01/30/26 at 2:15 PM revealed she was the MDS nurse. LVN A stated the process post-hospital discharge was to review the specific resident in the morning meeting, review the hospital discharge orders, and then the MDS nurse was supposed to determine what needed to be added, modified or removed from the care plan. LVN A stated multiple disciplines attended morning meetings, which included the MDS nurses, ADONs, DON, administrator, social services, wound care nurses, dietary, nurses from the halls and CNAs. Each department was expected to report changes to their residents observed within the prior 24 hours. LVN A stated the process was intended to capture changes in condition, hospitalizations, diet changes, therapy referrals, and emerging risks. LVN A did not remember Resident #1's stay as it occurred about a year prior. LVN A stated repeat hospitalizations and continued decline of a resident should be addressed and trigger a care plan update. She said those updates to the care plan were expected to be identified through a review of hospital records, weekend 24-hour reports and daily clinical review. LVN A stated acute issues that arose during a resident's stay, such as pneumonia, swallowing risks, decline or hospice consideration should be incorporated into the care plan as they occur. She explained while wound care nurses were the exception and they completed care plans specific to wounds, other clinical concerns were typically addressed by the MDS nurses. LVN A also stated diet changes, downgrades and texture requirements were expected to be reflected in the care plan. She stated the MDS nurses typically updated diet-related care plans, but if a change occurred on the weekend or when the MDS nurse was not available, then the ADON could complete it. LVN A stated accurate and current care plans were critical for staff providing direct care because they relied on the care plan to know what risks to monitor, which included diet changes, skin integrity issues and decline. She described care planning as vitally important to ensuring staff awareness and resident safety. LVN A stated there was a time when the facility experienced staffing shortages in the MDS department but since then processes were strengthened and morning meetings emphasized better communication in capturing resident changes. LVN A re-iterated while she could not speak to Resident #1's specific care plan, the facility's expectation was that repeated hospitalizations, pneumonia, diet changes, antibiotic use and decline should be reflected in the care plan to guide staff care and monitoring. Record review of the facility's policy titled, Comprehensive Person-Centered Care Plans, revised March 2022 reflected, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. 9. Care plan interventions are chosen only after data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making.12. The interdisciplinary team reviews and updates the care plan: a. when there has been a significant change in the resident's condition; b. when the desired outcome is not met; c. when the resident has been readmitted to the facility from a hospital stay; and d. at least quarterly, in conjunction with the required quarterly MDS assessment.

Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for one (Resident #1) of five residents reviewed for care plans. The facility failed to ensure Resident #1's comprehensive care plan addressed their oral care and condition including the resident's risk and/or underlying causes (to the extent possible) of the resident's dental/oral condition and the impact upon the resident's function, mood, and cognition. This failure could place residents at risk of receiving inadequate interventions not individualized to their mental health and dental health care needs.Findings included: Record review of Resident #1's annual MDS dated [DATE], reflected the [AGE] year-old female resident was admitted to the facility on [DATE] with a BIMS score of 13, indicating the resident was cognitively intact but at risk for mild memory/recall difficulties. Diagnoses included: recurrent depressive disorder (persistent sadness, loss of interest, and low energy that affects daily life), anxiety disorder (ongoing excessive worry and nervousness that interferes with daily life), diabetes (a condition where the body can't properly use sugar for energy, leading to high blood sugar and possible complications), and heart disease (blood vessels that carry oxygen and nutrients to the heart get clogged or narrowed by fatty buildup also known as plaque). Resident #1 scored a 5 on the MDS Self-Performance for Oral Hygiene, indicating the resident required set-up or clean up assistance only. Record review of Resident #1's dental record dated 01/28/2025 reflected the resident was seen by the dentist for Step 3 of the denture process (refers to the multi-step phase in the multi-step process of creating custom dentures). The exam reflected the resident was edentulous (missing some or all natural teeth), with gingival inflammation (bleeding gums), and required a new upper partial and full lower denture. The note reflected that the dentist completed a bite registration (procedure to correctly align the new upper flexible partial denture and the new lower full denture). The dentist instructed nursing staff to provide oral hygiene twice daily, removing dentures at night, assist with cleaning, and encourage the resident to wear dentures. Record review of Resident #1' dental record dated 02/20/2025 reflected the resident was seen by the dentist for Step 4 of the denture process. The exam reflected a try-in was performed for the resident's new upper flexible denture and full lower denture. (This step allowed the dentist to verify the fit, comfort, and aesthetics of the dentures before the final versions were made). Record review of Resident #1's dental record dated 03/21/2025 reflected the resident was seen by the dentist for Step 5 of the denture process. The exam reflected the resident was provided with her upper flex partial and full lower dentures. The note reflected the bite, fit, and esthetics were good and the resident was pleased. The note reflected the dentist would return on 03/22/2025 for a follow-up visit and again on 08/20/2025 for her annual exam. Record review of Resident #1's dental record dated 04/04/2025 reflected that the resident was not seen by the dentist as scheduled. The reason why she was not treated stated Patient was Unavailable: hygiene and was signed by the dentist. Record review of Resident #5's Comprehensive Care Plan dated 07/17/2025 revealed there were no goals or interventions related to dental/oral health care needs. During an interview with Resident #1 on 09/23/2025 at 9:15 AM, she reported she was having issues with her dentures. She reported the dentures did not fit and they fell off. She stated the dentures didn't look like real teeth and they felt like plastic. Resident #1 stated she was not offered any adjustments, repairs, or replacements. She said it made it difficult to eat and talk when she had them in. She stated she has not worn them since she got them. She stated she had not seen the dentist since she got them and needed to see the dentist again for another pair. She reported she told the Social Worker about the problem and nothing had been done. She reported she also sent an email to the Social Worker about a month ago and the Social Worker never responded. Resident #1 stated a couple of weeks ago she was eating, and she broke a tooth. She reported the tooth was hurting at first, but it no longer hurt. She stated she told her nurse about the broken tooth and was told by the nurse she would relay that information to the Social Worker. She said her tooth broke because she could not wear her dentures. She reported the broken tooth had made her self-conscious because it had affected the way she talked and chewed. She reported that when she would eat, she had to mostly use her gums and what few teeth she did have. During an interview with LVN A on 09/23/2025 at 10:45 AM, she reported she did not recall any issues regarding Resident #1's dentures or broken tooth. She stated if a resident reported problems with dentures or teeth, she notified the social worker who scheduled dental care either within the facility or with an outside dentist, and she also informed the physician as appropriate. She reported she was unsure why Resident #1 did not wear her dentures and stated that the resident refused to wear them. During an interview with CNA B on 09/23/2025 at 11:00 AM, she reported she was not aware that Resident #1 wore dentures. She reported she had never seen her wearing her dentures. During an interview with the Regional Director of Clinical Services on 09/23/2025 at 2:30 PM, he stated he was unaware that Resident #1's care plan did not address dental needs. He stated it was something that would need to be in her care plan. He stated the risk to the resident was not receiving appropriate interventions. The facility's Care Plan, Comprehensive Person-Centered dated March 2022 reflected the comprehensive, person-centered care Plan includes the measurable objectives and time frame .includes the residents stated goals and desire outcome . the interdisciplinary team reviews and updates the care plan: when there has been significant change in the residents condition, when the desired outcome is not met; when the resident has been readmitted to the facility from a hospital stay; and at least quarterly.

Based on observations, interviews, and record reviews, the facility failed to provide or obtain from an outside source, routine and 24-hour emergency dental services to meet the needs of 1 of 5 residents (Resident #1) reviewed for dental needs. The facility failed to obtain dental services for Resident #1, who had a broken tooth and oversized dentures. This failure could place the residents at risk for not having their dental needs met.Findings included: Record review of Resident #1's annual MDS dated [DATE], reflected the [AGE] year-old female resident was admitted to the facility on [DATE] with a BIMS score of 13, indicating the resident was cognitively intact but at risk for mild memory/recall difficulties. Diagnoses included: recurrent depressive disorder (persistent sadness, loss of interest, and low energy that affects daily life), anxiety disorder (ongoing excessive worry and nervousness that interferes with daily life), diabetes (a condition where the body can't properly use sugar for energy, leading to high blood sugar and possible complications), and heart disease (blood vessels that carry oxygen and nutrients to the heart get clogged or narrowed by fatty buildup also known as plaque). Resident #1 scored a 5 on the MDS Self-Performance for Oral Hygiene, indicating the resident required set-up or clean up assistance only. Record review of Resident #1's dental record dated 01/28/2025 reflected the resident was seen by the dentist for Step 3 of the denture process (refers to the multi-step phase in the multi-step process of creating custom dentures). The exam reflected the resident was edentulous (missing some or all natural teeth), with gingival inflammation (bleeding gums), and required a new upper partial and full lower denture. The note reflected that the dentist completed a bite registration (procedure to correctly align the new upper flexible partial denture and the new lower full denture). The dentist instructed nursing staff to provide oral hygiene twice daily, removing dentures at night, assist with cleaning, and encourage the resident to wear dentures. Record review of Resident #1' dental record dated 02/20/2025 reflected the resident was seen by the dentist for Step 4 of the denture process. The exam reflected a try-in was performed for the resident's new upper flexible denture and full lower denture. (This step allowed the dentist to verify the fit, comfort, and aesthetics of the dentures before the final versions were made). Record review of Resident #1's dental record dated 03/21/2025 reflected the resident was seen by the dentist for Step 5 of the denture process. The exam reflected the resident was provided with her upper flex partial and full lower dentures. The note reflected the bite, fit, and esthetics were good and the resident was pleased. The note reflected the dentist would return on 03/22/2025 for a follow-up visit and again on 08/20/2025 for her annual exam.Record review of Resident #1's dental record dated 04/04/2025 reflected that the resident was not seen by the dentist as scheduled. The reason why she was not treated stated Patient was Unavailable: hygiene and was signed by the dentist. Record review of Resident #1's dental record dated 05/05/2025 reflected that the resident was not seen by the dentist as scheduled. The reason why she was not treated stated Patient was Unavailable and was signed by the dentist. Record review of Resident #1's electronic health record reflected there were no further attempts, appointments scheduled, or treatment completed with the dentist between 03/21/2025 and 09/23/2025. During an interview with Resident #1 on 09/23/2025 at 9:15 AM, she reported she was having issues with her dentures. She reported the dentures did not fit and they fell off. She stated the dentures didn't look like real teeth and they felt like plastic. Resident #1 stated she was not offered any adjustments, repairs, or replacements. She said it made it difficult to eat and talk when she had them in. She stated she had not worn them since she got them. She stated she had not seen the dentist since she got them and needed to see the dentist again for another pair. She reported she told the Social Worker about the problem and nothing had been done. She reported she also sent an email to the Social Worker about a month ago and the Social Worker never responded. Resident #1 stated a couple of weeks ago she was eating, and she broke a tooth. She reported the tooth was hurting at first, but it no longer hurt. She stated she told her nurse about the broken tooth and was told by the nurse she would relay that information to the Social Worker. She said her tooth broke because she could not wear her dentures. She reported the broken tooth had made her self-conscious because it had affected the way she talked and chewed. She reported that when she would eat, she had to mostly use her gums and what few teeth she did have. During an interview with LVN A on 09/23/2025 at 10:45 AM, she reported she did not recall any issues regarding Resident #1's dentures or broken tooth. She stated if a resident reported problems with dentures or teeth, she notified the social worker who scheduled dental care either within the facility or with an outside dentist, and she also informed the physician as appropriate. She reported she was unsure why Resident #1 did not wear her dentures and stated that the resident refused to wear them. During an interview with the Medical Records Custodian on 09/23/2025 at 11:30 AM, she reported she was Resident #1's Angel meaning she would check on the resident every morning to ensure her room was in order and to see if she had any concerns. She stated she would take any concerns reported by the resident and provide them during the morning team meeting where all staff were present. She reported she could not recall the exact day of last week when Resident #1 reported to her that she was eating something and her tooth broke. The Medical Records Custodian stated the Social Worker was in the morning team meeting and was made aware of the concern. She stated the Social Worker reported in the meeting that she would make an appointment for Resident #1 to see the dentist.During an interview with the Social Worker on 09/23/2025 at 12:15 PM, she stated that the resident had expressed a desire to see the dentist after chipping or breaking a tooth and had informed the room Angel of this the prior week. She reported she contacted the dentist the day the resident reported the concern to her angel. She could not recall the exact date to request an appointment. She reported the appointment was anticipated during the first week of October. She was not aware of any issues with the resident's dentures or the reason they were not worn. The Social Worker confirmed the resident was already on the dental list to see the dentist. She explained that the in-house dentist treated a resident unless a resident was absent, ill, or refused. The Social Worker stated if a resident was receiving hygiene or incontinent care, the dentist would come back to them later but on the same day. The Social Worker did not know why Resident #1 was not seen for her denture follow up appointment, her annual cleaning, or the visits she was not seen on 04/04/2025 and 05/05/2025. During a phone interview with the [dental company] representative, on 09/23/2025 at 12:45 PM, she reported Resident #1 had a do not treat on her account since 05/23/2025 due to incomplete paperwork. She further explained that once a year each resident had to have a re-enrollment packet that was completed and submitted by the Social Worker of the facility. She stated if the packet was not received, the Resident could not be seen for services with the facility's contracted dentist through [dental company]. She reported they did receive part of the paperwork but never received the portion the resident's physician signed approving or disapproving of the resident's dental plan. She stated all the forms needed for the re-enrollment packet were sent all at once to the facility Social Worker to complete and send back for the resident to maintain dental coverage. She reported the packet was due at the same time each year. She reported the resident was placed on a list to see the dentist scheduled for 10/06/2025 but she would not be able to be seen until [dental company] received the needed paperwork signed by the physician. She stated the main point of contact they had for the facility was [Social Worker's Name]. During a follow-up interview with the Social Worker on 09/23/2025 at 1:15 PM, she reported she was made aware of the missing paperwork for Resident #1's re-enrollment for dental care today when she called [dental company] to confirm the residents' status of seeing the dentist in October. She reported she was not sure why the physician's form was not sent in. She further stated that the forms are not sent together by the [dental company]. She reported the forms were due at different times during the year so the forms were sent to her as they are due, which could have caused the physician form to not have been sent to her yet. The Social Worker stated she kept track of the forms by completing them as they were sent to her. During an interview with the Regional Director of Clinical Services on 09/23/2025 at 2:30 PM, he stated he was unsure why the resident was not seen per schedule by the dentist. He reported the resident should have been seen or rescheduled. He reported the resident was at risk of the broken tooth and ill-fitting dentures could affect her eating. Record review of the facility policy titled Dental Services, dated December 2013 reflected the following policies regarding dental services for residents: Oral health services are available to meet the resident's needs.Routine and emergency dental services are provided to our residents through:A contract agreement with a local dentist;Referral to the resident's personal dentist;Referral to community dentists; orReferral to other health care organizations that provide Dental Services.Our facility has a contract with a dentist that comes to the facility and provides dental services on a monthly basis.Residents are permitted to select dentists of their choice when dental care or services are needed.Selected dentists must be available to provide follow-up care.Failure of a dentist to provide follow-up services will result in the facility's right to use its Consultant Dentist to provide the resident's dental needs.A complete record of the resident's dental care and services are maintained in accordance with current regulations.Social Services personnel will be responsible for assisting the resident/family in making dental appointments and transportation arrangements as necessary.

