Every finding on record at Prairie Grove Health and Rehabilitation, LLC

Based on observation, interview, and facility policy review, the facility failed to ensure food was prepared under sanitary conditions during food preparation, specifically, in a manner to avoid cross-contamination during puree food process. This failed practice had the potential to affect all six residents that received a puree diet. The findings include: During an observation of the lunch meal preparation on 09/30/2025 at 10:40 AM, the Dietary Manager (DM) was preparing to puree peaches. This surveyor observed the DM remove the blender lid and place it on the metal table surface. The metal table contained visible white particulate debris and off-white liquid residue between the two blender units, which this surveyor observed prior to the start of food preparation. The DM returned the lid to the blender and resumed blending, then removed the blender lid a second time and again placed the lid directly onto the same unclean surface. The spatula used to scrape the sides of the blender, was also placed on the same metal table surface during the preparation process. A review of the weekly Kitchen's Cleaning Schedule revealed the table was last cleaned on Sunday, 09/28/2025, during the morning shift. During an interview on 09/30/2025 at 10:54 AM, the DM confirmed that a barrier of clean parchment paper should have been placed on the metal table surface for the lid and spatula, before the puree process was initiated. The DM did place a paper towel down halfway through the preparation process. The DM stated she was not aware of the particulates and spillage noted on the metal table, between the two blenders, at the time the puree had begun. During an interview on 09/30/2025 at 11:00 AM, the Regional Dietary Manager (RDM) stated the metal table should be cleaned and sanitized before use and confirmed that food debris or residue should not be present on any surface used during active food preparation. The RDM confirmed that all pureed foods that were processed during the observation were tossed in the trash and not served to the residents. During an interview on 11/19/2025 at 8:40 AM, the Administrator acknowledged responsibility of overseeing the kitchen processes, along with different department heads, to ensure residents received quality meals. The Administrator also acknowledged awareness of the cross-contamination incident that had occurred during the observation. During an interview on 11/19/2025 at 10:01 AM, the DM confirmed that the kitchen staff were educated on foodborne illnesses, cleaning the kitchen, and the kitchen equipment upon hire and every month. A review of a facility in-service on pureeing foods, dated 09/30/2025, indicated that a barrier for lids and utensils was required for the process, and was signed by kitchen staff. A review of the facility's Food Preparation Policy, revised 02/2023, showed the policy required all food-contact and adjacent preparation surfaces to be cleaned and sanitized before and throughout food preparation to prevent cross-contamination.

Based on a record review, interviews, and facility policy review, the facility failed to consistently ensure generally accepted accounting practices were followed as a steward of resident trust accounts for one (Resident #38) of three sampled residents, whose trust accounts were reviewed. The findings include: A review Resident #38's admission Record indicated the facility admitted the resident with diagnoses, which included cognitive communication deficit, dementia, and malaise. A review of Resident #38's quarterly Minimum Data Set (MDS) with an assessment reference date of 09/11/2026, revealed a brief interview for mental status of 12, which indicated the resident had moderate cognitive impairment. Resident #38's MDS also revealed the resident was able to ambulate with supervision or touching assistance up to 150 feet. A review of Resident #38's Care Plan Report revealed an impaired cognitive function and impaired thought process related to dementia. Resident #38's Care Plan also revealed the resident required assistance with decision making and was able to ambulate short distances with the assistance of a walker. A review of a Resident Trust Fund Authorization form, signed electronically by Resident #38's family member on 01/04/2024, designated the facility to hold, safeguard, and account for the resident's personal funds. A review of a Resident Liability and Representative Payee document, electronically initialed by Resident #38's family member, revealed the resident chose the facility to manage their personal funds. According to the Resident #38's Resident Liability and Representative Payee document, the facility would act on the resident's behalf in a legal ethical relationship, to hold, safeguard, manage and account for the personal funds of the resident. Resident #38 chose the facility as their legal representative to manage their money that is directly received from a federal agency, the funds would be managed according to State and Federal Regulations that required usual accounting standards to be maintained. On 11/18/2025, a review of Resident #38's receipt documentation for their trust account revealed the following: - On 02/02/2025, a transaction was debited from Resident #38's trust account from a retail [NAME] for $337.11. This transaction was reviewed and revealed items purchased for a female resident which included, one men's big and tall undershirt, two 3-pack packages of men's compression socks, two pairs of men's sneakers, one 6-pack of men's diabetic socks, one pair of big men's sweatpants, two puff paints, two men's sweatshirts, one pair of big men's sweatpants, two women's pajama sets, and one men's fleece hoodie. These items were purchased by Resident #38's family member with check number 2514. The Administrator confirmed that there was no verification of items purchased for this transaction. - On 09/12/2025, a transaction was debited from Resident #38's trust account from a retail [NAME] for $478.23. This transaction was reviewed and revealed items purchased for a female resident which included, two men's big and tall long sleeved undershirts, three women's pajama sets, three men's big and tall fleece sweatshirt and pants set, three women's oversized sweatshirt and pants sets, one10-pack of men's undershirts, four antiperspirants, one 8-pack of bar bath soap, two tubes of toothpastes, two 13-ounce containers of petroleum jellies, two party size cookie packages, and two packages of 24 mega roll toilet tissue. These items were purchased by Resident #38's family member, with check number 2619, supplied by the facility. The Administrator confirmed that there was no verification of items purchased for this transaction. - On 11/15/2025, a transaction was debited from Resident #38's trust account from a retail [NAME] for $726.79. This transaction was reviewed and indicated items purchased for a female resident which included, two packs of men's socks, three men's thermal tops, two pairs of sweatpants, two ladies' sweaters, and one pair of house shoes. The following food items were also included in the purchase: seven packages of cookies, three 1-quart orange juice container, one 76-ounce lemon drink, three bottles of hot sauce, four 36-ounce containers of salad dressing, fourteen skillet dinner mixes, six seasoning packets, fifteen seasoning containers, one frozen chicken package, one 32-ounce package of frozen meatballs, four 1-pound and 2-pound packages of dry beans, two 24-ounce containers of tomato ketchup, one microwave dinner five canned foods, nine jars of pasta sauce, one 5-pound bag of flour, two 4-pounds of granulated sugar, ten packages of smoked meat, four cartons of 18-count fresh eggs, 18 cans of canned fish, nine boxes of corn meal mix, one 32-ounce box chicken broth, one 20-count box of taco shells, five boxes of cereal, six packages of lunchmeat, three 24-count packages of cheese slices, two containers of 14-ounce sour cream, one package of shredded cheese, four 48-ounce containers of vegetable oil, seven family packages of drumsticks, 24 packages of ramen noodles, two gallons of milk, one 12-ounce container of heavy cream, two 2-pound packages of frozen catfish nuggets, five frozen dinners, three boxes of instant rice, one 5-pound bag of rice, four boxes of pasta and cheese mix, two boxes of 22-ounce frozen hashbrowns, two 12-ounce packages of frozen shrimp, one bag of frozen vegetables, three cans of cooking spray, and five packages of butter sticks. These items were purchased by Resident #38's family member, with a check supplied by the facility. The retail [NAME] system would only allow the amount of $726.79 to be purchased with a personal check, the balance of $588.95 was paid by the family member's personal debit card and presented for reimbursement from the residents trust account on 11/17/2025. - Additional purchases made on 11/15/2025, that had been deducted from Resident #38's trust account, during initial review of the account included: 11 boxed dinner mixes, one refrigerated pie crust, two 18-count boxes of uncooked sausage patties, three family packs of uncooked chicken wings, two packages of cubed ham, twelve 1-pound tubes of ground beef, twelve containers of yogurt, two 5-pound bags of pork chitterlings, five 2.5-pound packages of uncooked chicken thighs, four 2.5-pound packages of pork ribs, three packages of chicken drumsticks, two packages of chicken breast, twelve 3-pound packages of pork chops, four 2.5-pound packages of pork ribs, two 1.5-pound tubes of ground beef, two 1-pound bags of dried peas, one 2.5-pound package of ham hocks, four 12-ounce bags of frozen shrimp, four cans of soup, two packages of sliced bread, two 59-ounce containers of juice, fifteen lunch snack packs, one can of fruit, three 2-pound packages of frozen fish, two 21-ounce packages of meatballs, two 1-pound package of smoked sausages, two smoked hams, two racks of baby back ribs, two 32-ounce containers of egg nogg drink, and one 2-pack of cream cheese. These items were purchased by Resident #38's family member after instruction from the Administrator to spend down the resident's trust account, and the receipt was presented for payment in the amount of $588.95 on 11/17/2025. The Administrator had already made out check number 2647 for this amount and debited the amount from Resident #38's trust account, as indicated by review of the resident trust account statement provided on 11/17/2025 by the Administrator. The Administrator reported that after the interview with this surveyor, she contacted the family member and informed them that the amount could not be paid, due to the type of merchandise purchased. Resident #38's trust account was credited in the amount of $588.95 as revealed by review of the trust account statement provided by the Administrator on 11/19/2025. During an interview on 11/17/2025 at 12:30 PM, the Administrator reported that Resident #38's trust account was administered by herself. The Administrator stated reporting the process for the resident trust accounts was when the account approached the limit, the resident or their responsible party were contacted and instructed of the need to spend down their account. The Administrator denied giving any specific instruction other than the purchase was to be for the resident's personal use, indicating the party responsible, family, or the resident were contacted by phone or in person. The Administrator admitted that the receipt presented for payment out of Resident #38's trust account was not verified prior to the purchase amount being deducted from the residents trust account. The purchased items were sometimes brought much later. The Administrator reported that the family member was provided with a blank check and was instructed to bring the receipt back to the facility. The Administrator indicated that while serving as administer of Resident #38's trust account, she had never verified a purchase for the resident with the receipt provided. The Administer reported I've never had an issue with it, I just take it for granted and the Administrator failed to respond when asked if the purchases listed on the 11/15/2025 receipt, for $1,315.74 were appropriate for Resident #38. The Administrator confirmed that there was no verification of items purchased for this transaction and the family member had not presented any items for verification with the receipts. The Administrator's response when asked what evidence was provided by the family member to verify the items purchased was I don't know. The Administrator reported that Resident #38 did not indicate, by signature or verbal consent, to the gross expenditure from Resident #38's account on 11/15/2025, in the amount of $1,315.74. The Administrator denied requesting consent from Resident #38, prior to allowing the family member to spend $1,315.74 out of the resident's trust account. During an interview on 11/17/2025 at 2:02 PM, the Social Services Director (SSD) indicated they were the staff responsible for marking the personal items for the residents and adding the items to the inventory sheet. The SSD reported that they did not verify any purchases with the receipts, just marked the clothing when it was brought in for Resident #38. The SSD reported the last time Resident #38's family member brought anything in to be marked for the resident was 10/29/2025. The items were identified as two shirts, five pairs of sweats, and three pairs of pajamas. These items were identified from a purchase made on 09/07/2025, on the receipt of a local [NAME]. During an observation on 11/17/2025 at 2:00 PM, this surveyor observed clothing in Resident #38's closet, which revealed various t-shirt style tops, sweatshirt style tops and bottoms, and socks in the drawers, which did not match the clothing items on the receipt provided. During an interview on 11/17/2025 at 2:40 PM, Resident #38's family member reported that they had been contacted by the Administrator and informed that the resident's trust account had to be spent down. The family member reported that the facility was responsible for the residents trust account, and the statement came to them. Resident #38's family member reported that the only instructions they received for a spend down were that any purchases be for the resident. The family member indicated that Resident #38 did not go shopping with them on 11/15/2025, but that the items were purchased for Thanksgiving and the resident's birthday party. Resident #38's family member reported that to the best of their knowledge, the resident had not signed any papers indicating what the money could be spent for or if there were any preferences. The family member reported the items purchased for Resident #38 were brought to the facility for SSD to mark. The family member reported they had never been required to present items purchased with the receipt, which indicated the receipt was just slid under the door, and they got a check back if they made the purchases, prior to getting a check. During an interview on 11/18/2025 at 9:03 AM, the Administrator reported the facility did not require a resident to sign any documentation giving permission to a separate person for spending authority from their trust account. During an interview on 11/18/2025 at 11:36 AM, the Administrator indicated the facility did not have any documentation from Resident #38, which allowed family to make expenditures from the resident's trust account. The Administrator reported the facility did not have any Power of Attorney documents for financial management from the family member, allowing the residents family to make purchases on the resident's behalf, only the signature of the family member on the admissions paperwork. A review of a facility policy titled Management of Residents' Personal Funds with a review date of 6/24/2019 revealed 3. The facility will hold, safeguard, manage and account for the personal funds of the resident. 5. The residents will be notified in advance of any charges entered on their personal trust account, with written permission obtained from the residents. 6. A copy of all financial transactions will be filed in the resident's permanent record.

Based on observation, interview, and record review, it was determined that the facility failed to ensure kitchen equipment and surfaces were clean and clean dishes were stored properly. Findings include: 1. On 06/17/2024 at 11:15 AM, during the initial tour of the facility's kitchen, the Surveyor looked to the right of the kitchen door and saw there was a food blender sitting on a table. The table the blender was sitting on had a light brown runny substance that covered a 4 inch by 6 inch area. There was a metal kitchen ladle sitting on the table. The Dietary Aide (DA) brought over bread slices and a gallon of milk and began putting the bread and milk in the processor. The DA then turned the machine on to blend the food. 2. On 06/17/2024 at 11:20 AM, during an initial brief tour of the facility's kitchen, the Surveyor asked the Dietary Manager (DM) to slide the grease traps out. The DM slid the left side out and it had a piece of aluminum foil over it. On the top of the foil was mostly black in color with clumps of brown and black substance all over the top. The DM immediately took the foil off and discarded it stating, That needs to be cleaned. 3. On 06/17/2024 at 11:24 AM, the Surveyor walked to the right of the stove where dishes were stacked. The bowls were stored in an upright position instead of inverted. The Surveyor asked the DM if the dishes were clean. The DM stated, Yes, those are clean. 4. On 06/19/2024 at 11:33 AM, just before observing food puree, the Dietary Aide (DA) placed a barrier down for scoop and lid on the left of the blender. To the right side of the blender, there were light brown clumps or crumbs of an unknown substance. The DA then brought the food and placed it in the blender and began to blend. Once the DA finished blending the food, the DA washed the blender in preparation for another food to puree. While the DA was washing the blender, another dietary aide came over and wiped the clumps off that were on the right side of the blender. 5. On 06/19/2024 at 11:40 AM, a bread toaster was observed on a shelf underneath the blender. The toaster was covered in tiny light colored clumps or crumbs. There were also two skillets observed on the top of the stove being stored upright instead of inverted. a. On 06/19/2024 at 2:20 PM, the Surveyor asked the DM why it is important to keep grease traps on the stove clean. The DM stated to keep the stove from catching on fire. The DM was asked how often the grease trap is checked and cleaned. The DM stated that it is supposed to be checked at the end of each day. b. On 06/19/2024 at 2:22 PM, the Surveyor asked the DM why it is important to keep clean dishes stored upside down. The DM said to keep from contaminating them. The DM was asked why it's important to keep kitchen equipment clean. The DM said for infection control. c. On 06/19/2024 at 2:30 PM, the DM provided a copy of the in-service staff were provided on 5/15/2024 regarding coffee maker, food temperatures, proper thawing methods, labeling and dating, and utensil usage. d. On 06/19/2024 at 2:49 PM, the Administrator provided a copy of the policy for kitchen equipment cleaning, Policy 027. The policy stated, .1. All equipment will be routinely cleaned and maintained in accordance with manufacturer's directions and training materials. 2. All staff members will be properly trained in the cleaning and maintenance of all equipment. 3. All food contact equipment will be cleaned and sanitized after every use. 4. All non-foods contact equipment will be clean and free of debris. 5. The Dining Services Director will submit requests for maintenance or repair to the Administrator and/or Maintenance Director as needed. 6. The Dining Services Director will notify the Administrator when repairs are completed. 7. Copies of service repairs and preventative maintenance reports will be submitted monthly.

Based on observations, interviews, record review, and facility document review, the facility failed to ensure the call light system was functioning for 1 (Resident # 39) of 1 sampled resident reviewed for call light function. Findings include: During a concurrent observation and interview on 06/18/2024 at 8:32 AM, Resident #39 was asked about his room for function, comfort, and available supplies. Resident #39 stated his only complaint was his call light was broken. Resident stated it quit functioning last week and he told the girl at the time. When asked who he told, Resident #39 stated he couldn't remember her name, but it was one of the Certified Nursing Assistants (CNAs). This Surveyor asked the resident to press the call light. When the button was pushed, the light on the wall behind the Resident lit up. The light in the hallway above Resident #39's room did not light up from either direction in the hall. This Surveyor waited 2 minutes then walked to the nurse's station. Transporter #1 confirmed Resident #39's call light was not going off at the central call light screen. During an interview on 06/18/2024 at 9:20 AM, this Surveyor spoke with Maintenance Personnel #2 about procedures for work orders. Maintenance Personnel #2 handed me a binder and explained staff write any issues with the date and time in the binder and maintenance checks it each day and follows up. Maintenance Personnel #2 confirmed no issue with Resident #39's call light was documented in the binder prior to 06/18/2024 after it was identified by the Surveyor. During an interview on 06/20/2024 at 8:28 AM, CNA #4 verbalized the procedure for reporting maintenance issues; report it to the maintenance personnel and write it in the maintenance logbook that is kept in the slot on the outside of the maintenance door. During an interview 06/20/2024 at 11:40 AM, the Administrator was asked for the policy and procedures for call lights. The Administrator stated there was not a policy in place, but facility procedure was to do a monthly check on each resident's call light. The Administrator reported no recent operational issues with the call light system, and stated in the event there was a downtime of an individual call light or the system itself they have squeaky toys and bells in the disaster room. The Administrator also stated if a resident's call light was not functioning it should be written on the maintenance log for repair and in the event it occurs on the weekend, the staff should call and notify her or maintenance personnel. The Administrator confirmed no issue with Resident #39's call light was documented in the maintenance log prior to 06/18/2024.

Based on interview and record review, the facility failed to provide a written notice of a facility-initiated discharge for 1 (Resident #111) of 2 sampled residents reviewed for discharge. The findings are: Review of Resident #111's Admission Record revealed the resident was admitted to the facility on [DATE] with diagnoses of traumatic brain bleed and dementia with psychotic disturbance. According to the Admission Minimum Data Set with an Assessment Reference Date of 01/08/2024, the resident scored 8 on a Brief Interview for Mental Status indicating moderate cognitive impairment. Review of the Final Discharge Summary dated 02/29/2024, revealed Resident #111 was transferred to an inpatient psychiatric facility for treatment and from that facility was discharged home. During an interview on 06/20/2024 at 11:55 PM, the Administrator reported the facility was unable to keep Resident #111 safe due to continued suicidal ideations and repeated attempts of self-harm even after inpatient psychiatric stay. The Administrator stated the resident representative was informed verbally that the facility could not keep the resident safe and would not be able to readmit to the facility. The Administrator confirmed the facility provided a written transfer to the hospital notification to the resident representative but failed to notify the resident representative in writing of facility-initiated discharge due to not being able to meet the resident's safety needs. On 06/20/2024 at 1:57 PM, the Administrator provided a policy titled, Discharge/Transfer Letter. Upon review, the policy contained a statement and instructions for items to be included in the written notice of transfer or discharge, the reason for transfer or discharge, the effective date of transfer or discharge, and the location to which the resident is transferred or discharged .

Based on observation, record review, and interview, the facility failed to ensure Dietary Staff washed their hands and changed gloves before handling food items to prevent the potential for cross contamination for residents who received meals from 1 of 1 kitchen; ensure food items stored in the refrigerator, freezer and dry storage areas were covered or sealed and expired food items were promptly removed from stock to prevent potential food borne illness for residents who received meal trays from I of I kitchen; and to ensure frozen food items were kept frozen to prevent the potential for bacteria growth for residents who received meals from 1 of 1 kitchen, and the facility failed to ensure that the ice machine scoop was handled in a sanitary manner. These failed practices had the potential to affect 56 residents who received meals from the kitchen (total census: 56), as documented on a list provided by the Dietary Supervisor on [DATE]. The findings are: a. On [DATE] at 11:16 AM, Dietary Employee (DE) #1 turned on the hand washing sink's faucet and washed her hands. She then turned off the sink's faucet with her bare hands, contaminating them. She removed tissue from the tissue dispenser and dried her hands. Without washing them, she picked up a pan with her thumb inside of it and placed it on the counter. She emptied 2 cans of apple slices into a bowl. She held a box of gloves and removed gloves from the glove box into her hands, contaminating them. She added sugar to the apple, mixed it and transferred it into a pan. She also mixed the oatmeal and brown sugar and sprinkled the mixture on top of the apple, then placed the pan of apple crisp in the oven to be baked and served to the residents for lunch. b. On [DATE] at 11:29 AM, DE #2 held the box of gloves and removed gloves from the box, contaminating the gloves. Without changing the gloves, she used the same contaminated gloved hands to pick up the clean utensils by their tips and placed them in the condiment dispenser and holder for the residents to be used in eating their lunch. c. On [DATE] at 11:41 AM, DE #2 turned on the food preparation sink's faucet, picked up a glass by the rim, and obtained the water. She turned off the faucet and placed the glass of water on the counter, added thickener and mixed it to be served to the resident on a nectar thickened liquid diet. d. On [DATE] at 11:44 AM, the following food items on the counter in the kitchen were not covered or sealed: 1. An opened bag of [named mashed potatoes]. 2. An opened box of cornstarch. e. On [DATE] at 11:59 AM, DE #1 picked up a rag from the floor and placed it in a dirty container. Without washing her hands, she picked up a measuring cup with her fingers inside the cup and placed it on the counter. She poured the Italian dressing in the cup and poured it on the crushed tomatoes in a pan on the counter to be served to the residents for their lunch. f. On [DATE] at 12:02 PM, DE #1 turned on the hand washing sink's faucet and washed her hands. She removed the tissue and used them to turn off the faucet. She then used the same tissue to dry her hands. She placed the gloves on her hands, contaminating them. She removed the slices of cheese from the bag and placed them in a container to be used in the sandwiches to be served to the residents for their lunch. g. On [DATE] at 12:13 PM, DE #2 pushed a cart that contained glasses close to the ice machine in the Dining Room. She emptied the packets of sugar into 2 of the glasses that contained ice cubes. Without washing her hands, she picked up the glasses by their rims and poured tea to be served to the residents for their lunch. h. On [DATE] at 12:20 PM, DE #1 turned on the hand washing sink's faucet, washed her hands, and placed on her gloves. She unzipped a packet that contained slices of turkey. Without changing gloves and washing her hands, she removed a slice of turkey and placed it on the cutting board. i. On [DATE] at 12:23 PM, DE #1 turned on the hand washing sink's faucet and washed her hands. She removed the tissue and used them to turn off the faucet. She then used the same tissue to dry off her hands. She placed the gloves on her hands, contaminating them. She removed the slices of cheese from the bag to place them in a container to use in the sandwich to be served to the residents for their lunch. j. On [DATE] at 12:33 PM, DE #2 opened the refrigerator door and removed a pan that contained the beverages and placed it on the counter. Without washing her hands, she picked up the glasses by their rims and placed them on the pan of ice on the cold side of the steam table. The Surveyor asked DE #2, What should you have done after touching dirty objects and before handling clean equipment? She stated, I should have washed my hands. k. On [DATE] at 12:47 PM, DE #1 opened a bag of shredded lettuce and placed it on the counter. She placed gloves on her hands, contaminating them. Without changing gloves and washing her hands, she removed the shredded cheese from the bag and placed them in a bowl. She picked up the diced tomatoes and placed them on the shredded lettuce. At 12:50 PM, DE #1 sliced the turkey into pieces and placed it on the lettuce and tomatoes to be served to the residents who requested salad. The Surveyor asked DE #1, What should you have done after touching dirty objects and before handling clean equipment? DE #1 stated, I should have changed gloves and washed my hands. l. On [DATE] at 2:52 PM, DE #2 was putting up cartons of supplements and ice cream that was left over from lunch in the freezer. The Surveyor asked DE #2 to check the temperature on the chocolate milk. DE #2 stated, It was 58 degrees Fahrenheit. The Surveyor asked DE #2 if the ice cream was still frozen. She lifted the lid from the ice cream and stated, It melted. m. On [DATE] at 10:07 AM, there was an opened, uncovered box of bacon on the shelf in the refrigerator. n. On [DATE] at 10:14 AM, there was an opened, unsealed box of biscuits on the shelf in the freezer. o. On [DATE] at 10:18 AM, the following expired canned goods were on a shelf in the Storage Room. 1. Three of 3 cans of beets were on a shelf in the Storage Room with an expiration date of ,d+[DATE]. 2. Five of 5 cans of chocolate pudding with an expiration date of ,d+[DATE]. 3. Five of 5 cans of chili con carne [with meat] and with beans with an expiration date of ,d+[DATE]. p. The facility policy titled, Hand Washing, provided by the Dietary Supervisor on [DATE] at 3:32 PM documented, Handwashing with soap and water is required in a Dining Services Setting in the following situations: In between glove changes. For example, when changing tasks. After removing gloves. When beginning your shift, after handling dirty dishes or trash. When you take one step away from your workstation and Between tasks. 47916 1. Resident #30 has a diagnosis of Alzheimer's Disease with late onset, and Legal Blindness. a. The Quarterly MDS dated [DATE] reveals Resident #30 requires limited one-person assistance for meals. b. On [DATE] at 12:31 PM, Dietary Employee #1 exited the kitchen door and went into the Dining Area, used her hands to unlock the ice machine and scooped the ice into a silver bowl. The scoop rested on the ice machine door. c. On [DATE] at 12:33 PM, the Surveyor asked DE #1 if she performed hand hygiene before getting ice from the machine. DE #1 said, I washed my hands before I left the kitchen. The Surveyor asked what did she touch from the time she washed her hands in the kitchen. DE #1 said, I should have washed or re-sanitized my hands. The Surveyor asked about the possible outcome of not using hand hygiene, and the scoop touching the ice machine door. DE #1 said, Cross contamination. d. On [DATE] at 12:53 PM, CNA #1 was standing above Resident #25, taking her by the right hand and scooping food onto the spoon and feeding her. CNA #1 walked around the table and assisted Resident #30 by supporting a two handled spout cup. She placed her hands over Resident #30's hands and lifted the cup up to her mouth. She then rubbed Resident #30's left hand with her right hand. CNA #1 did not sanitize her hands between feeding the residents. e. On [DATE] at 1:00 PM, the Surveyor asked CNA #1 about her process for hand hygiene between Residents #25 and #30. CNA #1 said, I forgot we do not feed the residents while standing above them, and we use hand sanitizer. I usually have sanitizer in my pocket, but I did not have any sanitizer today. The Surveyor asked CNA #1 what the possible consequences were of not using hand hygiene between the residents. CNA #1 said, Cross contamination. f. On [DATE] at 8:25 AM, the Surveyor asked the Director of Nursing (DON) if it was appropriate for staff to place their hands on another resident hands to assist with eating, and to assist another resident with eating without washing their hands or using hand sanitizer. The DON said, No, they should probably get hand sanitizer between residents, The Surveyor asked if there are any possible consequences when not using hand hygiene between feeding the residents. The DON said, They are spreading germs. The Surveyor asked if it was appropriate to scoop ice from the ice machine after resting the scoop on the ice machine, and without performing hand hygiene. The DON said, No it is not. It spreads germs. g. The facility policy titled, Handwashing/hand Hygiene, provided by the DON on [DATE] at 8:41 AM, documented, All personnel shall be trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare associated infections, all personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. Hand hygiene products and supplies (sink, soap, towels, alcohol-based hand rub, etc.) shall be readily accessible and convenient for staff use to encourage compliance with hand hygiene policies. Use an alcohol-based hand rub containing .before and after direct contact with residents .

Based on observation, interview, and record review, the facility failed to treat 3 (Residents #13, #25, #30) of 5 (#13, #15, #25, #30, #33) sampled residents with dignity and respect while assisting with feeding the residents. The findings are: 1. Resident #13 had a diagnosis of Alzheimer's Disease, Unspecified, Dysphagia, Oropharyngeal Phase, other reduced Mobility. a. The Quarterly Minimum Data Set (MDS) dated [DATE] shows Resident #13 requires total dependence with one-person assistance for meals. b. On 06/19/23 at 1:53 PM, Certified Nursing Assistant (CNA) #2 was feeding Resident #13 applesauce while standing over him. On 06/19/23 at 2:08 PM, She sat down and continued to feed him. c. On 06/21/23 at 8:17 AM, the Surveyor asked CNA #2 what the procedures were for feeding the residents, and why Resident #13 was fed applesauce from a standing position. CNA #2 said, It was my first day working this shift. I normally work 2nd [second] shift and did not know. Someone had to come over and remind me. The Surveyor asked if there was any possible consequence from feeding residents from a standing position. CNA #2 said, It is like you are looming over them. It might make them feel inferior. 2. Resident #25 had a diagnosis of Multiple Sclerosis, and Paraplegia, Unspecified. a. The Quarterly MDS dated [DATE] showed Resident #25 is independent with set up assistance for meals. b. On 06/20/23 at 12:53 PM, CNA #1 was standing above Resident #25, assisting her with scooping food in her spoon. She took Resident #25 by the right hand and scooped the food onto the spoon. c. On 06/20/23 at 1:00 PM, the Surveyor asked CNA #1 about her process for feeding residents. CNA #1 said, I forgot we do not feed residents while standing above them. 3. Resident #30 had a diagnosis of Alzheimer's Disease with late onset, and Legal Blindness. a. The Quarterly MDS dated [DATE] showed Resident #30 requires limited one-person assistance for meals. b. On 06/20/23 at 8:22 AM, CNA #3 was standing over Resident #30 while feeding her cereal and assisting her with a nectar thick house shake. c. On 06/20/23 at 8:24 AM, CNA #3 said, I have to sit down. I'm getting old. CNA #3 sat down and assisted Resident #30 with the spout cup of house shake. d. On 06/21/23 at 8:23 AM, the Surveyor asked the Director of Nursing (DON) if it was appropriate to stand over the residents while assisting them to eat. The DON said, No, if they are having trouble, we tell them to go to the other side of the table to assist the resident with their meal. The Surveyor asked, Why we do not stand over residents to feed them? The DON said, It is a dignity issue. e. On 06/21/23 at 10:40 AM, the Surveyor asked CNA #3 if Resident #30 had any special accommodations that would require feeding while standing above her. CNA #3 said, No, I should have fed her from a sitting position. I did get a chair and moved to her side to finish feeding her. She is blind, and I can get her to eat better than others. The Surveyor asked if feeding a blind resident from across the table was an issue with assisting her to eat. CNA #3 said, No, but she does better when you sit to her side. That is why I did get a chair and sit to the side and feed her. f. The facility policy titled, Assistance with the Meals Policy, provided by the DON on 06/21/23 at 11:49 AM documented, Residents who cannot feed themselves will be fed with attention to safety, comfort, and dignity. g. The facility policy titled, Residents Rights, provided by the RN Consultant on 06/21/23 at 12:17 PM documented, The nurse consultant provided the Residents Rights policy stating our facility will make every effort to assist each resident in exercising his/her rights to assure that the resident is always treated with respect, kindness, and dignity.