Based on observation, interview, and record review, the facility failed to ensure a resident received appropriate treatment and services to prevent urinary tract infections to the extent possible for one (Resident #75) of four residents reviewed for indwelling urinary catheters. The facility failed to provide physician ordered catheter care to Resident #75 and failed to notify Resident #75's NP when she experience pain and discomfort from her urinary catheter. These failures led to Resident # 75 experiencing increased pain and discomfort from her catheter and placed Resident # 75 at risk for urethral tears, dislodging of the catheter, and urinary tract infections. Findings included: Review of Resident #75's quarterly MDS Resident assessment dated [DATE] revealed she was a [AGE] year-old female who admitted to the facility on [DATE]. Her active diagnoses included, coronary artery disease (heart disease), hypertension (high blood pressure), neurogenic bladder(lack of bladder control due to brain, spinal cord, or nerve problems), renal insufficiency(kidneys are functioning poorly and need treatment or further diagnosis), diabetes(condition that affects blood sugar levels), hyperlipidemia (high cholesterol), Non-Alzheimer's Dementia, anxiety disorder, depression, and bladder disorder. The resident had an indwelling catheter . Her BIMS score was 15 which indicated she was cognitively intact. Review of Resident #75's Physician Orders reflected: Oxycodone HCL Capsule 5 mg-give two tablets by mouth every six hours as needed for moderate to severe pain (start date 01/03/25); Oxycodone HCL Capsule 5 mg-give 5 mg by mouth every six hours as needed for pain (start date 01/16/25); Phenazopyridine HCL tablet 200 mg-give one tablet by mouth every 12 hours as needed for prophylaxis (measures used to prevent disease) (11/08/24). Foley catheter 22fr with 30cc bulb (refers to catheter size) every night shift starting on the 15th and ending on the 15th every month (start date 11/15/24); Foley catheter every night shift starting on the 15th and ending on the 15th every month (order date 10/21/24 - start date 11/15/24) (per DON the order referred to catheter change); and Foley catheter every night shift starting on the 1st and ending on the 1st every month (order date 10/21/24 - start date 12/04/24) (per DON the order referred to catheter change). Review of Medication Administration Record dated 01/01/25 - 01/31/25 reflected Resident #75 was sleeping and catheter was not changed on the 1st and 15th of January. There was no documentation noting Resident #75's catheter was changed on 01/09/25 . Resident #75 was administered the following medications: Phenazopyridine HCL tablet 200 mg (give 1 tablet by mouth every 12 hours as needed for prophylaxis) on 01/15/25 at 10:20 am; Oxycodone HCL capsule 5 mg (give 2 tablets by mouth every 6 hours as needed for moderate to severe pain) on 01/15/25 at 9:47 pm; Oxycodone HCL capsule 5 mg (give 2 tablets by mouth every 6 hours as needed for moderate to severe pain) on 01/16/25 at 11:45 am; Oxycodone HCL capsule 5 mg (give 2 tablets by mouth every 6 hours as needed for moderate to severe pain) on 01/16/25 at 9:47 pm; and Phenazopyridine HCL tablet 200 mg (give 1 tablet by mouth every 12 hours as needed for prophylaxis (measures used to prevent disease) ) on 01/16/25 at 9:47 pm. Review of Resident #75's progress note dated 01/09/25 reflected her catheter was changed. Review of Resident #75's Comprehensive Care Plan, undated, reflected she had an indwelling catheter. Her goal was to remain free from catheter-related trauma. Her interventions were to position catheter bag and tubing below the level of the bladder and away from entrance room door, check tubing for kinks with each interaction every shift, maintain enhanced barrier precautions, monitor/document for pain/discomfort due to catheter, and monitor/record/report to MD for signs and symptoms of UTI (pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temperature, urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, and change in eating patterns). An observation and interview with Resident #75 on 01/14/25 at 1:00 PM revealed she had an indwelling catheter. Resident # 75's catheter bag was clipped to her bed. Her catheter tubing appeared to have sediment and her urine appeared to be yellow and cloudy in color. Her catheter bag was dated 01/09/25. She stated staff were providing catheter care. She stated her catheter was previously changed. She stated her catheter was changed around the first week of January 2025. She stated her catheter tube frequently clogs due to sediment buildup. She stated she was diagnosed with a UTI in 12/2024 and received intravenous antibiotics. She stated she experienced pain when she previously had a UTI. She stated she was not currently experiencing pain . An observation and interview with Resident #75 on 01/16/25 at 2:15 PM revealed there was sediment in her catheter tubing and her urine was orange. She stated she was experiencing pain and discomfort from her catheter. Resident #75 stated her nurse (LVN C) was aware of her catheter pain and change in urine color. She stated she had been experiencing catheter pain and discomfort for two days. She stated her pain level was a 5. She stated LVN C gave her pain medication . An interview with LVN C on 01/16/25 at 3:12 PM revealed Resident #75 had a foley catheter. She stated all catheters in the building were to be changed monthly. She stated Resident #75's catheter was changed more frequently due to leaks and sediments. She stated the resident had a UTI in the past. She stated pain, fever, and cloudiness of urine were signs of a UTI. She stated Resident #75's urine appeared to be a little cloudy on 01/14/25 and the NP was notified. She stated the NP requested Resident #75 be monitored for a change in condition. She stated Resident #75 complained of catheter pain on 01/15/25 and 01/16/25. She stated Resident #75s catheter was changed on 01/15/25. She stated she did not document Resident #75's catheter change because she did not know how to navigate the new EMR system. She stated she should have documented Resident #75's catheter change. She stated Resident #75 was administrated oxycodone and phenazopyridine on 01/15/25 and 01/16/25. She stated Resident #75 experienced a change in condition and the NP was not notified until 01/16/25. LVN C stated she did not notify the NP until 01/16/25 because Resident #75 refused to move due to pain from the catheter. She stated she should have notified the NP on 01/15/25 due to a change in the resident's condition. She stated Resident #75 was at risk of an infection and retention . An interview with the DON on 01/16/25 at 4:56 PM revealed Resident #75 had a foley catheter. She stated Resident #75 had monthly and PRN orders for catheter changes. She stated LVN C informed her that Resident #75 received a catheter change on 01/13/25 . She stated the nurses check catheters during daily rounds. She stated she did not have any issues with nurses regarding catheter care. She stated Resident #75 had a history of UTIs, sediment back up, and was being seen by a urologist. She stated Resident #75 had a UTI within the last thirty days and received intravenous antibiotics. She stated cloudiness in urine was normal after being changed. She stated LVN C not notifying the NP until the second day of Resident #75's catheter pain was appropriate. The DON stated the nurses knew catheter discomfort was expected due to Resident #75's diagnoses. She stated there was no risk to Resident #75 because the catheter was changed on 01/13/25. She stated LVN C did not document the catheter change in Resident #75's EMR. An interview with the NP on 01/16/25 at 5:53 PM revealed Resident #75 had a catheter and frequently requested catheter changes. She stated Resident #75 had chronic UTIs and frequently experienced discomfort. She stated LVN C notified her on 01/16/2025 regarding Resident #75's sediment. She stated she visited Resident #75 the week of 01/06/25. She stated her expectation was for LVN C to notify her on 01/15/25 regarding Resident #75's pain. She stated the facility was good at notifying her regarding change of condition but did not know why she was not contacted about Resident #75's change . An interview with Infection NP on 01/16/25 at 6:23 PM revealed she was notified on 01/16/25 regarding Resident #75 needing a catheter change due to sediment. She stated she was notified Resident #75 was experiencing pain but was given medication to resolve problem. She stated Resident #75 had chronic dysuria (pain, discomfort, or burning during urination). She stated her expectation was for the facility not to notify her if Resident #75's pain was resolved. She stated the facility was supposed to notify her if Resident #75's pain persisted after phenazopyridine or fever. She stated Resident #75's sediment in catheter tubing was not new. She stated she was unaware Resident #75's was experiencing pain, cloudy urine, and sediment for the past two days. She stated she was concerned and would contact the facility to order labs (CBC and UA) immediately. Review of the facility policy titled, Catheter Care, updated March 2019, revealed Purpose: To prevent infection and to reduce irritation. Documentation: date, time, procedure, condition of the perineum and catheter insertion site; how well patient tolerated procedure; color, amount, consistency, and odor of urine; notification of the physician of any condition change; signature and title.

Based on observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchens reviewed for kitchen sanitation. The facility failed to ensure food was properly stored in the facility's kitchen. These failures could place residents at risk for food-borne illness. Findings Included: Observation of the facility's refrigerator on 01/14/25 beginning at 9:07 AM revealed: - 1 open bin of raw chicken open and exposed to air; and - 1 open bag of ham. Observation of a prep table located in the open area of the facility's kitchen on 01/14/25 beginning at 9:18 AM revealed: -1 box of bananas dated 01/06/25 with black spots and a bug; and - 1 box of bananas dated 01/08/25 with fuzzy white spots. An interview with the Dietary Supervisor on 01/16/25 at 4:47 PM revealed she completed walk throughs of the kitchen daily and before she left. She stated she checked produce in between food truck delivery days (Tuesdays and Thursdays). She stated she was responsible for ensuring dietary staff were storing food properly. She stated the chicken and ham were supposed to be sealed. She stated the bananas were supposed to be discarded. She stated improper food storage could cause harm to residents such as food borne illnesses . Record review of the facility policy titled Food Storage, undated, revealed Sufficient storage facilities are provided to keep foods safe, wholesome, and appetizing. Food is stored, prepared, and transported at an appropriate temperature and by methods designed to prevent contamination. Review of the Food and Drug Administration Food Code, dated 2017, reflected, .3-305.11 Food Storage. (A) .food shall be protected from contamination by storing the food: (1) In a clean, dry location; (2) Where it is not exposed to splash, dust, or other contamination .

Based on interviews and record review the facility failed to ensure all Pre-Admission Screening and Resident Review (PASRR) level 1 residents with mental illness were provided with a PASRR level 2 evaluation for 1 of 4 residents (Resident #91), reviewed for resident assessment. Resident #91's PASRR level 1 screening form did not reflect mental illness and the resident did not have a PASRR level II evaluation when Resident #91 had a diagnosis of schizophrenia. This could place residents at risk of not receiving necessary specialized services to meet their individual needs. Findings included: Record review of Resident #91's Quarterly MDS dated [DATE] revealed she was a [AGE] year-old female who was admitted on [DATE]. Her diagnoses included unspecified schizophrenia (a condition where a patient's symptoms do not meet the full diagnostic criteria for schizophrenia or another more specific psychotic disorder), major depressive disorder (a mental health condition that involves persistent feelings of sadness, hopelessness, and a loss of interest in activities), psychotic disturbance (a mental state where a person experiences a significant disruption in their perception of reality, often characterized by hallucinations [seeing or hearing things that aren't there] and delusions [strongly held false beliefs], leading to difficulty functioning in daily life), mood disturbance (a mental health condition that involves persistent feelings of sadness, irritability, or extreme highs and lows that are out of sync with a person's actual circumstances), and anxiety (a common mental health condition characterized by feelings of unease, worry, fear, and apprehension). Resident #91 MDS revealed a BIMS score of 4, indicating she had severe cognitive impairment. Record review of Rresident #91''s Care Plan, dated 1/15/2025 indicated Resident #91 was taking psychotropic medication(s) as evidenced by: Depression, schizoaffective disorder, anxiety, paranoia, aggression, cognitive impairment. Resident #91 was prescribed Haldol and Prozac. Record review of Resident #91's PASRR level 1 screening, dated 08/26/2024, reflected the resident did not have a serious mental illness and serious mental illness was checked as no. Record review of Resident #91'''s Electronic Health Record revealed no PASRR level 2 evaluation was completed. Record review of Resident #91's Electronic Clinical Notes revealed Resident #91 was admitted to the facility on [DATE] with diagnosis of cognitive deficit, dementia, and schizophrenia. An interview on 1/16/25 with the Administrator revealed she did not know why Resident #91 had a negative PASRR Level 1 screening. She said the MDS staff were responsible for checking for accuracy and the resident was at risk of not receiving services she could qualify for. An interview on 1/16/2025 with the MDS nurse revealed Resident #91 was negative for PASSR II. MDS nurse reported the original PASSR level I was completed June 10, 2022, when resident #91 first came to the facility. MDS nurse stated when the information was entered, Resident #91 did not have any mental or intellectual disability. MDS nurse stated with a diagnosis of dementia, she will not be eligible for PASRR Level II. MDS nurse stated the system was showing schizophrenia as her primary diagnosis, but she will change it to dementia in their system . MDS nurse reported she did not have a copy of Resident #91's PASSR level I completed 08/26/24. Surveyor explained it was obtained by surveyor in Resident's electronic health record. Review of the facility policy, CANTEX CONTINUING CARE NETWORK PATIENT CARE MANAGEMENT SYSTEM 12 Assessments dated November 2017 state: Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASRR recommendations. If a facility disagrees with the findings of the PASRR, it must indicate its rationale in the Patient's/Resident's medical record. In addition, the facility must provide or obtain the required services from an outside resource from a Medicare and/or Medicaid provider to provide any rehabilitative services such as physical therapy, speech-language pathology, occupational therapy, and rehabilitative services for mental disorders and intellectual disability, required in the Patient's comprehensive plan of care.

Based on interview and record review, the facility failed to develop and implement a baseline care plan for each resident that included instructions needed to provide effective and person-centered care for the resident that met professional standards of care within 48 hours of the resident's admission for two (Resident #118 and Resident #141) of 7 residents reviewed for baseline care plans. The facility failed to complete baseline care plans for Resident #118 and Resident #141 within 48 hours of their admission. This failure could place newly admitted residents at risk of not receiving effective and person-centered care and services. Findings included: Review of Resident #118's Face Sheet, dated 01/16/25, reflected she was a [AGE] year-old female who was originally admitted to the facility on [DATE] and readmitted to the facility on [DATE], with diagnoses including displaced trimalleolar fracture of the right lower leg (a break in the lower leg sections that form the ankle joint and help one move their foot and ankle). Review of Resident #118's Progress Notes, dated 12/05/24, reflected Resident #118 was admitted to the hospital for surgery following a visit with an orthopedic physician. Review of Resident #118's Progress Notes, dated 12/14/24, reflected Resident #118 was readmitted to the facility following her hospitalization . Review of Resident #118's the electronic medical record on 01/16/25 revealed her baseline care plan had been completed on 12/16/24, following her re-admission to the facility. A baseline care plan had not been completed prior to this time, following her initial admission to the facility on [DATE]. Review of Resident #141's Face Sheet, dated 01/16/25, reflected she was a [AGE] year-old female who was admitted to the facility on [DATE], with diagnoses including displaced fracture of greater trochanter of right femur (a break in the upper part of the thigh bone) and chronic obstructive pulmonary disease (a group of lung diseases that cause ongoing inflammation and damage to the airways, leading to difficulty breathing). Review of Resident #141's electronic medical record on 01/16/25 revealed her baseline care plan had been completed on 12/31/24. During an interview with RN B on 01/16/25 at 11:06AM, he stated he was responsible for monitoring the completion of Baseline Care Plans. He stated he was not sure of the timeframe in which Baseline Care Plans had to be completed. He said the facility utilized an electronic medical charting system, which provided staff with notifications when various assessments (including Baseline Care Plans) were due. RN B stated there was no risk posed when Baseline Care Plans were not completed in the required timeframe, as staff communicated amongst themselves to ensure residents still received proper care. During an interview with the Director of Nursing on 01/16/25 at 11:19AM, she stated Baseline Care Plans needed to be completed within 48 hours of a resident's admission to the facility. She said the facility utilized an electronic medical charting system, which provided staff with notifications when various assessments (including Baseline Care Plans) were due. She stated there may have been an error within the system, which caused staff not to receive a notification when Resident #118 and Resident #141's Baseline Care Plans were due. The Director of Nursing stated there was no risk posed when Baseline Care Plans were not completed in the required timeframe, as staff were still able to ensure residents received proper care. Review of the facility's Patient Care Management System 12 Policy and Procedure, dated 11/2017, reflected, .A Baseline, Person-centered Plan of Care for each patient that includes the instructions needed to provide effective and person-centered care of the patient that meet professional standards of quality care. The baseline care plan must be initiated within 48 hours of admission (including readmission) .

Based on observation, interview and record review, the facility failed to ensure that a resident fed by enteral means received the appropriate treatment and services to prevent complications of enteral feedings, for 1 (Resident #120) of 2 residents that were reviewed for feeding tubes. The facility failed to ensure LNV A verified G-tube (Gastrostomy tube a surgically placed tube directly into the stomach to deliver food and medicine) placement. LVN A failed to aspirate (the act of withdrawing fluid from the stomach to check G-tube placement and measure stomach content) prior to administering water flushes and medications. LVN A failed to administer G-tube water flushes by gravity (the use of gravity to move the water flushes and medications through the G-tube into the resident). This failure could place residents at risk for adverse reactions, inadequate therapy, and a decreased quality of care. Findings included: Record review of Resident #120's face sheet dated 01/16/25 reflected she was a [AGE] year-old female admitted to the facility on [DATE]. Resident #120 had diagnoses which included: type 2 diabetes, hypertension, disease of stomach and duodenum, obstructive and reflux uropathy . Record review of Resident #120's quarterly MDS assessment dated [DATE] revealed her BIMS score was 0 indicating severe cognitive impairment. The MDS revealed Resident #120's used a feeding tube and received total calories through the feeding tube. Record review of Resident #120's care plan last review dated 11/18/24 revealed: Focus, [Resident #120] requires G-tube feeding r/t Dysphagia . Goal, Will remain free of side effects. or complications related to tube feeding through review date. Intervention, Check for tube placement and gastric contents/residual volume per facility protocol and record. Is dependent with tube feeding and water flushes. See MD orders for current feeding orders. Record review of Resident #120's Physician Order Summary dated 10/24/24 revealed enteral - check tube placement every shift check tube for proper placement by auscultation of injected air or visual inspection of aspirated stomach contents prior to instilling medication, and/or initiating a feeding. During an observation on 01/16/24 at 12:47 PM of medication administration for Resident #120, LVN A checked the resident's vital signs. LVN A washed her hands. Then LVN A crushed Resident #120's Labetalol 200 mg 1 tablet and ISOSORB DIN 20 mg 1 tablet (both blood pressure medications). LVN A added 5 ml water to the medication cups. LVN A measured medication cups with 30 ml water to flush the G-tube before medication administration. Resident #120 was non-verbal. LVN A withdrew the 30ml of water with the syringe and slowly pushed the water using the syringe plunger into the G-tube. LVN A then administered the medications via gravity flushing in between with 10cc of water. In an interview on 01/16/24 at 01:30 PM, with LVN A she stated she checked the residual in the morning during medication administration. LVN A stated she was supposed to check for residual before medication administration, but she forgot. LVN A stated she was supposed to check for residual to make sure the resident did not have a lot in the stomach which could have led to aspiration. LVN A stated per the orders she was supposed to check for stomach content to confirm placement before medication administration . In an interview on 01/16/25 at 04:09 PM with DON she stated during medication administration if the nurse stopped the feeding to administer medication, then she did not need to check for residual. The DON stated she did not remember what the policy said regarding g-tube medication administration. After the DON reviewed the policy on G-tube medication administration, she stated the staff was to follow the facility policy on g-tube medication administration . She did not indicate on negative effects for not checking the g-tube residual. Review of the facility updated March 2019, titled Medication Administration through the Feeding Tube reflected, . disconnect the feeding from the set or open the Y port on the feeding tube. Check feeding tube for placement (refer to procedure for confirming placement). Check gastric content for residual feeding. Flushing feeding tube with at least 30 cc of water.

Based on interviews and record review, the facility failed to maintain clinical records that were complete and/or accurate for one (Residents #91) of four residents reviewed for clinical records. --Resident #91 received psychotropic medications without documented diagnoses for which the medication was prescribed. These failures placed residents at risk of not having accurate clinical records completed to indicate if a medication or treatment was administered, resulting in potential medical errors and a decline in health. Findings include: Resident #91 Record review of Resident #91's Quarterly MDS dated [DATE] revealed she was a [AGE] year-old female who was admitted on [DATE]. Her diagnoses included unspecified schizophrenia (a condition where a patient's symptoms do not meet the full diagnostic criteria for schizophrenia or another more specific psychotic disorder), major depressive disorder (a mental health condition that involves persistent feelings of sadness, hopelessness, and a loss of interest in activities), psychotic disturbance (a mental state where a person experiences a significant disruption in their perception of reality, often characterized by hallucinations [seeing or hearing things that aren't there] and delusions [strongly held false beliefs], leading to difficulty functioning in daily life), mood disturbance (a mental health condition that involves persistent feelings of sadness, irritability, or extreme highs and lows that are out of sync with a person's actual circumstances), and anxiety (a common mental health condition characterized by feelings of unease, worry, fear, and apprehension). Resident #91 MDS revealed a BIMS score of 4, indicating she had severe cognitive impairment. Record review of Resident #91's physician's active orders revealed she was prescribed Fluoxetine 40mg for Antidepressant, Gabapentin 100mg for Neuralgia, Haloperidol tab 2mg for Agitation, Haloperidol Decanoate Solution 100mg for Agitation, Memantine Tab HCL 10mg for Dementia, Rivastigmine Cap 3mg for Alzheimer's disease, HumaLog Injection Solution for Diabetes, Metformin for Diabetes. Record review of Resident #91's Clinical Treatment Plan Review completed 10/29/2024 indicates resident's psychotropic medications were monitored by clinical assessment, staff observations and feedback, and Patient's Self-Report. The report indicates GDR failed for resident. Record review of resident #91's Care Plan indicated Resident was taking psychotropic medication(s) as evidenced by: Depression, schizoaffective disorder, anxiety, paranoia, aggression, cognitive impairment. Resident took: Haldol and Prozac. During an nterview with the DON on 01/16/2025 at 4:11 p.m. the DON reported that Resident #91 needs both prescriptions of Haldol. DON stated that with her diagnosis and behaviors, if not given the injection of Haldol, Reisdent #91's behaviors will escalate. The DON reported gradual dose reductions (GDR) had been attempted and failed. The DON reported Resident #91 would become very hostile. The DON reported Resident #91 was stable with where she was with her medications. She does not recommend her medications to reduced or increased. Surveyor notified the DON that resident's diagnosis for the Haldol is listed as agitation. The DON stated that agitation was not the correct diagnosis. During an observation and interview of Resident #91 on 1/16/2025 at 12:03 p.m. Resident #91 stated she did not want to speak to surveyor and then said she would. She denied having any mental health diagnoses. Resident #91 stated she did therapy for walking. She denied participating in talking therapy. Resident stated she was done talking and ended the interview.

Based on observation, interview, and record review, the facility failed to maintain an Infection Prevention and Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 10 residents (Resident #75) observed for infection control. The facility failed to ensure LVN C used PPE while assessing the foley catheter on Resident #75 who was on enhanced barrier precautions. This failure could place residents at risk for cross contamination and risk of further infection. Findings included: Record review of Resident #75's Admission MDS assessment dated [DATE] reflected a [AGE] year-old female admitted to the facility on [DATE] and readmitted [DATE]. Resident#75 had a BIMS score of 15 which indicated she was cognitively intact. Diagnoses included encounter for surgical aftercare following surgery on the genitourinary system, calculus of kidney, urinary tract infection, site not specified, bladder disorder, unspecified, neuromuscular dysfunction of bladder, unspecified, type 2 diabetes mellitus, unspecified kidney failure . Record Review of Resident #75's physician orders dated 12/09/24 indicated the resident required enhanced barrier precautions. In an observation on 01/16/25 at 1:23pm, observed LVN C assess foley catheter drainage on Resident #75. LVN C entered room and did not don PPE. An Enhanced Barrier Precaution sign was posted outside of Resident # 75's door and a kit of gloves and gowns were outside the room. LVN C washed her hands put on gloves, assessed for placement of foley catheter and assessed sedimentation by touching the foley catheter tubing with gloves. LVN C then repositioned the catheter bag and hooked the foley catheter bag to a non-moveable part of the resident's bed. In an interview on 01/16/25 at 1:30 pm with LVN C revealed that she was aware the resident was on enhanced barrier precaution. LVN C verbalized that she had been in-serviced on enhanced barrier precaution and stated that she should have donned full PPE. LVN C stated that she was required to maintain enhanced barrier precautions to prevent the spread of infection. An interview on 01/16/25 at 4:27 pm with the DON revealed that all staff had been in-serviced on the use of enhanced barrier precautions and they were expected to use PPE on residents who were on enhanced barrier precautions. The DON stated that the risk of not using PPE on residents who were on enhanced barrier precautions would predispose residents to infections . Record review of enhanced barrier policy, reflected, Residents Requiring EBP .Indwelling Medical Devices (regardless of MDRO) central lines, urinary catheters, feeding tubes, tracheostomies .Duration .discontinuation of indwelling devices .Required PPE (gown/gloves) during High-Contact Resident care .Dressing, Bathing/showering, Transferring, Providing Hygiene, Changing linens, Toileting/Changing Brief, Device Care/Use, Wounds/Skin care & treatment .Implementation .Staff awareness .Update Care profile .Update POC .EBP Signage .PPE set up-Gloves, Gown, Hand Sanitizer . 42283

Based on interview, and record review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for one (Resident #3) of five residents reviewed for resident rights. The facility failed to ensure Resident #3 provided proper consent to a facility affiliated insurance company. This failure could place residents at risk for decreased dignity. Findings included: Review of Resident #3's Admission MDS assessment dated [DATE] revealed she was an [AGE] year-old female who was admitted to the facility 12/01/23. Her diagnosis included: hypertension, gastroesophageal reflux disease, urinary tract infection, non-Alzheimer's Dementia, and depression. Her BIMs score of 6 indicating she was severely cognitively impaired. She understood others and was understood by others. Review of Resident #3's Patient Choice Form dated 12/05/23 revealed the facility was affiliated with an insurance company, home health agency, and hospice agency. The form revealed she gave LBSW verbal consent to receive information from the affiliated companies as part of her plan of care. Review of Resident #3's face sheet dated 07/31/24 revealed her responsible party was her family member A. In an interview with Resident #3 on 07/31/24 at 4:18 PM revealed she did not respond to the surveyor when asked about providing verbal consent to receive information from the affiliated companies as part of her plan of care. Resident #3 appeared to be confused. Interview with Resident #3's family member B on 08/01/24 at 10:28 am revealed he and family member A were her responsible parties. He stated Resident #3 did not have mental capacity to consent to receiving information from the insurance company. He stated he was contacted by the insurance company regarding their benefits. He stated based off the information provided by the insurance company; he switched Resident #3's insurance plan. He stated after investigating the insurance company, services promised were not rendered. He stated Resident #3 was exploited by the facility because he, family member A, and resident did not consent to receiving information from the facility affiliated insurance company. He stated Resident #3's information should never have been released by the facility. Interview with the Administrator on 07/31/23 at 1:59 pm revealed he was the interim Administrator for the building and had worked at the facility for about a week. He stated he was unfamiliar with the facility affiliated insurance company, home health agency, and hospice agency. He stated facility affiliated companies cannot have access to residents' information without consent. He stated every resident should have a completed patient choice form in their admission packet. Interview with LBSW on 07/31/24 at 2:35 pm revealed she was unaware the patient choice form allowed a facility affiliated insurance company, home health agency, and hospice agency to contact the resident with information and to have access to their personal information. She stated she never read the form. She stated she also never read the forms to any resident. She stated she signed the forms herself and selected verbal consent. She stated Resident #3 was cognitively impaired and could not provide consent. LBSW stated she falsely documented residents' verbal consents on patient choice forms because she felt pressured from the previous administrator and corporate. She stated the administrator and corporate did not tell her to falsify the forms. She stated the previous administrator and corporate pressured her to complete a certain number of patient choice forms in hopes of increasing referrals to the facility affiliated companies. LBSW stated the residents rights were being violated and they were being exploited because she falsified the patient choice forms. Interview with the Chief Population Health Officer on 07/31/24 at 3:04 pm revealed he was a part of the corporate managing group for the facility. He stated the insurance company was one of six programs associated with the facility that he oversaw. He stated the patient choice form allowed the insurance company to have access the resident's information. He stated the insurance company would never contact the resident or responsible party without consent. Interview with the Administrator on 07/31/24 at 6:00 pm revealed he was unaware a staff member was falsifying patient choice forms. He stated he needed to know which employees were falsifying information because their employment needed to be terminated. He stated he needed to protect the residents at the facility. Review of facility policy, Resident Rights, dated February 2021, reflected, Employees shall treat all residents with kindness, respect, and dignity. Federal and state laws guarantee certain basic to all residents of this facility. These rights include the resident's right to: .be informed of, and participate in, his or her care planning and treatment .The unauthorized release, access, or disclosure of resident information is prohibited. Inquiries concerning residents' rights should be referred to the social services director.

Based on observations, interviews, and record reviews the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public for 2 (Resident #1 and Resident #2) of 8 residents reviewed for environment. The facility failed to ensure the wheelchairs used by Resident #1 and Resident #2 were clean and sanitary. This failure could place residents at risk for diminished quality of life due to the lack of a well-kept environment. Findings included: 1. An observation on 7/30/24 at 10:25 AM revealed Resident #1 was sitting in a wheelchair in the doorway to her room located on the 700 Hall. Both back wheels on her wheelchair had a thick buildup of dust and debris on all of the spoke surfaces. The metal frame of her chair along the sides and beneath her seat and surface of her brake lever were covered with a thick layer of dirt and debris. The areas surrounding the hardware on her seat were filled with a dried, thick, white substance. Resident #1 was unable to say how long her chair had looked or when it was last cleaned for her other than to say, it's been a while. She was unable to answer other general questions about her care. An observation and interview on 7/30/24 at 4:50 PM, the DON was shown Resident #1's wheelchair and asked about cleaning procedures. The DON stated the chairs were cleaned regularly. She stated Resident #1 had a habit of carrying food between her room and the dining room and was sometimes resistant to leaving her chair. She stated she would get it cleaned as soon as possible. An interview with the DON on 7/31/24 at 8:00 AM, she stated the nursing staff were responsible for monitoring the wheelchairs and could wipe them down. She stated the facility driver took the chairs outside and power washed them when needed for heavy cleaning. The DON stated there was no set schedule made for the cleaning as some were more heavily used than others, but a request could be made to herself or any unit manager for a deep cleaning. She stated everyone was responsible for ensuring the chairs were cleaned and she felt the facility maintained good communication. She stated she did not feel there was any risk to the residents as they still had a means of locomotion, and it did not interfere with the use of the wheelchairs. 2. An observation on 7/31/24 at 9:06 AM, Resident #2 was observed in her room on the 700 Hall, sitting in her wheelchair sipping water. Her wheelchair had a dried, thick, beige substance along her lower right side and streaks of what appeared to be the same substance spattered on her wheel. During an interview on 7/31/24 at 9:15 AM, RN A stated it was everyone's responsibility to monitor the wheelchairs for cleanliness. She stated, when the wheelchairs were dirty, they could wipe them down or ask housekeeping or maintenance staff to power wash them. She stated she could make an entry into the maintenance log kept at the nurses' station or just tell them. RN A stated Resident #1 had a habit of going and grabbing food and putting it in her chair. She stated they kept telling her to let them help but even when we clean her wheelchair, it became dirty quickly. RN A stated she could not explain the buildup of dust and debris on the wheels. During an interview on 7/31/24 at 9:36 AM, LVN B stated resident's wheelchairs should be checked daily and cleaned as needed. She stated if the chairs were heavily soiled, they could borrow a replacement chair from the therapy department and request a power wash. She stated the facility kept a maintenance log at the nurses' station for any requests or they reported it to management staff. In an interview on 7/31/24 at 9:45 AM, MA C stated anyone could request a wheelchair cleaning. She stated they could make a request to management, and someone would come, and power wash the wheelchairs. During an interview on 7/31/24 at 12:36 PM, the Maintenance Director stated they assisted with the maintenance and function of the wheelchairs and would sometimes take them out and power wash them when asked. He stated the staff utilized the maintenance logbooks or contacted management when needed. During an interview on 7/31/24 at 1:09 PM, CNA D stated everyone should monitor the wheelchairs to make sure they were clean. She stated they could let maintenance know by using the logbook or let a manager know if cleaning was needed. CNA D stated they had struggles with Resident #1 at times because she wanted food with her. She stated the resident did not want her chair taken from her room. She was unable to say when the chair was last reported as needing to be cleaned. When shown Resident #2's chair, CNA D stated she was surprised because the chair had just been cleaned the week before. She stated it looked like a milkshake may have been spilled and they would get it cleaned. Record review of the Maintenance Repair Log entries dated from 6/10/24 through 7/31/24 located at the nurse's station for Halls 500, 600, 700, 800, and 900 revealed there was only one entry requesting a wheelchair clean. The entry was dated 6/10/24 and was not related to Resident #1 or Resident #2. Record review of the facility's policy titled, Cleaning and Disinfection of Resident-Care Items and Equipment dated Revised July 2014, reflected, Resident-care equipment, including reusable items and durable medical equipment will be cleaned and disinfected according to current CDC recommendations for disinfection and OSHA Bloodborne Pathogens Standard .