Based on observation, interview, and record review, the facility failed to ensure Physician's Orders were followed for medication administration for 1 (Resident #43) of 2 (#8 and #43) sampled residents residing on the secure unit who utilized inhalers for respiratory treatment, and failed to ensure a beverage provided by staff belonged to the correct resident to prevent potential cross contamination for 1 (Resident #43) of 3 (#8, #14, and #43) sampled residents residing on the secure unit who had Physician Orders for thickened liquids as documented on the list provided by the DON on 06/22/23 at 8:49 AM. The findings are: 1. Resident #43 had diagnoses of Lobar Pneumonia, Emphysema, and Shortness of Breath. a. The Physician Order with a start date of 07/30/22 documented, .Resident to use a spacer with Albuterol and other Pulmonary Inhalers .every shift . b. The Physician Order with a start date of 06/05/23 documented, .Albuterol Sulfate HFA [Hydrofluoroalkane] Aerosol Solution 108 (90 Base) MCG/ACT 2 puff inhale every 6 hours as needed for SOB [Shortness of Breath] . c. The Physician Order with a start date of 12/05/22 documented, .diet .Nectar consistency . d. On 06/19/23 at 1:40 PM, Resident #43 was sitting in a wheelchair near the Day Room and was coughing. The surveyor heard Licensed Practical Nurse (LPN) #1 ask Certified Nursing Assistant (CNA) #4, Do you know if the thickened water PT [Physical Therapy] brought back is for Resident #43? I can't remember what she said CNA #4 stated, I don't know if it's hers. The surveyor observed LPN #1 take the half full, uncovered, plastic cup of thickened water and handed it to Resident #43 and stated to the Resident, Either way, it will be fine. LPN #1 stated to Resident #43, This should help. e. On 06/19/23 at 1:52 PM, Resident #43 continued sitting in her wheelchair near the Day Room coughing. LPN #1 obtained an inhaler from the medication cart and explained to Resident #43 that the medication was Albuterol. LPN #1 explained to Resident #43 to blow out then she would place the inhaler in her mouth, and that she needed to breathe in. LPN #1 failed to utilize a spacer to administer the inhaler to Resident #43. The Surveyor observed some of the mist of the medication exited out of the top of the inhaler around the canister. LPN #1 immediately gave Resident #43 a 2nd [second] puff. LPN #1 stated, I don't think you got any of that one. I need you to breathe in. LPN #1 gave Resident #43 a 3rd [third] puff and the Surveyor observed some of the mist spray out of the top of the inhaler. LPN #1 then administered a 4th [fourth] puff and stated, I think we got at least one good one. f. On 06/21/23 at 8:10 AM, the Surveyor asked LPN #4, If a thickened beverage is unlabeled and uncovered should it be served to a resident? LPN #4 stated, No. The Surveyor asked, If staff are unsure who a thickened beverage is made for, and has been sitting out, should it be given? The LPN #4 stated, No, never. A new one should be made. The Surveyor asked what the possible outcomes would be if a resident was given a beverage that was not theirs. LPN #4 stated, Sickness, infection, choking if it is not the right consistency, and spreading of germs. g. On 06/21/23 at 8:15 AM, the Surveyor asked the DON, If a thickened beverage is unlabeled and uncovered should it be served to a resident? The DON stated, Uncovered, No. The Surveyor asked, If staff were unsure of who the thickened beverage was made for, and if it has been sitting out, should it be given? The DON stated, No. The Surveyor asked what the possible outcomes would be if a resident was given a beverage that was not theirs. The DON stated, Spread of germs. h. On 06/21/23 at 9:34 AM, the Surveyor asked LPN #2, If the Physician's Order for an Albuterol inhaler was for 2 puffs, how many should be administered? LPN #2 stated, Two. The Surveyor asked, What is the purpose of the spacer? LPN #2 stated, So they can get more of it in. The Surveyor asked, What could happen if too many puffs were given? LPN #2 stated, They can get nauseous, and their heart rate can speed up. The Surveyor asked, What could happen if a spacer was not utilized? LPN #2 stated, They might not get enough of the medicine. i. On 06/21/23 at 9:39 AM, the Surveyor asked LPN #3 If the Physicians Order for an Albuterol inhaler was for 2 puffs, how many should be administered? LPN #3 stated, Two. The Surveyor asked, What is the purpose of the spacer? LPN #3 stated, To allow them to inhale all of the medication effectively and to prevent it from sticking in their mouth and causing thrush. The Surveyor asked, What could happen if too many puffs were given? LPN #3 stated, Could cause jitteriness, an increase in heart rate, and a med (medication) error. The Surveyor asked, What could happen if a spacer was not utilized? LPN #3 stated, They might not inhale all of the medication and not be effective. j. On 06/21/23 at 9:43 AM, the Surveyor asked the DON, If the Physician Order for an Albuterol inhaler was for 2 puffs, how many should be administered? The DON stated, Two. The Surveyor asked, What is the purpose of the spacer? The DON stated, To ensure they are getting all of the medication. The Surveyor asked, What could happen if too many puffs were given? The DON stated, An increase in heart rate. The Surveyor asked, What could happen if a spacer was not utilized? The DON stated, There is a chance that she does not get all of the medication. k. The facility policy titled, Administering Medications through a Metered Dose Inhaler, provided by the DON on 06/21/23 at 11:09 AM documented, .Preparation .6. Check the label on the inhaler and confirm the medication name and dose with the MAR [Medication Administration Record] .14. c. If the inhaler has a spacer, pull it away from the inhaler until it clocks into place .15 .Allow at least one (1) minute between inhalations of the same medication . l. The facility policy titled, Personal Competency Review, provided by the DON on 06/21/23 at 11:22 AM documented, .Competency: Med Pass (Nurse) dated 06/08/23 for LPN #1 .Number of previous observations: 1 . and was marked Pass next to Correct dose is administered. m. The facility policy titled, Therapeutic Diets, provided by the Administrator on 06/22/23 at 9:52 AM documented, .All residents have a diet order, including regular, therapeutic, and texture modification, that is prescribed by the attending Physician .

Based on interview and record review, the facility was in past non-compliance and failed to ensure adequate supervision and monitoring was provided to prevent an elopement for 1 (Resident #1) of 3 (#1, #2 and #3) sampled residents who were at risk for elopement. These failed practices resulted in non-compliance at the level of Immediate Jeopardy, which had the potential to cause injury, harm, and impairment for Resident #1, who eloped from the facility out the front door using the door code, was missing for approximately 2 hours, traversed over a mile from the facility, with access to a busy streets ,and had the potential to cause more than minimal harm to 11 residents who were at risk for elopement, as documented on a list provided by the Administrator on 06/06/23 at 9:54 AM. The Administrator was informed of the Past Immediate Jeopardy on 06/06/23 at 2:45 PM. The findings are: 1. Resident #1 was admitted to the facility's 200 Hall secure unit on 04/07/23 and had diagnoses of Unspecified Dementia. The Admission Minimum Data Set (MDS) with an Assessment Reference Date of 04/11/23 documented a score of 15 (indicates cognitively intact) on the Brief Interview of Mental Status (BIMS), required limited physical assistance of one person for locomotion on unit and locomotion off unit, Not steady, only able to stabilize with staff assistance. a. The Wandering assessment dated [DATE] documented a score of, .11 .high risk for wandering .known wanderer/hx [history] of wandering . b. The Care Plan with an initiated date of 04/10/23 documented, .has a diagnosis of Dementia .remains at risk for elopement, direction and cueing from staff . is a high risk for falls r/t [related to] deconditioning . confusion .increased risk of falls and fractures, dizziness c. The facility's Electronic Health Records documented on 04/27/23 that Resident #1 was moved from the 200 Hall secure unit to general population on the 500 Hall. d. The Witness Statement written by Nursing Assistant (NA)#1 on 05/13/23 documented .It was dinner time, we just started serving. I noticed she [Resident #1] wasn't out in the dining room, so I went in her room to go find her and she was not in there. I proceeded to let the nurse/CNAs know she was not anywhere around. e. The Progress Note dated 05/14/23 at 22:00 [10:00] documented, . resident was noted to not be in her room when staff went to get her for dinner. Resident was looked for in the day room, and staff was not able to find her. Staff notified this nurse and this nurse activated EOP for Elopement, called staff to search for the resident in the facility and outside. This nurse called the Director of Nurses (DON). The Resident had not been found so facility and outside was searched a second time. CNAs tried calling resident's cell phone several times, but the resident continued to hang up. DON and Social Services Director (SSD) arrived at facility and made contact with family who then called resident themselves and made contact. Family then notified DON resident's location, the DON then retrieved resident and escorted safely back to facility. Resident then moved to secure unit per family request. Q [every] 15-minute checks initiated along with body audit. f. On 06/06/23 at 10:30 AM, Resident #1 was sitting on the side of the bed in her room. The Surveyor asked, Tell me about when you left the facility and walked home to get some clothes and your electric wheelchair. Resident #1 replied, I wanted to go home, I live 5 blocks from here, to get some clothes and my electric wheelchair. The Surveyor asked, How did you know the code to get out of the front door? Resident #1 replied, I had watched someone else put the code in and remembered it. The Surveyor asked, Did you tell anyone you were leaving the facility? Resident #1 replied, No, I did not tell anyone I left, I got some clothes, and I was tired, so I got my electric wheelchair and rode back. She stated, I had put my address in my maps on my phone, but I got lost on the way back, I took a wrong turn, and my battery was low. I was missing a couple of hours before they noticed I was gone. The Surveyor asked, Have you always been on 200 Hall? Resident #1 replied, No, I was on 200 Hall, then they put me on 500 Hall, and after I left, they put me back on 200 Hall and I was [expletive], but I understand because I left without telling anyone. The Surveyor asked, Did you get hurt while you were out of the building? Resident #1 replied, No, I was sore from the walking, but didn't get hurt. Resident #1 stated, I called my [family member], then my [family member] called and said they were looking for me. g. On 06/06/23 at 1:05 PM, the Surveyor asked the SSD what occurred on 05/13/23 regarding Resident #1. The SSD stated, The DON called me. When I got here, I directed the staff to do another search. I called Resident #1's [family member], and she happened to be with Resident #1's [family member]. Resident #1's [family member] called Resident #1, and I could hear in the background that he reached her. I told the DON to get in the vehicle and Resident #1 was on the electric wheelchair down there. The Surveyor asked, Where was Resident #1? The SSD stated, They said she was at the water park. [named Resident #1] had told [named family member] she wanted clothes and her electric wheelchair, and she was on her way back. The Surveyor asked when she was notified of Resident #1 being missing. The SSD stated, the DON called me at 5:28 PM. The Surveyor asked if she saw Resident #1 leave. The SSD stated, I did not, No. The Surveyor asked the reason the DON was called and not the Administrator. The SSD stated, The staff had tried to call the Administrator first and then they called the DON, and the DON called me. h. On 06/06/23 at 1:05 PM, a telephone interview was conducted with Certified Nursing Assistant (CNA) #1. The Surveyor asked, Were you working with Resident #1 on 05/13/23? CNA #1 replied, I was working with Resident #1. The Surveyor asked, Did Resident #1 tell you she was leaving the building? CNA#1 replied, No, I had no idea. The Surveyor asked, When was the last time you saw Resident #1? CNA#1 replied, Around 4-4:30 PM, she was sitting on the bed crocheting. The Surveyor asked, When did you notice Resident #1 was gone? CNA#1 replied, We were getting ready for supper around 4-4:30 PM, I was passing room trays and the other CNA went to get Resident #1, and she wasn't in the room, I stopped and looked in the Bathroom and the Day Room, I couldn't find her, I told the Licensed Practical Nurse (LPN) #1. LPN #1 couldn't find Resident #1, so I went back to passing trays and LPN #1 called the Code for elopement and they started looking for her. The Surveyor asked, What time was it when Resident #1 was found? CNA#1 replied, Between 5:30 PM and 6:00 PM. The Surveyor asked, Had Resident #1 ever eloped before? CNA#1 replied, No. The Surveyor asked, Did Resident #1 have exit seeking behaviors prior to exiting the facility on 05/23/23? CNA#1 replied, No. The Surveyor asked, Did Resident #1 sustain any injuries? CNA#1 replied, Not that I know of. The Surveyor asked, Did Resident #1 see a Physician after returning to the facility? CNA#1 replied, Not sure, they moved her to the unit after that. i. On 06/06/23 at 1:13 PM, the Surveyor asked the Administrator, What occurred on 05/13/23 regarding Resident #1? The Administrator stated, They called me and notified me they could not find her. They had done a search of the grounds. [named SSD] had called family. I watched the cameras after and [named Resident #1] put in codes, fluffed her hair, and went out. I gave orders for audits and new Wander Assessments. She [Resident #1] had never had exit seeking before. The Surveyor asked, Who notified you and at what time? The Administrator stated, [named DON] called me. I was out of service when they 1st [first] called me. The first call was from [named LPN #2] the nurse at 5:20 PM and then from [named DON] at 5:31 PM. The Surveyor asked if she saw Resident #1 leave. The Administrator stated, I saw her leave the cameras at 3:30 pm. The Surveyor asked if any other residents eloped recently. The Administrator stated, No, the last one was a year ago. j. On 06/06/23 at 1:16 PM, a telephone interview was conducted with Licensed Practical Nurse (LPN) #1. The Surveyor asked, Did Resident #1 ever elope or have any exit seeking behaviors prior to 05/13/23? LPN #1 replied, No. The Surveyor asked, Did Resident #1 tell you or anyone she was leaving? LPN #1 replied, No. The Surveyor asked, When was the last time you saw Resident #1 that day? LPN #1 replied, On the 500 Halls, in the hallway talking to another resident, that was after 3 PM. The Surveyor asked, When did you find out Resident #1 was missing or couldn't be found. LPN #1 replied, Around dinner time, the assistants asked if I had seen Resident #1, they said she wasn't in the room, we looked in other residents' rooms, we couldn't find her, I called the code for elopement. The Surveyor asked, What time was the code called? LPN #1 replied, After 5:00 PM. The Surveyor asked, When you call the code for elopement, who do you notify? LPN #1 replied, We tried to call the Administrator and the DON, it took a couple of tries to get them, I think [named SSD] came in with the DON, and they notified the police, they looked inside and outside a couple of times. The Surveyor asked, Where was Resident #1 found? LPN #1 replied, The DON found Resident #1 at her old house, where she used to live, 5 blocks away. The Surveyor asked, How did Resident #1 get back to the facility? LPN #1 replied, The DON brought her back to the facility. The Surveyor asked, was Resident #1 seen by a doctor? LPN #1 replied, The in-facility doctor checked her out. The Surveyor asked, Did Resident #1 have any injuries? The LPN #1 replied, No. The Surveyor asked, What interventions were put in place after the elopement? LPN #1 replied, Resident #1 was moved from 500 Hall to 200 Hall, the secure unit, every 15-minute checks were done for maybe a day or two, not sure. The Surveyor asked, Has Resident #1 had any exiting seeking behaviors or eloped since the incident on 05/13/23? LPN #1 replied, No. k. On 06/06/23 at 1:19 PM, the Surveyor asked the DON, What occurred on 05/13/23 regarding Resident #1? The DON stated, [named LPN #1] called me and said they initiated a search and could not find her. The Surveyor asked what time she was notified. The DON stated, 5:26 PM. I live 3 min away. I called [named SSD] and she called the daughter in law [named]. Staff told me they had been calling [named Resident #1] for a while. The Surveyor asked what time she called the SSD. The DON stated, 5:28 PM I called [named SSD] and tried to call [named Administrator]. [named LPN #1] told me she had tried to call [named Administrator] but could not reach her. The Surveyor asked what time she called the Administrator. The DON stated, 5:29 PM. The [named SSD] told me the family told her that they knew where she was, and I went and followed her back here. The Surveyor asked what time she arrived at Resident #1 and where she was located. The DON stated, Honestly about 5:30 or so. She was on a side street, [named street], and she was on the phone with her [family member] when I pulled up. I escorted her back. The Surveyor asked how long she was missing. The DON stated, [named Administrator] stated she went out about 3:30 PM, so about 2 hours. The Surveyor asked if staff are responsible for knowing where residents are at all times. The DON stated, Yes. l. On 06/06/23 at 2:26 PM, the Surveyor asked the Administrator about the afternoon temperature on 05/13/23. The Administrator stated, 83 degrees. The Surveyor asked what she utilized to determine this. The Administrator stated, [named internet search engine]. The Surveyor asked if the address on Resident #1's face sheet was correct. The Administrator stated, Yes. The Surveyor asked what the distance was to Resident #1's home where she obtained the electric wheelchair. The Administrator stated, Exactly 1 mile. The Surveyor asked one way or total distance. The Administrator stated, One way. The Surveyor asked what she utilized to determine the distance. The Administrator stated, [named Map and location application]. The Surveyor asked what hazards were between the facility and Resident #1's home. The Administrator stated, Traffic is all I know of for sure. The Surveyor asked how the facility ensured door codes were not obtained by the residents. The Administrator stated, We change them monthly, and staff are trained to know they are kept confidential. Families know them, so that cannot be controlled. If we find out someone knows the code that should not, we immediately change them. m. The facility's policy titled, Elopements, provided by the Administrator at 9:54 AM documented, .4. If an employee discovers that a resident is missing from the facility, he/she shall .b. initiates a search of the building(s) and premises .c. If the resident is not located, notify the Administrator and the Director of Nursing Services, the resident's legal representative, the Attending Physician, law enforcement officials .