Based on, observation, interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 (Resident #1) of 8 residents reviewed for pharmacy services. 1. The facility failed to administer evening medications to Resident #1 when she asked to take them at a later time. 2. The facility staff failed to document the missed medication doses or notify the physician when Resident #1's medications were not administered. These failures placed residents at risk of not receiving the therapeutic benefits of their prescribed medications. Findings included: Record review of Resident #1's Face Sheet dated 1/30/24 revealed she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including anemia [low blood count] in chronic kidney disease, atherosclerotic heart disease, Type 2 diabetes, chronic kidney disease stage 3, hyperlipidemia [high cholesterol], primary insomnia [trouble sleeping], vitamin D deficiency, anxiety disorder, cough, and acute serous otitis media left ear [ear infection]. Record review of Resident #1's Annual MDS assessment dated [DATE] revealed she had a BIMS score of 15 indicating she was cognitively intact. Record review of Resident #1's Patient Medication Profile [orders] dated 1/30/24 reflected the following entries: Clonazepam 0.5 mg 1 tablet oral two times daily starting 2/21/22 Atorvastatin 10 mg 1 tablet oral one time daily starting 6/29/22 Calcium 600 + D(3) 600 mg-10 mcg (400 unit) 1 tablet oral two times daily starting 8/8/22 Trazodone 50 mg tablet (1/2 tab=25 mg) oral hour of sleep starting 9/27/22 Oxybutynin chloride 5 mg 1 tablet oral every 12 hours starting 1/16/23 Gabapentin 300 mg 1 capsule oral hour of sleep starting 7/5/23. Iron (ferrous sulfate) 325 mg (65 mg iron) 1 tablet oral two times daily starting 7/27/23 Methenamine Hippurate 1 gram 1 tablet oral two times daily for three hundred sixty five days starting 10/18/23. Record review of Resident #1's MAR dated January 2024 revealed the following entries: Clonazepam 0.5 mg 1 tablet two times daily starting 2/21/22 [diagnosis code] Anxiety Disorder. Schedule: 9:00 [9 AM] starting 10/10/23. 20:00 [8 PM] starting 10/10/23. The 8:00 PM entry for 1/14/24 reflected =. The MAR Legend reflected = meant Previously Scheduled. There was no indication on the MAR to indicate which staff member entered the symbol/code. Atorvastatin 10 mg 1 tab one time daily starting 6/29/22. [diagnosis code] hyperlipidemia. Schedule: 20:00 [8 PM] The 8:00 PM entry for 1/14/24 reflected =. The MAR Legend reflected = meant Previously Scheduled. There was no indication on the MAR to indicate which staff member entered the symbol/code. Calcium 600 + D(3) 600 mg-10 mcg (400 unit) 1 tablet two times daily starting 8/8/22. Schedule: 9:00 [9 AM] starting 10/10/23. 20:00 [8 PM] starting 10/10/23. The 8:00 PM entry for 1/14/24 reflected =. The MAR Legend reflected = meant Previously Scheduled. There was no indication on the MAR to indicate which staff member entered the symbol/code. Trazodone 50 mg tablet (1/2 tab=25 mg) hour of sleep starting 9/27/22. [diagnosis code] insomnia. Schedule: 20:00 [8 PM]. The 8:00 PM entry for 1/14/24 reflected =. The MAR Legend reflected = meant Previously Scheduled. There was no indication on the MAR to indicate which staff member entered the symbol/code. Oxybutynin chloride 5 mg 1 tablet every 12 hours starting 1/16/23. [diagnosis code] other muscle spasm. Schedule: 9:00 [9 AM] starting 10/10/23. 20:00 [8 PM] starting 10/10/23. The 8:00 PM entry for 1/14/24 reflected =. The MAR Legend reflected = meant Previously Scheduled. There was no indication on the MAR to indicate which staff member entered the symbol/code. Gabapentin 300 mg 1 capsule hour of sleep starting 7/5/23. [diagnosis code] pain Schedule: 20:00 [8 PM] The 8:00 PM entry for 1/14/24 reflected =. The MAR Legend reflected = meant Previously Scheduled. There was no indication on the MAR to indicate which staff member entered the symbol/code. Iron (ferrous sulfate) 325 mg (65 mg iron) 1 tablet two times daily starting 7/27/23. [diagnosis code] anemia in chronic kidney disease. Schedule: 9:00 [9 AM] starting 10/10/23. 20:00 [8 PM] starting 10/10/23. The 8:00 PM entry for 1/14/24 reflected =. The MAR Legend reflected = meant Previously Scheduled. There was no indication on the MAR to indicate which staff member entered the symbol/code. Methenamine Hippurate 1 gram 1 tablet two times daily for three hundred sixty five days starting 10/18/23. [diagnosis code] urinary tract infection. Schedule: 8:00 [8 AM] and 20:00 [8 PM]. The 8:00 PM entry for 1/14/24 reflected =. The MAR Legend reflected = meant Previously Scheduled. There was no indication on the MAR to indicate which staff member entered the symbol/code. Record review of Resident #1's progress notes dated 1/1/24 through 1/30/24 revealed there was no nursing entry made on 1/14/24 and no entry indicating the medications were refused or the physician was notified. An entry dated 1/17/24 at 10:39 PM by LVN H reflected: Resident stated she did not get her medication on Sunday night [1/14/24]. Resident agitated and wanting to take her night medication at [8:30 PM] every day. This nurse inform medication aide to give her medications at [8:30 PM] as requested. During an interview on 1/30/24 at 11:01 AM, MA B stated if a resident did not wish to take their medications at the time they were offered, she would circle back and try again. If they still did not wish to take them, she would attempt to find out the reason and then go and report it to the charge nurse. She stated the charge nurse handled the situation from that point on and it was the charge nurse's responsibility to document the missed doses. MA B stated she had the issue come up a couple of times on her hall but did not recall ever having an issue with Resident #1. She stated Resident #1 had taken her medications that morning and was participating in activities at the time of the interview. During an interview on 1/30/24 at 11:22 AM, LVN C stated if a resident did not want their medications and preferred them at a given time, the MA or nurse should go back and attempt to give them at that time. She stated if the time requested was outside the dose range, the nurse should call the physician and obtain guidance. She stated some medications may conflict with others due at a later time so it was up to the physician to determine whether it was okay to administer them. LVN C stated any changes or medication refusals should be documented in the MAR and progress notes and it was the nurse's responsibility to ensure the documentation was completed. She stated the risk for missing medications depended on the medication as they were prescribed for a reason. She stated, if a resident missed a blood pressure medication, it could cause an increase in their blood pressure and that was why they needed to let the physician know. LVN C stated she cared for Resident #1 and, from what she had heard, Resident #1 had preferences for her medication times and would call and let them know when she wanted them. An observation and interview on 1/30/24 at 12:27 PM revealed Resident #1 was in her room, sitting in her wheelchair, clean and well-groomed. Resident #1 complained she had missed her evening medications on 1/14/24. She stated it was a Sunday night about 7:30 PM and a MA came in to deliver her medications. She stated she told the MA it was too early and she did not want them yet. She could not remember the name of the MA. Resident #1 stated she later got changed and was waiting for him to return; she was playing a game on her phone and fell asleep. She stated she did not wake up until the next morning and remembered she did not get her medications the evening before. She stated she called for the morning nurse [LVN C] and complained to her that she had not received her medications the evening prior. Resident #1 stated LVN C asked her if she had called the evening nurse and asked about the medications and she told the nurse, No, because I was sleeping and it's not my job. Resident #1 stated she became angry and asked to speak to a manager. Resident #1 stated Unit Manager A came to see her and she reported the situation to him. She stated Unit Manager A returned later and stated he had spoken with the MA who admitted he had forgotten to follow-up on the medications but he had checked on her three times and she had been sleeping. Resident #1 stated she did not believe that was true because staff usually woke her up to take her medications. She stated Unit Manager A told her he planned to write-up the staff involved and give additional training and asked her if she felt better about the situation. Resident #1 stated she told him it did not make her feel better and she was going to call the State and make sure it didn't happen again. Resident #1 stated the Administrator came to see her the next day to investigate and she told the Administrator she did not want this to happen to other residents. Resident #1 stated the staff had previously offered to change her dose times but she refused and wanted the dose times to remain as they were. In an interview on 1/30/24 at 1:30 PM, LVN D stated residents had a right to refuse their medications and the MA or nurse should try to determine the cause. She stated the MA could try again and administer the medication if it was still within the dose window, otherwise they should report the refusal to the charge nurse. She stated it was the nurse's responsibility to determine the reason for the refusal, notify the physician and RP, and document the refusal and physician contact in the MAR and progress notes, and follow the physicians' orders. During an interview on 1/30/24 at 1:35 PM, Unit Manager A stated he was aware of Resident #1's complaint about missing her evening medications on 1/14/24. He stated they had in-serviced the staff and had 1 on 1 counseling with the MA involved, [MA E]. He stated he had done a full assessment of Resident #1 and she did not appear to have any adverse effects . He stated the pharmacy consultant had also come and provided 1 on 1 training to the medication aides related to medication rights and medication errors. Unit manager A stated staff should always follow the rights of medication administration. Medications could be administered 1 hour before to 1 hour after the scheduled dose time. He stated, if a resident did not take their medication, the MA should notify the charge nurse and could try again if it was still within the dosage window. He stated medications should never be signed as administered unless the medication was taken by the resident. He stated the medications were not signed out in the instance with Resident #1 and the MA was waiting for her to call and let him know she was ready. He stated the MAs did not document medication refusals. Unit Manager A stated the MA should report the occurrence to the charge nurse who then should assess the resident and document the refusal as they are responsible to follow-up with the resident and intervene when necessary. Contact information was requested for the MA and the LVN who worked with Resident #1 on 1/14/24. During a follow-up interview with LVN C on 1/30/24 at 2:30 PM, she stated she spoke with Resident #1 on the morning of 1/15/24 and she complained that she had missed her medications the evening before. She stated Resident #1 told her she had initially declined her medications because of an upset stomach. She stated Resident #1 told her the MA returned a second time and she told him she was not ready and asked him to leave the meds on her table and he refused. LVN C stated she had asked Resident #1 if she had called for her medications when she was ready for them, and she felt Resident #1 was annoyed with her for asking. She stated she reported the matter to Unit Manager A. LVN C stated she assessed Resident #1 and did not note any adverse reactions to missing her medications . During an observation and interview on 1/30/24 at 3:22 PM, LVN F was observed performing a medication pass. After the medication pass, LVN F stated if a resident had refused to take their medications when offered, she would have tried to determine why they did not want their medications and when they would want to take them. If the time was outside the administration window, she would document the refusal, notify the physician and RP and document the event in the progress notes. During a telephone interview with MA E on 1/30/24 at 3:45 PM, he stated he was aware of Resident #1's complaint about missing her medications on 1/14/14. He stated he attempted to administer medications to Resident #1 that evening and she told him she was nauseated and wanted to wait and asked him to come back later. MA E stated he reported what she told him to RN G. MA E stated he returned to Resident #1's room to try again at around 8:30 PM and she told him she would call when she was ready for them. MA E stated he locked her medications in his cart and forgot about it afterward. He stated his shift ended at 10:00 PM and he did not recall notifying anyone else about medications and repeated that he had informed the charge nurse when she initially refused them. He stated he did not notify the oncoming shift about the missed doses and should have taken it up with the nurse. He stated he did not document the missed doses anywhere because he did not have access to do so. When asked about the risks to residents if there was a failure to administer their medications, MA E stated, I did not fail to administer the medications. I attempted to give them. Failing is when you don't go; I went. In an interview on 1/30/24 at 3:57 PM, Unit Manager A provided contact information for RN G. Attempts to call RN G two times were unsuccessful and no voicemail box was available to leave a message. In an interview with the DON on 1/30/24 at 5:01 PM, she stated all residents had a right to refuse medications. If a resident requested to take them later and they were still within the administration window they should be administered. If outside the administration window or the resident outright refused the medication, the charge nurse should call the physician and discuss the situation and follow their guidance. She stated the nurse should document the refusal. The DON stated she was aware of the incident involving Resident #1 and MA E and had investigated it. She stated MA E told her Resident #1 had initially refused the medications complaining of nausea and refused them again a second time. She stated MA E told her he had reported the situation to the nurse. The DON stated she questioned RN G and he told her he was not aware Resident #1 had refused her medications. She stated she did not investigate the night nurse because the matter was between MA E and RN G. She stated the night nurse would not have known the medications were not administered because the MAR would only reveal medications due to be administered on their shift. She denied receiving any reports of medications left on the medication cart and that MA E told her he had destroyed the medications after the resident refused them. The DON stated she wrote up both employees the next day and could not tell what was what. She stated the pharmacy consultant conducted in-service training with the MAs. The DON stated it was important for the nurses to notify the physician when medications were missed so that the physician could determine if they needed to order different medications or change the plan of care. She stated the general risk for missing medications depended on the medication and number of doses missed. During a follow-up interview and record review with Unit Manager A and the DON on 1/30/24 at 5:40 PM, Unit Manager A stated he notified the physician the next day [1/15/24] and informed them of the missed doses. He stated the resident was fully assessed and had no adverse reactions. He stated he monitored MARs daily for missed doses or other concerns and discussed them in daily meetings. He stated, in Resident #1s instance, the complaint came to him first thing in the morning before he had pulled his reports. He stated Resident #1 had a thorough assessment and had no adverse effects. Unit Manager A reviewed the missed medications and stated he did not believe the missed medications contributed to her anxiety. He stated Resident #1 had a history of getting angry with staff and calmed down when they talked to her. He stated they had offered to change her medication times in the past and she never wanted the dose times changed. When deficient practice was discussed, the DON stated they did not feel they had deficient practice as the resident had refused her medications. She stated the refusal was documented on the MAR. When asked to identify the area on the MAR where the refusal was documented, the entries revealed =. The associated legend on the MAR reflected the symbol meant Previously Scheduled. There were no entries located on the MAR Legend which would indicate a resident refusal. Neither Unit Manager A or the DON were able to explain how a refusal was documented on the MAR and no documentation was provided to indicate anyone had documented Resident #1's refusal of her medications or that the physician had been notified on 1/14/24. In an interview with Physician I on 1/30/24 at 6:21 PM, he stated his Nurse Practitioner had been notified of Resident #1 missing her evening medications and had discussed the issue with him. He stated he was not certain when his Nurse Practitioner was notified. He reviewed the missed medications and did not believe there had been any risk posed to the resident when the medications were missed. Record review of an In-Service training Report dated 1/15/24 and conducted by Unit Manager A reflected, Topic: In-service/training completed on administering medications, rights of medication administration, Resident Rights, and abuse, neglect, exploitation and misappropriation. An attached undated document titled, Medication Administration In-Service reflected the following: 1. All Nurses must follow proper medication administration protocol. (6 Rights of Med Administration) . 5. All missed doses must be appropriately accounted for as follows: -Nurses must initial; then circle the omitted item. -Nurses must document on the back of the MAR why the dose was missed. Medication not available is not acceptable without a MD's order and documentation of the MD's intervention for the missed dose. This includes missed doses for new admissions. All other situations such as [patient's] refusal of a med or treatment must be explained with appropriate MD notification. Additional notes must be documented in the nurses notes. -The MD must be notified of a [patient's] initial refusal of a med or tx; if there are three consecutive refusals the MD must be notified again. MD's intervention MUST be documented!!! An attached attendance sheet reflected only MA E received the in-service training Record review of the facility's policy and procedure titled, Documentation of Medication Administration dated 2001, Revised November 2022 reflected the following: Policy Heading: A medication administration record is used to document all medications administered. Policy Interpretation and Implementation: 1. A nurse or certified medication aide (where applicable) documents all medications administered to each resident on the resident's medication administration record (Mar) .3. Documentation of medication administration includes, as a minimum .f. reason(s) why a medication was withheld, not administered, or refused (as applicable)

Based on observation, interview, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety in the facility's only kitchen. 1. The facility failed to ensure the ice machine was maintained in a clean and sanitary manner free of white crust and scale. 2. The facility failed to ensure food items and clean dishes were kept away from soiled surfaces and airborne contaminants. 3. The facility failed to ensure Styrofoam containers were stored away from the kitchen cleaning products and equipment. 4. The facility failed to ensure the microwave was maintained in a clean and sanitary manner free of dust and sticky residue. These failures could place residents, who received food from the kitchen, at risk for food contamination and food-borne illness. Findings included: An observation and interview with the Nutrition Supervisor, on 12/12/2023 at 8:45 AM, revealed the ice machine in the food tray assembly area of the kitchen to have white crust/scale around the lid, front, and sides. She said it was cleaned weekly and the kitchen staff were responsible to keep it clean. She stated there should not be any scale on the machine as it could flake off and contaminate the ice or other food in the kitchen. Dust and grey fuzz were observed on the utensil rack next to the three-compartment sink. The Nutrition Supervisor said the utensils hanging on the rack were clean and the rack should not have any dust on it because it could come into contact with the clean utensils and possibly cause food-borne illness. A fire extinguisher hanging on the wall beside the utensil rack had a coating of black grime, grease, and dust on the top and handle. A food preparation area was observed adjacent to the utensil rack and fire extinguisher. The Nutrition Supervisor said maintenance would be responsible to keep the fire extinguisher clean. An observation and interview with the Nutrition Supervisor, on 12/12/2023 at 8:55 AM revealed, a room with a wash basin on the floor along with brooms, mops, and cleaning supplies. Boxes of Styrofoam plates and bowls were also stored in the room. The Nutrition Supervisor said they did not have anywhere else to store them while they awaited staff to return them to another storage area. She said they should not be in the same area that they stored cleaning items because they could become contaminated with dirt, or cleaning products. She said she had a cleaning schedule and staff were expected to initial when they have completed each task on the schedule. She said she monitored this. In an interview on 12/12/2023 at 9:20 AM, the Dietitian stated she came to the facility weekly to answer any dietary questions. She said she expected the kitchen to be clean and free of any potential cross-contamination or food-borne illness concerns. An observation and interview with the Nutrition Supervisor, on 12/13/2023 at 7:30 AM, revealed the Cook plating breakfast trays at the steam table. A microwave in a shelf over the right side of the area was observed to have a sticky coating and dust covering the top and back of the microwave. The backside of the microwave was open to the tray assembly area and was on the same shelf with hand sanitizer which was observed being used by staff assembling trays. The Nutrition Supervisor said the microwave was cleaned daily and should not have dust or grease on it. She said there was a risk that the dust could blow off and get into food that was prepared in the area. An observation and interview with the Nutrition Supervisor on 12/13/2023 at 7:40 AM revealed, a wired shelving unit on the backside of the food plating area that had utensils and metal food containers on it. The shelves did not have any barrier or matting on them and had rust and dust on them. The Nutrition Supervisor said the rust particles and dust could fall off the shelving and onto the clean dishes causing contamination. She said kitchen staff were expected to keep the shelves clean. In an interview on 12/13/2023 at 7:45 AM, the Corporate Trainer said the Nutrition Supervisor recently took over responsibility of the kitchen and she was in the facility to assist her in getting acclimated with her responsibility. She said she understood the cleaning concerns and agreed they posed a risk of food contamination. In an interview on 12/14/2023 at 2:52 PM, the Maintenance Director said the facility had a contract with a company to take care of the ice machine. He said kitchen staff were responsible to clean the outside of the machine. He said there should not be any scaling on the machine because it could flake off and get into the ice or other food in the kitchen . Record review of the facility's cleaning schedule dated 11/27/2023 through 12/17/2023 reflected the ice machine was cleaned each day up to the review date of 12/12/23. Review of the Cooks cleaning schedule, dated 11/27/2023 through 12/17/2023 reflected the microwave was cleaned on 11/28, 12/1, 12/3, 12/8, 12/9, 12/10, and 12/11/23. Review of the PM Cooks cleaning schedule, Dish washer schedule, and Aides cleaning schedule dated 11/27/2023 through 12/17/2023 reflected no listing for the wire racks holding clean dishes, utensil holder, or cleaning closet. Record review of the facility's policy titled, Sanitation of dietary department, dated 11/3/2004 reflected, The dietary staff shall maintain the sanitation of the dietary department through compliance with a written, comprehensive cleaning schedule. The Dietary Manager shall record all cleaning and sanitation tasks for the department Record review of Federal Drug Administration Food Code dated 2022 section 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils revealed (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. (B) The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) NonFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris. 3-305.11 Food Storage. (A) Except as specified in (B) of this section, FOOD shall be protected from contamination by storing the FOOD: (1) In a clean, dry location; (2) Where it is not exposed to splash, dust, or other contamination. 14 Food Preparation. During preparation, UNPACKAGED FOOD shall be protected from environmental sources of contamination. 3-307.11 Miscellaneous Sources of Contamination. FOOD shall be protected from contamination that may result from a factor or source not specified under Subparts 3-301 - 3-306. 3-602.

Based on interviews and records review, the facility failed to ensure personnel provided basic life support, which included CPR, to a resident requiring such emergency care subject to the resident's advance directives for one (Resident #1) of four residents reviewed for cardiopulmonary resuscitation. On [DATE], LVN A found Resident #1 unresponsive. LVN A said she a pulse was not felt, and a heartbeat was faintly heard. LVN A did not initiate CPR to Resident #1. LVN A failed to review Resident #1's Advance Directives choice, Full Code, when she discovered Resident #1 unresponsive. An Immediate Jeopardy (IJ) was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 5:06 PM. While the IJ was lowered on [DATE], the facility remained out of compliance at a scope of isolated and severity level of actual harm that is not IJ due to the facility continuing to monitor the implementation and effectiveness of the corrective systems. This deficient practice could affect all residents who requested a full code status at risk of not receiving necessary life-saving measures. Findings included: Record review of Resident #1's Admission MDS (a standardized assessment tool that measures health status in nursing home residents) assessment, dated [DATE] revealed an [AGE] year-old female admitted to the facility on [DATE] with a BIMS score of 09, which suggested moderately impaired cognition (difficulty with problem-solving, remembering names and details, and may withdraw socially as new situations and places are challenging). Resident #1 had diagnoses of Medically Complex Conditions, active diagnoses of HF; HTN (when the pressure in the blood vessels is too high - ,d+[DATE] mmHg or higher); T2DM (a disorder in which the body does not produce enough or respond normally to insulin, causing blood sugar (glucose) levels to be abnormally high); HLD (abnormally high levels of fats (lipids) in the blood, which include cholesterol and triglycerides); and Pressure ulcer of sacral region, unstageable. The Admission MDS assessment reflected Resident #1 required one-person physical assist with bed mobility, dressing, eating, toilet use, and personal hygiene ADLs; and required two+ persons physical assist with transfer and locomotion on/off unit. Resident #1 functional status with balance during transitions and walking reflected not steady, only able to stabilize with staff assistance moving from seated to standing position and surface-to-surface transfer. Resident #1 was always incontinent of bladder and bowel. The Admission MDS did not indicate Resident #1 had any behavioral symptoms or rejection of care during the MDS review period. A significant change in status MDS assessment dated [DATE] reflected Resident #1 enrolled in a hospice program. A review of a Facility Notification of admitted d [DATE] reflected Resident #1's admitted ([DATE]) to hospice services and a Full Code (if a person's heart stopped beating and/or they stopped breathing, all resuscitation (action or process of reviving someone from unconsciousness or apparent death) procedures (chest compressions, intubation, and defibrillation) will be provided to sustain life. Resident #1 had a terminal diagnosis of cerebral infarction due to unspecified occlusion or stenosis of unspecified cerebral artery and comorbidities of T2DM, Hypertensive urgency (an acute, severe elevation in blood pressure without signs or symptoms of end-organ damage), chronic diastolic CHF (a weakened heart condition that causes fluid buildup in the feet, arms, lungs, and other organs), and PU of unspecified site. Record review of Resident #1's progress notes, revealed: [DATE] at 11:31 AM, LVN B entered, [Resident #1] refused breakfast and AM medication VS taken ,d+[DATE] (BP), 71 (HR) . LVN B notified family member and hospice provider. Effective date: [DATE] at 9:30 AM; Entered date: [DATE] at 8:48 PM by LVN B reflected, [Resident #1] on oxygen via nasal canula, tolerating it well with no distress noted, ate very little took AM medication . Effective date: [DATE] at 10:30 PM; Entered date: [DATE] at 5:24 AM by LVN A reflected, [Resident #1] resting in bed, continues on hospice care, no distress noted . Effective date: [DATE] at 5:24 AM; Entered date: [DATE] at 5:27 AM by LVN A reflected, [Resident #1] is in bed, no respirations, no pulse felt, hospice notified, is on the way to evaluate pt. Effective date: [DATE] at 7:00 AM; Entered date: [DATE] at 9:01 AM by LVN B reflected, hospice nurse arrived at the facility made a pronouncement (make the determination that a person was dead) at 6:37 AM. During an interview on [DATE] at 11:22 AM, the ADON indicated that the facility was responsible for providing care 24 hours a day and 7 days a week no matter if a resident was on hospice or not. The ADON indicated that nurses and CNAs were required to check on residents every two hours which was alternated between the nurse and the CNA every hour. The ADON described Resident #1 as total care, one person assistance for ADLs, two persons assist for transfers and repositioning, was incontinent, had an indwelling catheter, and wounds. The ADON said that on [DATE] he received a call from LVN A around 6 AM to notify that Resident #1 was found unresponsive and the hospice nurse was on the way. The ADON said that when he arrived at the facility, the hospice nurse was present and had pronounced Resident #1 dead. The ADON said that he spoke with LVN A to obtain more information about Resident #1's condition prior to discovered unresponsive. During an interview on [DATE] at 2:18 PM, CNA H indicated she worked and provided care to Resident #1 on [DATE] during the 2 PM - 10 PM shift. CNA H defined a change of condition as refusing to eat, sleeping more, or changes in behavior. CNA H said that staff are expected to check on residents every two hours. CNA H said Resident #1 required repositioning every two hours by two people. CNA H said that moaning was a common pain behavior for Resident #1. CNA H said that she assisted Resident #1 with eating and notified the nurse (on [DATE]) when Resident #1 moaned and refused to eat. CNA H said she checked on Resident #1 before the end of shift, around 9 PM, and with the oncoming CNA during change of shift rounds. CNA H said that Resident #1 did not present with acute distress. During an interview on [DATE] at 2:43 PM, the DON was not able to speak to the facility's policies and procedures because she was a new hire attending orientation. During an interview on [DATE] at 4:15 PM, LVN B indicated he worked a double shift (6A - 2P and 2P - 10P) on [DATE]. LVN B said that he was relieved by LVN A for the 10P to 6A shift. LVN B said that he conducted walking rounds with and gave verbal report to LVN A. LVN B said that Resident #1 was observed in bed during walking rounds, awake and alert, no acute distress. LVN B said upon arrival to work on [DATE] for the 6A - 2P shift, LVN A reported that Resident #1 passed away around 5 AM, that she called the hospice nurse, and was on the way. LVN B said that he went to observe and assessed Resident #1 condition. LVN B said that Resident #1 was unresponsive and not breathing. LVN B did not indicate if he felt Resident #1's pulse. LVN B said that he completed walking rounds and received report from LVN A. LVN B said that he called the ADON to inform about Resident #1 and then placed a call to the RP. LVN B said that the hospice nurse arrived sometime after 6 AM and pronounced Resident #1 dead shortly after 6:30 AM. LVN B said that Resident #1's hospice binder reflected the advance directives on the front page, the face sheet, that indicated Full Code status. During a phone interview on [DATE] at 4:37 PM, LVN A stated that she worked an extra shift on [DATE], 10P - 6A and was assigned to the hall Resident #1 resided. LVN A said that she received report and conducted walking rounds ([DATE]) with LVN B. LVN A said that she observed Resident #1 in bed. LVN A said that Resident #1 verbally acknowledged when LVN A introduced herself. LVN A said that she was not familiar with Resident #1, that she conducted rounds every two hours to check on all assigned residents. LVN A said that she did not document that she conducted rounds every two hours because it was not required and the CNA that worked that night could not corroborate because she did not assist the CNA to turn and reposition Resident #1. LVN A said that she administered Resident #1 a scheduled pain pill whole in pudding around 11 PM. LVN A said that she followed up with Resident #1 around 1 AM to check the effectiveness of the pain medication and checked Resident #1's vital signs. LVN A said that Resident #1 did not speak when asked about the effectiveness of the pain medication but opened eyes when name was called. LVN A said that Resident #1's vital signs were within normal level, baseline. When asked how she determined Resident #1's vital signs were within normal level, baseline, LVN A replied she compared to other vital sign measurements in the chart. LVN A stated she did not document after she measured the vital signs. LVN A said that she checked on Resident #1 at 3AM and the rise and fall of her chest was observed. LVN A said that when she checked on Resident #1 at 5:00 AM, she called out [Resident #1] name, did not hear a response, checked for breathing by visual inspection of Resident #1's chest for rise and fall, none noted. LVN A said that she did not feel a pulse on Resident #1's wrist or neck. LVN A said that she listened to Resident #1's heart and a heartbeat was faintly heard. LVN A stated she did not start basic life support (BLS). LVN A said that she did not start CPR within 10 seconds when a pulse was not felt. LVN A said that she did not use AED to check (heart) rhythm. LVN A said that she called the hospice nurse to report Resident #1's condition (not breathing, no pulse). LVN A said that she did not know Resident #1's code status because she was not familiar with the resident and knew to call the hospice nurse first about a change in condition. LVN A said that each resident on hospice services had a binder at the nurses' station with a face sheet that has the hospice agency phone number and instructions to call if the resident had a change in condition. LVN A said she did not recall if the face sheet in the hospice binder reflected [Resident #1] code status when she looked for the hospice agency phone number. LVN A said that she did not check Resident #1's chart to verify code status. A review of the hospice agency documents received [DATE] revealed the following: A patient communication form dated [DATE] received from the hospice agency indicated a call was received from the SNF at approximately 5:15 AM ([DATE]) to notify that [Resident #1] expired. A discharge - death progress note dated [DATE], time in: 6:30 AM and time out: 7:20 AM, entered by the hospice RN indicated upon arrival RN noted patient was not breathing. Auscultation confirmed the absence of breath and heart sounds. No carotid pulse (neck pulse) present. TOD 6:37 AM . Patient was treated with fentanyl patches and oxycodone for comfort. Patient had a fast decline. A written recertification by the attending physician, dated [DATE] revealed [Resident #1] was terminally ill with less than six-month life expectancy. The certification period was [DATE] - [DATE]. The narrative statement indicated Resident #1 was admitted to hospice on [DATE] with a terminal diagnosis and had several comorbidities (the simultaneous presence of two or more diseases or medical conditions), weight declined, increased respirations when talking, [Resident #1] denied SOB, if terminal condition allowed to run its natural course, prognosis was estimated 6 months or less. Review of a typed statement dated [DATE] reflected LVN A's actions when Resident #1 was discovered unresponsive on [DATE]: .at about 5:15 AM [Resident #1] in bed no respirations, . did not response when call by name, Radial pulse not felt. Apical Pulse (pulse point of heart on left side of chest) not heard. Hospice was notified [Resident #1] has no respiration and pulse and needs further evaluation. provided facility address and [Resident #1] name. could not Reach RP . NP on call could not be reached. Hospice Nurse informed on her way . The statement revealed LVN A gave handoff report to the oncoming nurse [LVN B] at ([DATE]) 6:20 AM. LVN A reported to LVN B that Resident #1 did not have a pulse or respirations and the Hospice Nurse was on the way to the facility. LVN A's name was typed at the end of the statement. Review of an Employee Coaching and Counseling Record dated [DATE] revealed LVN A violated policy by substandard work performance. The supervisor [ADON] remarks reflected, [LVN A] failed to check code status in EMR, failed to provide CPR, failed to notify RP and management of resident change of condition/expired. The Employee Coaching and Counseling Record reflected a final warning/action plan that indicated [nurses] must know the code status of all residents in their care. When a resident has a change of condition or expire, notify management and RP. During an interview on [DATE] at 2:43 PM, the NFA stated the facility investigated the incident, other residents who may be affected were identified, measures were developed and put in place to avoid reoccurrence of the deficient practice, implemented plans to monitor corrective steps, and provided sufficient evidence. The NFA said that it was the nurse responsibility to know each resident code status they were assigned and where to locate the information for any resident. The NFA indicated LVN A was suspended during investigation, received a final written warning, was in-serviced, and participated in a BLS/CPR recertification course on [DATE] (the course was available to all licensed nurse staff on [DATE] and [DATE]). The NFA stated the medical director was notified and an emergency QAPI meeting was held on [DATE]. The Texas Board of Nursing Licensed Vocational Nurse Scope of Practice, Revised ,d+[DATE], reflected in part, that LVNs must use clinical reasoning and established evidence-based policies, procedures, or guidelines as the basis for clinical judgment in nursing practice. LVNs are accountable and responsible for the quality of nursing care provided and must exercise prudent nursing judgment to ensure the standards of nursing practice are always met. The summary reflected, The LVN, with a focus on patient safety, is required to function within the parameters of the legal scope of practice and in accordance with the federal, state, and local laws, rules, regulations, and policies, procedures and guidelines of the employing health care institution or practice setting. The LVN functions under his or her own license and assumes accountability and responsibility for the quality of care provided to patients and their families according to the standards of nursing practice. The LVN demonstrates responsibility for continued competence in nursing practice, and develops insight through reflection, self-analysis, self-care, and lifelong learning. Review of the steps for responding to a cardiac arrest, according to the AHA ([NAME] et al., 2020), are: - Check for responsiveness. - Call 911 or have a bystander make the call. - Begin CPR while bystander retrieves an AED. Do not stop CPR. - If not breathing or breathing with agonal breaths (abnormal breathing that often sounds like snoring, snorting, gasping, or labored breathing), start CPR. [NAME] et al. (2020, [DATE]). Part 3: Adult basic and advanced life support - AHA/ASA journals. AHA Journals. https://www.ahajournals.org/doi/pdf/10.1161/CIR.0000000000000916 Record review of the facility's Advance Directives policy dated [DATE], reflected in part, the following: 5. An acknowledgement receipt for Advance Directives/Medical Treatment Decisions must be completed for each patient upon admission and upon any change . 6. Upon completion of an Out-of-Hospital DNR; a telephone order must be entered into the electronic medical record. 7. The Advanced Directive report must be reviewed daily for all patients. Record review of the facility's Hospice Services policy dated [DATE], reflected in part, the following: The facility must meet the following requirements: ensure hospice services meet professional standards . have a written agreement with the hospice of the services hospice will provide . hospice's responsibilities determining the hospice plan of care . services the facility will continue . a communication process. The facility immediately notifies the hospice about a significant change . clinical complications that suggest a need to alter the plan of care . need to transfer the resident from the facility . the resident's death. The NFA was notified of an Immediate Jeopardy (IJ) on [DATE] at 5:06 PM, due to the above failures and the IJ template was provided. The facility's Plan of Removal (POR) was accepted on [DATE] at 5:46 PM. The POR reflected immediate action to take the deficiency out of the IJ level of severity; systematic approach of how and when the facility would ensure residents were no longer at a high risk of serious injury, harm, impairment, or death; staff education; and monitoring to prevent recurrence of deficient practice. Immediate action The Medical Director was notified on [DATE] at 11:38 am and an emergency QAPI meeting was conducted with the focus on Hospice residents without a DNR and all care plans reflected resident code status. Root-cause identified that re-education of the CPR procedure was needed. Systematic Approach: 1. The Social Workers conducted chart audits and verified all residents' charts had the appropriate code status in their charts. This was completed on [DATE]. 2. An Advance Directives audit verified actual DNR orders and documentation in the chart. 3. The RDCS educated the NFA, AIT, DON and Unit manager on the CPR policy and procedure. This was completed [DATE] 4. On [DATE], [LVN A] was re-educated on the proper CPR procedure with focus on determining resident code status prior to beginning CPR. 5. The DON & Nurse Managers initiated an in-service on [DATE] to licensed nurses on the proper CPR procedure with focus on determining code status prior to beginning CPR. 6. The facility conducted an audit on [DATE] and verified licensed nursing staff files contained current CPR certification. CPR Training Courses were scheduled for licensed nursing staff. 7. Nurse Management conducted Mock code blue scenarios from [DATE] to [DATE] to ensure lifesaving procedures were understood and followed. A skills checkoff was completed for the nurses participated. The DON will continue to schedule monthly. Licensed nursing staff will be educated upon hires on CPR/Code Blue procedure. Any deficient practice will be corrected and reported to the ED immediately and all findings will be discussed monthly/and as necessary. 8. [LVN A] was suspended on [DATE] pending completion of a thorough investigation. 9. MDS nurses conducted a care plan audit on all resident's code status. This was completed on [DATE]. Education: I. Education began [DATE] on proper CPR procedures. Education will continue until 100% of licensed nursing - FT, PRN, new hire, agency staff have been educated by the DON/Unit Manager/Designee prior to working a scheduled shift. Education included: I. Assessing resident for vital signs to include breath and pulse in multiple locations. Staff should not leave the resident once found unresponsive, staff should stay and call for help. II. All licensed staff must respond to any Code Blue when doing so would not endanger other residents. III. Identifying Code Stats by checking Dr. Order, RN/LVN's checking EMR system and MA/CNA Daily care guides. IV. Elements of Full Code. A. Calling Code Blue/Paging for assistance. B. Division of duties during code. a. Calling 911 b. Crash Cart c. Performing Compressions d. AED use e. Suctioning f. Staff must notify DON to conduct Post incident review upon completion of code to ensure g. proper procedures were followed. Reviews will become part of our monthly QA process. 3. Scope of Practice LVN/RN A. Initiating Code B. Transfer of Code to EMS C. Requirements for ending Code - The facility in-service on scope of practice. CPR to be continued until transfer of care to emergency service personnel. CPR is not to be interrupted until transfer of care. 4. The ED, Unit Manager, and Clinical designee(s) conducted in-services on [DATE] for non-licensed staff regarding the following elements: I. Paging for Code Blue can be done by any staff member. II. Contacting 911 for assistance. III. Reporting to management. IV. AED and Crash Cart location. Monitoring: 1. On-going education competency to ensure understanding of CPR procedure and include: A. Verbal questions/ answers to ensure understanding. B. Daily review of Code status in the morning Clinical stand-up meeting. C. The Nurse will report all code status and changes during the Clinical stand-up meeting. D. DON or designated nurse will observe Code status weekly x 2 and then once monthly thereafter. E. The Executive Director will participate in the Stand-Up and the verbal review by the nurse or designee and review Management Meeting. 2. The Medical Director was notified of the Immediate Jeopardy status. 3. Rounding to ensure prevention methods are in place was completed [DATE]. Quality Assurance: 1. DON or designee will conduct a weekly random audit for a period of 4 weeks ensuring nursing staff will continue to follow Policies & Procedures for Code status. 2. DON or designee will conduct documentation review to ensure all code status is correct. 3. Monitored shifts include 6a-2p, 2p-10p 10p-6a, and the double weekends (6a-10p). 4. The DON will submit audit findings to the QA Committee for review, analysis and to give recommendations. 5. Completion date [DATE]. On [DATE] the surveyor began monitoring if the facility implemented their plan or removal sufficiently to remove the IJ by: Record review of an Advance Directive report printed [DATE] revealed the code status of all admitted residents. The type of directive, Full Code or DNR, was reviewed in sampled residents' charts for accuracy. Record review of QAPI meeting minutes dated [DATE] at 6:15 PM revealed special discussion items that included CPR procedure with focus on determining code status prior to beginning CPR and the focus on hospice residents without DNR advance directives. Record review of a code status report revised [DATE] of all hospice residents, revealed 16 total hospice residents. All hospice residents were DNR except for three residents that reflected a Full Code status. On [DATE], staff interviews were conducted with nurses scheduled on the 6A-2P [LVN B, RN G, LVN P, and RN F] and during the 2P-10P shifts [LVN L, LVN Q, and LVN R] indicated they participated in an in-service training about changes in condition that may require CPR, code status verification, and initiating CPR. Each nurse stated in their own words their responsibility to review the Advanced Directives report at the start of shift and where to locate the code status in the chart. Record review indicated the RDCS held an in-service on [DATE] with the NFA, AIT, DON, and ADON that reflected the immediate concerns, facility expectations, and topic of discussion covered in the in-services with staff. Record review of the POR education bundle was conducted to determine which staff participated in the immediate in-service training as part of the POR. Record review of in-services dated [DATE] titled CPR for LVNs/RNs; Code Status and Change of condition and notifying MD, RP, Management, Hospice for All Nursing Department conducted by the ADON were on-going and reflected the following: In-services conducted by the ADON beginning [DATE] and on-going, titled Code Status revealed a summary of training that code status must be checked at all times during change of condition even if the resident is a hospice patient. The sign in sheet reflected the following staff participated in the in-service: LVN E, LVN AS, LVN AG, LVN AF, LVN W, MDS K, MDS C, LVN Y, RN AT, RN F, LVN AX, RN G, LVN D, LVN S, LVN R, LVN Q, and LVN L. In-services conducted by the ADON beginning [DATE] and on-going, titled Change of Condition and notifying MD, RP, Management, and Hospice revealed a summary of training that Every change of condition must be communicated to the MD, RP, Management and Hospice must also be notified of any change with resident that are on hospice. SBAR (framework for communication between members of the health care team about a patient's condition) and documentation must be completed immediately when there is a change of condition with the resident The sign in sheet reflected the following staff participated in the in-service: RN F, LVN AX, RN AT, CNA H, RN G, CNA AD, LVN D, CNA V, LVN S, CNA I, LVN R, CNA BG, LVN Q, LVN L, CNA AL, LVN E, CNA AC, LVN AS, LVN AG, CNA AJ, LVN AF, LVN W, MDS C, MDS K, LVN Y, CNA BT, and CNA N. In-services conducted by the ADON beginning [DATE] and on-going, titled CPR revealed a summary of training that If an individual (resident, visitor, or staff member) is found unresponsive and not breathing normally a licensed staff member who is certified CPR/BLS shall initiate CPR unless: It is know that a Do Not Resuscitate (DNR) order that specifically prohibits CPR and/or external defibrillation exists for the individual; or There are obvious signs of irreversible death (e.g. rigor mortis [stiffening of the joints and muscles of a body a few hours after death]); if the resident's DNR status is unclear, CPR will be initiated until it is determined that there is a DNR or a Physician's order not to administer CPR. The sign in sheet reflected the following staff participated in the in-service: LVN W, LVN AS, LVN E, RN AR, LVN AY, LVN AG, RN F, LVN AX, LVN Q, LVN L, RN G, RN AT, LVN R, MDS K, MDS C, and LVN Y. Record review of course participants sign in sheet of the American Heart Association (AHA) BLS/CPR training reflected the following staff participated in the training and a skills check off was completed on [DATE]: LVN AM, LVN P, LVN W, LVN AP, RN AQ, LVN Y, LVN AX, ADON, LVN AS, RN AT, LVN Z, LVN B, MDS C, MDS K, RN AV, LVN AW, LVN D, RN BG, LVN AY, LVN BB, LVN BC, LVN BD, LVN BE, and RN AV. Record review of course participants sign in sheet for the American Heart Association (AHA) BLS/CPR training reflected the following staff participated in the training and skills check off was completed on [DATE]: LVN Q, RN G, LVN R, LVN AF, RN F, LVN P, LVN S, RN AZ, LVN Z, LVN BC, LVN E, LVN L and LVN BA. On [DATE] at 5:46 PM the NFA was notified the IJ was removed; however, the facility remained out of compliance at a severity level of actual harm that is not IJ and a scope of isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems.