Based on observation, interview, and record review the facility failed to ensure equipment was clean and dry between uses; staff used sanitary procedures when serving food; the walls, lights, sprinkler heads, and stove were clean; staff washed the hands prior to preparing food; outdated and spoiled food were removed from use; and staff were hair nets and covered all of their hair to provide a sanitary environment and prevent the potential for food borne illness. The findings are: 1. On 03/21/22, the following observations were made: a. At 11:40 AM, Cook #2 obtained small pans for pureed foods with his fingers, non-gloved, down inside pans. After Cook #2 pureed the casserole he wiped his hand on his chest. Cook #2 cleaned the food processor and left 1-2 tablespoons of sanitation water in processor bowl. DM #1 was asked to check the container and see how much water was in bowl. DM stated there was still 2 teaspoons of liquid in bowl and dumped it out in the sink. The Cook was not wearing gloves and picked up 5 slice of bread out of bag to puree and laid bread slices against food remnant covered chest, while he twist-tied the bread bag closed. The food processor parts were dripping with water between uses. Kitchen staff #3 was observed putting thumb on plates while holding and placed a piece of cake partially on thumb and then pulled thumb from under cake piece and covered with plastic wrap. b. At 11:56 AM, the paint was peeling and flaking off the wall near the dish washer and onto stainless area where dishes were sitting. There was brown and gray fuzzy build up hanging off of the sprinkler heads in the kitchen. c. At 12:08 PM, there was a dirt buildup hanging from edge of the light and around light on ceiling. There was brown and gray fuzzy build up hanging from a vent and brown box mounted above the steam table where food was halfway covered with lids. There was an opening in the ceiling to attic/crawl space above storage area for clean dishes, with no door or cover noted, with grayish fuzzy substance hanging from edges d. At 12:10 PM, while re-pureeing food, Cook #2 began coughing and exited area quickly out of sight of and was heard making gagging sounds. DM #1 began re-pureeing and Cook #2 joined. There was no observation of Cook #2 washing his hands upon return. d. At 12:14 PM, on the stove were food particles and blackish brown, thick, shiny build up around burners. DM #1 reported a new oven/stove was ordered today and should be arriving in the next few days due to burners not lighting appropriately. DM #1 had to light stove burner with handheld lighter. e. At 12:30 PM, onions on the dry food storage shelves had black, soft, mold-like areas and 3 inch long green growths on them. f. At 12:35 PM. in the single door freezer there were ice cream sandwiches dated as received 5/26 (21). There were grayish, iridescent, leathery ice crystals formed on sandwiches. DM #1 stated one could be opened to check. Some of the dark brown chocolate parts of the sandwich had lighter brownish-gray patches. DM #1 stated she should probably throw them away. g. At 12:39 PM, the triple door freezer contained: 1) Loose hamburger patty with grayish, iridescent, leathery ice crystals in box outside of bag that held other patties. 2) A box of peas with grayish, iridescent, leathery ice crystals dated opened 3/16 in open bag not tied. 3) Venom energy drink found in freezer on shelf not dated. DM #1 stated it was an employee's drink. 4) A box of French toast with grayish, iridescent, leathery ice crystals dated 3/16 found open in a bag not tied. 5) A box of cookie dough with grayish, iridescent, leathery ice crystals dated 3/16 found open not tied. h. At 12:41 PM, DM #1's hair net had hair in back hanging out and kitchen staff #3 had hair hanging out in the back and 4-5 inches out on the sides. 3. On 03/22/22 at 2:10 PM, DM #1 was asked to describe what she saw on the ceiling and around the lights and she stated, it looks like cobwebs, dirt, and well, just filthy and needs cleaned. DM #1 was asked how often the walls, vents, ceiling are cleaned the DM #1 stated monthly, but has not been done this month yet. Policies for storage and cleaning requested from DM #1. 2. On 3/23/22 at 8:35 AM Policy for Cold Food storage stated, 5. All foods will be stored wrapped or in covered containers, labeled and dated, and arranged in a manner to prevent cross contamination. The Environment policy received from DM #1 stated, 1. Dietary Services Director will ensure that the kitchen is maintained in a clean and sanitary manner, including floors, walls, ceilings, lighting, and ventilation. Equipment cleaning received from DM #1 stated, 2. All staff members will be properly trained in the cleaning and maintenance of all equipment . 5. The Dining Services Director will submit requests for maintenance or repair to the Administrator and/or maintenance Director as needed . 6. The Dining Services Director will notify the Administrator when repairs are completed. 3. On 3/24/22 at 8:59 AM, DM #1 was in the kitchen without hair net.

Based on observation, record review and interview, the facility failed to ensure kitchen lighting was in good repair and a hole in the laundry room was repaired to maintain a sanitary, comfortable, and home-like environment. Findings are: 1. On 03/21/22 at 11:40 AM, there were 5 partial-working ceiling lighting fixtures in the areas of dish cleaning, clean dish storage, and food storage in the kitchen. One metal light bar holder above the serving area had a duct tape covered end and one light tube was not working. Dietary Manager #1 (DM) was asked who takes care of repairing and replacing the lights and she stated maintenance. She was asked if maintenance had been notified to the lack of lighting, she stated, Not sure. I really hadn't noticed lately. I guess we just get used to it being this way. 2. On 3/22/22 at 2:27 PM, in the dryer room of the laundry room was a hole above the air conditioner 2 feet wide by 3 inches tall with dry, white spray foam dripping from the air conditioner. There were numerous pieces of dry spray foam on blankets folded under air conditioner. Laundry manager (LM) #1 was asked who was responsible for the repair, and he stated maintenance was. He was asked if maintenance was notified and LM #1 stated he was not sure. 3. On 3/24/22 at 8:35 AM, Laundry staff #2 asked how long the hole had been above air conditioner had been there. She stated Ever since I have worked here, Laundry Staff #2 was asked how long she had worked at facility, and she stated about 2 years. She was asked if she had ever noticed an issue with bugs or rodents and she stated she had not. She was asked if she felt the space above the air conditioner could allow bugs or rodents in and she stated No, she has not seen any. On 3/24/22 at 10:12 AM, Maintenance Manager #1 (MM) was asked when he was notified about the opening, and he stated about 2-2 1/2 months ago. MM #1 stated he had tried to fill area with spray white stuff about 2 ½ months ago but it didn't work. MM #1 was asked to show logbook mentioned. MM #1 stated there was not much in it because he throws them away when he is done with them. 4. On 3/24/22 at 8:59 AM, Staff #4 was washing dishes and there were no lights above work area working. 5. On 3/24/22 at 9:59 AM, Dry goods food storage policy received from DM #1 stated, .4. The Dining Services Director or designee regularly inspects the dry goods storage area to ensure it is well lit DM #1 was asked her title and she stated Dietary Manager. She was asked who was the Dining Services Director, and DM #1 stated she guessed that was her. 6. On 3/24/22 at 10:12 AM, Maintenance Manager #1 (MM) was asked how often lighting was evaluated and non-working bulbs changed. MM #1 stated the CNAs (Certified Nursing Assistants) write it in his logbook on his door or if he sees lights out, he changes them. MM #1 was asked about the non-working bulbs and lights in the dining room and kitchen. MM #1 stated he was not aware of bulbs out in the dining room, but he was replacing a light in the kitchen today and re-wiring two others. At 10:17 AM, MM #1 provided copies of logs he had. Maintenance logs dated 2/28/22 to 3/22/22 stated no reports of dining room or kitchen light maintenance requests. 7. On 3/24/22 at 10:20 AM, the Administrator was asked if she was aware of the non-working bulbs and lights in the dining room and kitchen and the hole to the outside in the laundry room. The Administrator stated she was aware of the kitchen lighting issue that happened yesterday afternoon because maintenance had accidentally cut a wire and now needed to install a new light and wrap wiring. Administrator was asked what she felt would possibly happen with the hole to the outside above the air conditioning unit in the laundry room. Administrator stated possible that insects or rodents and pests could come in. The Administrator was asked how staff reported concerns and how she monitored what the maintenance manager completed. The Administrator stated she performed rounds to check on what he completed and was not aware until today that he threw away all of the maintenance logs when he is finished. The Administrator was asked to provide maintenance policy. At 12:52 PM, the Administrator sent and email stating the facility did not have a maintenance policy 8. On 3/23/22 at 8:35 AM, Environment policy received from DM #1 stated 1. Dietary Services Director will ensure that the kitchen is maintained in a clean and sanitary manner, including .lighting .

Based on observations, record reviews, and interviews the facility failed to ensure physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The findings are: Resident #15 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/14/22 documented the resident scored 5 (0-7 indicated severe cognitive impact) on a Brief Interview for Mental Status (BIMS) and required no set up or physical help from staff for dressing, and one person assist for toileting. a. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . with a start date of 1/6/2020 . TED stockings to BLE [bilateral lower extremities] Q [every] AM [morning] before getting out of bed and remove qhs [every hour of sleep] two times a day . With a start date of 9/10/2019. b. On 03/22/22 at 8:00 AM, Resident #15 was sitting in a chair in her room wearing a short-sleeved t-shirt. She was not wearing Geri- sleeves or long sleeves. The TED stockings were not on her lower extremities. c. On 03/23/22 01:32 PM, the resident was sitting in her room. The resident pulled up her pant legs and was wearing yellow nonskid socks. She did not have on TED stockings. She stated, Why am I here? . Where am I at? d. On 3/23/22 a current Care Plan documented, [R15] is on Diuretic therapy r/t [related to] : hypertension . Staff will encourage [R15] to allow TED stockings to be applied in am and off at hs [hour of sleep] . [R15] is at risk for impairment to skin integrity . The Care Plan did not mention Geri- sleeves nor that the resident ever refused to wear the TED stockings. e. On 3/24/22 at 10:22 am, Certified Nursing Assistant (CNA) #2 was asked, What area of the facility do you work in? She stated she worked in the secured unit. She was asked, Who is responsible for assisting [R15] with putting on her Geri sleeves? She stated, She doesn't have any that I know of. She was asked, Who is responsible for ensuring [R30] has her TED stockings on while she is up? She stated, She dresses herself, but sometimes she refuses them. She was asked, Has she had them on this week? She stated, To be honest I don't know . She is usually pretty good about putting them on herself . f. On 3/24/22 at 10:29 am, CNA #3 was asked, What area do you work in? She stated, I've worked back here [secured unit] first shift for 4 years . She was asked, Has [R15] had her Geri -sleeves on or her TED stockings on this week? She stated, Can't say for sure .she usually dresses herself .I don't think she has Geri sleeves .sometimes she refuses the TED stockings . g. On 3/24/22 at 12:39 pm, the Director of Nursing (DON) was asked, What is [R15's] orientation? She stated, She knows her name. She was asked, Who is responsible for ensuring her physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] ? She stated, The nurses. She was asked, What is the physicians order for [R15's] TED stockings and Geri-sleeves or long sleeves? She stated, She should be wearing them during the day. She was asked, Why does she require TED stockings? She stated, She has some [CONDITION(S)] She was asked, Why does she require Geri sleeves? She stated, She was bumping her arms into random things.

Based on observation, record review and interview, the facility failed to ensure medication were not stored at 32 degrees Fahrenheit or below to maintain the integrity of the medications stored in 1 of 1 refrigerator. On 03/24/22 at 08:02 a.m., the facility's medication room and refrigerator was inspected with Director of Nursing (DON). The refrigerator temperature was noted to be 32 degrees. The DON was asked, At what temperature does liquid freeze? She stated, 32 degrees. a. The refrigerator contained, Glatapa 40mg 7 syringes, Hep B 4 vials, [MEDICATION(S)] syringe -11,[MEDICATION(S)] syringe -3, [MEDICATION(S)] 100 units - 4 pens, [MEDICATION(S)] 0.75 mg 3 pens, [MEDICATION(S)] 100 units - 4 pens, [MEDICATION(S)] 100 units - 3 pens ,[MEDICATION(S)] - 2 pens, [MEDICATION(S)] flextouch - 4 pens, [MEDICATION(S)] 18 mg/3 ml - 2 pens, [MEDICATION(S)] 100 mg/ml - 1 vial. All medication listed had a red sticker that documented, DO NOT FREEZE, keep in refrigerator. b. On 03/24/22 at 9:57 a.m., review of refrigerator temperature logs show that on March 1, 2, 3, and 4th. the temperature of the refrigerator was 32 degrees or below. On March 7, 8 and 9th was also 32 degrees or below. The dates of the 12th thru the 17th of the month were 32 degrees or below. The 19th thru 23rd were below acceptable temperature. c. On 03/24/22 at 09:57 a.m., the Director of Nursing was asked, When should staff report abnormal temperatures of the refrigerator? She stated, They should have reported it immediately. d. On 03/24/22 at 11:00 a.m., the Administrator was asked, Who is responsible for checking the refrigerator temperature logs? She stated, We all should be.

Based on record review and interviews, the facility failed to ensure the Minimum Data Set (MDS) assessment accurately reflected the use of an anticoagulant medication for 1 (Resident #36) of sampled resident who had a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] #36, R#23, R#44) sampled residents who had Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The findings are: Resident #36 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly MDS with an Assessment Reference Date of 2/10/22 documented the resident scored 4 (0-7 indicates severely cognitively impaired) on a Brief Interview for Mental Status and did not take an anticoagulant. a. On 03/22/22 at 02:43 PM, the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .start date 1.21.22 . b. The February Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . c. The Care Plan with a recent review date of 2/22/22 documented, .[R36] is on Anticoagulant therapy r/t [related to]: [CONDITION(S)] .[R36] will be free from discomfort or adverse reactions related to anticoagulant use through the review date. 6. On 3/24/22 at 12:09 PM, the MDS Coordinator was asked, Is [R36] receiving [MEDICATION(S)]? She stated, Let me check .yes. She was asked, When did she start taking [MEDICATION(S)]? She stated, The order date was 1/21/22. She was asked, What is the classification of [MEDICATION(S)]? She stated, Anticoagulant. She was asked, When was her last MDS completed? She stated, 2/10/22. She was asked, Does her MDS document that she was receiving the anticoagulant? She stated, No, it is not. She was asked, Should it have documented that she was receiving an anticoagulant? She stated, Yes, It should have been. I don't know I how I missed that .

Based on observation, record review and interview, the facility failed to ensure facial was removed to promote good personal hygiene for 1 (Resident #24) of 16 (Residents #R#31, R#3, R#27, R#30, R#25, R#16, R#13, R#24, R#41, R#37, R#11, R#2, R#51, R#44, R#5, and R#56) sampled residents who required their face to be shaved. This failed practice had the potential to affect 16 (Residents #R#31, R#3, R#27, R#30, R#25, R#16, R#13, R#24, R#41, R#37, R#11, R#2, R#51, R#44, R#5, and R#56) who required their face to be shaved as documented on a list provided by the DON (Director of Nursing) on 3/25/22. The findings are: Resident #24 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . a. A Care Plan, with a problem dated 1/24/22 that documented, [Resident (R) #24] has an ADL [Activities of Daily Living] Self Care Performance Deficit r/t [related to] Dementia . Interventions . PERSONAL HYGIENE/ORAL CARE: [Resident #24] requires staff participation with personal hygiene . b. On 03/22/22 at 08:02 AM, there were multiple gray hairs under R24's chin. c. On 03/23/22 at 08:32 AM, Resident #24 was asked, Do the staff assist you with grooming? R24 rubbed her chin and stated, .They are going to go to the dollar store as soon as they get somebody to do it to get some razors . That's my picture up there on my wall . That's how I always looked before. d. On 3/24/22 at 10:20 AM, Certified Nursing Assistant (CNA) #1 was asked, Do you have razors available to shave the residents? She stated, yes. She was asked, Who is responsible for providing [R24's] ADLs/ hygiene care? She stated, She has a hospice aide that comes. She was asked, [R24] told me you all were out of razors, and she hasn't gotten her chin hairs shaved. CNA #1 stated, I will shave them today. e. On 3/24/22 at 12:39 PM, the DON was asked, Who is responsible for ensuring the female residents do not have facial hair unless they want it? She stated, The aides. She was asked, Who is responsible for ensuring the facility has razors available? She stated, I do. She was asked, Do you have razors available now for the residents? She stated, Yes. She was asked, Should [R24] have multiple short chin hairs? She stated, Not if she doesn't want them. f. A policy titled Shaving Residents that was provided by the DON on 3/25/22 documented, The purpose of this procedure is to provided cleanliness and provide skin care . The policy did not address unwanted facial hair on a female resident.

Based on observation, record review, and interview, the facility failed to ensure meals were prepared and served in accordance with the planned, written, and posted menu to meet the nutritional needs of the residents for 1 of 2 meals observed. This failed practice had the potential to affect 57 (total census 59) who received meals from the kitchen. The findings are: 1. On 3/21/22 at 11:40 AM, the food observed on the steam table was tater tot casserole, green beans, & garlic toast for all diets. 2. The Menu received from Dietary Manager (DM) #1 stated Lunch for Monday was: a. REGULAR: Thin Crust Cheese Pizza, Garlic Green Beans, Breadstick, Margarine, and Lemon Cake with Lemon icing b. DYS ADV (Dysphasia Advanced): Cheese Ravioli w/Sauce, Garlic Green Beans, Dinner Roll/bread, Margarine, & Lemon cake with lemon icing c. PUREED: Cheese Ravioli w/sauce, Garlic Green Beans, Breadstick, Margarine, & lemon cake with lemon icing 3. On 03/22/22 at 2:10 PM, DM #1 was asked for documentation of dietician approving change in menu for 3/21/22. DM #1 stated she did not have documentation. DM #1 showed the surveyor a log for previously dated changes approved by Dietician but not changes made on 3/21/22. 4. At 2:12 PM the Surveyor stated bread sticks and pizza were on menu but toast and tater tot casserole were served. DM #1 stated the residents complained about bread sticks and pizza. DM #1 was asked where the menu was posted. DM #1 stated it was posted in the dining room. DM #1 was asked if the changes were posted, and DM #1 stated they did not post the change. DM #1 stated the residents would find out the change when they received the menu cards to choose their choices for the meal. 5. On 3/23/22 at 10:55 AM, Resident Council President R#49 and R#32 & R#56, who attend meetings regularly, were asked if they liked pizza and breadsticks and if they would like to see that served. R32 & R56 stated they liked pizza and would like that on the menu and R49 stated he also likes pizza but was tube fed. 6. On 3/24/22 at 10:39 AM, the Menu policy received from DM #1 documented, 5. A registered Dietician/Nutritionist (RDN) or other clinically qualified nutrition professional reviews and approves the menus . 6. Menus will be served as written, unless a substitution is provided in response to a preference, unavailability of an item, or a special meal . 8. Menus will be posted in the Dining Services department, dining rooms, and resident/patient care areas.

Based on record review and interview the facility failed to ensure the residents and/or their families were notified by 5 PM the next calendar day following the occurrence of a confirmed positive COVID-19 resident and a staff member; the facility also failed to ensure the resident and/or families received cumulative weekly updates regarding COVID-19 status for 5 (Residents (R) #1, 2, 5, 6, and 7) of 5 sampled residents. These failed practices had the potential to affect 56 residents residing in the facility per the Roster Sample Matrix provided by the Administrator on 2/22/22 at 2:36 PM. The findings are: 1. On 2/22/22 at 2:30 PM, the Administrator was asked, What method do you use to inform residents, their representatives, and families of COVID-positive residents and staff? She stated, We use a web-based program. She was asked, Who is responsible for making sure residents and/or their families are notified by 5 PM the next calendar day following the occurrence of a confirmed positive COVID-19 resident and staff members? She stated, This is updated on the Web based program. She was asked to provide documentation verifying that resident's and/or families were notified by 5 PM next day of a Resident testing COVID-19 positive on 1/17/22 and of a staff member testing COVID-19 positive on 1/31/22 and another on 2/21/22. 2. The Emergency Operation Plan regarding Pandemic - COVID-19 received from the Administrator on 2/22/22 at 2:36 PM documented, .The facility informed all residents, their representatives and families by 5 PM the next calendar day following the occurrence of a single confirmed COVID-19 infection or of three or more residents or staff with new onset of respiratory symptoms that occurred within 72 hours of each other .Initial notifications will be made by facility personnel and weekly updates are posted to facility website . 3. On 2/22/22 at 2:59 PM, the Administrator provided a typed statement regarding Resident/Family Notification that documented, Notification: Two different letters were mailed out in the past notifying all resident families of the notification plan of new positives being updated daily on our website. Outbreak status is posted on front door for anyone, internet or not. Testing of residents begins within 24 hours and residents are notified as to why. Admin communicates numbers to IT [information technology] department for updated posting. The Administrator was asked, Where is it documented that each resident and/or family were notified of the last COVID-19 positive resident on 1/17/22 and last two positive staff on 1/31/22 and 2/21/22 by 5 PM next calendar day? She stated, I'll go see if I can find it. 4. On 2/22/22 at 4:20 PM, the Administrator provided an email from Corporate that documented, The attached is what we can provide NOTES: Sometimes we post on the day of the positive employee or resident. Sometimes we post the next day. Sometimes, we make corrections when information was clarified. This especially happens when there is a positive [MEDICATION(S)], and the person is asymptomatic and then we do a PCR [polymerase chain reaction]. Sometimes, the date was entered based on the date of the test result and we correct it to the date of the test on PCRs. We can't show what were edits or corrections or changes on the date/time printout that is attached. The Administrator was asked, Where is documentation that your residents and/or families were notified by 5PM the next calendar day of the last positive resident and the last two positive staff members since the information on the Web site where IT post does not indicate the number of COVID-19 positive residents or staff member and does not contain information mitigating actions taken by the facility to prevent or reduce the risk of transmission, including if normal operations in the facility will be altered? She stated, I'll have to get back with you on this. 5. On 2/23/22 at 12:00 PM, the Social Service Director (SSD) was asked, Who is responsible for notifying residents and/or families of COVID-19 positive residents and staff by 5 PM the next calendar day after a single occurrence? She stated, This is posted in the Web based program. She was asked, Does anyone at the facility inform the residents and/or families when and how to access this Web based program? She stated, On admission there is a part in our paperwork where we have to have permission from resident's family to post on Facebook regarding activities occurring in the facility. While going over this, I inform them we have a website that they can go to for information. That's where the positive residents and staff for COVID-19 are documented. Unless they ask, we do not inform them how and when to access this information.Most tell me they don't have computer access . For those, if we are told to call, then we do. If I am told to call, I do and document in Family Notification in their electronic medical records. I am not the only one who does this and I'm not sure where, if anywhere, the others document this information. The SSD showed surveyors in electronic system where she was referring to and the most recent documentation was dated 10/24/21. The Surveyors gave a list of five residents to the SSD to determine if documentation of notification could be found that any had been called by 5 pm after the last resident and staff tested positive for COVID-19. On 2/23/22 at 12:33 p.m., the SSD stated the facility could not find any documentation/proof of residents' families being notified by 5 PM next day after last resident and staff tested positive for COVID-19. 6. As of 2/23/22 at 3:30 PM, after a review of 5 of 5 Residents' records (R1, R2, R5, R6, R7), there was no documentation in the electronic medical records of any notification of the COVID-19 positive resident on 1/17/22 or the resident on 1/22/22. 7. On 2/23/22 at 3:58 PM, the Administrator and Director of Nursing was asked if they give the resident and/or families cumulative updates regarding COVID-19 and they both indicated they didn't know this was a requirement.

Based on observation of the medication passes on 12/09/2020, record review, and interview of the medication passes on 12/09/2020 at 8:00 A.M., 12:00 P.M., and 1:00 P.M. the facility failed to ensure physician's orders were followed to maintain a medication error rate was less than 5% to prevent potential complications for 2 residents (Residents #30, and #5) of 5 residents observed during the medication passes resulting in medication errors. The medication errors were made by Registered Nurse (RN #1) who administered medications in the facility. The medication error rate was 8.0% (percent) based on 25 medications administered with 2 errors detected. This failed practice had the potential to affect 15 residents who received medications from RN #1 according to a list provided by the Administrator on 12/29/2020. The findings are: 1. Resident #30 had a [DIAGNOSES REDACTED]. a. The December 2020 Physician Orders documented, . Zinc tablet Give 200mg by mouth every day shift for vitamin deficiency . Order Date 12/06/2020. b. On 12/09/2020 at 7:25 A.M., RN #1 administered Zinc Sulfate tablet 220mg by mouth to Resident #30. 2. Resident #5 had a [DIAGNOSES REDACTED]. a. The December 2020 Physician Orders documented, . Zinc tablet Give 200mg by mouth every day shift for vitamin deficiency . Order Date 12/06/2020. b. On 12/9/2020 at 7:45 A.M., RN #1 administered Zinc Sulfate tablet 220mg by mouth to Resident #5. 3. On 12/09/2020 at 9:00 A.M., RN # 1 was asked, Why did you give (Resident #5) and (Resident #30) 220 mg of Zinc Oxide when the dose ordered by the doctor is 200mg? RN #1 stated, It's a stock medication and I think 220mg of Zinc is all we can get. 4. On 12/9/2020 at 9:20 A.M., the DON was asked, Should the nurse have given (Resident #5) and (Resident #30) 220mg of Zinc Oxide when the physicians order documented to give 200mg? The DON stated, The doctor gave the order for what we have in house. We have clarified the order with the physician, and we are changing the order to match the current supply. The DON was asked, Should the nurse have clarified the order before giving the medication? The DON stated, Yes. They should have read the MAR (Medication Administration Record) and clarified the order with the physician at that point. 5. An Administrating Medications policy provided by the DON on 12/09/2020 at 10:30 A.M., documented, . Medications shall be administered in a safe and timely manner, and as prescribed. Policy Interpretation and Implementation . 3. Medications must be administered in accordance with the orders . 7. The individual administering the medication must check the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication.

Based on record review, observation and interview the facility failed to properly prevent or contain the spread of COVID-19 by failing to use proper Personal Protective Equipment (PPE) when transferring residents who have been exposed to COVID positive residents; properly disinfecting a room of a COVID positive resident; failed to change dirty gloves and or hand wash/sanitize to prevent cross contamination from dirty to clean, and failed to store biohazard properly to prevent cross contamination. These failed practices had the potential to affect all 39 residents residing in the facility. The findings are: 1. On 12/08/2020 at 12:20 P.M., upon entering the Quarantine Unit Certified Nursing Assistant (CNA) #1 was asked, Where are isolation gowns kept? The isolation cart was empty. CNA #1 went to the dining room to retrieve a gown. The Isolation Cart was approximately 12 foot inside the back door of the unit. CNA #1 and #2 were moving residents on the quarantine hallway. Both of the CNA's had on mask and goggles. They were not wearing a gown or gloves. CNA #2 entered Resident room [ROOM NUMBER] and pulled out a resident's over bed table and nightstand. CNA #2 took the furniture down the hall to Resident room [ROOM NUMBER]. CNA #1 was in the hall and was asked, When are you supposed to wear gowns? She stated, Any time you come into contact with the resident or their belongings. These resident have been exposed. a. On 12/08/2020 at 12:23 P.M., CNA #2 came back up the hallway with the bedside table and nightstand. CNA #1 was putting on gown to move the resident to Resident room [ROOM NUMBER]. CNA #2 came back up the hallway. She did not have on a gown or gloves. She pushed the resident from the room in his wheelchair to Resident room [ROOM NUMBER]. She then went to Resident room [ROOM NUMBER] and started gathering the resident's belongings. CNA#2 did not have on a gown and gloves. b. On 12/09/2020 at 8:32 A.M., the Director of Nursing (DON) was asked, When residents are being moved to the quarantine unit, or being moved in the quarantine unit what is the protocol for wearing personal protective equipment (PPE)? She stated, The staff is to wear gown, gloves, mask and googles. 2. On 12/09/2020 at 9:28 A.M., Licensed Practical Nurse (LPN) #1 with gloved hands opened the top drawer of the medication cart. LPN #1 pulled out a box with an inhaler in it. He then reached back in the drawer to get another box. LPN #1 already had a medication cup with meds on the top of the cart. LPN #1 then poured a cup of water and walked over to the resident sitting in the doorway of Resident room [ROOM NUMBER] and handed the medication cup to the resident. He then handed her the water glass which she drank all of. LPN #1 took the cup from the resident, went back to the cart with the same gloved hands, and poured more water into the cup. LPN #1 went back to the resident and handed her the cup of water. LPN #1 then went back to the cart and proceeded to box up inhalers placing them back in the medication cart with the same gloved hand. He put all of the medication cards back into the medication cart without changing gloves. The Nurse then took off his gloves and sanitized his hands. a. On 12/09/2020 at 10:00 A.M., the Director of Nursing (DON) was asked, During medication pass on the quarantine unit, how do expect your staff to perform a medication pass? She stated, I expect them to use infection control policy. The DON was asked, The nurse was observed to pass medication to a resident with gloves on and during the medication pass he went back to get more water. (LPN #1) went back to the cart got more water and handed the cup back to the resident with the same gloves. Is this proper protocol? She stated, No. The DON was asked, (LPN #1) went back to the cart and continued to put back medication in the cart without changing gloves. How could this impact the rest of the residents? She stated, Infection Control. b. An Administering Medication Policy and Procedure provided by the DON on 12/09/2020 at 10:30 A.M. documented, . staff shall follow established facility infection control procedures COVID-19 Risk Mitigation plan states . while in contact with PUI or isolation room, limit opportunities for touch contamination . 3. On 12/09/2020 at 9:34 A.M., the biohazard room on the front of 200 hall had 6 biohazard boxes on the floor. The top two biohazard boxes were open. On 12/09/2020 at 9:45 A.M., the Maintenance Director was asked, How should biohazard be stored in the biohazard room? He stated, It should be stored in the boxes. He was asked, Should the boxes be open? He stated, No, not at all. They should be closed. He was asked, Should they be stored on the floor? He stated, No. He was asked, How often is the biohazard boxes picked up from facility? He stated, On Monday and Thursday. He was asked, Have you had any trouble getting biohazard picked up in the last four weeks? He stated, No. 4. On 12/09/2020 at 10:38 A.M., the Maintenance Director was asked, This morning you used a UV (ultraviolet light) on room [ROOM NUMBER]? He stated, Yes. He was asked, Did you wear PPE when you went in the room? He stated, Yes. He was asked, Who cleans the room? He stated, Housekeeping. On 12/09/2020 at 11:30 A.M., Housekeeper #1 was in Resident room [ROOM NUMBER] and had on gloves, mask and goggles. She did not have on a gown. The room was wiped down with Virex. The curtains were taken down and all surfaces cleaned. Housekeeper #1 was asked, Did you disinfect the trash cans? She stated, Yes. Housekeeper #1 was asked, Did you disinfect the windowsills and walls? She stated, Yes. She was asked, What did you do with the cloth rags that you cleaned the room with? She stated, I put them in a trash bag. She was asked, Did you wear a gown while cleaning the room? She stated, No. She was asked, Have you been in-serviced on how to clean a COVID positive room? She stated, Yes. She was asked, Were you told the room you just cleaned was a COVID positive room? She stated, No On 12/09/2020 at 11:40 A.M., the District Manager of Healthcare Services Group and the Regional Consultant was asked, Has Housekeeper #1 been in-serviced on how to clean a COVID positive resident room? The District Manager stated, Yes. The District Manager and the Regional Consultant was asked, According to your policy on page 4 the recommendation is to wear a disposable gown. Housekeeper #1 just cleaned Resident room [ROOM NUMBER] without a gown. Should she have been in full PPE since the resident was COVID positive? The District Manager and the Regional Consultant both said Yes. The District Manager and the Regional Consultant was asked, Your policy also states that .linens, rags, mop heads. Use the double bag method . Should the housekeeper have double bagged what came out of that room? The Regional Consultant and the District Manager both stated, Yes. The District Manager and the Regional Consultant was asked, The policy also states that a sign will be placed on the door to inform people that there was a COVID positive resident in that room. Should you have put a sign up? They stated, Yes. The District Manager and the Regional Consultant was asked, Do you believe the housekeeper could have done her job correctly if she had been given all the information she needed? They both stated, Yes.