Based on observation, interview, and record review, the facility failed to ensure residents receive proper assistive devices to prevent accidents for 1 (Resident #1) of 6 residents reviewed for accidents. The facility failed to ensure Resident #1 was properly fitted for a Hoyer lift sling during a two person transfer as a result the patient fell . An Immediate Jeopardy (IJ) situation was determined to have existed on [DATE]. It was determined to be past non-compliance due to the facility having implemented actions that corrected the non-compliance prior to the beginning of the survey. This failure could affect residents placing each at risk of injury related to falls . Findings Included: Review of Resident #1 face sheet dated [DATE] reflected Resident #1 admitted to the facility on [DATE], she was a [AGE] year old female diagnosed with cerebral infarction (a disruption of blood flow to the brain due to problems with blood vessels that supply it), dementia, dysphagia/aphasia ( language disorder resulting in partial to full loss of language), diabetes, gastrostomy (surgical opening into the stomach from the abdominal wall for introduction of food), hypertension, presence of cardiac pacemaker, pain unspecified, diastolic congestive heart failure (condition in which the heart's left ventricle becomes stiff and unable to fil properly), nausea with vomiting unspecified, personal history of urinary tract infections, and Alzheimer's disease. The face sheet reflected Resident #1 discharged from the facility to the hospital on [DATE]. Review of Resident #1's Quarterly Minimum Data Set, dated dated dated [DATE] reflected the resident to be absent of spoken words, rarely to never understood, had problems with both long- and short-term memory, never to rarely displayed cognitive skills for decision making. The resident was totally dependent on staff for activities of daily living such as: bed mobility, dressing, eating, personal hygiene, transfers, and required a wheelchair for mobility. Review of an admission progress note dated [DATE] reflected Resident #1 required two person staff assist with bed mobility, transfers, and required use of Hoyer lift. Review of Resident #1's most recent physical and occupational therapy assessment dated [DATE] reflected Resident #1 at her baseline functional mobility was totally dependent. Review of facility's care plan report dated [DATE] reflected Resident #1 required total assistance two persons for transfer with Hoyer Lift, was a risk for falls, had impaired communication as evidenced by aphasia, was a potential risk for injury due to unsafe transfers as identified by the nursing/rehabilitation assessment. The care plan report also reflected Resident #1's EC (essential caregiver) was instructed on use the facility sling for transfers and insisted on using the sling she brought to the facility. Review of the facility accident/incident report dated [DATE] reflected at 11:30 AM, the MD was notified by LVN B and CNA A: The nurse was assisting aide to transfer patient (Resident #1) from bed to chair with [NAME] (s/p Hoyer) lift, on the process of the transfer the sling was not properly fit, and the patient slipped but nurse quickly held the patient up and assisted her to the floor. Patient was assisted back to the bed, head to toe assessment completed no injury noted, vital sign (s/p signs) within the normal range. The supervisors, MD, and the patient family member notified. Will continue to monitor. Vital signs recorded at time of incident BP ,d+[DATE], Temp 97.80, Resp 18 breaths per minute, Pulse 74, O2 98. Review of facility treatment record for Resident #1 dated [DATE] reflected serial neurological checks and vital signs were conducted 12:00PM, 12:30 PM, 1:00 PM, 2:00 PM, 3:00 PM, 4:00 PM, and 5:00 PM with her systolic BP ranged from ,d+[DATE]/ diastolic BP ranged from ,d+[DATE], respirations remained at 18 breaths per minute, pulse ,d+[DATE] beats per minute, also assessed for neurological function were hand grasp, loss of consciousness, motor function, and pupil reaction were all assessed with no noted changes from her baseline neurological function. Review of facility nursing home to hospital transfer form dated [DATE] reflected Resident #1 was sent to the hospital on [DATE] with primary diagnosis nausea with vomiting, time of transfer was 9:30pm emergency contact was notified, physician was notified. The transfer form reflected Resident #1's vital signs at time of transfer were BP ,d+[DATE], Pulse 89, Temp 97.7, Resp 18, O2 97% on room air, pain evaluation indicated none, neurological evaluation indicated no changes observed. The transfer form summary stated: Pt was having N/V(nausea/vomiting) X1 on the evening shift while the family member was present in the room, and she requested for her to be sent to the hospital for further evaluation. Review of facility self-report to Texas Health and Human Services Commission(HHSC) dated [DATE], reflected an incident occurred involving Resident #1 and was reported to the facility by the resident's family. The self-report indicated it reported the incident to HHSC at 10:00 PM. The reported indicated alleged perpetrators as LVN B and CNA A. The allegation description reflected, The patient family member reported that her mom had a fall when the nurse (LVN B) and CNA (CNA A) were transferring her mom via mechanical lift. The nurse (LVN B) stated that she went to the patient room to assist the CNA (CNA A) with the transfer from the bed to the wheelchair. The CNA (CNA A) hooked the sling to the mechanical lift; during the movement of the lift one of the hooks on the sling pulled away from the lift causing the patient body to shift and her lower body to touch the floor. The nurse and CNA (CNA A) denies the patient hit her head when she was going down with the sling. The self-report described no injury at the time of an assessment completed [DATE] at 12:30 PM, it noted there were no bruises, no hematoma, or skin impairments to Resident #1. Review of the facility self-report investigation summary dated [DATE] reflected, The nurse (LVN B) reported that the family member wanted her mom up OOB (out of bed) for 2 hours in her chair. During the transfer the nurse and the CNA (CNA A) was transferring the patient via Hoyer lift and suddenly one of the sling hooks came apart from the lift. Leaving 3 hooks still intact to the lift, while the nurse immediate (s/p) jump to assist with protection the patient from hitting her head. The nurse (LVN B) and CNA (CNA A) denies hitting her (Resident #1) head. The family provided video footage and it appears that one of the sling hooks came un-hedged from the lift. All nurses and CNAs were provided with in-service on mechanical lift, including return demonstrations and skills check off, ongoing education to continue. Both the nurse and CNA were terminated due to inappropriate use of the sling. Review of facility witness statement dated [DATE], made by LVN B reflected, During the process of transferring the patient (Resident #1) from the bed to chair with Hoyer lift, with the sling provided by the family member. I noticed that one end of the lower part of the sling suddenly came apart. I quickly jumped over to the other side to stop the patient from completely hitting floor, but the patient body was intact on the sling, lowered to the floor. I did not see the patient (Resident #1) head hit the floor. Head to toe assessment was completed. There was no sign of bruises or skin break down noted. The managers were notified and when they came to observe the patient, no distress noted. The family member always lay (s/p lays) out the patient clothes the night before; we was following her instructions. In an interview on [DATE] at 11:48 AM with LVN B she stated Resident #1 required total care with transfers and need two-person assistance with a Hoyer lift. She stated on [DATE] ADON C, in morning meeting, told her Resident #1's family member wanted to have the resident transferred from the bed to the wheelchair. LVN B stated between 11:00 AM and 11:30 AM she went to assist CNA A and observed a sling in the wheelchair of Resident #1. She stated the family member of Resident #1 the night before would lay out in the resident's room the items staff were to use to care for her mother. LVN B stated CNA A placed the sling under Resident #1 and she positioned herself behind the resident's wheelchair. She stated CNA A hooked the sling to the Hoyer lift spreader bar and prior to lifting the resident from the bed they both ensured the hooks or loops of the sling were secure to the Hoyer lift spreader bar. LVN B stated the sling used had been provided by the resident family member and was not a facility sling. She stated it was different in color, there was only one hook at either corner of the sling provided and facility slings had multiple hooks of different colors at each corner of the sling. LVN B stated during the transfer she positioned herself behind the wheelchair attempted to move the wheelchair under the resident when she noticed one end of the sling suddenly came off of the Hoyer lift spreader bar hook. She stated she then jumped to the side of the patient but by the time she got there Resident #1 had been lowered with the sling to the floor closer to CNA A. LVN B stated Resident #1 was still in the sling and the end of the sling that disconnected was the attachment point nearest the resident's leg. LVN B stated she supported Resident #1's head as CNA A lowered the resident completely to the floor. She stated CNA A went to get a facility sling and they transferred the resident back to bed. LVN B stated she performed a head-to-toe assessment and checked Resident #1 for injuries which she had none. She stated there were no noted bruises, signs or symptoms of distress, resident vital signs were normal, the resident had not vomited, and she noted no signs or symptoms of pain like grimacing. LVN B stated she called the unit managers and physician immediately notified them what happened and that she did not witness the resident hit her head on the floor. She stated ADON C notified Resident #1's family member of what happened, and she notified the resident's family member of a change in the resident's condition when she vomited later in the day at 2:00 PM. LVN B stated after the incident at 11:30 PM every 15 minutes for the 1st hour after the incident and then every 30 minutes for the next hour she monitored Resident #1 for any changes in condition and there were none. She stated at 2:00 PM CNA A notified her Resident #1 vomited but had a hx (history) of vomiting with her gastrostomy tube feedings, she notified the NP who told her to hold the tube feedings and she administered physician ordered breathing treatment. LVN B stated during a Hoyer lift transfer as one person was operating the lift the second person was to ensure the resident is well positioned with the wheelchair. She stated she believed the accident occurred because one of the sling ends suddenly came apart. LVN B stated she had been trained on use of the Hoyer lift with in-service training and before using the lift she should check the sling to ensure it was intact, there were no rips, and the hooks were in proper position. She stated also being trained to check the Hoyer battery was charged. She stated before the incident with Resident #1 she and CNA A checked to see the Hoyer lift battery was operation and the sling hooks and attachments of the sling were intact. Review of facility witness statement dated [DATE], made by CNA A reflected, I (CNA A) went into the patient (Resident #1) room and the patient family member had the patient clothes was hanging up in front of the closet and she (family member) laid the sling in the chair. The family member always demands to use what she brings in for her mother. The nurse in charge (LVN B) and myself went to transfer Resident #1 from the bed to her chair with the Hoyer lift. We hooked the four ends of the sling on the lift. While lifting her up one of the sling ends came apart from the lift, the other 3 ends including the two at the top of the head was still on the Hoyer lift. I begin lowering the lift to prevent the patient from falling completing on the floor. While my nurse rushed to hold the patient head, I lowered the lift to the floor. Then we put her back in bed for the nurse to examine her body for any injuries. She also checks her vital signs, there was no injury and vital signs were good, we then transfer her in her chair for two hours. In an interview on [DATE] at 10:48 AM with CNA A she stated Resident #1 was total care dependent for transfers and positioning and could not assist with any of her activities of daily living. She stated [DATE] was the first time she had helped Resident #1 up from her bed to the wheelchair. CNA A stated LVN B told her Resident #1's family member requested the resident be transferred from her bed to the wheelchair. CNA A stated Resident #1's family member came to the facility each evening and prepared the items staff were to use to care for Resident #1. She stated in her room were laid out the dress Resident #1 was to wear and a sling on the wheelchair the family member left for staff to use to transfer Resident #1. CNA A stated the sling she observed was not a facility sling and on the sling Resident #1's name was in black marker with the note personal property of Resident #1. CNA A stated she had not seen the sling she described prior to [DATE]. CNA A stated the items Resident #1's family member wished for her to use in the care of her mother were laid out for her as they had been in the past. CNA A stated she told LVN B the sling was not a facility sling because the name of the resident was on the sling, it was one piece of cloth and the facility sling was netted, it had only one attachment hook at each of the four corners and the facility sling had multiple points of attachment at each corner. CNA A stated she did not see anything to be wrong or defective with Resident #1's sling. CNA A stated LVN B responded Resident #1 did not get up from bed often but did not comment on the sling when she stated it looked different. CNA A stated it had been her experience while caring for Resident #1 for the last 8 months that the resident's family member wanted staff to use the items she provided to care for her mother and not facility items. CNA A stated she and LVN B placed the sling under Resident #1 and then hooked the four end of the sling to the hooks of the Hoyer lift. CNA A stated she operated the Hoyer controls from one side of the resident's bed while LVN B positioned herself on the opposite side of the bed. CNA A stated she then slowly lifted Resident #1 from the bed and lowered the resident's bed. She stated then moving the resident's bed out of the way to have enough space to move the lift and Resident #1 over the wheelchair. CNA A stated as she raised the Hoyer lift with Resident #1 in the sling LVN B stabilized the resident in the sling with her hands to move the resident toward her wheelchair. She stated LVN B then moved behind the wheelchair to position the wheelchair under Resident #1. She stated as LVN B attempted to position the wheelchair under the resident they heard a bang and one of the ends where the sling was hooked to the Hoyer lift spreader bar came apart. CNA A stated Resident #1 started to fall down because the sling was not balanced, and the resident's weight was shifted to one side. CNA A stated Resident # 1 did not entirely come out of the sling, LVN A jumped the bed and positioned herself next to the resident as she lowered Resident #1 in the sling to the ground. CNA stated she did not see Resident #1 hit her head at any time and that things happened quickly within seconds. CNA A stated LVN B ensured Resident #1's head did not hit the floor. CNA A stated once Resident # 1 was on the floor she removed the damaged sling, ran to get a facility Hoyer sling, placed the new sling under the resident, and with LVN B assisted Resident #1 back to bed. She stated she assisted LVN B with turning the resident in bed as LVN B assessed the resident for injuries. CNA A stated LVN B assessed the resident entire body. CNA A stated Resident #1 had not vomited during the assessment. CNA A stated during the assessment she did not observe any bruising or other injuries. She stated Resident #1 normally was not verbal and was not vocal after the incident. She revealed no other changes in Resident #1's behavior and stated Resident #1 did not grimace as if in pain. CNA A stated she continued to work with Resident #1 after the incident up to 10:00 PM. CNA A stated she was assigned to Resident #1 that day because the resident's family member had issues with other aides abiding by her directions for caring for her mother and she did follow the direction of the resident's family member. CNA A stated Resident #1's family member did not tell her to use the sling but after working with the resident for 8 months it was normal behavior for the family member to provide the items, she wished for staff to use in the care of Resident #1 and that is why she used the sling she was placed in Resident #1's wheelchair with her name on it. CNA A stated after LVN B assessed the resident they placed Resident #1 in her wheelchair using facility sling and LVN B called the other two-unit managers ADON C and ADON D to assist her and she left the room. CNA A stated when Resident #1 was assisted to the wheelchair she was had not vomited. She stated Resident #1 remained in up in the wheelchair for approximately 2 hours. She stated during the two hours she observed LVN B continue to monitor Resident #1's BP. CNA A stated at 2:00 PM when Resident #1 was assisted back to bed she noticed the resident had vomited and notified LVN B who immediately notified the unit managers. She stated Resident #1's family member arrived at the facility between 8:00 PM and 9:00 PM and Resident #1 had a small portion of vomit on her shirt. CNA A stated she was trained on using the Hoyer lift with in-service training approximately every ,d+[DATE] weeks. She stated being trained to ensure the sling was in good condition, the hooks of the sling were not cut, and ensure the Hoyer lift moved up and down before using it on a resident. She stated she performed the checks as trained with the Hoyer lift equipment and that is why she noticed the sling used was different than facility slings. She stated the facility sling had multiple points of attachment and if one were to break other points of attachment would have caught the sling. She stated she did not like the sling provided by the family member and would not have used that sling, but the family member had arguments with other aides not using the equipment she provided for Resident #1, and she used the sling provided to avoid the family member having issues with her. Review of facility witness statement dated [DATE], made by a Student bystander reflected, On [DATE]th, 2022 at approximately 11:20 (A.M), I witnessed an incident involving a resident and two staff members of which I cannot name because I am not aware of their names; I stood across the hall and witnessed the Hoyer lift being used on a resident incapable of moving and at a moments' notice I noticed that the resident was falling and had abruptly fallen on the ground. The resident had sharply and suddenly hit the ground, and from where I was standing, it seemed as if the resident first hit their back and buttocks; I had heard groaning but could not distinguish whether it was the resident as mentioned earlier or another resident. After that, the staff members checked the resident to ensure they were okay, and shortly after, I made my way toward my classmate and partner to alert her of what had just happened. After notifying my partner, I made conversation with the resident I was currently with, then slowly made my way toward the scene and asked about another resident's bed bath. I was told something along the lines of: Can't you see we're busy? Can't you see there's a resident on the ground? I believe the room number was 811, Resident #1. The Hoyer lift sling did not look damaged or torn it any shape or form from my standpoint of view. All I know about the care staff involved is that it was a nurse and a NA (nurse aide) assigned to the 800 hall, on [DATE]th. Record Review of facility Continuing Care Network Mechanical Lift Competency Skills Checklist dated [DATE] for LVN B and CNA A. Record Review of facility photograph provided [DATE] of sling used by LVN B and CNA A during the incident involving Resident #1. The sling was grey in color, had four points of attachment (loops one at each corner of sling) for the Hoyer lift spreader bar (portion of lift where sling is to be attached), written on the sling was Personal Property of Resident #1 RM 811. In an interview on [DATE] at 12:38 PM with ADON C stated Resident #1 required total staff assistance with transfers. He stated Resident #1 was nonverbal in speech and he had been involved in her care for over 2 years. ADON C stated [DATE] LVN B retrieved he and ADON D and stated Resident #1 during a transfer from bed to wheelchair using the Hoyer lift was falling but she assisted the resident to the floor breaking her fall and lowered the resident to the ground. He stated asking LVN B specifically if Resident #1 hit her head to which she replied no and LVN B stated she had assisted Resident #1 with her hands lowered her to the floor. ADON C stated he and ADON D went to Resident #1's room around 11:45 AM and 12:00 PM and the resident had already been placed in the wheelchair by LVN B and CNA A. ADON C stated he observed Resident #1 to be comfortable, with no signs or symptoms of pain like moaning, abnormal body movements, or grimacing to the face. ADON C stated when he was in the room, he noticed the sling LVN B and CNA A used to transfer Resident #1 was not a facility sling and both LVN B and CNA A told him the resident's family member and EC brought the sling to the facility. ADON C stated the sling used was smaller than the facility slings, there was only 1 attachment hooks of the sling one at each of the four corners of the sling and facility slings had 4 different attachment hooks at each of the four corners of the sling. ADON C stated the sling used appeared to have one of the attachment hooks come apart as though it loosened but did not complete break. ADON C stated he believed the sling used was too little and the weight of the resident in the sling loosened the attachment point. ADON C stated when he initially responded to the room to see Resident #1, she had not vomited. He stated at the time of the incident around 11:45 AM and 12:00PM he along with LVN B and ADON D called the resident's family member to report the incident. He stated he returned to Resident #1's room around 3:00 PM to assess the resident and at that time the resident had no injuries, no vomit was noted, she was not showing any changes in condition nor pain. ADON C stated between 8:00 PM and 9:00 PM Resident #1 had vomited, he along with the assigned nurse went to the room called 911 at the request of the family member and EC who was present, and the resident was taken to the hospital. ADON C stated he had spoken to the family member after Resident #1 has been admitted to the hospital and was told the resident passed away. He stated in [DATE] he trained staff himself on the use of Hoyer lift transfers and each had to return demonstration on safety measures. ADON C stated a Hoyer lift required use of minimum two persons at all times, before equipment was used staff are to ensure it if functioned well by plugging it in to check it elevates and descends, the battery was charged, inspect the sling hooks for tears and worn areas, and if any defects are noted in the equipment, it should be discarded and not used. He stated in Resident #1's situation the family member was very involved in her care and wanted it performed a particular way. He stated he believed LVN B and CNA A when they stated the family member provided the sling used, but he was not sure how long ago it had been brought into the facility. ADON C stated he had not been told by LVN B or CNA A the sling used was in the resident's room, he stated the risk of using the sling provided by the family member was it might not hold the resident and the resident may fall. He stated he had not instructed staff to use the sling provided by the family member during his Hoyer Lift training. In an interview on [DATE] at 1:28PM with ADON D she stated on [DATE] around 11:00 AM she and ADON C were summoned to Resident #1's room by LVN B. She stated LVN B told her during a transfer of Resident #1 from bed to the chair the resident was almost falling but LVN B told her she broke the resident fall and lowered her to the ground. ADON D stated she immediate went to Resident #1's room and saw the resident seated in her wheelchair. ADON D stated she had cared for Resident #1 in the past for 2 to 3 years and when in the room did not note any changes in the resident's condition. She stated Resident #1 was seated comfortably in the wheelchair with a facility sling behind her. ADON D stated she observed the sling used during the initial transfer and it was the first time she had seen the sling and noted it was not one used normally in the facility. She stated the sling had only one attachment point at each of its 4 corners and facility slings had multiple points of attachment at each of its 4 coroners. She stated the resident's sling appeared to be big enough and CNA A told her the resident's family member brought the sling to the facility for her to use. ADON D stated LVN B told her one of the attachment points of the sling came loose during the transfer of Resident ##1 who was falling but both LVN B and CNA A had broken the fall of the resident. ADON D stated LVN B did not tell her Resident # 1 hit her head during the transfer and based upon her assessment of the resident and interactions with her in the past she did not note any changes in the resident's condition. ADON D stated being told by LVN B later in the day she was unsure what time it was, but that Resident #1 had vomited, and she saw the emesis on the resident's chest. She stated was a gastrostomy tube feeding resident with a history of vomiting in the past. ADON C stated she and LVN B sopped the resident gastrostomy tube feeding, notified the NP and assisted the resident back to bed from her wheelchair with the head of the bed elevated. In an interview on [DATE] at 2:36pm with NP she revealed she provided care for Resident # 1 for 3 to 4 years. She stated Resident #1 required maximum assistance from staff for transfers with the use of a Hoyer lift. NP stated she was notified Resident #1 had an incident on [DATE] and asked LVN B if there were any injuries and was told Resident #1 was assisted to the floor after a malfunction of the Hoyer lift. She stated based upon initial reports provided by LVN B of the incident she did not provide LVN B any additional physician orders to administer for Resident #1. The NP stated she was notified by LVN B around lunch time on [DATE] Resident #1 vomited, staff held the gastrostomy tube feeding and the resident had no other changes in her condition or vital signs at that time. She stated Resident #1 had a history of vomiting with her gastrostomy feedings in the past and the facility with adjusting her tube feeding rates it would resolve. The NP stated the Resident #1 was transferred to the hospital and her family member and EC left a message on her phone which indicated Resident #1 later passed away at the hospital. She stated Resident #1's attending MD told her he had spoken with Resident #1's family, and it was reported to him the resident was treated for a subdural hematoma, sepsis as result of a urinary tract infection, and pneumonia. She stated Resident #1's family with the resident at the hospital decided comfort care as a treatment plan for the resident. The NP stated she viewed a video clip of the incident Resident #1's family member and EC sent to her Sunday [DATE]. She stated based on the video she could not actually see if the Resident #1 hits or falls to the floor because at a point the resident was out of camera view. She stated Resident #1 could have sustained an injury or possible trauma as result of the incident, but she could not tell for certain without seeing what happened from the video clip provided. An interview on [DATE] at 9:55 AM with Resident #1's the attending MD revealed he was her physician for the last couple years. He stated Resident #1 required total assistance with Hoyer lift transfers, was totally bed bound with advanced dementia, and had a history of recurrent urinary tract infections. MD stated his NP was notified on [DATE] of the incident at the facility with Resident #1. He stated based upon his review of Resident #1's hospital medical records revealed she expired but he did not know the cause of death. He stated he believed Resident #1 at the hospital was treated for a fall and an infection, as a result the family choose comfort care and Resident #1 expired in the hospital. The MD stated the hospital did perform a computerized tomography (CT-series of x-ray images taken from different angles around the body creating cross-sectional images of bones, blood vessels and soft tissue) of her brain an noted a subdural hematoma. He stated he did not know if the subdural hematoma was acute or chronic and could not correlate any of Resident #1's injuries with the incident that occurred at the facility. The MD stated Resident #1 was an elderly dementia patient with multiple comorbidities, multiple infections over course of her treatment, multiple gastrostomy tube feeding issues and all of the above along with the incident on [DATE] could have contributed to her death. He stated it was difficult for him to state the incident on [DATE] was Resident #1's cause of death but all of her comorbidities could have contributed to her outcomes at the hospital. He stated Resident #1 had a history of vomiting at times during his care for her. He stated at times in the past when Resident #1 would not tolerate her gastrostomy feeding staff would stop the feeding allowing her stomach to adjust and start it again afterwards and had been doing so for over the last 2 years. He stated the reported vomiting for Resident #1 based upon her history and staff response to remedy it wound not be something staff would send her to the hospital for. The MD stated he was not aware Resident #1's family member and EC provided a sling to the facility to use for her mother. An observation and interview on [DATE] at 10:28 AM of video reported by Regional RN was provided by Resident #1's family member and EC. The video was 4 minutes and 59 seconds in length and observation was made with Regional Nurse. Regional Nurse stated video started with Resident # 1 in her room HOB elevated resident in the bed with sling under her, two staff members LVN B and CNA A standing on opposite sides of the bed. He stated CNA A was nearest the Hoyer lift controls and LVN B was nearest the side of the bed closest the bathroom door. Regional Nurse stated Resident #1 at the opening of the video in the sling with four hooks of the sling attached to the Hoyer lift spreader bar Resident #1's body still resting on the bed, with both CNA A and LVN B talking to each other but not in English. At 4 minutes 09 seconds time stamp on the video Regional RN stated he observed Resident #1 in bed HOB elevated, seated in the sling, all hooks of the sling attached to the Hoyer lift spreader bar when CNA A started to raise the resident from the bed and tension with tension applied to all 4 hooks of the sling straps. At 3 minutes 59 seconds time stamp on the video Regional RN stated he observed Resident #1 suspended off of the bed with both CNA A and LVN B with hand on the sling attachment points closest the resident knees, tension in all 4 attachments of the sling and he described there did not appear to be any failure in the sling. Regional RN stated he did not identify the sling in the video as being a facil [TRUNCATED]

Based observation, interview, and record review, the facility failed to maintain an Infection Prevention and Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one (Resident #1) of fourteen residents observed for infection control. 1. CNA B and CNA C failed to sanitize the hoyer lift before and after resident use. 2. CNA B failed to perform hand hygiene after Resident #1's care. These failures placed residents at risk of infections. Findings included: 1. Review of Resident #1's Face Sheet, dated 12/23/2020, revealed she was a [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1's care plan, dated 12/23/2020, revealed Resident #1 had . catheter and is at risk for increase UTI's . R/T: [MEDICAL CONDITION] . Further review revealed a care plan goal that . catheter will remain patent and (Resident #1) will not develop increased incidence of UTI's over the next 90 days. Resident #1's care plan further reflected (Resident #1( has DX [MEDICAL CONDITION] . is at risk for increased weakness . and tiredness. Further review revealed a care plan goal that (Resident #1( will have needs met and provided by staff for the next 90 days . monitor (Resident #1( for infections and protect from infectious persons after [MEDICAL CONDITION] has been completed. Observation on 12/23/2020 at 10:01 a.m. revealed CNA B pushed a Hoyer lift down the hall towards Resident #1's room. CNA B then parked Hoyer lift across from Resident #1's room Observation on 12/23/2020 at 10:17 a.m. revealed CNA B and CNA C entered Resident #1's room and washed their hands, then donned a hospital gown and gloves. CNA C then exited Resident #1's room and obtained a Hoyer lift from the hallway and pushed it into Resident #1's room. CNA B and CNA C failed to clean or sanitize the Hoyer lift before bringing it into Resident #1's room. CNA B and CNA C transferred Resident #1 from her bed to her electric wheelchair. During maneuver, Resident #1 was observed grasping both hands on the Hoyer lift. Once is the transfer was completed, CNA B pushed the Hoyer lift into the hallway outside of Resident #1's room. CNA B and CNA C were observed providing care for the resident then exited Resident #1's room. CNA B and CNA C fail to sanitize the Hoyer lift after use. 2. Observation on 12/23/2020 at 10:32 a.m. revealed CNA B assisted Resident #1 with personal hygiene. CNA B then exited Resident #1's room, ambulated to a different hallway to the dirty linen room where she touched the keypad for entry. CNA B failed to perform hand hygiene after exiting Resident #1's room. Interview with CNA B on 12/23/2020 at 1:01 p.m. revealed she did not sanitize the Hoyer lift device before or after use with Resident #1. She stated she did not do it as a routine and did not remember being trained on it. When asked what could happen if shared equipment was not sanitized between use with residents, she stated spread of infection can occur. CNA B also acknowledged she did not perform hand hygiene immediately after exiting Resident #1's room and after performing care. She further stated the potential outcome when proper hand hygiene practices were not followed included germs and infections can spread. Interview with CNA C on 12/23/2020 at 1:28 p.m. confirmed she did not sanitize the Hoyer life before or after use with Resident #1. She stated she was educated about sanitizing equipment upon hire but was not aware of any in-services since then. She stated that infections and germs could be passed on if shared equipment was not sanitized before and after resident use. Interview with DON on 12/23/2020 at 3:29 p.m. revealed his expectations were for staff to sanitize equipment before and after use. He stated if equipment was not sanitized before and after use, it could result in infection spread. The DON also stated his expectations was for staff to perform hand hygiene after resident care, stating that if proper hand hygiene was not practiced, it could contribute to the spread of infection. Interview with Administrator on 12/23/2020 at 3:48 p.m. revealed her expectations were for staff to sanitize equipment before and after use. She stated if equipment was not sanitized before and after use, it could result in bacteria and germs growing. The Administrator also stated her expectations were for staff to perform hand hygiene after resident care, stating that if proper hand hygiene was not practiced, it can contribute to the passing on of infections. Record Review of the facility's policy, revised March 2019, titled CLEANING MULTI USE MEDICAL EQUIPMENT revealed, Multi use medical equipment such as . lifts . that goes in and out of Patient's rooms will be disinfected before and after using the equipment with an [MEDICAL CONDITION] wipe or approved disinfectant solution. PROCEDURE . Prior to entering the Patient's room clean any medical equipment you will be using on the Patient with the appropriate [MEDICAL CONDITION] wipe. Allow to dry. Immediately after exiting the Patient's rooms clean the medical equipment you used with the appropriate [MEDICAL CONDITION] wipe. Allow to dry. Record Review of the facility's policy, revised March 2019, titled HANDWASHING GUIDELINES revealed, After patient contact . wash hands with soap and running water . may use hand sanitizing gel in place of soap and water.