Based on observation, interview, and record review the facility failed to ensure fingernails were trimmed, cleaned, and free of jagged edges to promote good personal hygiene and grooming for 1 (Resident #15) of 1 sampled resident. This failed practice had the potential to affect 15 residents who were dependent on staff for nail care according to a list provided by Director of Nursing on 12/10/2020 at 11:51 A.M. The findings are: Resident # 15 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set with an Assessment Reference Date of 11/29/2020 documented the resident scored 8 (8-12 indicates moderately impaired) on a Brief Interview for Mental Status and required extensive assistance with transfers, toileting, dressing, personal hygiene, and was independent with eating. a. The Care Plan with a start date of 11/30/2020 documented, . Focus: ADL (Activities of Daily Living) self-care deficit rt (related to) Dementia, impaired balance, limited mobility and [MEDICAL CONDITION] . Interventions . PERSONAL HYGIENE/ORAL CARE: requires ext. (extensive) 1 staff participation with personal hygiene and oral care . b. On 12/07/2020 at 1:47 P.M., Resident #15 was sitting on the bed. Her fingernails on the right hand were uneven in length with jagged edges extending approximately 1/8 of an inch past the nail bed. There was a brown substance under the nails. (Photo taken.) c. On 12/08/2020 at 7:41 A.M., Resident #15 was sitting up on the side of the bed eating cereal. The nails on her right hand were uneven in length with jagged edges. There was a brown substance under the nails and a brown substance around the cuticle of the thumb nail. (Photo taken.) d. On 12/10/2020 at 8:45 A.M., the Director of Nursing (DON) was asked, How often should nail care be done? The DON stated, The Certified Nurse's Aides (CNA's) usually check once a week while giving the showers. Some residents are reluctant to allow their nails to be done. The DON was asked, How much assistance with Activities of Daily Living (ADL's) does (Resident #15) require? The DON stated, She requires one person assistance. When they take her food to her, staff show her where the food is located. The DON was shown a photograph of Resident #15's nails and was asked, Should these nails have been cleaned? The DON stated, Yes. We used to utilize her daughter to do her nails because she was reluctant to allow staff to do them. The DON was asked, Is there a build-up of a dark substance by the resident's cuticles on the residents' hands? The DON stated, Yes. She uses her hands to eat. The DON was asked, Should staff have washed the resident's hand before she started eating her breakfast? The DON stated, Yes, they have wipes they can assist residents to use to clean their hands. e. On 12/10/2020 at 9:25 A.M., Certified Nursing Assistant (CNA) #4 was asked, Do you provide care to (Resident #15)? CNA #4 stated, Yes. CNA #4 was asked, How much assistance with Activities of Daily Living does (Resident #15) require? CNA #4 stated, She requires moderate assistance with toileting. Here lately she has been almost total care with everything. CNA #4 was asked, How often should nail care be performed? CNA #4 stated, Nail care is done on the residents shower days. That is usually twice a week. CNA #4 was asked, When are (Resident #15's) shower days? CNA #4 stated. Yesterday she had a shower. I would have to look to see what other day she has a shower. CNA #4 was shown a photograph of Resident #15's nails and asked, Should the residents nails have been cleaned before she ate? CNA #4 stated, Yes. CNA #4 was asked, Does (Resident #15) refuse ADL care? CNA #4 stated, Sometimes she does. She is afraid of the shower at times, so we give her a bed bath and try to wash her nails. CNA #4 was asked, Did the aide that did (Resident #15's) shower yesterday clean her nails? CNA #4 stated, Yes, the shower aide soaked her nails for a long time yesterday. She sometimes gets build up around her nails that is hard to get off and there was still some build up left even after she soaked the nails. f. On 12/10/2020 at 9:45 A.M., Registered Nurse (RN) #1 was asked, How much assistance with activities of daily living does (Resident #15) require? RN #1 stated, She is total assistance with transfers, and dressing. She feeds herself after we set up the tray. RN # 1 was asked, How often is nail care performed? RN #1 stated, Nail care is done with the residents showers and any time that you see that it needs to be done. RN #1 was asked, Who is responsible for performing nail care? RN #1 stated, The shower team on shower days. The nurses or the aides if they see that they need to be done. RN #1 was shown a photograph of (Resident #15's) nails and was asked, Should the residents' hands have been washed and nails cleaned before the resident ate? RN #1 stated, Yes they should. RN #1 was asked, Has it ever been reported to you that (Resident #15) has refused ADL care? RN #1 stated, It has never been reported to me that she refuses care. RN #1 was asked, How do the CNA's know when a residents shower day is scheduled? RN #1 stated, There is a list in the shower room of the resident's shower days, and it is updated often. RN #1 was asked, What days does (Resident #15) get a shower? After looking at the shower schedule RN #1 stated, She gets a shower on Saturday and Wednesday. g. A Care of Fingernail/Toenails policy provided by the DON on 12/10/2020 at 11:30 A.M. documented, Purpose: The purposes of this procedure are to clean the nail bed, to keep the nails trimmed, and to prevent infection. Nail care includes daily cleaning and regular trimming .

Complaint # (AR 746) was substantiated, all or in part, with these findings: Based on observation, record review and interview, the facility failed to ensure the emergency generator was maintained in proper working order and key facility personnel were trained regarding the ability to manually transfer power if the automatic transfer switch failed in the event of a power outage. These failed practices could result in the inability to provide continuous fire protection services and crucial care and services, which could have caused serious harm, injury or death for all 59 residents who resided in the facility, according to a Resident Census provided by the Administrator on 10/25/19 at 2:30p.m. The Administrator was notified of the Immediate Jeopardy on 10/24/19 at 5:40 p.m. The findings are: On 10/24/19 at 11:30 a.m., the Generator Test Log for monthly testing under load documented, Generator Not Working on 9/17/19, 9/24/19, 10/1/19, 10/8/19, 10/15/19 and 10/22/19. a. On 10/24/19 at 1:20 p.m., the Maintenance Director and the Administrator were asked about the non-working generator. The Maintenance Director was asked when he had first identified that the generator was not working. He stated, The 17th of October. I notified the Administrator right away that the transfer switch had gone bad and the generator was not providing electrical power to the building. The motor for the generator would run but, there was no emergency power coming into the facility until the switch was replaced. The Administrator nodded her head Yes in agreement with the Maintenance Director's statements. The Maintenance Director was asked, Who services the facility generator? He stated, (Name of Generator Service company). This surveyor asked to see any invoices from the company. At 1:40 p.m., the Administrator produced an invoice dated 10/2/19 which documented an ATC (Automatic Transfer Control) Switch was needed to repair the generator. When asked if the facility had an invoice prior to 10/2/19 in which the generator service company had been contacted by the facility or had made a service call to the facility. He stated, I know I called them right away, but I do not have the date written down. They have not come out to the facility, but I told them what part we needed. The Administrator stated the part had been placed on backorder and she was unsure when the part would arrive. The Administrator was asked what interventions were immediately put into place when she knew the generator was not working to ensure residents were safe in the event of a power outage. She stated, We immediately in-serviced the staff on what to do if the power went out. The Administrator was asked if the facility had in-serviced the staff on what to do regarding loss of heat / air conditioning, a list of residents that might require immediately being moved to the hospital for critical services, a list of residents at risk for elopement if doors did not lock, loss of food items in freezer / refrigerators and any other critical issues if the facility lost power for an extended period of time without the generator powering the facility. She stated, No. b. An Inservice report titled Topic-Power Outage and dated 9/24/19 documented, .We do not have a generator currently. In case of a power outage, please refer to the Emergency list in the Emergency Supply Room on the 400 Hall. This will give you numbers of people to contact, residents that will need O2 (oxygen) tanks, residents that will need to get up in W/C (wheelchair) DT (due to) air mattress deflating. There will be a checklist for nurses to sign off on to make sure everything is done. We have ordered the part to fix the generator, but we are unsure when it will be here. If you have any questions, please feel free to talk to (Name of Administrator), (Name of Registered Nurse / Director of Nursing (RN/DON)) or (Name of Maintenance Director). A copy of the Emergency List in the Emergency Supply Room documented the names of 11 residents who required oxygen tanks and 8 residents who were on air mattresses. There were no Emergency Contact Numbers documented on the form that had been posted. The In-service form dated 9/24/19 was not completed until 7 days after the Maintenance Director initially identified that the generator was not in proper working order. The in-service attendance form was signed by 25 facility employees; however, the Employee Information form dated 10/24/19 documented the facility employed 57 staff. The facility also employed an additional 14 contracted employees in Dietary, Housekeeping and Laundry, as documented on Contracted Employee list dated 10/25/19. A total of 46 of these employees were not in-serviced. c. On 10/24/19 at 3:04 p.m., the Minimum Data Set (MDS) Nurse (Employee #1), hired on 7/20/15, was asked if she was aware of any problems with the generator. She stated, I know we are having problems with it, yes. When asked how long the generator issue had been going on, she stated, A couple of weeks. She was asked, if the power were to go out, what would you do? She stated, I know we have red plugs. (The red emergency plugs would provide power to certain outlets only if the generator was functional). When asked if she had been in-serviced regarding the generator not supplying emergency power to the building, she stated, No. d. On 10/24/19 at 3:10 p.m., Contracted Kitchen Employee #2 was asked if she was aware of any problems with the facility generator. She stated, No. Not that I am aware of. When asked if she would know what to do if there was a power outage, she stated, I watched videos when I was hired a couple of months ago . I can't remember any specifics, as the video was about 4 hours long. e. On 10/24/19 at 3:12 p.m., Certified Nursing Assistant (CNA) Employee #3, hired on 5/7/19, was asked if she was aware of any problems with the facility generator. She stated, No. When asked if she would know what to do if the power were to go out, she stated, I really don't really know. I have not been in-serviced on power outages. f. On 10/24/19 at 3:15 p.m., Contracted Housekeeping Supervisor (Employee #4) stated she had worked at the facility for approximately 6 months. When asked if she was aware of any problems with the generator, she stated, I know they are waiting on a part and that's all I know. She was asked, if the power were to go out and the generator did not work what would you do? She stated, I have not attended any in-services where specifically the generator did not come on. g. On 10/24/19 at 3:30 p.m., Employee #5, a Contracted Laundry Employee, stated he had been working at the facility for several years. When asked if he was aware of any problems with the generator he stated, No. When asked if he had specifically been in-serviced regarding the generator not working and what to do if the power went out, he stated, No. h. On 10/24/19 at 3:46 p.m., Employee #6, the Certified Activities Director hired on 5/22/17, was asked if she was aware of any problems with the generator. She stated, Yes, waiting on a part. Don't know for sure, will probably be a couple of weeks. When asked what she would do if the power were to go out, she stated, We had a disaster training on 10/18/19. I can't remember an in-service specifically about no power. We would get residents to safety if power was out. i. On 10/24/19 at 1:35 p.m., an in-service sign in sheet dated 10/18/19 documented, In-Service Instructors - (Names of Maintenance Director, DON, and Social Service Director) . In-Service Overview: Disasters. The Maintenance Director was asked for documentation of the specific topics covered during the Disaster In-service. He stated, Pretty much everything. When asked for documentation that was shared with or presented to the employees during the in-service, he stated he did not have any documentation. j. On 10/24/19 at 1:50 p.m., the Administrator was asked what date the needed part had been ordered for the generator. She stated she did not know. On 10/24/19 at 3:39 p.m., the Surveyor contacted a representative with the generator service company designated by the facility. He was asked when the facility ordered the part for the generator's transfer switch and when it was expected to arrive. He stated the generator estimate invoice had been approved and the part ordered on [DATE] by a corporate employee. He stated he was not sure when the part would come in, but was hoping for around the first of (MONTH) 2019. k. On 10/25/19 at 12:05 p.m., the Corporate Office Regional Manager stated he in-serviced the Administrator and the Maintenance Director at 8:15 this morning to inform them that the generator could still operate if they utilized the manual switch. The Inservice form documented, .In case of power outage, the transfer switch panel has an Emergency Lever that will be pulled all the way down after starting the generator and that will manually deliver power to (name of facility) . At this time, both the Administrator and the Maintenance Director stated they were unaware of the manual switch they could have used when the ATC switch had stopped working. l. On 10/25/19 at 3:00 p.m., the facility was unable to provide documentation that the Maintenance Director had ever been in-serviced or trained, prior to 10/25/19, regarding the manual switch on the generator. The Maintenance Director's personnel file documented he had changed positions, from being a Certified Nursing Assistant to the facility's Maintenance Director in (MONTH) (YEAR). There was no documentation in the file that the Manual Switch on the Generator had been addressed in his training. The Regional Manager stated a Maintenance Director from the Little Rock area had come to the facility several times and spoken with the Maintenance Director. An email from the first visit was dated 1/4/19 and documented, (facility name) first visit on 1/4/19 . My objective on first visit. 1). Meet new maintenance director and review building, grounds and current life safety binder. 2). Orient (name of Maintenance director) on inspections, processes and repairs. 3). Obtain building layout and study locations of key items such as generator, high voltage room, low voltage room, call light system and hot water heaters . 4). Obtain and update service contact list . 5). Gutter Guards missing . Review electromagnet locks. 5). Fire extinguishers . 6). External Storage . 7). Door handles.8). Ceiling in housekeeping office . 9). Multiple areas in hot water heater rooms .10). Kitchen Hot water heater .11). Hot and cold-water faucets . 12). Evidence of multiple roof leaks . 13). Track doors to kitchen serving windows . 14). Needing a part to repair a wheelchair . Recommendations: 1) keypads, 2). Contact insurance company, 3) Break box installed by fire panel to hold fire panel key and keys to facility for fire department. 4). Building rekey . 5). Revamp Life Safety binder . There was no training specifically regarding the manual switch for the generator in the event of a power outage if the emergency generator failed to produce electricity to the facility. The facility did not have any other training information to provide for the Maintenance Director. m. The Immediate Jeopardy was removed and the scope and severity reduced to F on 10/25/19 at 8:15 a.m., when the facility implemented the following plan of removal: 1.) On 10/24/19 at 6:00 p.m., staff were in-serviced before they could take the floor, on emergency procedures to follow in case of power outage, including residents on air mattresses, oxygen, who to call, hard wiring the generator, designated employees to walk the halls in place of call lights and fire system, elopement lists and risks/monitoring, unit door watch, emergency lighting, cell phones, check sheets and lists with their locations, emergency menus/dietary procedures, linens, fire extinguishing, emergency supplies, emars (Electronic Medication Administration Records) , etc (et cetera). Regional Manager also in-serviced Maintenance Director on the use of the Emergency Generator Manual Transfer switch that can be activated immediately to provide power to the home. 2.) Each employee will be required to verbally walk through emergency power outage procedures in relation to their position before they can return to work, starting 10/24/19 at 6:00 p.m. 3.) To ensure deficient practice does not re-occur, Administrator/designee will check off 3 employees per shift on Emergency Power Outage procedures 5 x (times) a week x 6 weeks or until compliance is reached, using the verbal Power Outage Explanation Sign off form. Any negative findings will be corrected immediately, and Administrator will be notified. 4.) The Administrator will report all negative findings to the monthly Quality Assurance Committee for further review/recommendations .