Based on interview and record review, it was determined the facility failed to ensure one (Resident #1) of five residents (Residents #1, #2, #3, #4, and #5) received the proper treatment and respiratory care to maintain his oxygen saturation level. The facility failed to provide Resident #1 with the physician-ordered amount of oxygen. Resident #1's oxygen saturation levels were decreasing to the 70s, but three (RN B, Unit Manager C and LVN A) of three licensed nurses did not increase the amount of oxygen he was receiving. They failed to consult with the facility's Respiratory Therapist consultant to ensure the resident was provided with the oxygen needed when he was admitted to the facility. An Immediate Jeopardy (IJ) was identified on [DATE]. While the IJ was lowered on [DATE] to a severity level of "Actual harm that is not immediate jeopardy" and a scope of "pattern," the facility remained out of compliance due to continuing to provide training to staff, monitoring staff for implementation of the plan of removal to ensure new admissions were screened appropriately for care requirements, use of respiratory equipment and meeting residents' oxygen needs. These failures caused Resident #1's respiratory status to deteriorate to [MEDICAL CONDITION]. The resident's family member called 911 due to the resident's continued respiratory distress, and he was taken to the hospital where he died on [DATE]. These failures presented a risk of potential harm to the 30 residents residing in the facility, who required oxygen therapy, and placed them at risk for respiratory difficulty, respiratory distress, and potentially [MEDICAL CONDITION]. Findings included: Resident #1's history and physical for re-admission to the facility dated [DATE] listed [DIAGNOSES REDACTED]. An undated, handwritten document identified by the DON on [DATE] as a hospital report called to the facility prior to the admission for Resident #1 reflected the following: "...End stage [MEDICAL CONDITION], [MEDICAL CONDITIONS] Pneumonia, [MEDICAL CONDITION] and Depression. O2 = Mask 100% (Non Breathing) 96% Drop when the mask is removed. A&O X ,[DATE] (Alert and Oriented to person and place), 1 PM pick up from ______ (Hospital)...." An invoice dated [DATE] from a Durable Medical Equipment (DME) company reflected the following was ordered by the facility, a 10 liter concentrator, a high flow tubing and cannula and a high flow humidifier. A hospital progress note dated [DATE] at 10:30 AM, written by the discharge planner from a local hospitl where Resident #1 was a patient reflected the following, "Pt. (patient) eval. (evaluated) by Prairie Estates and they have accepted the pt. and made arrangements to have 10 L (liters) O2 available and can care for pt. on 100 % NRB (mask)...." Resident #1's Physician transfer orders dated [DATE] reflected the following: "...3) Discharge to NH (nursing home), 4) Admit to hospice, 5) DX - End stage [MEDICAL CONDITION], Severe [MEDICAL CONDITION], S/P (status [REDACTED]...8) O2 100% NRB (Non Re-Breather)...." An ambulance transfer document dated [DATE] reflected Resident #1 was picked up from the hospital on [DATE] at 1:05 PM. He was transferred to the cot via two person lift and placed on 10 liters of oxygen per minute via NRB (Non Re-Breather) and his oxygen saturation level was 96% (normal is 95% - 100%). According to the document, Resident #1 arrived at the facility at 1:33 PM. The nurse's note dated [DATE] at 2:00 PM (25 minutes later) reflected Resident #1 arrived at the facility at 2:00 PM, and the resident was receiving oxygen at 10 liters per minute LPM via NRB mask, which was being administered by the ambulance personnel, who had transferred him to the facility. RN B was identified as the nurse receiving Resident #1 at the facility. RN B documented the resident's oxygen saturation as 85%. The document further reflected, "During the nurse's initial assessment, ambulance staff were still present and waiting for the nurse to set up the O2 concentrator, the pt. was continuously receiving O2 from the oxygen tank (pure oxygen) provided by the ambulance. Nurse disconnected the O2 tubing from the tank (and attached it) to the concentrator without any difficulty." The document did not reflect the setting of the oxygen concentrator. The nurses note further reflected, "A few minutes later, resident's ____ (family member) complained that the O2 was not working. Nurse checked the facemask and machine and both were working fine. But the ____ (family member) kept insisting that it wasn't." RN B in her note indicated a portable oxygen tank was obtained, and then the family member began to yell for a supervisor. RN B documented when she asked why the family member wanted a supervisor, the family member replied, "No one here knows what they are doing." The note reflected it was at this point, the resident began to have respiratory distress with a 77% oxygen saturation level. The nurse's note had documentation with a 6 written over a 4 to reflect the oxygen concentrator was set at 6 liters of oxygen per minute. A nurse's note written by LVN A dated [DATE] and timed 2:05 PM reflected the LVN was called to Resident #1's room and asked to stay with him while RN B obtained a portable oxygen tank. The note reflected the following: "Resident alert and responsive, on continuous O2 @ 6 lpm via mask, O2 stats checked @ 77%." The 6 had been written over a 4. When LVN A was asked about the liter flow, she stated it was at 4 LPM. LVN A provided a written statement on [DATE] at 12:30 PM, which reflected she affirmed Resident #1's oxygen was set at 4 liters per minute. Unit Manager C's nurse's note dated [DATE] at 2:10 PM reflected she was called to the room of Resident #1, because the family member was requesting a supervisor. The note reflected the family member was upset, and finally stated, "Never mind. I called 911. Minutes later 911 arrived and assumed care. Resident left facility with O2 sats @ 77% on O2." Unit Manager C's note did not reflect the rate of flow of oxygen for Resident #1. On [DATE] at 11:30 AM, Resident #1's family member was interviewed. He/She stated he/she had been with the resident in the hospital the morning of the transfer. Resident #1's oxygen saturation levels had been in the 90s except when he had removed his mask to eat, and his saturation levels had dropped to ,[DATE]%. He/She stated he/she and Resident #1 had been told his condition was grave, and he was given a choice to go home with him/her and perhaps survive just a few days or go to the facility and live a couple of weeks. Resident #1 had chosen to return to the facility on hospice. During the transfer in the ambulance, Resident #1 had done well. He was awake and alert, and his saturation levels were staying in the 90s. He/She stated when they arrived at the facility and were taken to his room, there was no oxygen concentrator in the room. The EMTs (Emergency Medical Technician) had to ask staff for oxygen, so they could remove Resident #1 from their equipment. The family member further stated facility staff brought in the oxygen (which she described as a box they rolled in), but he/she noticed the oxygen (concentrator) only went up to (a maximum of) five liters of oxygen per minute (not the 10 LPM the resident needed). He/She stated the facility staff told him/her the unit ordered for Resident #1 (which provided as much as 10 LPM of oxygen) was actually in another room, and they would have to get it. The family member stated by the time they brought in the other oxygen concentrator, Resident #1 was having trouble "catching his breath." "I kept telling them to hurry," he/she stated, "because he couldn't breathe." He/She said he was breathing rapidly, and the bag on the mask was empty and deflated (instead of being inflated). He/She stated the nurse then left the room. At that point, Resident #1 complained of worsening shortness of breath and stated, "Help me! I can't breathe!" During the same interview, the family member stated a different staff member came into the room and tested the oxygen to make sure air was coming out. "He (Resident #1) was shaking," the family member said so he/she then requested the staff get a supervisor. The family member stated RN B came back into the room with portable oxygen, and RN B was upset, because she said, "She (RN B) did not know Resident #1 was coming." He/She stated, at one point, staff tried to put a nasal cannula on Resident #1, but he/she told them, it would not be enough oxygen, and he could not breathe through his nose. At that point, the family member said he/she called 911, because he/she felt the facility staff did not know what they were doing. While on the phone, he/she stated Nurse Practitioner F entered Resident #1's room and checked his oxygen saturation, which he/she saw was 76%. "When the ambulance got there, he was breathing deeply, but there were several seconds in between, I knew he was gone," he/she stated. According to the family member, the EMTs started CPR in the ambulance, but she asked that CPR be stopped in the emergency room , where he died . In an interview and written statement on [DATE] at 12:30 PM, LVN A stated she was aware a co-worker (RN B) was admitting a resident (Resident #1) to the facility on [DATE], but she was assigned to another hall. She stated RN B had called to her and asked her to stay with Resident #1 while she (RN B) went to get a portable oxygen tank. LVN A stated, Resident #1 was in bed with the head of the bed elevated. The resident was awake and alert and asking for help. His respirations were rapid. LVN A stated Resident #1 was wearing a NRB mask connected to an oxygen concentrator set at 4 LPM of oxygen. She stated Resident #1's oxygen saturation was in the 70's. LVN A was asked whether she adjusted his oxygen setting since Resident #1's saturation levels were so low, and she stated, "No, because I knew ____ (RN B) was on her way back." LVN A stated when RN B returned to the room, they switched Resident #1 from the oxygen concentrator to the portable oxygen tank, but his oxygen saturation level remained in the 70's. LVN A stated RN B was anxious and running around. In an interview and written statement on [DATE] at 12:40 PM, Unit Manager C stated the staff had discussed Resident #1 in stand-up meeting, and he was returning to the facility on 6 liters of oxygen, so they had ordered the special concentrator, which provided 10 liters of oxygen per minute, as their oxygen concentrators only provided up to 5 liters of oxygen per minute. She further stated she was alerted on [DATE] at 2:10 PM, someone wanted a manager. She stated as she approached Resident #1's room, she observed a family member on the phone in the hallway with 911. She stated she entered the resident's room and Resident #1 was clearly anxious, and he was stating he could not breathe. Unit Manager C stated Resident #1 was wearing an oxygen mask connected to a concentrator set at 6 liters of oxygen per minute. She stated there was a portable oxygen tank in the room, but it was not in use and not connected to the resident. Unit Manager C stated they were using a special oxygen concentrator that went up to 10 liters of oxygen per minute. Unit Manager C stated she asked LVN A what the resident's oxygen saturation level was, and LVN A had reported it as 77%. Unit Manager C was asked if she had increased the amount of oxygen Resident #1 was receiving, and she stated, "No." On [DATE] at 10:20 AM, Unit Manager C was asked about Resident #1's physician discharge orders dated [DATE] at 9:10 AM, which reflected the following, "O2 100% NRB." She was asked what equipment she would need for this resident in order to fulfill the physician order. She stated, "It would have made me nervous. I would have had to call someone." In an interview and written statement on [DATE] at 1:10 PM, the Supply Coordinator stated he was made aware of the need for the 10 liter oxygen concentrator one week before Resident #1's admission. He stated equipment that was rented specifically for a resident was stored in the central supply closet. He stated at approximately 2:00 PM on [DATE], he was notified of the room Resident #1 was going to be in. He said he went to the supply room, obtained the oxygen concentrator, and took it to Resident #1's room. He said when he brought the oxygen concentrator into Resident #1's room, the EMTs, who had transported the resident from the hospital, were still there, with their oxygen tank connected to the resident. A non re-breather mask was already on Resident #1. He stated the EMTs were still in Resident #1's room when the resident was switched to the oxygen concentrator, and the facility staff kept the non re-breather mask on Resident #1, which was supplied by the EMTs. The Supply Coordinator stated he was not aware what setting the nurse placed the resident on as he left the room. The Supply Coordinator stated he was called back to the room approximately five minutes later when RN B notified him Resident #1 was not getting any air. He stated LVN A had brought in a portable oxygen tank, tubing and a nasal cannula which had been placed on the resident along with the concentrator. At that time, the EMTs were present to transport the resident from the facility. On [DATE] at 10:35 AM, EMT E was interviewed. He stated he had transported Resident #1 from the hospital to the facility on [DATE]. He stated he clearly recalled the run and Resident #1, because he had required a high level of oxygen. EMT E stated during the run, Resident #1 was on 15 liters of oxygen via NRB, but his oxygen saturation levels were 97%. So he turned him down to 10 LPM, and his oxygen saturation level remained at 96%. The resident was alert and oriented. EMT E further stated, when they arrived at the facility, it took a long time for any staff to come to the room. "I had to call my dispatch and tell them we were delayed, because there was no staff," he stated. When someone finally came to the room, he stated, "I told them he was on 100% oxygen, and the staff said, 'We were not informed of that.' " EMT E said it was another five minutes before staff brought an oxygen concentrator into the room. It had a humidifier bottle on it, but it only went up to 5 LPM. He said he told the nurse Resident #1 needed to be on high flow oxygen, but the nurse responded by saying the 5 LPM would be enough, because it had a humidifier. EMT E added, "As we were leaving, I heard the _____ (family member) say he needed more oxygen. He was still alert and oriented when we left him." When he was asked why he left Resident #1 if he had concerns about the oxygen, he stated, "I told the nurse, and he was her patient. I assumed she knew what he needed." EMT E stated, "I think they didn't give him enough O2, and I told the nurse that when she called." He was asked what call he was referring to, and he stated 10 -15 minutes after he left the facility, his dispatcher received a call from RN B requesting he call her back. He stated when he called her, she said, "You saw me put him on oxygen didn't you?" He said he responded by saying, "I told you I had him on 10 LPM, and you bumped him down to 5 LPM." On [DATE] at 8:15 AM, the Director of Respiratory Therapy of a local hospital was interviewed. He described a NRB mask as a mask, which covers a resident's nose and mouth. The mask has a bag attached into which oxygen should be pumped and held. A valve separating the mask from the bag opens when the resident takes a breath, delivering the oxygen from the bag. The valve closes when the resident exhales preventing the exhaled air from mixing with the oxygen in the bag, thus preventing the resident from re-breathing the expired air. He stated in order for the system to work, the resident would need to be on a high flow of oxygen in order to ensure the bag remained inflated with oxygen. The flow of oxygen would routinely be set between 10 LPM and 15 LPM, but it would depend on the resident's respiratory rate and volume. On [DATE] at 8:35 AM, the discharge planner from the local hospital where Resident #1 was a patient was interviewed. She stated she had worked with the facility to ensure they were prepared to care for Resident #1. The discharge planner stated, "I told them multiple times we had him (Resident#1) on 10 LPM." She referred to a progress note she had written in the resident's clinical record dated [DATE] at 10:30 AM, which reflected the following, "Pt. (patient) eval. (evaluated) by ____ (name of facility) and they have accepted the pt. and made arrangements to have 10 L (liters) O2 available and can care for pt. on 100 % NRB (mask)...." On [DATE] at 9:18 AM, RN B was interviewed. She was asked about Resident #1's admission. She stated she was not aware she was receiving a new admission until "just before he arrived." She stated she was involved in a situation at the nurse's station, and someone else took report from the hospital. RN B stated it was just ,[DATE] minutes after Resident #1 arrived, they had an oxygen concentrator for him. She stated it was the 10 LPM oxygen concentrator, and he was placed on 6 liters of oxygen. She was asked if the orders and hospital report indicated he needed to be on 100% oxygen NRB, how would she accomplish this, and she stated, "A mask with oxygen at 6 liters." She then stated, "I am not really familiar with all the respiratory stuff. I just know 6 liters would be safe to begin with. His sats (oxygen saturation levels) were dropping on 10 liters." To clarify, she was asked if his oxygen sats were dropping on the 10 LPM the EMTs had him on, yet you thought he should go down to 6 LPM, and she responded, "Yes." RN B was then asked why she chose 6 liters when the report from the hospital and the physician orders did not specify the liters to be provided. She stated she did not know what the physician's orders were at the time, but she felt like she followed the physician orders by placing the resident on oxygen at six LPM. RN B described Resident #1 when he arrived at the facility as awake and responsive. She stated a few minutes after the EMTs had left the building, she was starting her assessment, and Resident #1's family member stated he was not getting enough oxygen. So, to make the family member feel more secure, she decided she would go and get a portable oxygen tank. RN B stated, when she returned to the room, Resident #1 was more anxious, his respirations had increased and he was asking for help. She stated, at that point, she put him on oxygen through a nasal cannula at 6 LPM on the portable tank, but his oxygen saturation levels remained below 80%. She stated, at some point, Unit Manager C and Nurse Practitioner F entered the room. Resident #1 was conscious and nodding "yes" or "no" to questions. Then EMS arrived, and she left the room to get his transfer paperwork ready. When asked about EMT E's statement she had called him after the resident had left the facility, she denied having contacted him. On [DATE] at 10:30 AM, during an interview with the DON, she stated they saw the need for a concentrator that provided more than 5 liters of oxygen a minute, because that was all the facility's currently provided. So they made arrangements to have a concentrator, which provided 10 liters of oxygen per minute and the concentrator was to be set at six liters per minutes. The DON stated the Supply Coordinator told her he would have a second concentrator available for Resident #1, which could supply an additional 5 liters of oxygen a minute if it was needed to satisfy the 100% oxygen NRB. The DON stated they would stay with the six liters on the larger concentrator, which would supply 96% oxygen. The DON then stated she was not aware Resident #1 was on 15 LPM in the hospital to maintain an oxygen saturation (of over 90%). The DON stated they were not given that information. On [DATE], it was determined an Immediate Jeopardy situation existed in the areas of Quality of Care with Substandard Quality of Care and Administration. The Administrator, Corporate Nurse and the DON were notified of the Immediate Jeopardy situation at approximately 3:30 PM on [DATE]. They were requested to provide a Plan of Removal for the Immediate Jeopardy. On [DATE] at 10:15 AM, the DON was interviewed and was asked what she would have done to fulfill the physician's order for 100% oxygen via NRB. The DON responded, she would have verified the order, had a 10 liter concentrator and liquid oxygen ready. She stated she would have contacted the RT (respiratory therapist) to figure out how to accomplish the order and call the pulmonologist...." She stated, "It was hard to find fault with the nurse (RN B), because ____ (family) was interfering, questioning the nurse the whole time." When she was asked why the facility's failures resulted in an Immediate Jeopardy, she stated, "I thought we did the best in that short span of time. They did the best they can, because they were crying afterward." On [DATE] at 11:15 AM, Respiratory Therapist (RT) H, the consultant RT for the facility was interviewed. She was asked if she was consulted regarding Resident #1's oxygen therapy, and she stated, "No." According to the Mosey Elsedier PDQ for Respiratory Care 2010 Edition used in inservices provided to the facility staff on [DATE], a "Non Rebreather flow rate of oxygen is ,[DATE] liters per minute...80% - 100%...with O2 flow rate >7l/m to flush out CO2 (carbon [MEDICATION NAME])." According to the website Medline plus at <http://www.[MEDICATION NAME].org/clinical/[MEDICAL CONDITION]-guidelines/for-patients/why-do-i-need-oxygen-therapy.php> Air is a mixture of gases. Oxygen and nitrogen are the two main gases in the air we breathe. Oxygen accounts for about 21% of gas in air. The abbreviation for oxygen is O2. Every cell in our body needs oxygen to live. In order for oxygen to get to these cells, it must be transported through the airways of the lungs... In some [MEDICAL CONDITION] patients, adequate air is brought into the alveoli, but the oxygen contained in the air is not able to pass into the capillaries surrounding the alveoli. This results in low oxygen levels and is called hypoxemia. By breathing even small amounts of additional oxygen, the oxygen level in the air rises above 21% to 23 or 24%. This small amount is enough to help "push" the oxygen into the capillaries. Since the body cannot store oxygen, oxygen needs to be given whenever the body is low on oxygen. In some instances, this means that the [MEDICAL CONDITION] patient must use oxygen 24 hours a day. The need for continuous oxygen is called long term oxygen therapy (LTOT). Oxygen therapy is important to understand because oxygen is not useful for everyone with [MEDICAL CONDITION]. In fact, oxygen is probably one of the least understood and misused therapies for people with [MEDICAL CONDITION] According to the website Medline plus at <http://www.[MEDICATION NAME].org/clinical/[MEDICAL CONDITION]-guidelines/resources/[MEDICAL CONDITION].pdf> "The nonrebreathing face mask is indicated when an FI,O2 >40% is required...Oxygen flows into the reservoir at ,[DATE] L?min, washing the patient with a high concentration of oxygen. Many episodes of worsening breathlessness in patients coming to the end of life can be avoided in a reliable care system with effective treatment (with assurance of terminal sedation if warranted) and with comprehensive advance care planning. Many patients with terminal [MEDICAL CONDITION] choose not to use ventilator support, or to use it only for a time-limited span, if they can be sure of competent relief of terrifying breathlessness...." On [DATE], the following Plan of Removal was accepted and implemented by the facility: It reflected: The Business Development Specialist and the Admissions Coordinator will both be responsible for ensuring oxygen orders and equipment needs are communicated to the nursing team for all new admissions per the pre-admission checklist. The charge nurse is responsible for ensuring all oxygen equipment needs are available. All transport services, excluding 911 emergencies will sign in at the front desk, and nursing personnel will be present before the resident is transferred to the bed. On [DATE], the facility re-assessed all current residents with respiratory needs. Orders were reviewed to ensure appropriate administration and clarified. Oxygen saturation levels were assessed. On [DATE], the facility implemented an updated assessment form for the discharge planner to utilize to more effectively and completely gather clinical data about potential new residents. On [DATE], the facility provided inservice training to staff regarding ensuring appropriate oxygen administration on admissions/re-admissions, oxygen device delivery, oxygen LPM, administration of oxygen and use of a NRB mask. The Medical Director was informed of the past event of Resident #1, which occurred on [DATE]. Quality Assurance meeting to be held by [DATE] to review, assess and reinforce items implemented from plan of removal. Quality Assurance to be informed of negative findings for review and opportunities for improvement. On [DATE] the surveyors were provided with a notebook containing copies of the reassessments of all the residents, who required respiratory care, copies of the inservices provided to staff and the sign-in sheets from [DATE] and [DATE] and copies of the updated intake forms. On [DATE] at 11:15 AM, 11:30 AM, 11:55 AM, 12:57 PM, and 1:05 PM and on [DATE] at 2:20 PM and 2:35 PM, nursing staff were interviewed regarding the training they had received. They were able to demonstrate the process for setting up oxygen therapy for a new resident. On [DATE], Residents #2, #3, #4, and #5 were reviewed for oxygen services, and no negative issues were identified. On [DATE], it was determined the IJ could be lowered to a Non-Immediate Jeopardy at a severity level of "Actual harm that is not immediate jeopardy" and a scope of "pattern." The facility remained out of compliance due to continuing to provide training to staff, monitoring staff for implementation of the plan of removal to ensure new admissions were screened appropriately for care requirements, use of respiratory equipment and meeting residents' oxygen needs. Review of the facility's 802 (Roster/Sample Matrix) revealed there were a total of 30 residents with respiratory care requirements.