Based on observation, record review, and interview, the facility failed to ensure [MEDICAL CONDITION] care, including suctioning and replacement of the outer cannula when it became dislodged, was provided when needed and by competent nursing staff, to ensure a resident with copious tracheal secretions maintained a patent airway and prevent serious potential complications for 1 of 1 (Resident #22) sampled residents who had a [MEDICAL CONDITION]. The failed practice resulted in immediate jeopardy, which caused or could have caused serious harm, injury or death to Resident #22, who was observed multiple times with copious secretions that were not suctioned by the licensed nurse responsible for the resident's care and was also observed with his outer cannula dislodged, with the assigned nurse being untrained and uncomfortable with addressing the situation. The Administrator was notified of the Immediate Jeopary on 7/20/18. The failed practice had the potential to cause more than minimal harm to 1 resident who had a [MEDICAL CONDITION] (trach), as documented on a list provided by the Administrator dated 7/27/18. The findings are: Resident #22 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set with an Assessment Reference Date of 5/23/18 documented the resident had severely impaired cognitive skills for daily decision making per a staff assessment for mental status, required total assistance of 2 plus persons for bed mobility and transfers, and had a [MEDICAL CONDITION] a. Care Plan dated 3/3/16 documented, (Resident #22) has [MEDICAL CONDITION] r/t (related to) impaired breathing mechanics .Suction as necessary . b. A Physicians Order dated 9/9/16 documented, [MEDICAL CONDITION] needed, [MEDICAL CONDITION] . c. The (MONTH) Medication Review Report documented, Change outer cannula every three months due to (diagnosis) of Multi Drug Resistant Pseudomonas . d. On 7/09/18 the following observations were made of the resident: At 12:03 p.m., the resident was lying in bed. There was an approximately 1-inch area where off-white frothy secretions had drained out of [MEDICAL CONDITION] the resident's chest. A washcloth had been placed on the resident's chest, and additional drainage had collected on the cloth. A suction set up dated 7/9/18 was at the bedside, and there were secretions in the bottom of the canister, approximately ¼ inch in depth. At 12:09 p.m., the secretions in the resident'[MEDICAL CONDITION] audibly gurgling as the resident exhaled and off-white secretions were bubbling [MEDICAL CONDITION]. The resident was breathing normally, in no apparent distress, and his skin and lips were pink, with no signs of cyanosis. The head of the bed (HOB) was elevated approximately 30 degrees and a tube feeding of [MEDICATION NAME] 1.5 was infusing at 70 cubic centimeters per hour (cc/hr) via the resident's feeding tube. At 12:25 p.m., Licensed Practical Nurse (LPN) #1 parked her medication cart in the hallway across from the resident's room. The LPN looked into the room at the resident, who was still audibly gurgling with each exhalation but in no apparent distress. The LPN continued on with her medication pass without attempting to suction the resident. At 1:09 p.m., the resident was still audibly gurgling with each respiration, and the gurgling sounds could be heard approximately 1 to 2 doors down from the resident's room. LPN #1 continued with the medication pass. At 1:13 p.m., LPN #1 went into the resident's room and checked on the resident, who continued to have gurgling respirations. The LPN did not suction the resident at this time. At 2:09 p.m., LPN #1 entered the resident's room again to [MEDICAL CONDITION]. The LPN gloved, suctioned the secretions from the exterior of the [MEDICAL CONDITION] and on the resident's neck/chest area with the [MEDICATION NAME] (oral suction device), used filtered water from the medication room to clear the suction tubing, then changed gloves. She cleansed the skin around [MEDICAL CONDITION] with wet gauze and placed a clean, dry washcloth under the lower edge of the [MEDICAL CONDITION]. She then cleansed the resident's lips and applied Chapstick. The resident continued to audibly gurgle with respirations; however, the LPN did not suction [MEDICAL CONDITION] remove the inner cannula to clean it [MEDICAL CONDITION]. The LPN was asked who cleaned and suctioned the inner cannula and stated, The night shift does the cleaning, changing, suctioning at night. If the resident gets bad, the nurse on the floor working does it as needed. I have suctioned him (with the [MEDICATION NAME]) every 2 hours, or 3 to 4 times, today. It would be non-stop suctioning for him if we did the inner cannula suctioning. He has constant gurgling, even after suctioning, has tried medications for this, [MEDICATION NAME], levacin, and has tried the patch. e. On 7/10/18 the following observations were made of the resident: At 7:57 a.m., the resident was lying in bed with his eyes closed. His skin and lips were pink, respiratory rate was 18 breaths per minute, and there were no signs / symptoms (s/s) of respiratory distress. There were no gurgling sounds coming from the trach, nor were there any visible secretions at this time. The suction canister at the bedside was empty. At 9:08 a.m., Certified Nurse Assistant (CNA) #2 and CNA #3 went in to provide care for the resident. After closing the door and approaching the resident, the CNAs noticed the outer cannula of his [MEDICAL CONDITION] tubing was out of the stoma and lying on the resident's neck. The [MEDICAL CONDITION] strap was still secured around the resident's neck. The resident was in no apparent distress; respirations were 20 breaths per minute and his lips were pink. There were off white to light-yellow secretions underneath [MEDICAL CONDITION] at the ostomy site, where a washcloth was positioned on the resident's chest. CNA #3 went to get a nurse. At 9:16 a.m., LPN #6 entered the room. and stated, Oh, his [MEDICAL CONDITION] is out. She assessed the resident and went to inform the Advanced Practice Registered Nurse (APRN), who was in the building at this time. The LPN returned to the room and stated the APRN had instructed her to send the resident to the hospital to replace the trach. The resident was coughing and his face was turning red, and white to yellow sputum was bubbling out the stoma, but retracting back into the stoma when the resident inhaled. The nurse made no effort to suction the resident at this time. A period of 3 minutes later, the APRN entered the room. At 9:19 a.m., when the APRN entered the room, she asked the nurse to check the resident's oxygen saturation. LPN #9 used a pulse oximeter and obtained a reading of 87%. The resident was no longer coughing and his skin color had returned to normal, with perspiration present on his face. At approximately 9:23 a.m., the resident began coughing again, with yellow / white sputum bubbling from the stoma, but retracting back into the stoma as he inhaled. His face again became dark red. The APRN instructed LPN #9 to suction the [MEDICAL CONDITION]. LPN #9 obtained a [MEDICATION NAME] from the cabinet and connected it to the bedside suction set-up, then stated to APRN, I can't put this down that (stoma opening). The resident continued to cough, but was unable to clear the sputum. The LPN stated, I don't feel comfortable to the APRN. The APRN gloved, took a suction catheter and cleared the resident's airway. The resident's oxygen saturation returned to 94%, then the ambulance crew arrived to transport the resident to the hospital. After the resident's care was turned over to the ambulance crew, LPN #9 was asked how she was trained to respond to the need for [MEDICAL CONDITION] suctioning and stated, I don't do the deep suctioning on him unless he gets really bad. I just suction the top and clean him up. The last time I suctioned him deep was about on Friday, a week ago. f. On 7/11/18 at 11:55 a.m., the Director of Nursing (DON) was asked what training the facility's nurses had received on [MEDICAL CONDITION] care, suctioning, and how to respond to [MEDICAL CONDITION] extubation. She stated, We train all the nurses yearly with a respiratory consultant from (Respiratory Supply Company); (Respiratory Therapist #1) comes in yearly to do an in-service for us. There are no other check-offs or in-services related to [MEDICAL CONDITION] care. I called (Respiratory Therapist #1), and he is unavailable, on vacation, but answered me and said he left a sign-in sheet here. We are attempting to locate it. He does an in-service with all the nurses on [MEDICAL CONDITION] including the emergencies and care needed. Our APRN was here yesterday when the resident pulled out the [MEDICAL CONDITION] - she can replace the [MEDICAL CONDITION]. One nurse on night shift (LPN #9 ) and one experienced nurse on 3 to 11 shift (LPN #8) are very familiar [MEDICAL CONDITION] and could possibly replace [MEDICAL CONDITION] an emergency. The [MEDICAL CONDITION] inner canula is cleansed and suctioned on night shift, once a day, and if needed by the floor nurses at other times. Regarding the pulled out [MEDICAL CONDITION] and sputum he was unable to clear with coughing, this resident, I would have expected the nurse to stay with the resident, set up the suction and suction as needed, roll him to his side if that would assist with clearing the sputum and monitor him until help arrives. We have called corporate and they are assisting us with setting up training / check offs, and we are having (Respiratory Therapist #1) from (Respiratory Supply Company) to come to the facility in the next few weeks for retraining. g. On 7/11/18 at 2:30 p.m., LPN #6 was asked about her training on [MEDICAL CONDITION] care / suctioning and emergencies related to the tracheotomy. The LPN stated, I have had an in-service yearly by Respiratory Therapy. Two in-services since working here 2.5 years. She stated that the in-services consisted of training on suctioning, cleaning, using a pulse oximeter while [MEDICAL CONDITION], removing the inner cannula and cleansing. The LPN was asked if the in-services included replacing [MEDICAL CONDITION] was pulled out. She stated she did not recall any education on replacing a [MEDICAL CONDITION] or any emergency care regarding that topic. She stated she did a, .deep suction on the resident's [MEDICAL CONDITION] this morning around 6:30 a.m. and cleaned it. Ostomy was clean, with no gurgling or secretions at that time. h. On 7/12/18 at 9:17 a.m., the MDS Coordinator was asked what training she had received [MEDICAL CONDITION]. The LPN stated, We do a yearly in-service with (Respiratory Therapist #1) who comes in for training on cleaning, suctioning [MEDICAL CONDITION]. In the event of an emergency with the trach, I would stay with the resident, call for help, call MD (Medical Doctor), and suction PRN (as needed) to clear his airway and send out to the hospital as ordered. i. On 7/12/18 at 9:30 a.m., the DON was asked if she was able to find any other documentation related to the in-services. No further documentation was provided as of the survey exit date. 2. The immediate jeopardy was removed 7/20/18 at 5:15 p.m. and the scope and severity reduced to E when the following plan of removal was implemented: a. On 7/20/18 at 10:00 a.m., all nursing staff was in-serviced on all aspects of daily trache care and on emergencies, including when to suction, when not to suction, and emergency techniques, by (Respiratory Therapist #1). b. Each Licensed Nurse will be required to verbally walk through the trache competencies before returning to work, demonstration who, when, how to perform trache care daily and in emergency situations. c. To ensure deficient practice does not re-occur, Director of Nursing will check off one Licensed Nurse per shift on trache care/emergency trache care, to perform audits 5xweekx6 weeks or until compliance is reached, using the Trache Check Off Audit form. d. The Administrator will report all negative findings to the monthly Quality Assurance Committee for further review/recommendations. e. Completion date 8/1/18.

Based on observation, record review, and interview, the facility failed to ensure licensed nurses assigned to care for a resident who had a [MEDICAL CONDITION] (trach) with copious secretions were competent to provide the necessary care, including tracheal suctioning, when the resident was unable to clear the secretions from [MEDICAL CONDITION] coughing, and replacement of the outer cannula when it became dislodged, to ensure a patent airway was maintained and prevent serious potential complications for 1 of 1 (Resident #22) sampled residents who had a [MEDICAL CONDITION]. The failed practice resulted in immediate jeopardy, which caused or could have caused serious harm, injury or death to Resident #22, who was observed multiple times with copious secretions that were not suctioned by the licensed nurse responsible for the resident's care and was also observed with his outer cannula dislodged, with the assigned nurse being untrained and uncomfortable with addressing the situation. The failed practice had the potential to cause more than minimal harm to 1 resident who had a [MEDICAL CONDITION] (trach), as documented on a list provided by the Administrator dated 7/27/18. The findings are: 1. Resident #22 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set with an Assessment Reference Date of 5/23/18 documented the resident had severely impaired cognitive skills for daily decision making per a staff assessment for mental status, required total assistance of 2 plus persons for bed mobility and transfers, and had a [MEDICAL CONDITION] a. Care Plan dated 3/3/16 documented, (Resident #22) has [MEDICAL CONDITION] r/t (related to) impaired breathing mechanics .Suction as necessary . b. A Physicians Order dated 9/9/16 documented, [MEDICAL CONDITION] needed, [MEDICAL CONDITION] . c. The (MONTH) Medication Review Report documented, Change outer cannula every three months due to (diagnosis) of Multi Drug Resistant Pseudomonas . d. On 7/09/18 the following observations were made of the resident: At 12:03 p.m., the resident was lying in bed. There was an approximately 1-inch area where off-white frothy secretions had drained out of [MEDICAL CONDITION] the resident's chest. A washcloth had been placed on the resident's chest, and additional drainage had collected on the cloth. A suction set up dated 7/9/18 was at the bedside, and there were secretions in the bottom of the canister, approximately ¼ inch in depth. At 12:09 p.m., the secretions in the resident'[MEDICAL CONDITION] audibly gurgling as the resident exhaled, and off-white secretions were bubbling [MEDICAL CONDITION]. The resident was breathing normally, in no apparent distress, and his skin and lips were pink, with no signs of cyanosis. The head of the bed (HOB) was elevated approximately 30 degrees and a tube feeding of [MEDICATION NAME] 1.5 was infusing at 70 cubic centimeters per hour (cc/hr) via the resident's feeding tube. At 12:25 p.m., Licensed Practical Nurse (LPN) #1 parked her medication cart in the hallway across from the resident's room. The LPN looked into the room at the resident, who was still audibly gurgling with each exhalation but in no apparent distress. The LPN continued on with her medication pass without attempting to suction the resident. At 1:09 p.m., the resident was still audibly gurgling with each respiration, and the gurgling sounds could be heard approximately 1 to 2 doors down from the resident's room. LPN #1 continued with the medication pass. At 1:13 p.m., LPN #1 went into the resident's room and checked on the resident, who continued to have gurgling respirations. The LPN did not suction the resident at this time. At 2:09 p.m., LPN #1 entered the resident's room again to [MEDICAL CONDITION]. The LPN gloved, suctioned the secretions from the exterior of the [MEDICAL CONDITION] and on the resident's neck/chest area with the [MEDICATION NAME] (oral suction device), used filtered water from the medication room to clear the suction tubing, then changed gloves. She cleansed the skin around [MEDICAL CONDITION] with wet gauze and placed a clean, dry washcloth under the lower edge of the [MEDICAL CONDITION]. She then cleansed the resident's lips and applied Chapstick. The resident continued to audibly gurgle with respirations; however, the LPN did not suction [MEDICAL CONDITION] remove the inner cannula to clean it [MEDICAL CONDITION]. The LPN was asked who cleaned and suctioned the inner cannula and stated, The night shift does the cleaning, changing, suctioning at night. If the resident gets bad, the nurse on the floor working does it as needed. I have suctioned him (with the [MEDICATION NAME]) every 2 hours, or 3 to 4 times, today. It would be non-stop suctioning for him if we did the inner cannula suctioning. He has constant gurgling, even after suctioning, has tried medications for this, [MEDICATION NAME], levacin, and has tried the patch. e. On 7/10/18 the following observations were made of the resident: At 7:57 a.m., the resident was lying in bed with his eyes closed. His skin and lips were pink, respiratory rate was 18 breaths per minute, and there were no signs / symptoms (s/s) of respiratory distress. There were no gurgling sounds coming from the trach, nor were there any visible secretions at this time. The suction canister at the bedside was empty. At 9:08 a.m., Certified Nurse Assistant (CNA) #2 and CNA #3 went in to provide care for the resident. After closing the door and approaching the resident, the CNAs noticed the outer cannula of his [MEDICAL CONDITION] tubing was out of the stoma and lying on the resident's neck. The [MEDICAL CONDITION] strap was still secured around the resident's neck. The resident was in no apparent distress; respirations were 20 breaths per minute and his lips were pink. There were off white to light-yellow secretions underneath [MEDICAL CONDITION] at the ostomy site, where a washcloth was positioned on the resident's chest. CNA #3 went to get a nurse. At 9:16 a.m., LPN #6 entered the room. and stated, Oh, his [MEDICAL CONDITION] is out. She assessed the resident and went to inform the Advanced Practice Registered Nurse (APRN), who was in the building at this time. The LPN returned to the room and stated the APRN had instructed her to send the resident to the hospital to replace the trach. The resident was coughing and his face was turning red, and white to yellow sputum was bubbling out the stoma, but retracting back into the stoma when the resident inhaled. The nurse made no effort to suction the resident at this time. A period of 3 minutes later, the APRN entered the room. At 9:19 a.m., when the APRN entered the room, she asked the nurse to check the resident's oxygen saturation. LPN #9 used a pulse oximeter and obtained a reading of 87%. The resident was no longer coughing and his skin color had returned to normal, with perspiration present on his face. At approximately 9:23 a.m., the resident began coughing again, with yellow / white sputum bubbling from the stoma, but retracting back into the stoma as he inhaled. His face again became dark red. The APRN instructed LPN #9 to suction the [MEDICAL CONDITION]. LPN #9 obtained a [MEDICATION NAME] from the cabinet and connected it to the bedside suction set-up, then stated to APRN, I can't put this down that (stoma opening). The resident continued to cough, but was unable to clear the sputum. The LPN stated, I don't feel comfortable to the APRN. The APRN gloved, took a suction catheter and cleared the resident's airway. The resident's oxygen saturation returned to 94%, then the ambulance crew arrived to transport the resident to the hospital. After the resident's care was turned over to the ambulance crew, LPN #9 was asked how she was trained to respond to the need for [MEDICAL CONDITION] suctioning and stated, I don't do the deep suctioning on him unless he gets really bad. I just suction the top and clean him up. The last time I suctioned him deep was about on Friday, a week ago. f. On 7/11/18 at 11:55 a.m., the Director of Nursing (DON) was asked what training the facility's nurses had received on [MEDICAL CONDITION] care, suctioning, and how to respond to [MEDICAL CONDITION] extubation. She stated, We train all the nurses yearly with a respiratory consultant from (Respiratory Supply Company); (Respiratory Therapist #1) comes in yearly to do an in-service for us. There are no other check-offs or in-services related to [MEDICAL CONDITION] care. I called (Respiratory Therapist #1), and he is unavailable, on vacation, but answered me and said he left a sign-in sheet here. We are attempting to locate it. He does an in-service with all the nurses on [MEDICAL CONDITION] including the emergencies and care needed. Our APRN was here yesterday when the resident pulled out the [MEDICAL CONDITION] - she can replace the [MEDICAL CONDITION]. One nurse on night shift (LPN #9) and one experienced nurse on 3 to 11 shift (LPN #8) are very familiar [MEDICAL CONDITION] and could possibly replace [MEDICAL CONDITION] an emergency. The [MEDICAL CONDITION] inner canula is cleansed and suctioned on night shift, once a day, and if needed by the floor nurses at other times. Regarding the pulled out [MEDICAL CONDITION] and sputum he was unable to clear with coughing, this resident, I would have expected the nurse to stay with the resident, set up the suction and suction as needed, roll him to his side if that would assist with clearing the sputum and monitor him until help arrives. We have called corporate and they are assisting us with setting up training / check offs, and we are having (Respiratory Therapist #1) from (Respiratory Supply Company) to come to the facility in the next few weeks for retraining. g. On 7/11/18 at 2:30 p.m., LPN #6 was asked about her training on [MEDICAL CONDITION] care / suctioning and emergencies related to the tracheotomy. The LPN stated, I have had an in-service yearly by Respiratory Therapy. Two in-services since working here 2.5 years. She stated that the in-services consisted of training on suctioning, cleaning, using a pulse oximeter while [MEDICAL CONDITION], removing the inner cannula and cleansing. The LPN was asked if the in-services included replacing [MEDICAL CONDITION] was pulled out. She stated she did not recall any education on replacing a [MEDICAL CONDITION] or any emergency care regarding that topic. She stated she did a, .deep suction on the resident's [MEDICAL CONDITION] this morning around 6:30 a.m. and cleaned it. Ostomy was clean, with no gurgling or secretions at that time. h. On 7/12/18 at 9:17 a.m., the MDS Coordinator was asked what training she had received [MEDICAL CONDITION]. The LPN stated, We do a yearly in-service with (Respiratory Therapist #1) who comes in for training on cleaning, suctioning [MEDICAL CONDITION]. In the event of an emergency with the trach, I would stay with the resident, call for help, call MD (Medical Doctor), and suction PRN (as needed) to clear his airway and send out to the hospital as ordered. i. On 7/12/18 at 9:30 a.m., the DON was asked if she was able to find any other documentation related to the in-services. No further documentation was provided as of the survey exit date. j. On 7/12/18 at 2:25 p.m., LPN #6 was asked about the lack of suctioning for the resident who had bubbling, gurgling secretions and stated, I meant I was uncomfortable with putting the [MEDICATION NAME] into the stoma. I would reposition him and use a warm rag to wipe the [MEDICAL CONDITION] off. I don't know if I can do a deep suction in a stoma instead of the [MEDICAL CONDITION] cannula. If I was properly trained in how to replace the [MEDICAL CONDITION], I would do that in an emergency. I don't feel competent to do that. I didn't practice for that or do that in the training. He (Respiratory Therapist #1) just showed us the technique of turning the cannula for placement. It wasn't demonstrated. I never did it or was never appropriately trained to do that. k. On 7/12/18 at 2:55 p.m., LPN #2, who works in infection control, was asked about the training for [MEDICAL CONDITION] care and stated, on admission, there is no specific training for tracheostomies with new nurses, whoever works with them for orientation, at least 3 days, does the training for [MEDICAL CONDITION]. There is no specific orientation testing for [MEDICAL CONDITION] care. l. On 7/12/18 at 3:30 p.m., LPN #8 was asked about the training for [MEDICAL CONDITION] care and stated she was employed by the facility in (MONTH) (YEAR) and had 3 days orientation and in-services on the computer, but couldn't recall one specifically on [MEDICAL CONDITION] care. The LPN stated, The nurse on the floor showed me how to care for (resident's) [MEDICAL CONDITION]. I am not comfortable with suctioning him with deep suctioning. I don't fear doing it; I'm not confident because I haven't had to deep suction him yet. I have been cleaning him up on the outside of his [MEDICAL CONDITION]. In the event of any emergency related to his trach, I would ensure the airway patency, assess him for respiratory distress, and would suction him if the [MEDICAL CONDITION] was occluded. I am not comfortable replacing the [MEDICAL CONDITION]. I haven't attended a [MEDICAL CONDITION] class here. m. The facility's policy and procedure titled, [MEDICAL CONDITION] Care, provided by the Administrator on 7/10/18 at 2:08 p.m., documented, Policy: Residents with obstructed airways may have a [MEDICAL CONDITION]. Care of the [MEDICAL CONDITION] is important to maintain an open airway and to prevent infection of the site . 2. The immediate jeopardy was removed 7/20/18 at 5:15 p.m. and the scope and severity reduced to E when the following plan of removal was implemented: a. On 7/20/18 at 10:00 a.m., all nursing staff was in-serviced on all aspects of daily trache care and on emergencies, including when to suction, when not to suction, and emergency techniques, by (Respiratory Therapist #1). b. Each Licensed Nurse will be required to verbally walk through the trache competencies before returning to work, demonstration who, when, how to perform trache care daily and in emergency situations. c. To ensure deficient practice does not re-occur, Director of Nursing will check off one Licensed Nurse per shift on trache care/emergency trache care, to perform audits 5xweekx6 weeks or until compliance is reached, using the Trache Check Off Audit form. d. The Administrator will report all negative findings to the monthly Quality Assurance Committee for further review/recommendations. e. Completion date 8/1/18.

Complaint # (AR 741) was substantiated (all or in part) with these findings: Based on observation, record review and interview, the facility failed to ensure hot packs were applied to residents only by staff who were trained on their safe and proper use, to prevent burn injuries for 1 (Resident #8) of 2 (Residents #3 and #8) case mix residents who were dependent on staff for bed mobility. The failed practice resulted in actual harm for Resident #8, who sustained first and second degree burns to her back, and had the potential to cause more than minimal harm to 3 residents who were dependent on staff for bed mobility documented on a list provided by the Director of Nursing on 12/22/14. The findings are: 1. Resident #8 had [DIAGNOSES REDACTED].#1 through #4) and Muscle Spasms. The Annual Minimum Data Set (MDS) with an assessment reference date of 11/8/14 documented the resident scored 15 (13-15 indicates cognitively intact) on the Brief Interview for Mental Status, was totally dependent on two or more persons for bed mobility and transfers, had functional limitation in range of motion in both upper and lower extremities, required a wheelchair for mobility, and had one unhealed stage III pressure ulcer. a. The Care Plan updated 11/7/14 documented, "(Resident #8) has an ADL (Activities of Daily Living) Self Care Performance Deficit r/t (related to) quadriplegia/quadriparesis ... Interventions: Requires total assist (assistance) with ADLs, bed mobility and transfers... Encourage to use breath activated call light to call for assistance... Transfers: requires Mechanical lift with x (times) 2 staff for transfers." b. A Nurse's Note dated 12/9/14 at 8:36 a.m. and signed by Licensed Practical Nurse (LPN) #1 documented, "(Resident #8) requested a heating pad to her back per CNA (Certified Nurse Assistant). Heating pad applied for approx. (approximately) 20 minutes when discovered by this nurse and was removed. Upper back was reddened and warm. Resident refuses to lay on her side, so cool wash cloths were applied. Tissue is returning to normal temperature and color. Denies pain or discomfort. Will continue to monitor." c. A Nurse's Note dated 12/9/14 at 2:52 p.m. and signed by LPN #5 documented, "nurse aide brought to nurses attention that resident had some red marks and open skin on her upper back. Nurse went to assess resident and noticed that resident had several reddened areas and some open skin that appeared to look like large blisters on her upper and middle back. Obtained resident v/s (vital signs) and notified DON (Director of Nursing). Resident states not having any pain related to blisters on back at this time..." d. The OLTC (Office of Long Term Care) Incident and Accident (I&A) Report (Division of Medical Services (DMS) Form-7734) dated 12/9/14 at 3:15 p.m. and completed by the Social Services Director (SSD) documented, "Resident put on call light because she was cold. The aides adjusted her heater but resident stated it was not warm enough. One CNA offered resident a heat pack. Resident agreed. CNA went to therapy, got a heat pack, wrapped it according to resident, and placed it under her shoulders. After a short period, resident turned her call light on to have staff remove the hot pack because it was bunched up under her left shoulder. When hot pack was removed, her back had a reddened area between her shoulders. LPN and CNA are being suspended until further notice, staff inserviced, access to the therapy room has been limited to one staff member." e. The OLTC Witness Statement Form dated 12/10/14 (not timed) and signed by CNA #2 documented, "I came in and (CNA #1) said come lift (Resident #8's) shoulders for me to put this hot pack under her I just said okay. (CNA #1) wrapped two pads around it and I lifted (Resident #8) up and (CNA #1) placed it under her shoulder and (Resident #8) said I can't feel anything. (CNA #1) asked her if she was sure (Resident #8) said yes. (CNA #1) said to lift her up and (CNA #1) pulled one pad off it, wrapped it with one pad and placed it back under her, about 10 minutes later the nurse (LPN #1) told us she had taken the hot pack out and (CNA #1) needed to go put it up. Around 4:45 - 5:00 (a.m. or p.m. not specified in the documentation) (Resident #8's) light came on I (CNA #2) and (CNA #3) answered the light. (Resident #8) said she needed to be checked. We went and got the stuff and when I rolled her over her upper back was red and there were two blisters. We cleaned her up and as soon as we got done I went to (LPN #1) and told her about the redness and the blisters. She said okay I will be down in a moment. I said okay. After that I started rounds and (LPN #1) got (CNA #1) and they went in to look at it and that's all I heard." f. The OLTC Witness Statement Form dated 12/10/14 at 8:05 a.m. and signed by CNA #1 documented, "anserd (answered) (Resident #8's) light she ask for covers, she was cold, her heater didn't work, I got a pad from therapy, rap (wrapped) it in two bed pads. Ask (Asked) her were (where) in the bed she wanted it, she said that she wants it on her back, this was at around 4:45 Nurse took it off around 5:00." a.m. or p.m. was not specified in documentation for the times given. ) On 12/10/14 at 11:45 a.m., CNA #1 was asked to demonstrate how she wrapped the hot pack used for (Resident #8) on 12/9/14. CNA #1 took the hot pack and wrapped it in 2 incontinent pads. The CNA stated she had no training on how to use the hot packs and did not know the hot packs had a special cover. CNA #1 stated, "I went to (LPN #1) and asked if I could use the hot pack. She just said to wrap it and just don't put the pack on her skin." CNA was asked if she was sure the LPN understood how she was going to use the hot pack. The CNA stated, "Yes." CNA #1 also stated after she placed the hot pack behind the resident's back, around 5:15 a.m., (Resident #8) complained the towel that was wrapped around the hot pack was crunched behind her neck and was uncomfortable and she could not feel the heat from the hot pack. CNA #1 took one incontinent pad off, leaving only one pad wrapped around the hot pack. The CNA stated the hot packs were on the resident for about 10 minutes. CNA #1 was asked what made her feel that it was ok to go to therapy, get one of their devices they use as a treatment when you were not trained to use it. CNA #1 stated, "It was simple as it sounds. I didn't think about that. I just did it to warm her up." g. The OLTC Witness Statement Form dated 12/10/14 at 8:10 a.m. and signed by LPN #1 documented, "At approximately 0445 (4:45) am on 12/9/14 a CNA, (CNA #1), asks if she could put a heat pad from therapy in (Resident #8's) bed to warm her up due to being very cold. I told her yes but do not let it touch her. Then at 0500 (5:00 a.m.) I was on the hall and had just given another resident her morning meds when (Resident #8) called me to her room. At that time I saw her lying on the heat pad on her upper back. I immediately removed it and assessed her back. It was red and warm. I continued passing meds and at around 0530 (5:30 a.m.) another CNA came and told me her back was really red and had blisters. At that time I asked (CNA #1) to assist me in putting cold packs on her. The redness began to go away at that time. (Resident #8) denied pain or discomfort. She did not want to lay on her side so the cold packs were placed under her." 1.) On 12/10/14 at 12:15 p.m., LPN #1 was asked about the incident with (Resident #8) on 12/9/14 and stated, "about 4:30 p.m. (CNA #1) came and asked if it was ok if she could get a hot pack for (Resident #8). I told her it was ok, just don't let it touch her. About 5a.m. (Resident #8) called me in her room. I checked and saw the heat pad was on her back. I saw the pack was wrapped with an incontinent pad. I told (CNA #1) her back was red and I would be back around in a little to check it again. I continued with my med pass. (CNA #2) came and told me she thought blisters were on her back and really red. I got (CNA #2) to help with cold packs and we put them on her back. I checked her 3 to 4 more times. It looked like it was returning to it's normal color and temperature. We wouldn't put those hot packs on a patient without an order. I had no idea that she would put the packs on her skin." 2.) A hand written statement dated 12/10/14 (no time) and signed by LPN #4 documented, "Yesterday morning (12/9/14) at 4:30 (a.m. or p.m. not specified in the documentation), I came in to help pass meds. I hurt (heard) the other LPN (LPN #1), tell (CNA #1) to, 'not put it on her skin' and 'to be sure and check on her.' I did not know who or what they were talking about at the time. Later, (LPN #1) told me one of her patients had a red spot from either a heating pad or hot water bottle. I can't remember exactly which one." h. The Weekly/Monthly skin assessment/Pressure/Stasis form dated 12/9/14 and 12/10/14 documented the following: 1.) The form dated 12/9/14 at 3:49 p.m. documented, "Upper Left Back (rash) - 8 centimeters (cm) x 2cm Upper Mid Back (rash) - 6.5cm x 2cm Upper Right Back (blister) - 10cm - 10cm Mid Back (rash with blister) - 2.5cm x 10cm" 2.) The form dated 12/10/14 at 9:56 a.m. documented, "Upper Back (blister) - 6cm x 7cm Mid Back (blister) - 20cm x 7cm" i. A Physician Visit Note dated 12/10/14 at 1:00 p.m. and signed by the Medical Director documented, "Notified on 12/9 that patient had requested a heat pack to place on her back, and when staff removed it there was a lot of redness, as well as some blisters and peeling skin. When re-addressed on 12/10, there was quite a bit of improvement of the redness. Action: Measurements reviewed in skin assessments. Slight improvement from 12/9 - 12/10 Areas of [DIAGNOSES REDACTED] as well as some blanched patches with blisters. Response: Possible 1st degree burn (redness) with spots of 2nd degree burns vs. (versus) contact dermatitis from adhesive or material. Encouraged triple antibiotic and dressings to the blistered area. Appears to be improving. Continue to monitor." j. On 12/10/14 at 10:50 a.m., Physical Therapist (PT) #1 was asked about the hot pack used for the resident on 12/9/14 and stated, " ...moist hot packs - that is why they are so hot - because they are moist hot. It's a modality. It's got to be given in conjunction with another skillable treatment. They are used to reduce pain, increase circulation and healing. The water tank is called a Hydrocollator. The water temperature runs no hotter than 165 degrees. I just checked it, 155 degrees. We use tongs to take the hot packs out of the tank. The hot packs have a special cover and have Velcro to shut it. Towels are also used and they are folded for a double layer. For the back area, based on the patient's condition, I use approximately one hot pack covered with 4 towels and I would be constantly checking them. We were told in school we would need to check on it every 5 minutes. CNAs are not trained on this and knowing the contraindications when using." The PT was asked if she knew other staff had a key and access to the therapy room. She stated, "I was unaware of staff having a key." The PT was asked if she was informed about (Resident #8's) injury. PT stated, "Yes, my first thoughts were, 'why is anyone going into our therapy room and getting those things (hot packs)?' I also thought that the CNA who did it should be reprimanded." 2. The User Manual for Hydrocollator Heating Units received from the Social Services Director on 12/10/14 documented, "WARNING: ...The water temperature in the Hydrocollator Heating Unit... the water scalding temperature is approximately 120 degrees F (Fahrenheit) (49 degrees C (Celsius))... Individuals with circulatory problems should consult with a physician before using this product."